Citation Nr: 21076078 Decision Date: 12/22/21 Archive Date: 12/22/21 DOCKET NO. 18-01 054 DATE: December 22, 2021 REMANDED Entitlement to a temporary total evaluation because of treatment for a service-connected back disorder is remanded. REASONS FOR REMAND The Veteran served in the United States Air Force from June 1966 to June 1967. This matter comes before the Board of Veterans' Appeals (Board) on appeal of a November 2017 rating decision from a Department of Veterans Affairs (VA) Regional Office (RO). The Veteran testified before the undersigned Veterans Law Judge in an October 2021 videoconference hearing, and a transcript of this hearing is associated with the claims file. 1. Entitlement to a temporary total evaluation because of treatment for a service-connected back disorder is remanded. The Veteran contends that his L3-L4 decompression and synovial cystectomy surgery in September 2017 is related to his service-connected back condition and that entitlement to a temporary total evaluation due to the surgery is thus warranted. The Veteran was afforded VA examinations in November 2015 and November 2018. While the Veteran's surgery occurred after his November 2015 VA examination, this examiner determined that the Veteran's service-connected back condition was a lumbosacral strain. Additionally, although the examiner also found the Veteran to have degenerative arthritis of the spine and intervertebral dis syndrome (IVDS), the examiner opined that these conditions were less likely than not related to his lumbosacral strain. In the November 2018 VA examination, the examiner again diagnosed the Veteran's service-connected back condition as a lumbosacral strain. The examiner diagnosed the Veteran with degenerative arthritis, although the examiner did not diagnose him with IVDS. The examiner opined the Veteran's degenerative arthritis was less likely than not related to his lumbosacral strain because osteoarthritis is not caused by lumbosacral strain. Instead, the examiner explained that the Veteran's osteoarthritis was more likely than not age-related, and the Veteran's reported radiculopathy symptoms were more likely than not related to his osteoarthritis and not to his lumbosacral strain. During the October 2021 hearing, the Veteran's representative argued that the November 2015 and November 2018 examinations were inadequate because the examiners based their opinions on an incorrect diagnosis, stating the Veteran was service-connected for a lumbosacral strain when his records indicate he was originally service-connected for "low back syndrome." In support of this claim, the representative referenced the Veteran's USAF Medical Evaluation Board Report which notes a diagnosis of thoracic scoliosis, idiopathic, with a curve of 10 degrees and psychophysiological musculoskeletal reaction with back pain, with a mild to occasionally moderate disability. The Veteran was then service connected for low back syndrome in 1967. Furthermore, when the Veteran's claim for an increased rating for his back condition was denied in August 1972, the referenced condition was low back syndrome and not a lumbosacral strain. The representative argued that the Veteran's service-connected back condition was originally rated under Diagnostic Code (DC) 5295, which was later adjusted to a new Diagnostic Code that reflected lumbosacral strain. The representative argued that this adjustment in the Diagnostic Code improperly changed the characterization of the Veteran's condition to lumbosacral strain, which the November 2015 and November 2018 examiners then assessed. However, neither the November 2015 or November 2018 examiner addressed the Veteran's history of thoracic scoliosis or psychophysiological musculoskeletal reaction with back pain, nor did they provide an explanation as to why the Veteran's back disability, which was initially diagnosed and service-connected as low back syndrome, should now be evaluated instead as lumbosacral strain. Because of this, the representative contends that these examinations are inadequate. After reviewing the evidence of record, the Board agrees that the November 2015 and November 2018 examinations are inadequate. As noted by the Veteran's representative, the Veteran was originally service connected for low back syndrome and assessed under DC 5295. However, the rating criteria governing DC 5295 were revised in 2003, and the current DCs do not contain a provision specifically covering low back syndrome. 38 C.F.R. § 4.71a. However, although the November 2015 and November 2018 examiners noted the Veteran was service connected for a lumbosacral strain, and the RO has since evaluated the Veteran under DC 5237, governing lumbosacral strain, there is no explanation as to why this is the appropriate diagnosis when the Veteran was previously service connected for the more general low back syndrome. Additionally, neither the November 2015 nor the November 2018 examiner addressed the Veteran's thoracic scoliosis or psychophysiological musculoskeletal reaction with back pain, which were diagnosed by the Medical Evaluation Board and explicitly considered when the Veteran was service connected for a low back syndrome in August 1967. Seeing as the Veteran was originally service-connected based on these two diagnoses, the Board finds that further examination is required to address whether these conditions are separate from the current diagnosis of lumbosacral strain, as well as whether or not these conditions would have led to the Veteran's current degenerative arthritis, which is the underlying condition for which the Veteran had the surgery his current claim is based upon. Seeing as the Board has found both the November 2015 and November 2018 examinations to be inadequate, an addendum opinion is necessary in order to determine the Veteran's current service-connected back conditions, as well as whether any of these conditions were the underlying reason for his back surgery. Accordingly, the matter is REMANDED for the following action: Obtain an addendum opinion from a qualified examiner in order to determine the nature of the Veteran's service-connected low back condition(s). Provide a complete copy of the Veteran's claims file to the examiner, to include the Veteran's service treatment records. The examiner must provide a thorough discussion of each of the following: (a.) Provide diagnoses for all current back conditions. (b.) Review the USAF Medical Evaluation Board Report from 1967 and the July 1972 VA examination which discuss the Veteran's diagnoses of thoracic scoliosis and psychophysiological musculoskeletal reaction with back pain, then opine on if and how these conditions are related to any of his current diagnosed back conditions. (c.) Opine on whether the Veteran's September 2017 L3-L4 decompression and synovial cystectomy is a result of the Veteran's thoracic scoliosis, his psychophysiological musculoskeletal reaction with back pain, or any other currently diagnosed back conditions. If the September 2017 surgery is determined to be due to a back condition other than his thoracic scoliosis or psychophysiological musculoskeletal reaction with back pain, opine on whether the back condition is secondary to or otherwise aggravated by these two conditions. A complete rationale for all opinions must be provided. If the examiner cannot provide a requested opinion without resorting to speculation, it must be so stated, and the examiner must provide the reasons why an opinion would require speculation. The examiner must indicate whether there was any further need for information or testing necessary to make a determination. Additionally, the examiner must indicate whether any opinion could not be rendered due to limitations of knowledge in the medical community at large and not those of the particular examiner. Caroline B. Fleming Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Gabrielle Ongies, Associate Counsel The Board's decision in this case is binding only with respect to the instant matter decided. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.