Citation Nr: 21077150 Decision Date: 12/28/21 Archive Date: 12/28/21 DOCKET NO. 14-36 053 DATE: December 28, 2021 REMANDED Entitlement to service connection for a cervical spine disorder, to include degenerative disc disease/degenerative joint disease (DDD/DJD), is remanded. Entitlement to service connection for a left arm disorder, tingling and numbness of the left arm, to include as secondary to the claimed cervical spine disorder, is remanded. REASONS FOR REMAND The Veteran served on active duty in the United States Navy from July 1987 to July 1991. These matters come before the Board of Veterans' Appeals (Board) on appeal from a December 2012 rating decision. In October 2018, the Veteran testified at a Board videoconference hearing before the undersigned Veterans Law Judge. A transcript of the hearing is included in the electronic claims file. In May 2019, the Board remanded these matters for additional development. In December 2020, the Board denied these service connection claims. The Veteran appealed the decision to the United States Court of Appeals for Veterans Claims (Court). The parties filed a Joint Motion for Partial Remand (Joint Motion) in September 2021, which was granted by Order of the Court that same month. 1. Entitlement to service connection for a cervical spine disorder, including DDD/DJD, is remanded. In the September 2021 Joint Motion, the parties agreed that the November 2019 VA examination findings were inadequate and based on an inaccurate factual premise. It was noted that the VA examiner found the Veteran's "injury was acute during service and no records [exist] to support the chronicity of care until 2006." The examiner also stated that "based on reviewing the STR[s], the neck injury/cervical strain during service was acute. He reported his issues didn't start until 2006 which is 15 years after he left the service." The parties to the Joint Motion noted that those findings were undermined by the lay evidence of record, including the Veteran's assertions that his neck pain worsened on service discharge, that he started having tingling in his left arm and left side of his neck in 1989 but never paid attention, that his neck pain began gradually, and that he was first seen and diagnosed with DJD by a chiropractor in 2000. Finally, the parties noted that a VA examiner must specifically address the Veteran's assertions of symptoms related to his neck condition during service in 1989 but that he never paid attention as a possible explanation as to why there was a gap in records between separation from service and the start of the post-service records regarding the claimed cervical spine disorder. 2. Entitlement to service connection for a left arm disorder, tingling and numbness of the left arm, to include as secondary to the claimed cervical spine disorder, is remanded. In the September 2021 Joint Motion, the parties also agreed that the November 2019 VA examination findings were inadequate, as the examiner failed to consider the Veteran's assertions that his left arm tingling started in 1989. Finally, the parties noted that a VA examiner must also consider whether the Veteran's tingling and numbness in his left arm was caused or aggravated by his cervical spine disorder. Evidence of record further reflects that the Veteran received VA medical treatment for his claimed cervical spine and left arm disorders from Salisbury VAMC. As evidence of record only includes treatment records dated up to July 2020 from that facility, all pertinent VA treatment records should be obtained and properly associated with the record. 38 U.S.C. § 5103A(c) (2012); see also Bell v. Derwinski, 2 Vet. App. 611 (1992). In addition, the AOJ must obtain a complete copy of all records associated with the Veteran's claim/award for Social Security Administration (SSA) disability benefits and associate them with the electronic claims file. See Golz v. Shinseki, 590 F.3d 1317, 1323 (Fed. Cir. 2010). The matters are REMANDED for the following actions: 1. Obtain updated treatment records pertaining to the Veteran's claimed cervical spine and left arm disorders from Salisbury VAMC dated from July 2020 to present. 2. Obtain a complete set of SSA records pertinent to any claim made by the Veteran for disability benefits, including the medical records relied upon concerning that claim. 3. Obtain a VA medical opinion to clarify the etiology of the Veteran's claimed cervical spine disorder from an appropriate examiner. If an opinion cannot be provided without an examination, one should be provided. The electronic claims file must be made available to the examiner, and the examiner must specify in the medical opinion that the file has been reviewed. Based on a review of the electronic claims file and the Veteran's lay assertions, the examiner must provide an opinion as to whether any current cervical spine disorder, including DDD/DJD, was at least as likely as not (50 percent or greater probability) incurred during or causally related to his active military service, to include documented in-service neck treatment in June 1989 (cervical strain) and October 1990 (neck injury while lifting weights) as well as other asserted in-service activities such as carrying a 40-pound medical pack, injuries while playing basketball and softball, and lifting weights in the gym. The examiner should acknowledge and discuss the Veteran's lay assertions (that his neck pain worsened on service discharge, that he started having tingling in his left arm and left side of his neck in 1989 but never paid attention, that his neck pain began gradually, and that he was first seen and diagnosed with DJD by a chiropractor in 2000) as well as the findings in the post-service treatment records and the October 2011 and November 2019 VA examination reports/medical opinions. The VA examiner must also specifically address the Veteran's assertions of symptoms related to his neck condition during service in 1989 but that he never paid attention as a possible explanation as to why there was a gap in records between separation from service and the start of the post-service records regarding the claimed cervical spine disorder. In providing this additional opinion, the examiner should also discuss medically known or theoretical causes of any current cervical spine disorder and describe how such a disorder generally presents or develops in most cases, in determining the likelihood that any current disorder is related to in-service events as opposed to some other cause. 4. Obtain a VA medical opinion to clarify the etiology of the Veteran's claimed left arm disorder from an appropriate examiner. If an opinion cannot be provided without an examination, one should be provided. The electronic claims file must be made available to the examiner, and the examiner must specify in the medical opinion that the file has been reviewed. Based on a review of the electronic claims file and the Veteran's lay assertions, the examiner must provide an opinion as to whether any current left arm disorder was at least as likely as not (50 percent or greater probability) incurred during or causally related to his active military service, to include his assertions of left arm tingling during service in 1989. The examiner must also provide an opinion as to whether any previously or currently diagnosed left arm disorder was at least as likely as not (50 percent or greater probability) caused or aggravated (worsened) by the Veteran's claimed cervical spine disorder. The examiner is advised that permanent worsening of the condition beyond its natural progression need not be shown. The possibility of temporary worsening should be addressed. Aggravation refers to any incremental increase in disability, any additional impairment of earning capacity in non-service-connected disabilities resulting from service-connected conditions, above the degree of disability existing before the increase regardless of its permanence. The examiner should acknowledge and discuss the Veteran's lay assertions, post-service treatment records, and the findings in the October 2011 and November 2019 VA examination reports/medical opinions. 4. Rationale for all requested opinions shall be provided. If the examiner cannot provide an opinion without resorting to mere speculation, he or she shall provide a complete explanation stating why this is so. In so doing, the examiner shall explain whether the inability to provide a more definitive opinion is the result of a need for additional information or that he or she has exhausted the limits of current medical knowledge in providing an answer to that particular question(s). The Veteran is hereby advised that failure to report for any scheduled VA examination without good cause shown may have adverse effects on his claims. 38 C.F.R. § 3.655. 5. After completing the above actions and any other necessary development, the claims on appeal must be re-adjudicated, taking into consideration all relevant evidence associated with the record since the July 2020 SSOC. If any benefit on appeal remains denied, a SSOC must be provided to the Veteran and his representative. After the Veteran has had an adequate opportunity to respond, the appeal must be returned to the Board for appellate review. MICHAEL MARTIN Veterans Law Judge Board of Veterans' Appeals Attorney for the Board J. D. Deane, 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.