Citation Nr: 21005488 Decision Date: 02/01/21 Archive Date: 02/01/21 DOCKET NO. 16-13 477 DATE: February 1, 2021 REMANDED Entitlement to service connection for a left knee disability is remanded. Entitlement to service connection for a right knee disability, to include as secondary to service-connected disability, is remanded. REASONS FOR REMAND The Veteran served on active duty from September 1981 to June 1982. This matter is on appeal of a February 2015 rating decision. In December 2018, a hearing was held before the undersigned. A transcript of the hearing is of record. VA is obligated to provide an examination and/or opinion where the record contains evidence that the claimant has a current disability, the record indicates that a disability or signs or symptoms of disability may be associated with active service or service-connected disability, and the record does not contain sufficient information to make a decision on the claim. 38 U.S.C. § 5103A; 38 C.F.R. § 3.159(c)(4); McLendon v. Nicholson, 20 Vet. App. 79 (2006). Once VA undertakes the effort to provide a medical examination or opinion, it must provide an adequate one. A medical opinion is inadequate if it relies on an inaccurate fact. See Reonal v. Brown, 5 Vet. App. 458, 461 (1993). A medical opinion is further inadequate if it does not take into account the Veteran’s reports of symptoms and history, even if recorded in the course of the examination. Dalton v. Nicholson, 21 Vet. App. 23 (2007); see also Barr v. Nicholson, 21 Vet. App. 303, 311-12 (2007). In February 2015 and May 2018, VA examiners provided opinions regarding the etiology of the Veteran’s left knee disability. The opinions appear to have dismissed the Veteran’s report of experiencing on-going left knee pain since an in-service injury. The VA examiners’ opinions and rationales appear to also be based on the lack of objective clinical evidence of any treatment for many years after the Veteran’s discharge from service. While the Veteran’s reported history of an in-service injury and ongoing symptoms since his discharge from service were noted in the February 2015 opinion, the examiner did not adequately address these reports in the rationale for the opinion provided. Moreover, the Veteran has since argued that his right knee disability is either caused or aggravated by his left knee disability, and no VA clinician has addressed the etiology of the right knee disability. Additionally, at the December 2018 hearing, the Veteran’s representative indicated that he had recently enrolled for treatment at VA and that he planned to begin seeking treatment there. Shortly thereafter, in January 2019, a request was made for VA treatment records and the records obtained reflected that the Veteran had an upcoming appointment in February 2019. Thus, any outstanding VA treatment records since January 2019 should also be obtained. On remand, after any outstanding treatment records have been obtained, an addendum medical opinion must be obtained that adequately considers the Veteran’s allegations of in-service left knee injury with continuity of symptomatology since his service. See Buchanan v. Nicholson, 451 F.3d 1331, 1336 (Fed. Cir. 2006) (stating that the absence of documented treatment cannot, alone, serve as a basis for finding that lay evidence lacks credibility).   The matters are REMANDED for the following action: 1. Obtain and associate with the claims file any records of VA treatment the Veteran has received since January 2019. 2. Ask the Veteran to complete a VA Form 21-4142 for any outstanding private treatment records for his left and right knee disabilities not already of record. Based on his response, make two requests for any authorized records, unless it is clear after the first request that a second request would be futile. 3. After obtaining any additional records, an addendum medical opinion must be obtained from a clinician with sufficient experience and expertise. Another examination (including via telehealth interview) of the Veteran need only be performed if deemed necessary by the clinician providing the opinion. The electronic claims file must be made available to the examiner. Based on review of the pertinent evidence of record, the clinician should provide the following opinions: (a). Is it at least as likely as not (50 percent or better probability) that the Veteran’s current left knee disability, status post total knee replacement, had its onset in service or is related to his active duty service or any incident therein, to include any injuries sustained in basic training or the result of the April 1982 vehicular accident? (b). If the clinician finds that the Veteran’s current left knee disability is as likely as not related to his active duty service or any incident therein, is it at least as likely as not (50 percent or better probability) that any currently diagnosed right knee disability is or was caused or aggravated by his left knee disability? A complete rationale for all opinions must be provided that addresses the Veteran’s report of in-service left knee injuries and continuous left knee pain since his injuries in service and subsequent to his discharge, as well as subsequent right knee pain as a result of compensation for the left knee disability. If the clinician cannot provide a requested opinion without resorting to speculation, it must be so stated, and the clinician must provide the reasons why an opinion would require speculation. The clinician must indicate whether there was any further need for information or testing necessary to make a determination. Additionally, the clinician 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. M. SORISIO Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board L. J. Wells-Green 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.