Citation Nr: 21005699
Decision Date: 02/02/21	Archive Date: 02/02/21

DOCKET NO. 09-27 089
DATE: February 2, 2021

REMANDED

Entitlement to service connection for a low back disability, to include lumbar degenerative disc disease and myofascial pain syndrome, is remanded.

REASONS FOR REMAND

The Veteran served on active duty from May 2004 to December 2005, with service in the Southwest Asia Theatre of Operations from November 2004 to October 2005. She also had active duty for training from August 1982 to February 1983  and additional reserve service. This matter comes before the Board of Veterans’ Appeals (Board) from a July 2008 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO).

In October 2018, the Veteran and her husband testified at a hearing before the undersigned Veterans Law Judge. A transcript of the hearing is of record.

In May 2019, the Board remanded the matter for additional evidentiary development.

1. Entitlement to service connection for a low back disability, to include lumbar degenerative disc disease and myofascial pain syndrome

Following the Board’s May 2019 remand, an addendum VA opinion was obtained in January 2020. However, the opinion is not fully responsive to the remand directives. While the examiner diagnosed lumbar degenerative disc disease at     L5-S1 and myofascial pain syndrome of the lumbar spine, the negative nexus opinion did not adequately address whether the diagnosed conditions are post-traumatic residuals of events in service. Thus, an addendum opinion is warranted.

The matter is REMANDED for the following action:

1. Return the claims file to the VA examiner who provided the January 2020 medical opinion on the Veteran’s claim for a low back disability. If that examiner is not available, the addendum should be provided by another qualified VA examiner. If a new examination is deemed necessary to respond, one should be scheduled.

After reviewing the claims file, the examiner should explain why the Veteran’s lumbar degenerative disc disease at L5-S1 and myofascial pain syndrome of the lumbar spine are/are not merely a delayed post-traumatic residual from wearing heavy gear during active duty and/or allegedly diving over a berm in 2005.  

2. If the claim remains denied, issue a supplemental statement of the case.

 

 

K. A. BANFIELD

Veterans Law Judge

Board of Veterans’ Appeals

Attorney for the Board	M. C. Birder

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.