Citation Nr: 21006120 Decision Date: 02/03/21 Archive Date: 02/03/21 DOCKET NO. 13-18 337 DATE: February 3, 2021 REMANDED Entitlement to service connection for a low back disability is remanded. REASONS FOR REMAND The Veteran had active military service from October 1964 to November 1968. By way of procedural history, this matter was previously before the Board of Veterans’ Appeals (Board) in June 2017. At that time, the Board issued a remand for further development. In October 2018, the matter came back before the Board for adjudication. At that time, the Board denied entitlement to service connection for a low back disability. The Veteran’s appealed the decision to the United States Court of Appeals for Veterans’ Claims (Court). The Court issued a decision in June 2020 which vacated the Board’s October 2018 decision and remanded the matter back to the Board for readjudication. The Court vacated the October 2018 Board decision due to inadequate statement of reasons or bases. Upon readjudication, the Board finds a remand is warranted based on the inadequacy of the August 2017 VA examination and medical opinion. Specifically, the examiner’s opinion failed to address important medical evidence. In an April 1974 VA treatment record, the examiner found a diagnosis of recurrent low back strain, residuals of old injury. See April 1974 VA Orthopedic Compensation. The Board notes the examiner opined that the Veteran’s back strain in service resolved without any residuals. See August 2017 VA Back Conditions Disability Benefits Questionnaire (DBQ). This 1974 diagnosis must be addressed in order for the Board to make an informed decision. Lastly, the Court in the June 2020 Memorandum Decision noted that the Veteran, through his representative, asserted that additional private medical records were not obtained by the Board. The Board finds on remand that it is necessary to attempt to obtain any additional private medical records. The matters are REMANDED for the following action: 1. Contact the Veteran and request authorization to obtain any outstanding records pertinent to his claims, including any private treatment records following proper VA procedures (38 C.F.R. § 3.159(c)). The RO must attempt to obtain the most recent VA treatment records. 2. After the above is completed, schedule the Veteran for a VA examination for his low back disability to determine the etiology of this disability. The Board recognizes the potential practical difficulties in scheduling an examination in light of the COVID-19 epidemic and requests flexibility and understanding in affording the Veteran any warranted examination. The RO should consider acceptable clinical examination (ACE) if needed. Access to the claims file must be made available to the examiner for review. Any and all studies, tests, and evaluations deemed necessary by the examiner should be performed. (a.) The examiner must provide a medical opinion as to whether it is at least as likely as not (50 percent or greater probability) that the Veteran’s low back disability is related to his active service. (b.) The examiner must report on whether the current low back symptomatology is the same noted during service. The Veteran’s lay contentions must be considered in this regard. (c.) The examiner must address the findings of the April 1974 VA clinical record as it pertains to recurrent low back strain, residuals of old injury. The examiner should also be aware that in rendering an opinion, it must “contain not only clear conclusions with supporting data, but also a reasoned medical explanation connecting the two.” See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 301 (2008). A. C. MACKENZIE Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board J. Glaeser, 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.