Citation Nr: 21006372 Decision Date: 02/04/21 Archive Date: 02/04/21 DOCKET NO. 18-37 281 DATE: February 4, 2021 REMANDED Entitlement to service connection for an upper back condition, cervical myositis, thoracic spine degenerative disc disease (DDD), spondylosis, is remanded. REASONS FOR REMAND The Veteran had active duty service from March 1970 to October 1971. This matter comes before the Board of Veterans’ Appeals (Board) from a January 2016 rating decision issued by a Department of Veterans Affairs (VA) Regional Office (RO). In September 2020, the Veteran’s claims were remanded by the Board to obtain an addendum opinion. In characterizing the issues on appeal, the Board recognizes that when a claimant makes a claim, he is seeking service connection for symptoms regardless of how those symptoms are diagnosed or labeled. See Clemons v. Shinseki, 23 Vet. App. 1 (2009). As the medical evidence of record indicates, the Veteran received multiple diagnoses for his upper back condition, the issue of entitlement to service connection has been expanded as noted above, consistent with Clemons. 1. Entitlement to service connection for an upper back condition, cervical myositis, thoracic DDD, spondylosis The Veteran contends his upper back condition is related to service. See January 2021 Appellant’s Post-Remand Brief; see also January 2016 VA 21-0958, Form 9. In a September 2020 Board decision, this matter was remanded to obtain an addendum opinion regarding secondary service connection. Specifically, the examiner was to opine whether mild cervical myositis, mild thoracic DDD from thoracic vertebrae T-7 to T-10 and spondylosis were due to his service-connected low back disability and/or aggravated beyond their natural progression by his service-connected low back disability. In a September 2020 opinion, Although the examiner concluded that the currently diagnosed upper back conditions were less likely than not proximately due to or aggravated by the service-connected low back condition, the examiner noted only the mild thoracic DDD and spondylosis in the rationale. It is not clear whether the examiner addressed each condition listed: cervical myositis, thoracic DDD and thoracic spine spondylosis. Further, the examiner did not provide a clear rationale regarding aggravation. Moreover, the Veteran was diagnosed with cervical spondylosis in 2013. See August 16, 2013 VA Treatment record. This diagnosis was not addressed in the December 2019 VA examination upon which the 2020 addendum opinion is based. See December 2019 VA Examination, Section I, Diagnosis, pp. 1-2. Once VA has provided a VA examination, it is required to provide an adequate one, regardless of whether it was legally obligated to provide an examination in the first place. See Barr v. Nicholson, 21 Vet. App. 303 (2007). Therefore, the Board finds that the claim should be remanded for an addendum opinion. The matters are REMANDED for the following action: 1. Obtain an addendum opinion addressing the nature and etiology of the Veteran’s cervical myositis, cervical spondylosis, thoracic DDD and thoracic spondylosis. 2. Thereafter, upon review of the record, to include this remand, the VA examiner is asked to opine whether it is as least as likely as not (50 percent probability or greater) that the Veteran’s: a) Cervical myositis is: (1) proximately due to his service-connected low back disability, and or (2) aggravated beyond its natural progression. (b) Cervical Spondylosis is:(1) proximately due to his service-connected low back disability, and or (2) aggravated beyond its natural progression. (c) Thoracic DDD is:(1) proximately due to his service-connected low back disability, and or (2) aggravated beyond its natural progression. (d) Thoracic Spondylosis is:(1) proximately due to his service-connected low back disability, and or (2) aggravated beyond its natural progression. Aggravation for VA purposes means the condition is worsened beyond its natural progression. If aggravation is found, the examiner should address to the extent possible: (1) the baseline manifestations of each condition found prior to the aggravation; and (2) the increased manifestations which, in the examiner’s opinion, are proximately due to the Veteran’s service-connected low back disability. (Continued on the next page)   The examiner must provide a complete rationale for the opinions stated. If the examiner cannot provide any of the requested opinions without resorting to mere speculation, the examiner should indicate this and provide supporting rationale as to why an opinion cannot be made without resorting to mere speculation. K. J. ALIBRANDO Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board K. McKenzie, 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.