Citation Nr: 21006856 Decision Date: 02/05/21 Archive Date: 02/05/21 DOCKET NO. 16-58 093 DATE: February 5, 2021 REMANDED Entitlement to service connection for a cervical spine disorder is remanded. REASONS FOR REMAND The Veteran served on active duty in the United States Air Force from August 2003 to March 2012. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from an August 2013 rating decision issued by a Department of Veterans Affairs Regional Office (RO). The Veteran testified before the undersigned Veterans Law Judge at a November 2020 hearing. A hearing transcript has been associated with the record. 1. Entitlement to service connection for cervical spine disorder remanded. The Veteran contends that his current cervical spine disorder is the result of service, specifically as a result of wearing a helmet and googles during flight duties and/or sleeping on a poor quality mattress. Service treatment records show that the Veteran was evaluated in June 2011 while in service, at a military hospital which noted his complaints of neck pain and his treatment with aspirin. Post-service treatment records reflect that the Veteran was diagnosed with torticollis, also known as “wry neck.” During the November 2020 hearing, the Veteran testified regarding his neck pain and the functional impairments associated with his cervical spine. VA must provide a medical examination when there is (1) competent evidence of a current disability or persistent or recurrent symptoms of a disability, (2) evidence establishing that an event, injury, or disease occurred in service, or establishing certain diseases manifesting during an applicable presumptive period for which the claimant qualifies, and (3) an indication that the disability or persistent or recurrent symptoms of a disability may be associated with the veteran’s service or with another service-connected disability, but (4) there is insufficient competent medical evidence on file for the Secretary to make a decision on the claim. McLendon v. Nicholson, 20 Vet. App. 79 (2006); see also 38 U.S.C. § 5103A(d)(2), 38 C.F.R. § 3.159(c)(4)(i). The third prong, which requires that the evidence of record “indicate” that the claimed disability or symptoms “may be” associated with the established event, is a low threshold. McLendon, 20 Vet. App. at 83. As the Veteran has reported a current cervical spine disorder during his November 2020 hearing and the record reflects in-service complaints of neck pain, a VA examination is warranted to determine the nature and etiology of the Veteran’s claimed cervical spine disorder. Such a VA examination should be conducted on remand. The matter is REMANDED for the following action: 1. The Veteran should be given the opportunity to identify any outstanding private or VA treatment records relevant to the claim on appeal. After obtaining any necessary authorization from the Veteran, all outstanding records should be obtained, to include updated VA treatment records. For private treatment records, make at least two (2) attempts to obtain records from any identified sources. If any such records are unavailable, inform the Veteran and his representative and afford him an opportunity to submit any copies in their possession. For federal records, all reasonable attempts should be made to obtain such records. If any records cannot be obtained after reasonable efforts have been made, issue a formal determination that such records do not exist or that further efforts to obtain such records would be futile, which should be documented in the claims file. The Veteran must be notified of the attempts made and why further attempts would be futile, and allowed the opportunity to provide such records, as provided in 38 U.S.C. § 5103A(b)(2) and 38 C.F.R. § 3.159(e). Following the receipt of outstanding records, schedule the Veteran for an examination by an appropriate clinician to determine the nature and etiology of his claimed cervical spine disorder. The record, to include a copy of this Remand, should be made available to the examiner, and all indicated tests should be conducted. The need for an in-person examination is left to the discretion of the examiner. The examiner is asked to respond to the following questions: (A) Identify all of the Veteran's cervical spine disorder(s) since April 2012. (b) For each such diagnosis, is at least as likely as not (50 percent probability or greater) that the Veteran's cervical spine disorder was incurred in service; a result of an illness, injury, or event in service; and or is otherwise related to her active service? The examiner should specifically address the Veteran’s complaint of neck pain in December 2011. The examiner should also address the Veteran’s contentions that his neck pain is the result of wearing a helmet and googles during flight duty or the result of sleeping on poor quality mattresses during service. A rationale should be provided for all opinions offered. If it is not possible to provide a specific opinion regarding the above questions, the examiner must state whether the need to speculate is due to a deficiency in the state of general medical knowledge (no one could respond given medical science and the known facts), a deficiency in the record (additional facts are required), or the examiner (does not have the knowledge or training). The medical opinion must support the conclusions reached with an analysis that is adequate for the Board to consider and weigh against other evidence of record; medical opinions must contain not only clear conclusions with supporting data, but also a reasoned medical explanation connecting the two. If an opinion cannot be expressed without resort to speculation, ensure that the clinician so indicates and discusses why an opinion is not possible, to include whether there is additional evidence that could enable an opinion to be provided, or whether the inability to provide the opinion is based on the limits of medical knowledge. KRISTY L. ZADORA Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Kashif I. Ali, 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.