Citation Nr: 21007680 Decision Date: 02/10/21 Archive Date: 02/10/21 DOCKET NO. 17-08 241 DATE: February 10, 2021 REMANDED Entitlement to service connection for low back disorder, including degenerative disc disease (DDD), is remanded. REASONS FOR REMAND On initial review of this case the Board remanded it to the Agency of Original Jurisdiction (AOJ) for additional development. See 11/05/2019 BVA Decision. The Board finds less than substantial compliance with the remand directive. See Stegall v. West, 11 Vet. App. 268 (1998). The Veteran has another perfected appeal that entails several issues. It will be the subject of a separate Board decision. Entitlement to service connection for low back disorder, including DDD, is remanded. The AOJ arranged an examination of the Veteran as directed in the Board remand. See 01/09/2020 C&P Exam, 1st Entry. The Board finds that the examination report is inadequate for appellate review purposes, for the clinician’s rationale for the negative nexus opinion is simply not a complete explanation. Basing a negative nexus opinion solely on the absence of treatment records without an explanation of the relevance of that factor does not constitute a full rationale. Further, there is no indication in the examination report that the clinician even considered the Veteran’s lay reported history of a lifting injury while serving on the USS Iowa. See 01/09/2020 C&P Exam, 3rd Entry. The Board also notes that its review of the claims file does not locate the May 1991 lumbar spine x-ray referenced by the clinician. See 01/09/2020 C&P Exam, 1st Entry, P. 1. The earliest dated medical evidence and x-rays located by the Board in the claims file is dated in 1997. The matters are REMANDED for the following action: The issue is still whether it is at least as likely as not (at least a 50 percent probability) that the Veteran’s currently diagnosed low back disorder, including lumbar spine DDD, had onset in active service or is otherwise causally connected to active service. Send the claims file to the clinician who conducted the January 2020 VA spine examination, or an equally or higher qualified clinician. Ask the clinician to provide an addendum wherein the following is addressed. Please identify the exact location in the claims file where the referenced May 1991 lumbar spine x-ray is located. Inform the clinician that the lay evidence of record must be considered, and that the Board has not yet made a determination of the reliability and accuracy of the lay evidence of record. Hence, the clinician must address whether the lay evidence of an in-service, shipboard lifting injury was considered in arriving at the nexus opinion. If the absence of treatment records is significant, then the significance must be explained, as the absence of contemporaneous medical documentation, alone, is not a sufficient reason for rejecting lay evidence. Buchanan v. Nicholson, 451 F.3d 1331, 1337 (Fed. Cir. 2006). A full and complete rationale will encompass and address all of the above factors. Eric S. Leboff Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board W. T. Snyder 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.