Citation Nr: 21009574 Decision Date: 02/22/21 Archive Date: 02/22/21 DOCKET NO. 16-23 520 DATE: February 22, 2021 REMANDED Entitlement to service connection for a lower back condition, to include as secondary to service-connected right hip injury is remanded. REASONS FOR REMAND The Veteran had active duty service with the U.S. Army from May 2009 to December 2009. This case comes before the Board of Veteran’s Appeals (Board) on appeal from a February 2015 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO). In November 2018, the Veteran had a hearing before the undersigned Veterans Law Judge (VLJ) at the RO. A transcript of that hearing is of record. Unfortunately, the Board finds that the Veteran’s claim for lower back disability must again be remanded to ensure compliance with the directives of the Board’s prior remand. A January 2015 VA examination found no low back pathology or disability; this was found inadequate in light of complaints of back pain which can constitute a disability. In April 2019, the Board remanded this issue for a new VA examination and medical opinion. The VA examiner was asked to identify all current disabilities of the low back and for each, to opine as to whether it is at least as likely as not such disability was caused or aggravated by military service and/or a service-connected disability, to include the right hip condition. In a November 2020 VA examination report, the VA examiner opined that the diagnosed low back disability was less likely than not incurred in or caused by service. The examiner explained that the records and the current complaints were inconsistent with her current back pain, including the back strain/chronic pain, being caused or incurred by her military service. The examiner did not provide an adequate rationale for his opinion explaining how they are inconsistent. He simply stated that service records did not show a nexus. The VA examiner made bare statements and had not expressed his reasoning or the bases for his conclusion; in contrast the question of secondary service connection to the hip was thoroughly addressed. Additionally, the examiner has discounted in-service complaints of back pain and diagnoses of low back strain. Therefore, the opinion is inadequate, and the Board must remand the claim for a new examination and medical opinion. See Stegall v. West, 11 Vet. App. 268 (1998 The matters are REMANDED for the following action: 1. Obtain updated VA treatment records. 2. Schedule the Veteran for a VA spine examination. The claims file must be reviewed in conjunction with the examination. Please identify all current disabilities of the low back and for each, opine as to whether it is at least as likely as not such disability is caused or aggravated by military service. The examiner is asked to address the complaints and diagnosis of chronic lower back pain in-service. 3. Thereafter, readjudicate the remanded issue. If any benefit sought remains denied, issue a supplemental statement of the case. After an appropriate time for response, the case should be returned to the Board for appellate review if otherwise in order. WILLIAM H. DONNELLY Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board S. Baxter 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.