Citation Nr: 21010261 Decision Date: 02/24/21 Archive Date: 02/24/21 DOCKET NO. 16-49 841 DATE: February 24, 2021 REMANDED Entitlement to service connection for a left hip disorder is remanded. Entitlement to service connection for a right hip disorder is remanded. Entitlement to service connection for a left shoulder disorder is remanded. Entitlement to service connection for a right shoulder disorder is remanded. Entitlement to service connection for a back disorder is remanded. REASONS FOR REMAND The Veteran served on active duty from April 2000 to May 2000, from October2003 to February2004, and from March 2004 to July 2004. In July 2019, the Veteran presented testimony before the undersigned Veterans Law Judge of the Board. A copy of the transcript has been associated with the claims file. The Board also notes the issues of entitlement to service connection for an acquired psychiatric disability, to include PTSD and anxiety disorder, and entitlement to a total disability rating due to individual unemployability (TDIU) were remanded in the prior January 2020 decision. In an October 2020 rating decision, the Regional Office (RO) granted the claim of entitlement to a service connection for a psychiatric disability and entitlement to a TDIU, effective from May 15, 2015. As the grants of service connection and entitlement to a TDIU, effective from May 15, 2015, the date of receipt of the claims, represent a full grant of the benefits sought, these matters are no longer on appeal. Unfortunately, another remand is required in this case. Although the Board sincerely regrets the additional delay, it is necessary to ensure that there is a complete record upon which to decide the claims so that the Veteran is afforded every possible consideration. 1. Back, left and right hips, and left and right shoulder disorders The Veteran is seeking entitlement to service connection for back, left and right hips, and left and right shoulder disorders that she believes is the result of her military service. Alternatively, with respect to the left and right hip disorders, she believes these disorders are due to or aggravated by her back disorder. She is also alleging entitlement to service connection for all of the claimed disorders pursuant to the provisions of 38 C.F.R. §3.317. In the prior January 2020 Board remand, it was requested that the Veteran be examined to confirm diagnoses for the claimed right and left hips, right and left shoulders, and low back disorders. In the October 2020 VA Hip and Thigh Conditions Disability Benefits Questionnaire (DBQ), a diagnosis of bilateral hip strains was provided. The October 2020 VA Back Conditions DBQ diagnosed the Veteran with lumbosacral strain, and the October 2020 VA Shoulder Condition DBQ noted diagnoses of right shoulder strain and arthritis (confirmed by x-ray findings), and left shoulder rotator cuff repair. The Board then requested that the VA examiner provide etiological opinions for each diagnosed disorder. The Board directed that the VA examiner must comment on the findings of July 2019 private DBQs etiologically attributing the claimed disorders to the Veteran’s military service. Here, however, in each October 2020 VA medical opinions, the VA examiner failed to consider the findings in the July 2019 private DBQs. Further, neither the VA examiner nor the October 2020 supplemental statement of the case applied the provisions of 38 C.F.R. § 3.317. In light of these deficiencies, the Board is left without discretion to proceed in adjudicating these matters and the claims must be remanded to comply with the Board’s January 2020 remand directives. See Stegall v. West, 11 Vet. App. 268 (1998). The matters are REMANDED for the following action: 1. Obtain addendum opinions regarding the etiology of the claimed disorders. (a.) Low Back: For each diagnosed low back disorders, the examiner is asked to provide an opinion as to whether it is at least as likely as not that any currently diagnosed low back disorder is due to or the result of the Veteran’s military service. In providing the above requested opinion, the examiner MUST COMMENT on the findings of July 2019 private DBQs etiologically attributing the claimed disorder to the Veteran’s military service. (b.) Right and left hips: For each diagnosed right and/ or left hip disorders, the examiner is asked to provide an opinion as to whether it is at least as likely as not that any currently diagnosed disorder is due to or the result of the Veteran’s military service. In providing the above requested opinion, the examiner MUST COMMENT on the findings of July 2019 private DBQs etiologically attributing the claimed disorders to the Veteran’s military service. (c.) Alternatively, the examiner is asked to opine whether it is at least as likely as not that any currently diagnosed right and/ or left hip disorder underwent any incremental increase in disability, regardless of its permanence, due to: 1. the service-connected back disability (if applicable), 2. any other service-connected disability (d.) Right and left shoulders: For each diagnosed right and/ or left shoulder disorders, the examiner is asked to provide an opinion as to whether it is at least as likely as not that any currently diagnosed disorder is due to or the result of the Veteran’s military service. In providing the above requested opinion, the examiner MUST COMMENT on the findings of July 2019 private DBQs etiologically attributing the claimed disorders to the Veteran’s military service. • The examiner is instructed to review all pertinent records associated with the claims file. • It should be noted that the Veteran is competent to attest to factual matters of which she has first-hand knowledge, including observable symptomatology. If there is a medical basis to support or doubt the history provided by the Veteran, the examiner should provide a fully reasoned explanation. • A clear rationale for all opinions would be helpful and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. Because it is important “that each disability be viewed in relation to its history [,]” (38 C.F.R. § 4.1), copies of all pertinent records in the Veteran’s claims file, or in the alternative, the claims file, must be made available to the examiner for review. 2. The AOJ must review the claims file and ensure that the foregoing development action has been completed in full. If any development is incomplete, appropriate corrective action must be implemented. If any report does not include adequate responses to the specific opinions requested, it must be returned to the providing examiner for corrective action. YVETTE R. WHITE Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board T. Berry, 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.