Citation Nr: 21010535 Decision Date: 02/25/21 Archive Date: 02/25/21 DOCKET NO. 15-00 418A DATE: February 25, 2021 REMANDED Entitlement to service connection for cervical spine disability is remanded. REASONS FOR REMAND The appellant served in the Army Reserves and had periods of active duty for training (ACDUTRA) from June 2000 to December 2000, and in September 2001. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from an October 2012 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO). In December 2018, the appellant testified before the undersigned Veterans Law Judge (VLJ). A hearing transcript is associated with the record. In June 2019, the Board remanded the appeal. In remanding these matters, the Board makes no finding, implicit or otherwise, as to the credibility of the appellant’s assertions. Neither the appellant’s credibility nor any lack thereof should be presumed in this remand.   Entitlement to service connection for cervical spine disability is remanded. The appellant contends that she has a cervical spine disability due to a September 2001 injury in service in which she crashed upside down against a wall landing between her neck and the bottom of her shoulder blades. See Hearing Transcript (December 2018). During the December 2018 hearing, the appellant identified relevant outstanding private treatment records. She testified that she had sought treatment for her neck at Medical University in Charleston, South Carolina (MUSC). See Hearing Testimony (December 2018). The records are not in evidence; and VA did not get authorization to obtain the records on her behalf. A negative November 2019 VA medical opinion reported an inability to find dedicated medical visits or care for neck pain in service or any medical care prior to July 2014 and from 2015 to October 2019. The opinion noted that VA treatment records reflected the appellant’s PCP had ordered an MRI that had not yet been scheduled; and though the Veteran reported treatment at MUSC with her last visit in July 2019, those records were not in evidence. Based on the foregoing, the Board finds the medical opinion is inadequate as it is not based on a complete medical history of the appellant. Therefore, the Board finds that the evidence of record is inadequate to decide the appeal. To ensure that VA has satisfied its duty to assist, the RO attempt to obtain all relevant outstanding private treatment records and then obtain an addendum medical opinion. The Veteran is reminded that VA’s duty to assist in the development of a claim is not a one-way street. Wood v. Derwinski, 1 Vet. App. 190 (1991). The Veteran should cooperate and assist as requested in the development of the appeal. The matters are REMANDED for the following action: 1. Obtain the Veteran’s VA treatment records for the period from May 2020 to the Present. 2. Ask the appellant to complete a VA Form 21-4142, Authorization for Release of Information, for all non-VA medical providers seen for her neck symptoms since September 2001, to include Medical University in Charleston, South Carolina. Make two requests for the authorized records from all identified sources, unless it is clear after the first request that a second request would be futile. Notify the appellant of any unsuccessful efforts to obtain the records and provide her another opportunity to provide complete copies of those records. 3. Then, obtain an addendum opinion from an appropriate clinician addressing the Veteran’s claimed neck disability, to include whether any cervical spine disability is at least as likely as not related to an incident in service to include the claimed September 2001 injury. In doing so, detail the Veteran’s reported symptoms in service and thereafter, including the nature, onset, progression and severity of the Veteran’s reported symptoms. If there is any medical reason to accept or reject the proposition that the reported symptoms in service and thereafter represented the onset of a current neck disability, this should be noted. The entire claims file, to include a copy of this REMAND, should be made available to and reviewed by the examiner. The addendum should, among other things, include a discussion of (i) the appellant’s documented history and assertions and (ii) the August & September 2004 medical treatment records documenting that the appellant stated that her “pain generated from a car accident” incurred approximately in 2003, outside of any ACDUTRA period. (a) Identify any cervical spine disability found present, since roughly August 2012, specifically considering that pain alone may suffice if it results in functional impairment such that the neck pain may be considered a disability for VA compensation purposes. (b) For each neck disability found to be present, to include neck pain with functional impairment, opine on whether it is at least as likely as not that such disability had its onset during any period of ACDUTRA or resulted from a disease or injury incurred during the training, to include the September 2001 ACDUTRA injury. 4. Ensure that the VA medical opinions obtained include a complete rationale for the conclusions reached. The medical opinions 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. (Continued on next page) 5. Readjudicate. C.A. SKOW Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board C. Edwards 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.