Citation Nr: 21011254 Decision Date: 03/01/21 Archive Date: 03/01/21 DOCKET NO. 11-26 099 DATE: March 1, 2021 REMANDED Entitlement to service connection for a low back disability is remanded. REASONS FOR REMAND The Veteran served in the United States Army, from February 1985 to July 1988. This issue comes before the Board of Veterans’ Appeals (Board) from a rating decision issued in June 2012 by a Department of Veterans Affairs (VA) Regional Office (RO). The Veteran’s claim was remanded by the Board in June 2018 for a VA examination and for further development on the claim. In April 2018, the Veteran had a hearing before the undersigned Veterans Law Judge. A copy of the hearing transcript has been associated with the claims file. 1. Entitlement to service connection for a low back disability is remanded. The Veteran seeks entitlement to service connection for a low back injury. Specifically, the Veteran has been diagnosed with degenerative arthritis of the spine, as well as mild degenerative disc disease. The VA medical records and private medical records show that the Veteran has had a chronic low back disability since 2010. The Veteran has been diagnosed with a herniated disc, chronic lumbar spine pain, mild degenerative disc disease, degenerative joint disease, a lumbar spine strain, lumbar radiculopathy and degenerative spine arthritis since his first report of the back pain in 2010. The Veteran has also made multiple lay statements attempting to show that there was an in-service incurrence that led to the back disability. Throughout the claims file, the Veteran makes statements that his back injury is due to being in battle, having to carry heavy equipment and gear, jumping out of Blackhawk helicopters, or potentially from a fall he suffered when he hit his head at Fort Steward, Georgia. In October 2019, the Veteran was afforded a VA examination of his low back disability. The examiner diagnosed the Veteran with degenerative spine arthritis. However, the examiner held that the back condition was less likely than not incurred in or caused by any claimed in-service injury, event, or illness. The examiner’s rationale simply stated that there was no documentation to support the claim and the STRs were absent of any complaint, treatment, or diagnosis for a low back disability. The Board’s 2018 remand decision, specifically directed the examiner opine whether it at least as likely as not began during active service, manifested within one year after discharge, or was noted during service with continuity of the same symptomatology since service. Furthermore, the Board also directed the examiner to offer a detailed rationale discussing why and how all conclusions and opinions were reached. In rendering the requested opinion, the examiner was advised that the Veteran is competent to report in-service injuries, symptoms, and history. The Board stated that the examiner should acknowledge and consider these reports in formulating any opinions. The October 2019 VA examination was insufficient, as it did not adhere to these specific remand directives given by the Board in rendering its conclusion and opinion. Stegall v. West, 11 Vet. App. 268 (1998). Specifically, the October 2019 VA examination fails to consider or mention the Veteran’s lay statements, as well as the positive opinion provided by the Veteran’s private physician. It also did not provide a detailed rationale for the opinion provided. As such, another opinion is necessary. The matters are REMANDED for the following action: 1. Forward the claims file to another appropriate clinician to provide a VA medical opinion as to the nature and etiology of the back disability. The examiner must review all the evidence of record, including this remand directive. The Veteran should receive another in-person VA examination if the clinician deems it to be necessary. The examiner must provide a complete written history, including all statements and reports made by the Veteran as to his military service. The examiner must opine as to whether the low back disability it is at least as likely as not related to an in-service injury, event, or illness. The examiner must comment on the following: a) lay report of injury due to being in battle, having to carry heavy equipment and gear, jumping out of Blackhawk helicopters, or potentially from a fall he suffered when he hit his head. b) The February 2015 opinion of R.Q., M.D. (Continued on the next page)   A complete and detailed rationale is required for each opinion that the examiner makes. In each rationale, the examiner should discuss how and why all the conclusions were reached and should specifically consider the lay statements on the record. H. SEESEL Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board E.L. Aumiller, 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.