Citation Nr: 21011494
Decision Date: 03/02/21	Archive Date: 03/02/21

DOCKET NO. 15-20 980
DATE: March 2, 2021

REMANDED

Entitlement to service connection for a back disability is remanded.

REASONS FOR REMAND

The Veteran served on active duty from January 1974 to January 1977.

In a February 2019 decision, the Board denied the claim. The Veteran subsequently appealed that decision to the United States Court of Appeals for Veterans Claims (Court). In a March 2020 order, the Court granted a Joint Motion for Remand (JMR), which vacated the Board’s decision and remanded the Veteran’s appeal to the Board for action consistent with the terms of the JMR. 

Entitlement to service connection for a back disability is remanded.

The Board is unable to make an informed decision on the Veteran’s claim for service connection for a back disability because additional development is necessary. There are multiple diagnoses related to the Veteran’s back; lordosis, chronic lumbosacral strain and degenerative changes. As the parties to the March 2020 JMR identified, a new examination is necessary to assist in determining whether any of the Veteran’s diagnosed back conditions are related to his service. Although, the Veteran submitted a positive private opinion in February 2021, the Board finds that this opinion is inadequate because the examiner appears to rely on facts that are not consistent with the record or the Veteran’s prior statements contemporaneous with prior VA examinations or while seeking treatment. Therefore, on remand a new VA examination is warranted. 

The matters are REMANDED for the following action:

Schedule the Veteran for a VA examination with an appropriate VA examiner, to determine the nature and likely etiology of any diagnosed back disability. Copies of all pertinent records must be made available to the examiner. 

After reviewing the claims file, the examiner is asked to answer the following questions:

(a) Identify all currently diagnosed back disabilities. 

(b) Is it at least as likely as not (50 percent probability) that any currently diagnosed back condition was incurred in or is otherwise related to service, to include the preexisting lordosis?

In answering this question, the examiner must specifically consider and discuss the following: (i) the January 1974 enlistment examination noting lordosis; (ii) a June 1975 STR showing a complaint of sudden onset of back pain eight months prior; assessment was lumbosacral strain; (iii) a May 1976 STR entry noting chronic lower back pain for three years, and; (iv) a July 1976 STR entry noting lower back pain, without a history of trauma, the Veteran’s report that the pain began three to four years prior while he was in high school, and diagnosis of chronic low back pain with lordosis.

A complete rationale must be provided for all opinions, citing to supporting factual data and medical literature, as appropriate. If the examiner cannot provide an opinion without resort to speculation, the examiner must state why. 

 

 

M.E. Larkin

Veterans Law Judge

Board of Veterans’ Appeals

Attorney for the Board	M. G. Perkins, 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.