Citation Nr: 21011776 Decision Date: 03/02/21 Archive Date: 03/02/21 DOCKET NO. 18-31 894 DATE: March 2, 2021 REMANDED Entitlement to service connection for bilateral eye scars is remanded. Entitlement to service connection for a cervical spine injury is remanded. Entitlement to service connection for a left knee injury is remanded. Entitlement to service connection for a right knee injury is remanded. Entitlement to service connection for a lumbar spine injury is remanded. Entitlement to service connection for right hip injury is remanded. REASONS FOR REMAND The Veteran had active service from June 1956 to March 1960. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a May 2016 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Houston, Texas. In September 2018, the Veteran testified at a videoconference hearing conducted with the undersigned Veterans Law Judge. A transcript of the hearing is of record. This claim was previously before the Board in June 2020, at which time it was remanded for additional development. 1. Entitlement to service connection for bilateral eye scars Pursuant to the June 2020 Board remand, the Veteran received a VA examination in January 2021 with an optometrist and stated that he had particles removed from his eyes that were due to welding in the Navy. The examiner concluded, however, that the eye scars were less likely as not related to service, as the supplied service treatment records were inadequate to link the bilateral eye scars to military service without resorting to speculation. Once again, the Board must point out that the lack of documented treatment in service cannot by itself constitute an adequate basis for a negative opinion. Dalton v. Peake, 21 Vet. App. 23 (2007). The Board therefore finds the examiner’s conclusion inadequate and that a new medical opinion is warranted. When VA undertakes to provide a VA examination or obtain a VA opinion it must ensure that the examination or opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303 (2007). 2. Entitlement to service connection for a cervical spine injury is remanded. 3. Entitlement to service connection for a left knee injury is remanded. 4. Entitlement to service connection for a right knee injury is remanded. 5. Entitlement to service connection for a lumbar spine injury is remanded. 6. Entitlement to service connection for right hip injury is remanded. Pursuant to the June 2020 Board remand, the Veteran received VA examinations in September 2020 and the Veteran indicated that he injured his cervical spine, bilateral knees, lumbar spine, and right hip during service when he fell off of a gangway and fell onto a platform. The examiner found, however, that the cervical spine, bilateral knees, lumbar spine, and right hip injuries were less likely than not related to service, as there was no evidence of this reported in-service injury. The examiner again discounts the Veteran’s reports based on the lack of documentation in the record, which the Board found inadequate previously in its June 2020 decision. See Dalton v. Peake, supra (the lack of documentation in the record is an inadequate basis for a negative opinion and a medical opinion is also inadequate if it does not take into account the Veteran’s reports of symptoms and history (even if recorded in the course of the examination)). Therefore, a new medical opinion is also warranted with respect to these claims. The matters are REMANDED for the following action: 1. Provide the claims file to an appropriate eye specialist for an addendum opinion regarding the nature and etiology of the Veteran’s eye scars. The examiner is asked to opine as to whether it is at least as likely as not (a 50 percent probability or greater) that the Veteran’s bilateral eye scars had their onset in service or are otherwise the result of an incident in service, to include flash burns and debris in the eyes due to working as a welder during service. In rendering the requested opinion, any examiner is advised that the Veteran is competent to report in-service injuries, his symptoms and history. Such reports must be specifically acknowledged and considered in formulating any opinions. The lack of documented treatment in service, while probative, cannot serve as the sole basis for a negative finding. All opinions should be supported by a clear rationale. 2. Provide the claims file to a VA examiner for an addendum opinion regarding the nature and etiology of the Veteran’s cervical spine, left and right knee, lumbar spine, and right hip injuries. The examiner is asked to opine as to whether it is at least as likely as not (a 50 percent probability or greater) that any disability of the cervical spine, left and right knee, lumbar spine, and right hip had its onset in service or are otherwise the result of an incident in service, to include a fall off of a gangway onto a platform. In rendering the requested opinion, any examiner is advised that the Veteran is competent to report in-service injuries, his symptoms and history. Such reports must be specifically acknowledged and considered in formulating any opinions. The lack of documented treatment in service, while probative, cannot serve as the sole basis for a negative finding. All opinions should be supported by a clear rationale. Michael J. Skaltsounis Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board A. Daniels, 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.