Citation Nr: 21013286 Decision Date: 03/09/21 Archive Date: 03/09/21 DOCKET NO. 18-34 125 DATE: March 9, 2021 REMANDED Entitlement to service connection for a lumbar spine disability is remanded. REASONS FOR REMAND The Veteran served on active duty in the United States Army from December 1972 to December 1974. This matter comes to the Board of Veterans’ Appeals (Board) on appeal from a February 2017 rating decision issued by a Department of Veterans Affairs (VA) Regional Office. This case was previously before the Board in August 2018, when it was remanded to the agency of original jurisdiction (AOJ) for additional development. After taking further action, the AOJ confirmed and continued the prior denial and returned the case to the Board. Entitlement to service connection for a lumbar spine disability is remanded. In August 2018, the Board remanded this case, in part, to have the Veteran scheduled for a VA examination to determine the nature and etiology of any currently diagnosed lumbar spine disability. The Board directed that the VA examiner should address an August 1974 service treatment record (STR) showing that the Veteran had been treated in service for bruises on his back and arm, as well as the Veteran’s contention that he had had back problems since service. The Veteran underwent the requested VA examination in November 2019. After examining the Veteran and noting diagnoses of degenerative arthritis of the thoracolumbar spine and spondylolisthesis, the examiner opined that it was less likely than not that the Veteran’s disability was related to service. In support of that opinion, the examiner noted that there was no radiological evidence of any of the Veteran’s conditions during service; that there were no sick calls; that there were no lineal treatments seen during service or for a year thereafter; and that his conditions were most likely due to the aging process, rather than to any falls or traumas. In so doing, however, the examiner did not substantively address the August 1974 STR reflecting in-service treatment for bruises on the Veteran’s back and arms, or his contention that he had had back problems since service. Because the examination report is not compliance with the Board’s remand directives, further development is required. Stegall v. West, 11 Vet. App. 268, 271 (1998). This matter is REMANDED for the following action: 1. Obtain copies of records pertaining to any VA treatment the Veteran has received since the time that such records were last procured, following the procedures set forth in 38 C.F.R. § 3.159. The evidence obtained, if any, should be associated with the record. 2. After the foregoing development has been completed, make arrangements to provide the record on appeal to the VA examiner who previously offered an opinion with respect to the etiology of the Veteran’s low back disability in November 2019. The examiner should be asked to review the record and prepare a supplemental report with respect to the matter of whether it is at least as likely as not (i.e., whether it is 50 percent or more probable) that the Veteran has a disability of the spine that had its onset during, or is otherwise related to, service. In doing so, the examiner must specifically address the medical significance, if any, of an August 1974 STR showing that the Veteran was treated for bruises on his back and arm, and that he was found at that time to exhibit loss of motor movement, lateral instability, and tenderness to the back. The examiner must also address the Veteran’s contention that he has had back problems since service. If the November 2019 examiner is no longer employed by VA or is otherwise unable to provide the opinion(s) requested, arrange to obtain the requested information from another qualified examiner. The need for another examination and/or telephonic or video interview of the Veteran is left to the discretion of the examiner selected to offer the requested opinion(s). A complete rationale for all opinions expressed must be provided. 3. After completing the above, and any other development as may be indicated by any response received as a consequence of the actions taken in the proceeding paragraphs, the Veteran’s claim should be readjudicated based on the entirety of the evidence. If the benefit on appeal remains denied, the Veteran and his representative should be issued a supplemental statement   of the case. An appropriate period of time should be allowed for response. DAVID A. BRENNINGMEYER Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board B. Willis, 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.