Citation Nr: 21014254 Decision Date: 03/11/21 Archive Date: 03/11/21 DOCKET NO. 14-31 738A DATE: March 11, 2021 REMANDED Entitlement to service connection for a disability of the mid or upper back, to include as due to undiagnosed illness, is remanded. REASONS FOR REMAND The Veteran served on active duty in the Army from September 2002 to September 2005, May 2007 to March 2008, and May 2009 to August 2012, including service in Afghanistan and with receipt of the Combat Infantryman Badge. This matter is before the Board of Veterans’ Appeals (Board) on appeal from a January 2013 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO). In July 2016, February 2019, and June 2020, the Board remanded the Veteran’s appeal to the RO for further evidentiary development. Entitlement to service connection for a disability of the mid or upper back, to include as due to undiagnosed illness, is remanded. Unfortunately, the matter must be remanded to ensure that VA has obtained an adequate medical opinion based upon a full history. Once the Secretary undertakes the effort to provide an examination, even if not statutorily obligated to do so, he must provide an adequate one. Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). Medical examination reports are adequate “when they sufficiently inform the Board of a medical expert’s judgment on a medical question and the essential rationale for that opinion.” Monzingo v. Shinseki, 26 Vet. App. 97, 106 (2012). An adequate medical opinion must be based upon a consideration of the Veteran’s prior medical history and must describe the Veteran’s condition in sufficient detail so as to allow the Board to make a fully informed evaluation. Ardison v. Brown, 6 Vet. App. 405, 407 (1994). In short, an adequate medical opinion should contain sufficient information such that the Board is not required to rely on its own independent medical judgment. Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007). A medical opinion based on an inaccurate factual premise must be dismissed as non-probative. See Reonal v. Brown, 5 Vet. App. 458, 460-61 (1993) (medical opinion based on inaccurate factual premise may properly be rejected as non-probative). Here, following the Board’s June 2020 remand, the Veteran was afforded a VA examination in December 2020. Examination at that time resulted in no assessment of any mid or upper back disability. The examiner concluded that the Veteran did not have a disability of the cervical spine or thoracolumbar spine, i.e. the mid or upper back, and attributed Veteran’s reports of pain in these areas to the service-connected left shoulder subscapular bursitis, recurrent strain. The examiner stated that he reviewed the entire claims file in offering his opinions. However, the opinions do not mention a June 2018 VA Gulf War Examination report, which saliently document an assessment of DDD (degenerative disc disease) of the cervical spine “to explain [the] upper back symptoms.” The examiner’s opinions are based upon an insufficient reading of the Veteran’s prior history. Accordingly, the December 2020 report is returned for an addendum opinion. 38 C.F.R. § 4.2. The matters are REMANDED for the following actions: 1. Provide the Veteran an opportunity to identify any outstanding medical treatment records relevant to his claimed disability. After obtaining necessary authorization from the Veteran, all outstanding records should be obtained, to include all updated VA medical treatment records. 2. After obtaining any outstanding records, obtain an addendum opinion from the December 2020 VA examiner (or a suitable substitute if the examiner is unavailable) for the Veteran’s claimed disability. The claims file must be made available to and reviewed by the examiner. The examiner should comment as to the following: (a.) Please provide a diagnosis for the Veteran’s reported mid-to upper back pain, and offer an opinion as to whether it is at least as likely as not (a 50 percent probability or greater) that the condition is related to an in-service injury, event, or disease, including service-connected left shoulder bursitis and left arm numbness. a. In the event that you determine that the most appropriate diagnosis for the complained of mid-to upper back pain is myofascial pain syndrome, please state whether such is distinct from the myofascial pain syndrome that has been determined to be associated with the Veteran’s service-connected disabilities of the left upper extremity (shoulder bursitis and numbness). (b.) In determining whether the diagnosed condition is related to service, the examiner should consider: (1) reported back pain (described as upper back tightness and twitching) in a February 2008 report of medical assessment; (2) upper back pain listed as a problem in February 2012 service treatment records; (3) the April 2012 Compensation and Pension Examination for back conditions finding no thoracolumbar back condition; (4) VA X-rays showing normal cervical spine radiography in April 2013; (5) a VA MRI of the cervical spine in September 2013 showing a normal MRI of the spine except for tiny disc protrusions and C4-5 and C5-6 that resulted in minimal spinal canal narrowing; (6) the November 2014 private physician’s opinion that the Veteran had myofascial pain in his upper back and that the pain was at least as likely as not related to his service; (7) The June 2018 VA Gulf War Examination report, in that documents an apparent assessment of DDD of the cervical spine “to explain [the] upper back symptoms”; (8) February 2015 and January 2019 statements to VA that his symptoms were continuing; and (9) the November 2019 VA examination report stating that the Veteran denied a mid or upper back condition and the condition was not further examined. (Continued on the next page)   (c.) If arthritis is diagnosed, the examiner should opine whether it at least as likely as not (50 percent probability or greater) (1) began during active service, (2) manifested within one year after discharge from service, or (3) was noted during service with continuity of the same symptomatology since service. A rationale for all opinions must be provided. If the clinician cannot provide a requested opinion without resorting to speculation, it must be so stated, and the clinician must provide the reasons why an opinion would require speculation. The clinician must indicate whether there was any further need for information or testing necessary to make a determination. Additionally, the clinician must indicate whether any opinion could not be rendered due to limitations of knowledge in the medical community at large and not those of the particular examiner. R.R. Watkins Acting Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Joseph R. Keselyak, 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.