Citation Nr: 21014785 Decision Date: 03/15/21 Archive Date: 03/15/21 DOCKET NO. 19-14 198 DATE: March 15, 2021 REMANDED Entitlement to service connection for right lower extremity radiculopathy is remanded. Entitlement to service connection for left lower extremity radiculopathy is remanded. REASONS FOR REMAND The Veteran served in a reserve capacity in the United States Marine Corps, commencing an initial period of active duty for training (ACDUTRA) between March 1967 and August 1967, and returning for subsequent periods of ACDUTRA and INACDUTRA in 1968. This matter comes to the Board of Veterans’ Appeals (Board) on appeal from a December 2018 rating decision from the Department of Veterans Affairs (VA) Regional Office (RO) in Sioux City, South Dakota. As a preliminary matter, the Board acknowledges that this matter has been remanded previously for additional development in November 2019, but that development has not been adequately completed. A remand by the Board of Veterans Appeals confers on the veteran or other claimant, as a matter of law, the right to compliance with the remand orders. Stegall v. West, 11 Vet. App. 268, 271 (1998). 1. Entitlement to service connection for right lower extremity radiculopathy is remanded. 2. Entitlement to service connection for left lower extremity radiculopathy is remanded. A medical opinion is adequate when it is based upon consideration of the veteran’s prior medical history and examinations and also describes the disability in sufficient detail so that the Board’s evaluation of the claimed disability will be a fully informed one. Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). Here, the Veteran attended a new examination to evaluate the nature and etiology of his right and left lower extremity radiculopathy in December 2020. The examiner diagnosed bilateral lower extremity radiculopathy, but opined against a relationship to the Veteran’s service-connected spine disability, basing her negative nexus opinion largely on a lack of objective medical evidence showing that the Veteran’s radiculopathy was related to degenerative disc disease prior to 2001. However, private treatment records obtained in January 2020, following remand, suggest a potential relationship may exist. Specifically, a February 2001 surgical report describes the Veteran’s “severe low back pain radiating to the buttocks and legs,” noting the Veteran’s “severe degenerative joint disease with spinal stenosis” and confirming that the “examination is consistent with spinal stenosis and mechanical low back pain.” The December 2020 examiner’s opinion does not adequately address such evidence. A new medical opinion is therefore necessary to consider relevant private treatment records and resolve open medical questions regarding the relationship between the Veteran’s service-connected degenerative disc disease of the lumbar spine and his radiculopathy. The matters are REMANDED for the following action: 1. Schedule the Veteran for a spine examination to address whether the Veteran’s service-connected lumbar spine disability is causing or aggravating his diagnosed bilateral lower extremity radiculopathy. The claims file should be sent to, and reviewed by the examiner. Upon review of the entire record, to include service records and post-service treatment for the Veteran’s longstanding spine disability, the examiner should provide responses to the following questions: Is it at least as likely as not (50 percent or greater probability) that the Veteran has a right or left lower extremity radiculopathy disability that was either caused or aggravated beyond its natural progression by his service-connected lumbar spine disability? The examiner is advised that the Veteran is competent to report his symptoms and history, and that his assertions in this regard must be considered in formulating the requested opinions. Importantly, if the Veteran does not appear for a scheduled in-person examination, a response to the question above is still requested based on review of the evidence of record, to the extent such is possible. If it is not possible to respond to the question above without an in-person examination, this should be made clear. (Continued on Next Page) 2. Thereafter, and after undertaking any further development deemed necessary, readjudicate the claim. V. Chiappetta Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board A. Hennessy, 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.