Citation Nr: 21015664 Decision Date: 03/18/21 Archive Date: 03/18/21 DOCKET NO. 16-03 381 DATE: March 18, 2021 REMANDED Entitlement to service connection for a low back disability is remanded. REASONS FOR REMAND The Veteran served on active duty from August 1978 to May 1986. This matter comes before the Board of Veterans’ Appeals (Board) on appeal of a May 2015 rating decision by a Department of Veterans Affairs (VA) Regional Office (RO). In November 2019, the Veteran testified at a hearing conducted by the undersigned Veterans Law Judge. A transcript of the hearing has been added to the Veteran’s claims file. In February 2020, the Board remanded the Veteran’s claim for additional development. The case is once again before the Board. Entitlement to service connection for a low back disability is remanded. Once VA undertakes to provide an examination or obtain an opinion, it must ensure that it is adequate. Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). In the Veteran’s case, he reported to an examination the same month the Board remanded the claim. There, the examiner rendered a negative nexus opinion, but it’s clear from the examination report that the examiner did not have access to the Veteran’s service treatment records (STRs). Recognizing this, VA asked for an addendum medical opinion. After reviewing the complete record, the examiner again opined that the Veteran’s low back disability was less likely than not related to his service. She explained that the Veteran’s service treatment records (STRs) show treatment in June 1983 and that there are no additional documented complaints of or treatment for a back injury during service. However, the Veteran also received treatment for back pain in July 1984. He reported suffering from a stiff back for three days, and the military doctor assessed recurrent low back pain as the problem. Because the examiner relied on an inaccurate factual premise, remand is required for an addendum opinion. Reonal v. Brown, 5 Vet. App. 458, 461 (1993). Finally, as the case is being remanded for additional development, any outstanding VA treatment records should be associated with the claims file. See Bell v. Derwinski, 2 Vet. App. 611, 613 (1992) (per curiam). The matter is REMANDED for the following action: 1. Obtain all outstanding VA treatment records and associate them with the claims file. 2. Then, arrange for an appropriate healthcare provider to review the Veteran’s claims file and provide an opinion as to whether it is at least as likely as not (50 percent probability or greater) that the Veteran’s low back disability had its clinical onset during service or is due to an event or incident of the Veteran’s period of active service. The examiner shall address Dr. Kumar’s August 2002 medical opinion when rendering an opinion. If the reviewing health care provider finds that physical examination or telehealth interview of the Veteran and/or diagnostic testing is necessary, such should be accomplished. A clear rationale for all opinions would be helpful and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. 3. After undertaking any additional development deemed appropriate and giving the Veteran full opportunity to supplement the record, adjudicate the Veteran’s pending claim in light of any additional evidence added to the record. If any benefit sought on appeal remains denied, the Veteran and his representative should be furnished with a Supplemental Statement of the Case and be afforded the applicable opportunity to respond before the record is returned to the Board for further review. M. Donohue Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board C. Canedy, 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.