Citation Nr: 21016067 Decision Date: 03/19/21 Archive Date: 03/19/21 DOCKET NO. 16-16 256 DATE: March 19, 2021 REMANDED Entitlement to service connection for neck disability is remanded. REASONS FOR REMAND Although the Board regrets the additional delay, a remand is necessary to ensure that due process is followed and that there is a complete record upon which to decide the Veteran’s claim so that he is afforded every possible consideration. See 38 U.S.C. § 5103A; 38 C.F.R. § 3.159. The Veteran had active military service from October 1983 to October 1987 and from May 2006 to May 2007. This matter comes before the Board of Veterans’ Appeals (Board) from an April 2012 rating decision from a Department of Veterans Affairs (VA) Regional Office (RO). This matter was previously before the Board in February and June 2020 and September 2018 and was remanded for further development. Entitlement to service connection for neck disability is remanded. The Veteran contends that his cervical spine disability is related to his military service. As noted above, this matter was previously before the Board in February 2020 and was remanded for further development. Specifically, the Board found that there had not been substantial compliance with the Board’s previous remand directives and determined that the Veteran’s previous May 2019 VA opinion regarding his cervical spine disability was inadequate. Therefore, the Board remanded this matter for an addendum opinion to be obtained. Subsequently, in February 2020, an addendum VA medical opinion was obtained. The opinion stated that the Veteran’s cervical spine disability is less likely than not related to his military service. However, the only rationale provided for this opinion was that the Veteran’s current VA ‘problem list’ does not state that the Veteran’s neck disability is being treated or is a major concern, and that degenerative disc disease is extremely common in the general population. The Board found in its June 2020 remand that this opinion and accompanying rationale were inadequate. Specifically, the examiner did not provide any explanation regarding why or why not the Veteran’s cervical spine disability is related to his military service. The Board also noted that it was unclear if the examiner accepted the Veteran’s history of sustaining a neck injury in service. The examiner seemed to believe that the service records were negative. The Board noted, however, that a service record dated April 2, 2007, titled Post-Deployment Health Assessment notes that the Veteran reported getting hit in the head and sustaining a neck injury. He said that his then current concerns included the neck back and chest. The examiner in service stated that the health assessment was “neck and back nl [normal], muscle spasms.” Therefore, this matter had to be remanded to obtain substantial compliance with the Board’s previous remand directives and to obtain an adequate opinion regarding the etiology of the Veteran’s cervical spine disability. As a result of the June 2020 remand, another VA examination and opinion was conducted in August 2020. Again, the Board finds the opinion unsupported by a rationale. An examination’s rationale should provide a set of reasons or a logical basis that supports and explains the medical opinion provided, such that the Board can weigh the value of the examiners opinion in reaching a final decision in the matter. Instead of a rationale section following the opinion explaining the underlying medically significant facts and how the examiner applied medical knowledge in arriving at the opinion, the June 2020 examination report instead provided the following “conclusion” paragraph preceding the opinion: The USMC STR [Service Treatment Record] fails to show a Chronic diagnosed Neck condition while on active duty status. The Veteran reported one incident in OCT 2006 that he states caused reduced ROM in the neck. An ortho referral was to be made but the only orthopedic eval post deployment observed was for the Veteran's feet. In MAR 2008 the Veteran had neck pain and an MRI showed minimal disc changes at C5/C6. There is no correlation between this finding and his single report of an injury in OCT 2006 where no medical care or diagnosis is recorded. Again, as in another previous VA examination for this issue, it is not clear if the examiner accepted the Veteran’s statement about the October 2006 incident. The Veteran’s statements should be accepted as truthful unless otherwise shown by the record; a full explanation is required for any history rejected. The examiner may not reject a Veteran’s lay testimony merely because it is not corroborated by contemporaneous medical records. In this case, there is some corroboration in the Veteran’s STR. Further, lay testimony can constitute competent evidence regarding continuity of symptomatology of an observable condition; that is, lay testimony iterating knowledge and personal observations of the witness are competent to prove that a Veteran exhibited certain symptoms at a particular time. The matter is REMANDED for the following action: 1. Obtain an addendum opinion from an appropriate clinician to address the etiology of the Veteran’s neck disability, degenerative arthritis of the cervical spine. An examination is not necessary unless determined to be by the VA examiner. The opinion should indicate whether it is at least as likely as not (i.e. probability of 50 percent or greater) it began in service, manifested to a compensable degree within one year after discharge, or is otherwise related to in-service injury or disease. The examiner must discuss the report of being hit in the head/neck with a duffel bag. The Veteran’s statements should be accepted as truthful unless otherwise shown by the record; a full explanation is required for any history rejected. (Continued on the next page)   Ensure that the VA medical opinion obtained includes a complete rationale for the conclusions reached. The medical opinion must support the conclusions reached with an analysis that is adequate for the Board to consider and weigh against other evidence of record; medical opinions must contain not only clear conclusions with supporting data, but also a reasoned medical explanation connecting the two. If an opinion cannot be expressed without resort to speculation, ensure that the clinician so indicates and discusses why an opinion is not possible, to include whether there is additional evidence that could enable an opinion to be provided, or whether the inability to provide the opinion is based on the limits of medical knowledge. H. SEESEL Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board J. Black, 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.