Citation Nr: 21020734 Decision Date: 04/08/21 Archive Date: 04/08/21 DOCKET NO. 14-24 229A DATE: April 8, 2021 REMANDED Entitlement to service connection for a low back disability is remanded. REASONS FOR REMAND The Veteran served in active service from April 1964 to April 1966. In October 2020, the Board remanded this case for additional development. The Board finds that there has not been substantial compliance with the remand directives regarding the Veteran's claims for a low back disability. Another remand for further development is required. Stegall v. West, 11 Vet. App. 268 (1998). Entitlement to service connection for a low back disability is remanded. The issue of entitlement to service connection for a low back disability was remanded in October 2020 because the July 2020 examiner relied on the absence of chronic symptoms or treatment in service in opining that the claimed disability less likely than not related to service. At a January 2021 VA examination, the examiner concluded that there was a “negative connection” between any back disability and the service. The examiner observed that, although the Veteran’s lay statement concerning a fall in May 1965 was supported by service medical records, the records did not show trauma, injuries, or complaints related to the back. Further, x-rays were negative. When VA provides an examination or obtains an opinion, the examination or opinion must be adequate.  Barr v. Nicholson, 21 Vet. App. 303 (2007).  The Board finds the January 2021 VA examination to be incomplete.  An opinion that relies only on the absence of symptoms or treatment during service is incomplete. The examiner did not discuss whether the corroborate fall in service at least as likely as not caused any current back disability, with consideration of the Veteran’s lay statements during and since service. Because the January 2021 examiner relied on the absence of complaints or treatment in-service to support the opinion, the Board finds the January 2021 VA examination to be incomplete.  That is a pre-decisional duty to assist error. Accordingly, the Board finds the January 2021 VA examination report to be incomplete for rating purposes, and remand is required for additional examination. Further, VA treatment records prior to February 2014 appear to be incomplete. On remand, VA should make reasonable attempts to obtain these records and associate them with the claims file. The matters are REMANDED for the following action: 1. After obtaining any necessary releases, obtain all relevant VA and private treatment records not already associated with the claims file. All attempts to locate records must be documented in the claims file. Specifically, obtain VA treatment records after February 17, 2021, prior to February 2014, and those scanned into VISTA, to include x-ray or other imaging reports. 2. Then, schedule the Veteran for a VA examination, with a medical doctor who has not previously examined the Veteran in conjunction with this claim, to determine the nature and etiology of a claimed low back disability. The examiner must review all pertinent records associated with the claims file and indicate review of the file in the examination report. Any studies or tests deemed necessary should be performed.  The examiner must opine whether it is at least as likely as not (50 percent or greater probability) that any low back disability is etiologically related to active service or any event, disease, or injury during active service, including whether the disability (1) began during active service, (2) manifested as back arthritis within one year after separation from service, or (3) was noted during service with continuity of the same symptomatology since service. The examiner should address the Veteran’s lay statements, including hearing testimony, regarding the low back disability and its etiology, and any symptoms during and since service. The examiner must specifically address the fall during service, and the Veteran’s lay statements about symptoms at the time of and since that fall, and whether it is at least as likely as not (50 percent or greater probability) that any current back disability is related to that fall. A clearly stated rationale for each opinion offered must be provided and must not be based on the lack of an in-service record of the claimed disability. Harvey P. Roberts Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board D. Duke, 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.