Citation Nr: 21020843 Decision Date: 04/08/21 Archive Date: 04/08/21 DOCKET NO. 15-30 016 DATE: April 8, 2021 REMANDED Entitlement to service connection for ankylosing spondylitis is remanded. REASONS FOR REMAND The Veteran served on active duty from January 1977 to January 1982. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from an August 2014 rating decision by a Department of Veterans Affairs (VA) Regional Office (RO). On October 30, 2019, the Veteran appeared virtually at a hearing before the undersigned Veterans Law Judge. A copy of the hearing transcript is of record. 1. Entitlement to service connection for ankylosing spondylitis is remanded. In the April 2020 Remand instructions, the Board requested that the Veteran be scheduled for an examination by a VA rheumatologist to determine the nature and etiology of claimed ankylosing spondylitis, to include both service and post-service medical records, private medical opinions, general information about ankylosing spondylitis submitted by the Veteran, and to include lay statements submitted by the Veteran and fellow service members. At a January 2021 VA examination, the examiner opined that ankylosing spondylitis was less likely than not incurred or caused by the claimed in-service injury, event, or illness. The examiner noted that the service records, and records within one year following separation from service, did not document any back injury or problems. The private and VA documentation of back problems were decades after service. The VA examiner mentioned the Veteran’s and his fellow service member’s statements regarding the Veteran’s back problems during service, the examiner discounted those statements without analyzing the credibility and weight of the lay statements against the other evidence, the examiner discounted the Veteran’s contentions because he “did not present for medical evolution” and there were “no records or documentation that the [Veteran] had any back problems.” The Board finds that the examiner incorrectly relied on the lack of documentation to support the finding that ankylosing spondylitis was not related to service. Because the examiner provided a negative etiology opinion by relying on the absence of chronic symptoms or treatment during and continuously since service and did not consider the lay statements of both the Veteran and his fellow service members, the Board finds the September 2020 VA examination to be incomplete. A remand by the Board imposes upon VA a duty to ensure compliance with the terms of the remand. Stegall v. West, 11 Vet. App. 268 (1998). When VA obtains an evaluation, the evaluation must be adequate. Barr v. Nicholson, 21 Vet. App. 303 (2007). An opinion that relies only on the absence of symptoms or treatment in service is not adequate.   The matters are REMANDED for the following action: 1. Schedule the Veteran for a VA examination by a rheumatologist who has not previously examined him in conjunction with this claim, to determine the nature and etiology of ankylosing spondylitis. The examiner must review the entire record, to include the service medical records; the post-service medical records; the July 2013 and March 2014 private opinions; the general information about ankylosing spondylitis submitted by the Veteran; and the lay evidence, to include the Veteran’s statements and those of fellow service members. A clearly stated rationale for each opinion offered must be provided and cannot be based solely on the lack of any in-service records. After a review of the evidence, an interview with the Veteran, and an examination, the examiner must provide the following opinions: (a.) Confirm that the examiner is a rheumatologist who has not previously examined the Veteran in conjunction with this claim. (b.) Is it at least as likely as not (50 percent or greater probability) that ankylosing spondylitis is related to service or any event, injury, or disease during service, to include reported in-service back pain? The examiner should discuss the lay statements submitted by the Veteran and the Veteran’s statements regarding symptoms during and since service. (c.) Is it at least as likely as not (50 percent or greater probability) that ankylosing spondylitis (1) began during active service, (2) manifested within one year after the Veteran’s January 1982 separation from service, or (3) was noted during service with continuity of the same symptomatology since service? The Veteran is competent to report symptoms during and since service, and those reports must be acknowledged and considered in formulating the opinion. If the Veteran’s and lay statement reports are discounted, the examiner should provide a reason for doing so.  The examiner must consider and discuss any lay statements of record and should reconcile the opinion with any previous opinions of record. Harvey P. Roberts Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Sonya S. Tsao, 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.