Citation Nr: 21021384 Decision Date: 04/12/21 Archive Date: 04/12/21 DOCKET NO. 17-21 060 DATE: April 12, 2021 REMANDED Entitlement to service connection for renal insufficiency is remanded. Entitlement to service connection for a heart disorder is remanded. Entitlement to service connection for a lumbar spine disability is remanded. REASONS FOR REMAND The Veteran served on active duty from May 1955 to July 1979. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a January 2017 rating decision by a Department of Veterans Affairs (VA) Regional Office (RO). In December 2018, the issues currently on appeal were remanded to the Agency of Original Jurisdiction (AOJ) for additional development, to include obtaining VA examinations and medical opinions. The Board finds that there was no substantial compliance with the December 2018 Board remand instructions; therefore, the issues on appeal must be remanded for further development. See Stegall v. West, 11 Vet. App. 268, 271 (1998) (Board remand confers a right on a claimant to compliance with the remand order); Dyment v. West, 13 Vet. App. 141, 147 (1999) (clarifying that substantial compliance with Board remand is required. 1. Entitlement to service connection for renal insufficiency is remanded. 2. Entitlement to service connection for a heart disorder is remanded. The December 2018 Board decision requested that the AOJ schedule the Veteran for a VA examination with opinion with respect to the etiology of his renal insufficiency and his heart disorder. Specifically, the Board requested that the VA examiner offer opinions as to whether the Veteran’s renal insufficiency and heart disorder are related to an in-service injury, disease, or event, including in-service exposure to paint, chemicals, and solvents. The Board also requested that the examiner address an April 1966 periodic service medical examination report that noted that the Veteran worked in a paint shop for the previous 11 years and was experiencing shortness of breath and burning chest pain for the previous two and a half years. The Veteran was afforded VA examinations of his renal insufficiency and his heart disorder in January 2020. The examiner opined that there was no evidence that the Veteran’s coronary artery disease and renal insufficiency were related to in-service exposures. The examiner explained that the Veteran left military service in 1979 and was not diagnosed with heart disease until 2005. It was further explained that there was no medical evidence of blockage of the coronary arteries and paint exposure. The examiner noted that renal insufficiency was not diagnosed until many years after service and had been very stable with no signs of renal failure. The examiner explained that the Veteran’s heart disease and renal insufficiency were diagnosed when he was in his mid-60’s, which is not uncommon at that age. While the January 2020 VA examiner addressed the relationship between the Veteran’s disabilities (renal insufficiency and heart disorder) and in-service exposure to paint, chemicals, and solvents, the examiner did not address the April 1966 notation that the Veteran experienced shortness of breath and burning chest pain after inhaling paint fumes. As such, the January 2020 VA opinion is incomplete, and a remand for addendum opinions is required. See Barr v. Nicholson, 21 Vet. App. 303, 312 (2007) 3. Entitlement to service connection for a lumbar spine disability is remanded. The December 2018 Board remand requested the AOJ obtain an addendum opinion with respect to the etiology of the Veteran’s lumbar spine disability. The examiner was asked to specifically address a July 1975 service treatment record that noted that the Veteran had a back ache all day, had a slight increase in muscle tension in the lower back, and was assessed with a paravertebral muscle strain, as well as the May 1979 service separation examination, which noted that the Veteran had recurrent pain in the lumbar spine. A January 2020 VA examiner provided a negative nexus opinion. The rationale, in part, noted that the Veteran was seen once in 1975 for a back ache, but that the service separation examination in 1979 was normal since there was no real evidence of a lumbar impairment because he had good range of motion, and because x-rays only noted slight disc space narrowing, with no evidence of arthritis. The examiner then noted that the next records were from 2005 where the Veteran was seen for his neck and back, and then in July 2010 when he had a computerized tomography (CT) scan for his kidneys, which demonstrated that he had degenerative arthritis of the lumbar spine. The examiner explained that this was discovered when the Veteran was 70 years old, and that it would be normal for his age to have degenerative arthritis. The examiner opined that since the Veteran’s back pain seemed consistent with his age, it is less likely than not that there was some injury in service that caused his lumbar spine disability. The Board finds that the above-referenced January 2020 VA medical opinion is inadequate because it is based on an inaccurate factual premise. Specifically, while the January 2020 VA examiner noted that the 1979 service separation examination was normal and that there was no real evidence of a lumbar spine disorder, the service separation examination shows an abnormal evaluation of the spine in that the spine was tender albeit with good strength and full range of motion, and that the Veteran had recurrent back pain. As such, a remand for an addendum opinion is required. The record also shows that in May 2019, the Veteran provided authorization for release of medical records, to include from a Family chiropractic. A review of the claims file does not show any attempts to obtain these records. Accordingly, upon remand, the AOJ should attempt to obtain these records. The matters are REMANDED for the following action: 1. Ask the Veteran to identify, and provide appropriate releases for, any care providers who may possess new or additional evidence pertinent to the issues on appeal. If he provides the necessary release(s), assist him in obtaining the records identified, following the procedures set forth in 38 C.F.R. § 3.159. Any new or additional (i.e., non-duplicative) evidence received should be associated with the record. If any of the records sought are not available, the record should be annotated to reflect that fact and the Veteran and his representative should be notified. 2. Obtain copies of records pertaining to any VA treatment the Veteran may have received since the time that such records were last procured, following the procedures set forth in 38 C.F.R. § 3.159. The evidence obtained, if any, should be associated with the record. 3. Obtain an addendum opinion from an appropriate clinician as to whether it is at least as likely as not (i.e. 50 percent probability or more) that the Veteran’s renal insufficiency had its onset in, or was otherwise attributable to, the Veteran’s active service, to include in-service exposure to paint chemicals, and solvents. In providing the above-referenced opinion, the examiner is requested to address the significance of the April 1966 periodic service medical examination report that noted that the Veteran experienced shortness of breath and burning chest pain after inhaling paint fumes. A complete medical rationale for all opinions expressed must be provided. 4. Obtain an addendum opinion from an appropriate clinician as to whether it is at least as likely as not (i.e. 50 percent probability or more) that the Veteran’s heart disability had its onset in, or was otherwise attributable to, the Veteran’s active service, to include in-service exposure to paint chemicals, and solvents. In providing the above-referenced opinion, the examiner is requested to address the significance of the April 1966 periodic service medical examination report that noted that the Veteran experienced shortness of breath and burning chest pain after inhaling paint fumes. A complete medical rationale for all opinions expressed must be provided. 5. Obtain an addendum opinion from an appropriate clinician as to whether it is at least as likely as not (i.e. 50 percent probability or more) that the Veteran’s lumbar spine disability had its onset in, or was otherwise attributable to, the Veteran’s active service. In providing the above-referenced opinion, the examiner is requested to specifically address the significance of medical evidence during military service from July 1975 where the Veteran reported a back ache all day and a slight increase in muscle tension to the right lower back with an assessment of paravertebral muscle strain, as well as the May 1979 service separation examination report that noted an abnormal assessment of the spine, and indicated that the Veteran had recurrent pain in the lumbar spine. A complete medical rationale for all opinions expressed must be provided. 6. After completing the above, and any other development as may be indicated by any response received as a consequence of the actions taken in the preceding paragraphs, the issues on appeal should be readjudicated based on the entirety of the evidence. If any benefit sought remains denied, the appellant and his representative should be issued a supplemental statement of the case. An appropriate period of time should be allowed for response. J. Ragheb Acting Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board S. Imam, 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.