Citation Nr: 21021775 Decision Date: 04/14/21 Archive Date: 04/14/21 DOCKET NO. 16-57 899 DATE: April 14, 2021 REMANDED Entitlement to service connection for a lumbar spine disability is remanded. Entitlement to service connection for a left hip disability is remanded. REASONS FOR REMAND The Veteran served on active duty from September 1970 to November 1976. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a February 2014 rating decision by the Department of Veterans Affairs (VA). This case was remanded in December 2020 for further development. In December 2020, the Veteran testified at a Board hearing before the undersigned Veterans Law Judge; a transcript of that hearing is of record. 1. Entitlement to service connection for a lumbar spine disability. The Veteran underwent a VA examination in January 2021, wherein the examiner diagnosed degenerative arthritis and opined it was less likely than not that the Veteran’s disability was related to his service. This opinion is inadequate because the examiner did not discuss the Veteran’s report of continued pain since service. Thus, remand for a new opinion is necessary. 2. Entitlement to service connection for a left hip disability. During his December 2020 Board hearing, the Veteran reported that he had left hip pain that interfered with his ability to walk and sit for long periods of time. During a January 2021 VA examination, the examiner opined that the Veteran did not have a left hip disability. However, pain with functional impairment is considered a disability for VA purposes. See Saunders v. Wilkie, 886 F.3d 1356 (Fed. Cir., 2018). As a result, the VA examiner’s opinion is inadequate, and remand for a new examination is necessary. The matters are REMANDED for the following action: 1. The AOJ should obtain copies of VA treatment records from December 2020 to the present. 2. After the above development is completed, the AOJ should arrange for a VA examination of the Veteran to determine the nature and likely cause of any lumbar spine disability. The examiner should review the claim file (including this remand) and note such review was conducted. Based on review of the record and examination of the Veteran, the examiner should provide an opinion with detailed rationale that responds to the following: Is it at least as likely as not (50% or greater probability) that the Veteran’s lumbar spine degenerative arthritis was either incurred in or otherwise related to his military service? Please explain why. The examiner must consider the Veteran’s report of injuring his back in service, corroborated by STRs, and his report of back pain since service. The examiner may not rely solely on the absence of medical evidence immediately after service. 3. After the development in the first directive is completed, the AOJ should arrange for a VA examination of the Veteran to determine the nature and likely cause of any left hip disability. The examiner should review the claim file (including this remand) and note such review was conducted. Based on review of the record and examination of the Veteran, the examiner should provide an opinion with detailed rationale that responds to the following: For each left hip disability diagnosed or, if there is no diagnosis, for left hip pain with functional impairment, is it at least as likely as not (50% or greater probability) that such disability was either incurred in or otherwise related to the Veteran’s military service? Please explain why. The examiner must consider the Veteran’s report of injuring his hip in service, corroborated by STRs. The examiner may not rely solely on the absence of medical evidence during or immediately after service. CONTINUED ON NEXT PAGE 4. If upon completion of the above action the issues remain denied, the case should be returned to the Board after compliance with appellate procedures. E. I. VELEZ Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board J. Sandler, 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.