Citation Nr: 21021850 Decision Date: 04/14/21 Archive Date: 04/14/21 DOCKET NO. 15-37 232 DATE: April 14, 2021 REMANDED Entitlement to service connection for a lumbar spine disorder is remanded. Entitlement to service connection for a right leg disorder, to include as secondary to a lumbar spine disorder, is remanded. Entitlement to service connection for a right leg disorder, to include as secondary to a lumbar spine disorder, is remanded. Entitlement to service connection for headaches is remanded. REASONS FOR REMAND The Veteran served on active duty from May 1973 to June 1977. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from an August 2013 rating decision by the Department of Veterans Affairs (VA) Atlanta, Georgia Regional Office (RO). In May 2019, the Veteran testified before the undersigned Veterans Law Judge. A hearing transcript is associated with the record. In May 2020, the Board remanded the above-noted issues on appeal. A March 22, 2021 letter was sent to the Veteran notifying him that his appeal had been docketed and that he had 90 days from the late of the letter or until the Board issues a decision in the appeal, whichever came first, to submit any additional argument or evidence. The Board finds that it may proceed to adjudicate this case. See Williams v. Wilkie, 32 Vet. App. 46, 53 (2019) (noting that in the case of an appeal returning to the Board after a remand to the AOJ, the Board is not required to wait 90 days). 1. Entitlement to service connection for a lumbar spine disorder is remanded. At the February 2016 RO hearing and the May 2019 Board hearing, the Veteran asserted that his lumbar spine disorder stems from strenuous physical activities during service. The Veteran also asserts that it is related to a spinal tap he received while undergoing a circumcision procedure during service. The Board finds that remand is required to obtain an adequate VA opinion. The Board is obligated by law to ensure that the RO complies with its directives. Stegall v. West, 11 Vet. App. 268, 271 (1998). RO compliance with remand directives is not optional or discretionary and the Board errs as a matter of law when it fails to ensure remand compliance. Stegall, 11 Vet. App. at 271. Where VA provides the veteran with an examination in a service connection claim, the examination must be adequate. Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). The failure of a VA examiner to consider lay testimony when formulating an opinion renders that opinion inadequate. McKinney v. McDonald, 28 Vet. App. 15, 30-31 (2016). A medical examination report must contain not only clear conclusions with supporting data, but also a reasoned medical explanation connecting the two. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 301 (2008). In a May 2020 remand, the Board directed that a VA examiner provide an etiological opinion that addressed the April 1975 circumcision procedure and the Veteran’s lay statements concerning his strenuous physical activities during service. A September 2020 VA examination and opinion was obtained. The examiner opined that the lumbar spine disorder was not incurred in or caused by a lumbar spine disability during service, noting primarily that the diagnosis was not provided until 2012, 35 years after service. Although noted in the examination report, the examiner did not discuss the 1975 circumcision procedure or lay statements regarding the Veteran’s in-service strenuous activities. This does not comply with the Board remand and is not an adequate reasoned medical explanation. Accordingly, remand is required. 2. Entitlement to service connection for a right leg disorder, to include as secondary to a lumbar spine disorder, is remanded. 3. Entitlement to service connection for a left leg disorder, to include as secondary to a lumbar spine disorder, is remanded. At the February 2016 RO hearing and the May 2019 Board hearing, the Veteran asserts that his leg disorders had onset during service. He asserts that the disorders are related to pulled muscles and strains during service and the physical activities during active duty. He also argues that this bilateral leg disabilities are secondary to his lumbar spine disorder. The Board finds that remand is required to obtain an adequate VA opinion. Where VA provides the veteran with an examination in a service connection claim, the examination must be adequate. Barr, 21 Vet. App. at 311. Generally, a medical opinion should address the appropriate theories of entitlement. Stefl, 21 Vet. App. at 123-24. A medical examination report must contain not only clear conclusions with supporting data, but also a reasoned medical explanation connecting the two. Nieves-Rodriguez, 22 Vet. App. at 301. In a May 2020 remand, the Board directed that a VA examination be provided. The examiner was requested to provide an etiological opinion regarding direct service connection, addressing the in-service left leg muscle strains. The examiner was also requested to provide an etiological opinion regarding whether the disorders were caused or aggravated by a lumbar spine disorder. A September 2020 VA examination was provided. The examiner opined that the right and left leg disabilities were not incurred in or caused by the right and left leg disabilities during service, noting that although the Veteran was seen in 1977 for left knee strain and in 2005 and 2012 for right knee osteoarthritis, the conditions were not related to the back or headaches that were diagnosed. The examiner also opined that the peripheral neuropathy of the lower extremities was not due to service, stating that the radiculopathy may be causing pain in both legs, but that the record was silent on low back pain during service. The examiner provided an inadequate rationale for the negative opinions, noting that the conditions were not related to back or headaches, but not providing an explanation for that conclusion. Accordingly, remand is required to obtain adequate addendum opinions. 4. Entitlement to service connection for headaches. At the February 2016 RO hearing and the May 2019 Board hearing, the Veteran asserts that his headaches began during service, after the spinal tap prior to his 1975 in-service circumcision procedure. He also asserted that the headaches were due to loud airplane engine noises during active duty. The Board finds that remand is required to obtain an adequate addendum opinion. Where VA provides the veteran with an examination in a service connection claim, the examination must be adequate. Barr, 21 Vet. App. at 311. A medical examination report must contain not only clear conclusions with supporting data, but also a reasoned medical explanation connecting the two. Nieves-Rodriguez, 22 Vet. App. at 301. In a May 2020 remand, the Board directed that an addendum opinion be obtained that addressed the April 1975 circumcision procedure. A September 2020 VA opinion was obtained. The examiner opined that the headaches were not incurred in or caused by headaches during service. In the rationale, the examiner noted the 1975 procedure and headaches a few days later, with no further medical entries for continued symptoms. This may be an accurate recitation of the facts, but it is not a reasoned medical explanation of why the current headaches are not related to the headaches during service. Accordingly, remand is required to obtain an adequate opinion. The matters are REMANDED for the following action: 1. Obtain the Veteran’s VA treatment records for the period from August 2020 to the Present. 2. Schedule the Veteran for an examination(s) by an appropriate clinician to determine the etiology of any lumbar spine disability and bilateral leg disability. The examiner must opine on: Lumbar Spine Disability (a) Whether any lumber spine disability is at least as likely as not related to an in-service injury, event, or disease. Consider the April 1975 circumcision procedure and the Veteran's lay statements concerning his physical activities during service. (b) For arthritis of the lumbar spine, whether it at least as likely as not (1) began during active service, (2) manifested within one year after discharge from service, or (3) was noted during service with continuity of the same symptomatology since service. Bilateral Leg Disability (c) Whether any leg disability is at least as likely as not related to an in-service injury, event, or disease. Consider the in-service left leg muscle strains. (d) For peripheral nerves of the lower extremities, whether it at least as likely as not (1) began during active service, (2) manifested within one year after discharge from service, or (3) was noted during service with continuity of the same symptomatology since service. (e) If the Veteran is found to have a lumbar spine disability etiologically related to service, then opine on whether any leg disability is at least as likely as not (i) proximately due to service-connected lumbar spine disability, or (ii) aggravated beyond its natural progression by service-connected lumbar spine disability. 3. Obtain an addendum opinion from an appropriate clinician regarding the Veteran's headaches. The clinician must opine on whether it is at least as likely as not that it had its onset in service or is related to an in-service injury, event, or disease, to include the April 1975 circumcision procedure and/or loud airplane engine noise exposure. If there is another etiology for the headache symptoms, this should be discussed and explained. 4. Ensure that the VA medical opinions obtained include a complete rationale for the conclusions reached. The medical opinions 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. C.A. SKOW Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board K.M., 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.