Citation Nr: 21022241 Decision Date: 04/15/21 Archive Date: 04/15/21 DOCKET NO. 15-06 273 DATE: April 15, 2021 REMANDED Entitlement to service connection for a left knee disability is remanded. REASONS FOR REMAND The Veteran served on active duty in the United States Air Force from January 1967 to December 1970. In July 2018, the Veteran testified at a video conference hearing before the undersigned. 1. Entitlement to service connection for a left knee disability is remanded. Regrettably, this claim must be remanded as the opinions obtained in July, September, and October 2020 are not adequate to decide the claim. The examiner concluded that the Veteran’s left knee disability was not related to service or a service-connected disability because there was no documentation of a high energy left knee injury or repetitive microtrauma to the left knee in service, no documentation of the Veteran’s reported continuous left knee pain since service, and no medical literature to support a clear causative mechanism between left heel pathology or a lumbar spine disability/left leg radiculopathy and a left knee disability. He also generally concluded that the literature did not support that his usual active duty work activities were a risk factor for chronic left knee pathology. However, he failed to explain why the Veteran’s military occupational specialty as a jet mechanic and his reports of jumping off plane wings in conjunction with those duties could not cause repetitive microtrauma to the knee. He also failed to cite the medical literature that supported his negative conclusion. Finally, he relied on the lack of contemporaneous medical evidence as a reason to dismiss the Veteran’s claims of continuous left knee pain since service. The mere fact that an appellant’s assertions are not supported by contemporaneous clinical evidence does not render them inherently incredible. Buchanan v. Nicholson, 451 F.3d 1331, 1337 (Fed. Cir. 2006) (“the Board cannot determine that lay evidence lacks credibility merely because it is unaccompanied by contemporaneous medical evidence”). In light of the above deficiencies, the Board finds that the VA opinions of record are inadequate, and the claim must be remanded for a new opinion that appropriately considers the lay evidence and provides a thorough rationale. See Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). The Board finds that this issue poses a medical problem of such obscurity or complexity that an advisory opinion from an independent medical expert (IME) is required. See 38 U.S.C. § 5109; 38 C.F.R. § 3.328. Specifically, multiple VA opinions have been unable to adequately answer the question of the etiology of the Veteran’s left knee disability. The AOJ must follow its established procedures for requesting an advisory opinion furnished by a medical school, university, or clinic on remand. The matters are REMANDED for the following actions: 1. Obtain an advisory medical opinion from an independent medical expert pursuant to 38 U.S.C. § 5109; 38 C.F.R. § 3.328. The AOJ must follow its established procedures for requesting such an advisory opinion. The entire claims file should be provided to the physician. The following should be addressed: (a) Whether the Veteran’s left knee disability is related to service (direct service connection) or caused or aggravated by his service-connected lumbar spine disability with associated left lower extremity radiculopathy (secondary service connection). The independent medical expert should specifically address the following questions: (a) Is it at least as likely as not that the Veteran’s left knee disability: i. is proximately due to his service? ii. is proximately due to his service-connected lumbar spine disability and/or left lower extremity radiculopathy? iii. underwent an incremental increase (was aggravated), regardless of permanence, beyond its natural progression by his service-connected lumbar spine disability and/or left lower extremity radiculopathy? The examiner must comment and address the following: (a) The August 2018 private chiropractor letter (b) The Veteran’s reports of jumping off plane wings as a jet mechanic and whether this could cause a left knee disability (c) The Veteran’s reports of continuous left knee pain since service Be advised that an absence of medical literature is not a sufficient rationale for a negative opinion. The particular circumstances of the Veteran’s case must be discussed in detail. The term “incremental increase in disability” means additional impairment of earning capacity. Objective measurement, or numerical quantification, is not required to ascertain an increase in disability. Moreover, any “incremental increase in disability” need not be permanent. The term “at least as likely as not” does not mean “within the realm of medical possibility.” Rather, it means that the weight of medical evidence both for and against a conclusion is so evenly divided that it is as medically sound to find in favor of the conclusion (e.g., etiology) as it is to find against the conclusion. 2. THE AOJ MUST REVIEW THE CLAIMS FILE AND ENSURE THAT THE FOREGOING DEVELOPMENT ACTION HAS BEEN COMPLETED IN FULL. IF ANY DEVELOPMENT IS INCOMPLETE, APPROPRIATE CORRECTIVE ACTION MUST BE IMPLEMENTED. IF ANY REPORT DOES NOT INCLUDE ADEQUATE RESPONSES TO THE SPECIFIC OPINIONS REQUESTED, IT MUST BE RETURNED TO THE PROVIDING EXAMINER FOR CORRECTIVE ACTION. [CONTINUED ON THE NEXT PAGE] YVETTE R. WHITE Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board M. Moore, 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.