Citation Nr: 21022315 Decision Date: 04/15/21 Archive Date: 04/15/21 DOCKET NO. 17-14 101 DATE: April 15, 2021 REMANDED Entitlement to service connection for a cervical spine condition is remanded. REASONS FOR REMAND The Veteran served on active duty from October 1986 to September 1990. This matter is on appeal from a June 2016 decision of a Department of Veterans Affairs (VA) Regional Office (RO). The case was previously before the Board in July 2018 when it was reopened and remanded for further development. The Board also remanded additional claims for service connection which were granted in January and February 2021 rating decisions and are no longer in appellate status. See Grantham v. Brown, 114 F.3d 1156, 1158 (Fed. Cir. 1997). Entitlement to service connection for a cervical spine condition is remanded. The Veteran contends that he is entitled to service connection for a cervical spine condition. However, upon review of the record, the Board finds that an additional opinion is necessary to adjudicate this claim. In January 2021, the Veteran was provided with a VA examination in which the examiner opined that the cervical condition is less likely than not incurred in or related to service. He noted that the Veteran was involved in a motor vehicle accident in April 2006 and stated that a car accident is one of the most common causes of muscle spasms that can become chronic. He further concluded that the Veteran’s cervical condition is unrelated to service and is related to the event of the motor vehicle accident in 2006. However, the record contains private treatment records from January 2004 which reflect that the Veteran underwent a cervical spine MRI which showed possible rheumatoid involvement of the atlantoaxial joint, small left posterolateral C3-C4 hard herniated disc, and mild C4-C5, C5-C6, and C6-C7 foramina stenosis. This evidence is favorable to the claim because it indicates that the Veteran’s cervical condition may have predated the motor vehicle accident in 2006; however, the January 2021 opinion does not address this favorable evidence. Once VA undertakes the effort to provide an examination for a service-connection claim, it must provide an adequate one or, at a minimum, notify the claimant why one will not or cannot be provided. Barr v. Nicholson, 21 Vet. App. 303, 311-12 (2007). An opinion is considered adequate when it is based on consideration of an appellant’s prior medical history and examinations and describes the disability in sufficient detail so that the Board’s evaluation of the claimed disability is a fully informed one. Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007). As such, this matter must be returned to the examiner for an addendum opinion to adequately address this pertinent medical history. The record also reflects the Veteran receives VA treatment; thus, updated VA treatment records should be associated with the claims file. The matters are REMANDED for the following action: 1. Obtain the Veteran’s VA treatment records for the period from February 2021 to the present. 2. After obtaining any additional records, arrange for the record to be returned to the examiner who provided the medical opinion for the cervical condition in January 2021. If the January 2021 examiner is unavailable to provide an addendum opinion, then arrange for the record to be forwarded to another appropriate clinician for review and to provide the opinion sought. If further examination of the Veteran is deemed necessary, arrange an in-person examination. The reviewing clinician should be requested to provide an addendum opinion (based on a review of the record) to answer the following: Is it at least as likely as not (a 50 percent or greater probability) that the Veteran’s cervical condition was incurred in service or is otherwise related to an in-service injury, disease, or event? In providing an opinion, the examiner is asked to address the cervical spine MRI findings in February 2004 which showed possible rheumatoid involvement of the atlantoaxial joint, small left posterolateral C3-C4 hard herniated disc, and mild C4-C5, C5-C6, and C6-C7 foramina stenosis. A complete rationale for all opinions must be provided. If the clinician cannot provide a requested opinion without resorting to speculation, it must be so stated, and the clinician must provide the reasons why an opinion would require speculation. The clinician must indicate whether there was any further need for information or testing necessary to make a determination. Additionally, the clinician must indicate whether any opinion could not be rendered due to limitations of knowledge in the medical (Continued on the next page)   community at large and not those of the particular examiner. J. B. FREEMAN Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board M. H. White, 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.