Citation Nr: 21023935 Decision Date: 04/21/21 Archive Date: 04/21/21 DOCKET NO. 16-41 140 DATE: April 21, 2021 REMANDED Entitlement to service connection for a low back disability is remanded. REASONS FOR REMAND The Veteran served on active duty from January 1984 to May 1993. The matter comes before the Board of Veterans’ Appeals (Board) on appeal from a May 2013 rating decision issued by a Department of Veterans Affairs (VA) Regional Office. The Veteran provided testimony before the undersigned Veterans Law Judge at a December 2020 virtual Board hearing. A copy of the transcript has been associated with the claims file. Entitlement to service connection for a low back disability is remanded. The Veteran seeks service connection for a low back disability. Specifically, the Veteran contends that his current back disability, including low back pain, has continued since his active duty service. See December 2020 Hearing Transcript; July 2013 Correspondence. The Veteran’s service treatment records demonstrate the Veteran was treated for complaints of low back pain in service in November 1987 and October 1992. In November 1987, the Veteran reported low back due to lifting 55-gallon drums and was assessed with muscular skeletal pain. In October 1992, the Veteran reported low back pain due to lifting heavy boxes and was assessed with a lower back strain. Additionally, the Veteran contends he injured his back in 1991 due to lifting heavy furniture while in service. See July 2013 Correspondence. Unfortunately, the Board finds that additional development must be undertaken before this claim can be adjudicated on the merits. The record contains May 2013, May 2014, and March 2019 VA medical opinions. However, the Board finds the medical opinions inadequate for decision making purposes. When VA undertakes to provide an examination in a service connection claim, it must ensure that the examination is adequate for decision-making purposes. See 38 C.F.R. § 3.159(c)(4); see also Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). For a medical opinion to be adequate, it must be: (1) based upon sufficient facts or data; (2) be the product of reliable principles and methods; and (3) be the result of principles and methods reliably applied to the facts. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 302 (2008). In a May 2013 VA medical opinion, a VA examiner opined that it was less likely than not that the Veteran’s current low back disability was proximately due to the complaints of low back pain during his active duty service. See May 2013 VA medical opinion. As rationale, the VA examiner noted the Veteran was status post spinal fusion surgery in 2009 following a truck accident in 2008, continued to have lower back since, and there was no mention of any lower back pain prior to this injury. Id. In a May 2014 VA addendum medical opinion, the VA examiner noted the Veteran did not provide a history of back pain prior to 2008, all outside orthopedic and back clinic medical records noted back pain and a herniated disc following the motor vehicle accident in 2008, and the complaints of back pain could not be related to his current complaints. In a March 2019 VA examination, a VA examiner also opined that the Veteran’s current low back disability was less likely than not related to his in-service complaints of back pain. See March 2019 VA examination. As rationale, the VA examiner noted the Veteran’s motor vehicle accident that led to surgeries, and his present low back condition is more likely related to the motor vehicle accident and the resultant surgeries. Id. However, as noted, the Veteran reported he has experienced back since his military service. See December 2020 Hearing Transcript; July 2013 Correspondence. The Veteran provided July 2008 and August 2008 private treatment records that notes a history of back pain indicating the Veteran’s symptoms existed prior to the motor vehicle accident suffered in 2008. Additionally, the Veteran provided a June 2013 letter from his private physician. The Veteran’s private physician noted the Veteran’s back pain existed prior to October 2008 and dates back to at least November 1987. Neither the May 2013, May 2014, or March 2019 VA examiners addressed the Veteran’s lay statements or private treatment records that indicated a history of low back pain prior to the 2008 motor vehicle accident. Therefore, the VA examiners did not adequately address the Veteran’s assertions regarding his lower back pain since his injuries on active duty that existed prior to his motor vehicle accident in 2008. See McKinney v. McDonald, 28 Vet. App. 15, 30-31 (2016) (“the VA examiner’s failure to consider [the Veteran’s] testimony when formulating her opinion renders that opinion inadequate.”); See Nieves-Rodriguez, 22 Vet. App. at 302. Accordingly, remand is necessary to obtain an addendum medical opinion. The matters are REMANDED for the following action: 1. Obtain updated VA treatment records 2. Forward the record and a copy of this Remand to the examiner who provided the March 2019 VA examination, or, if that examiner is unavailable, to another suitably qualified examiner, for completion of an addendum opinion regarding the nature and etiology of the Veteran’s claimed low back disability. If the examiner determines that a new examination is necessary to provide the requested opinion, such examination should be scheduled. a. The examiner must provide an opinion as to whether it is at least as likely as not (50 percent probability or greater) that any low back disability demonstrated during, and/or proximate to the claim, had its onset during service or is causally or etiologically due to an in-service injury, event, or disease. The VA examiner must consider and address the Veteran’s lay statements regarding his reports of experiencing low back pain since service, as well as service treatment records that demonstrate complaints, treatment, and assessments for low back conditions. The VA examiner must consider and address the Veteran’s private treatment records that demonstrate reports of low back pain since active duty service and prior to his 2008 motor vehicle accident, including a November 1987 incident lifting 55-gallon drums, an October 1992 incident lifting heavy boxes; and a 1991 incident lifting heavy furniture.. See December 2020 Hearing Transcript; July 2013 Correspondence; June 2013 private treatment letter; and July 2008 and August 2008 private treatment records. In responding to the above, the clinician is requested to address the following: b. What type of symptoms would have been caused by the Veteran moving and lifting 55-gallon drums, heavy boxes and heavy furniture during service? c. Is there any medical reason to accept or reject the proposition that the Veteran’s in-service low back pain and/or strain injuries could have led to the current disorder(s)? A complete rationale should be given for all opinions and conclusions expressed. If the examiner cannot provide an opinion without resorting to speculation, he/she should explain why an opinion cannot be provided. Tiffany Dawson Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board C. P. Moore, 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.