Citation Nr: 21025147 Decision Date: 04/27/21 Archive Date: 04/27/21 DOCKET NO. 09-18 075 DATE: April 27, 2021 REMANDED Entitlement to service connection for residuals of a whiplash injury to the neck and shoulders, to include as secondary to the service-connected lumbar spine degenerative arthritis, is remanded. Entitlement to a total disability rating based on individual unemployability due to service-connected disabilities (TDIU) is remanded. REASONS FOR REMAND The Veteran had service in the United States Air Force and the United States Air Force Reserve. She had active duty service from August 1981 to August 1985, October 2001 to September 2002, and February 2003 to February 2004 with various periods of active duty for training (ACDUTRA) and inactive duty for training (INACDUTRA). These matters come to the Board of Veterans’ Appeals (Board) on appeal from a May 2008 rating decision from the Department of Veterans Affairs (VA) Regional Office (RO) in Houston, Texas. The Veteran testified at a videoconference hearing before the undersigned Veterans Law Judge in December 2015. A copy of the transcript from that proceeding is associated with the record. 1. Entitlement to service connection for residuals of a whiplash injury to the neck and shoulders, to include as secondary to the service-connected lumbar spine degenerative arthritis, is remanded. Although the Board regrets the additional delay, remand is required for an adequate VA opinion. 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). 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). The Board is also 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. The Veteran was provided with a VA examination to evaluate her neck and shoulder in August 2018. The Veteran was diagnosed with left shoulder strain, cervical osteoarthritis, and degenerative arthritis of the cervical spine. The examiner determined that the Veteran’s whiplash condition was less likely than not caused by her lumbar spine condition. He stated that degenerative disc disease (DDD) of the cervical spine and DDD of the lumbar spine were related but that there was no cause and effect and therefore there was no nexus. The examiner also denied that the Veteran was diagnosed with spondylitis. The examiner then stated that there was no relationship between neck DDD, osteoarthritis, and lumbar spine arthritis. The examiner also found that the Veteran’s shoulder condition was less likely than not due to DDD of the lumbar spine as there is no relationship between the two conditions. In an October 2019 addendum opinion, an examiner determined that the Veteran’s neck and shoulder conditions were less likely than not caused by service. The examiner stated that there was insufficient evidence to support a left shoulder condition stemming from service. He then determined that the Veteran’s shoulder condition clearly and unmistakably existed service as there was no notation of a shoulder condition on the enlistment examination and was not aggravated thereby. First, the Board finds that the August 2018 opinion is inadequate as the examiner determined that the Veteran did not have spondylitis, but did not address March 2010 service treatment records (STR) and an April 2010 Medical Board Report that diagnosed spondylitis. As the examiner did not address the diagnoses of record, remand is required. Second, the Board finds the August 2018 opinion and October 2019 addendum to be inadequate, as the examiner provided no rationale or medical evidence for his nexus opinions. The examiner simply stated that the conditions were unrelated, and that medical literature did not indicate an association between the conditions. The examiner’s opinions are conclusory and without rationale. Finally, the Board also finds that the examiner failed to address certain pieces of evidence as instructed by the October 2018 Board remand. The examiner was asked to address the Veteran’s lay statements from the December 2015 hearing, the Veteran’s statements from the March 1989 Report of Medical History, and the August 2018 VA examination. As the examiner failed to discuss this evidence, remand is required for an adequate VA opinion. 2. Entitlement to TDIU is remanded. As the adjudication of the service connection claim being remanded could impact adjudication of the claim for TDIU, it is inextricably intertwined, and this issue is also remanded. See Harris v. Derwinski, 1Vet. App.180, 183 (1991) (holding that two issues are inextricably intertwined when they are so closely tied together that a final Board decision on one issue cannot be rendered until the other issue has been considered). The matters are REMANDED for the following action: 1. Contact the appropriate VA Medical Center and obtain and associate with the electronic record all outstanding records of treatment. If any requested records are not available, or the search for any such records otherwise yields negative results, that fact must clearly be documented in the electronic record. Efforts to obtain these records must continue until it is determined that they do not exist or that further attempts to obtain them would be futile. The non-existence or unavailability of such records must be verified, and this should be documented for the record. Required notice must be provided to the Veteran and her representative. 2. Contact the Veteran and afford her the opportunity to identify by name, address and dates of treatment or examination any relevant medical records. Subsequently, and after securing the proper authorizations where necessary, make arrangements to obtain all the records of treatment or examination from all the sources listed by the Veteran which are not already on file. All information obtained must be made part of the file. All attempts to secure this evidence must be documented in the claims file, and if, after making reasonable efforts to obtain named records, they are not able to be secured, provide the required notice and opportunity to respond to the Veteran and her representative. 3. After any additional records are associated with the claims file, obtain an addendum opinion regarding the etiology of the left shoulder strain from a VA examiner. The entire claims file must be made available to and be reviewed by the examiner. If an examination is deemed necessary, it shall be provided where any and all studies, tests, and evaluations deemed necessary by the examiner should be performed. The examiner is requested to review all pertinent records associated with the claims file, including the Veteran’s service treatment records, post-service medical records, and lay statements. A thorough explanation for any opinion must be provided. The examiner must obtain a full history from the Veteran. The Veteran is competent to attest to factual matters of which she has first-hand knowledge, including observable symptomatology. If there is a medical basis to support or doubt the history provided by the Veteran, the examiner must provide a fully reasoned explanation. For each current shoulder disability, the examiner must provide the following opinions: a) Is it at least as likely as not (a 50 percent or greater probability) that the left shoulder disability had its onset in or is otherwise related to active duty service (from August 1981 to August 1985, October 2001 to September2002, and February 2003 to February 2004)? b) For the verified periods of ACDUTRA or INACDUTRA is it at least as likely as not (a 50 percent or greater probability) that the left shoulder disability was incurred in or aggravated during one of these periods? c) Did the left shoulder disability clearly and unmistakably preexist active duty (from August 1981 to August 1985, from October 2001 to September 2002, and from February 2003 to February 2004)? If so, was such left shoulder disability clearly and unmistakably not aggravated by this period of active service? If not, is it at least as likely as not (a 50 percent or greater probability) that the left shoulder disability had its onset in or is otherwise related to this period of active service? In providing an opinion, the examiner must address the following: (1) the Veteran’s testimony from the December 2015 Board hearing that she experienced a whiplash injury that occurred in 1988 or 1989; (2) the Veteran’s statement in the March 1989 Report of Medical History that she had been treated by a chiropractor for whiplash on December 28, 1988; (3) the Veteran’s testimony from the December 2015 Board hearing that the injury occurred after an argument when her hair was grabbed, her head was yanked, and her head was hit against a wall; (4) the Veteran’s testimony from the December 2015 Board hearing that she had to wear a neck brace for a long time after the injury, and she could not work for a while; and (5) the August 2018 VA examination which diagnosed the Veteran with a left shoulder strain. 4. Notify the Veteran that it is her responsibility to report for any scheduled examination and to cooperate in the development of the claims, and that the consequences for failure to report for a VA examination without good cause may include denial of the claims. In the event that the Veteran does not report for any scheduled examination, documentation must be obtained which shows that notice scheduling the examination was sent to the last known address. It must also be indicated whether any notice that was sent was returned as undeliverable. K. MILLIKAN Acting Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Ashley Ki 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.