Citation Nr: 21025241 Decision Date: 04/27/21 Archive Date: 04/27/21 DOCKET NO. 15-08 798 DATE: April 27, 2021 REMANDED Entitlement to service-connection for low back condition is remanded. REASONS FOR REMAND The Veteran served on active duty with the United States Navy from September 1989 to August 1993. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a November 2013 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO) denying service-connection for a low back condition. The Veteran testified at a hearing before the undersigned in January 2019. This matter was previously remanded by the Board in May 2019 and again in December 2020. The case has been returned to the Board at this time for further appellate review. Unfortunately, another remand is necessary in this case. The Veteran contends that he developed a low back condition, diagnosed as degenerative arthritis of the spine, intravertebral disc syndrome (IVDS), and spinal stenosis. He claims that he incurred this disability after a traumatic in-service motor vehicle accident in August 1992. The December 2020 remand noted that the Veteran had never been afforded a VA medical examination and remanded to obtain a medical opinion as to the etiology of his back condition. The subsequent January 2021 VA examiner offered a negative opinion, finding that the Veteran’s back condition was less likely than not related to service. However, the examiner did not provide adequate rationale. The report improperly relies on the absence of contemporaneous medical records of back complaints between the 1992 in-service incident and 2015 to deny a nexus. The Board notes that the absence of contemporaneous records does not preclude granting service connection for a claimed disability. See Buchanan v. Nicholson, 451 F.3d 1331, 1337 (Fed. Cir. 2006) (finding lack of contemporaneous medical records does not serve as an “absolute bar” to the service connection claim); Barr v. Nicholson, 21 Vet. App. 303 (2007) (“Board may not reject as not credible any uncorroborated statements merely because the contemporaneous medical evidence is silent as to complaints or treatment for the relevant condition or symptoms”). Further, this opinion completely disregards the Veteran’s lay statements that was explicitly told by medical personnel after an X-ray that his back condition was due to the accident and that he did in fact establish a continuity of care following the accident, but was not able to retrieve records of it. The Veteran is competent to testify as to his subjective experience, and the examiner therefore must provide a rationale explaining why the Veteran’s testimony was not given any weight or otherwise considered. See Layno v. Brown, 6 Vet. App. 465, 470 (1994) (providing that a Veteran is competent to report on that of which he or she has personal knowledge). Additionally, the examiner repeatedly made blanket statements that the evidence of record was “insufficient” to support the Veteran’s claim without explaining what the insufficiency was, which is particularly problematic given that there are service treatment records showing multiple complaints about the back in the months immediately following the Veteran’s accident. The examiner also did not address the argument advanced by the Veteran and his representative in the January 2019 hearing that the in-service accident was severe enough to cause widespread trauma to the Veteran’s body – including adrenal damage, liver lacerations, a collapsed lung, a broken rib, and permanent cardiovascular complications – and therefore it is probable that the back was also damaged, but given less attention in records in light of the severity of the rest of his injuries. Because of the deficits in the January 2021 medical opinion, the Board finds that this issue must be remanded for an addendum addressing the aforementioned inadequacies. The matter is REMANDED for the following action: Obtain an addendum opinion from a qualified clinician to determine whether any low back disability found during the period on appeal is related to the Veteran’s military service.  If the selected clinician determines that an examination is necessary to respond to this request, such examination should be scheduled. After review of the claims file, and examination of the Veteran if deemed necessary, the examiner should opine whether it is at least as likely as not (50 percent or greater probability) that the Veteran’s low back disability, to include degenerative arthritis, IVDS, and/or spinal stenosis, began in or is otherwise caused by the Veteran’s active service.  In doing so, the examiner must address the Veteran’s (1) in-service back injuries, (2) in-service motor vehicle accident, after which service treatment records document complaints of back pain, (3) lay statements that he has experienced back pain continuously and repeatedly sought treatment since his in-service motor vehicle injury, (4) lay statements that, after having his back X-rayed, he was told by doctors that he had a back injury associated with his in-service accident, and (5) contentions that a back injury was likely given the severity of the motor vehicle accident and its subsequent injuries. The examiner is advised that blanket statements of “insufficient” evidence, without further explanation, will be considered inadequate rationale for the purposes of adjudication. The examiner is also advised that the Veteran is competent to report his symptoms and history, and such reports must be specifically acknowledged and considered in formulating any opinion. If the examiner rejects the Veteran’s reports, he or she must provide a reason for doing so. The Veteran’s report of symptoms capable of lay observation may not be disregarded solely on the basis that they are not recorded in contemporaneous medical treatment records.  All findings must be reported in detail and all opinions must be accompanied by a clear rationale.  If any of the above issues cannot be resolved without resorting to speculation, then a detailed medical explanation as to why this is so must be provided. M. HYLAND Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Narnor, Harriyah 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.