Citation Nr: 21025299 Decision Date: 04/27/21 Archive Date: 04/27/21 DOCKET NO. 16-34 675 DATE: April 27, 2021 REMANDED Entitlement to service connection for a neck disability is remanded. REASONS FOR REMAND The Veteran served on active duty in the United States Army from July 1988 to July 1990 and from January 1991 to March 1991. This matter is on appeal from a September 2014 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Montgomery, Alabama, that found no new and material evidence sufficient to reopen the claim. The matter had previously been denied in a final August 2012 rating decision. Thereafter, in a November 2018 Board decision, the Board determined that new and material evidence had been submitted sufficient to reopen the neck disability claim. The issue was reopened and the merits were remanded for further evidentiary development. Although the Board regrets the additional delay, remand is again needed before a decision may be rendered on the claim. See Stegall v. West, 11 Vet. App. 268 (1998). Entitlement to service connection for a neck disability is remanded. The Veteran has current diagnoses pertaining to a neck disability. He has contended that the condition is related to his active service, including due to lifting and carrying heavy military equipment. Service treatment records (STRs) did not contain any complaints, symptoms, treatment, or diagnoses relevant to the neck. There is no service separation examination in the claims file. A September 2014 private opinion was submitted which diagnosed peripheral neuropathy in the neck and shoulder and found that it was more likely than not that the condition was related to military service. No rationale for the opinion was provided. In August 2017, the Veteran reported to VA clinicians that he had cervical pain that had been present for years and which was getting worse. Following a cervical MRI in May 2018, cervical spondylosis with some neural foraminal narrowing was diagnosed. In accordance with the November 2018 remand, a VA examination was conducted in November 2019. The examiner diagnosed cervical strain. The examiner determined that the claimed condition was less likely than not incurred in or caused by service. In support, the examiner stated that there was no diagnosis or treatment for a neck condition or a related cervical condition in the STRs. The first documented neck diagnoses were after active duty. The Board finds that a new VA examination and medical opinion are needed before a decision may be rendered on the claim. The VA examiner did not address the other diagnoses of record, including peripheral neuropathy and cervical spondylosis, did not address the September 2014 private opinion, and based the etiology opinion merely on a lack of notation in the STRs without any analysis regarding whether the Veteran’s condition is the result of his described in-service activities of lifting and carrying heavy military equipment. See Miller v. Wilkie, 32 Vet. App. 249 (2020) (holding when an examiner fails to address the Veteran’s lay evidence, and the Board does not find the Veteran not credible or not competent to offer that lay evidence, a new exam is needed). As such, it is not an adequate basis upon which to determine service connection and a new opinion is needed. The matters are REMANDED for the following action: 1. Schedule the Veteran for a VA examination with an appropriate medical professional to determine the etiology of his neck disability. The claims folder should be provided to and reviewed by the examiner. After a review of the examination findings and the entire evidence of record, the examiner is asked to: (a.) Determine all current diagnoses of the neck. The examiner is asked to address the diagnoses of record, including peripheral neuropathy, cervical spondylosis, and cervical strain. (b.) Render an opinion as to whether the Veteran’s neck disability is at least as likely as not (probability of 50 percent or greater) the result of his active service, specifically to include lifting and carrying heavy military equipment. (c.) The examiner is reminded that a lack of in-service complaints should not form the sole basis of any opinion. (Continued on the next page)   (d.) A full rationale for all opinions expressed should be provided. Special attention is directed to the Veteran’s lay statements regarding the onset of symptoms and his current complaints. The examiner is asked to specifically address the September 2014 private opinion and the November 2019 VA examination opinion and to reconcile any different conclusions with those opinions. 2. After the above development and any additionally indicated development has been completed, readjudicate the issue on appeal. Shereen M. Marcus Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Rachel E. Jensen, 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.