Citation Nr: 21026357 Decision Date: 04/30/21 Archive Date: 04/30/21 DOCKET NO. 16-18 849 DATE: April 30, 2021 REMANDED Entitlement to service connection for lumbar spine degenerative joint disease with bilateral lumbar radiculopathy is remanded. REASONS FOR REMAND The Veteran served on active duty in the United States Army from December 1969 to September 1972. In July 2019, the Veteran testified at a Board hearing. The transcript is of record. 1. Entitlement to service connection for lumbar spine degenerative joint disease with bilateral lumbar radiculopathy The Board regrets the additional delay; however, a remand is necessary to ensure compliance with the Board’s prior remand instructions and to ensure that due process is met. Stegall v. West, 11 Vet. App. 268, 271 (1998). In November 2019 the Board remanded this case to obtain a medical opinion that addresses the lay evidence of record. In October 2020 the VA examiner opined that the lumbar spine condition and bilateral radiculopathy are less likely than not incurred in or caused by military service. The rationale cited to the in-service 1972 motor vehicle accident resulting in a spinal cord contusion and separation examination that did not report any back or neurological conditions. The examiner noted that post-service the Veteran was seen for back pain in 1980 with normal imaging results of the lumbar spine and again in 2015, 2017, 2018, 2019 and 2020 for lower back pain. The examiner concluded that the initial injury from the motor vehicle accident resolved based on the normal separation examination and the eight years that lapsed before he had another medical evaluation with normal x-rays. An addendum opinion for clarification was requested as the examiner failed to consider and discuss the lay evidence as directed. In response the examiner reported that the Veteran’s lay statements do not change that the medical records revealed no chronicity or recurrence of any type of back condition during active service. The Board finds that the medical opinion again fails to properly address the Veteran’s statements, which have been deemed competent and credible. The examiner continues to rely on the lack of evidence of a back condition at the separation examination and the eight years between separation and the complaints documented in the post-service medical records without explaining the significance of such or properly addressing the Veteran’s statements of continued symptoms and treatment since service. See Fountain v. McDonald, 27 Vet. App. 258, 272-75 (2015); Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000). As a medical examination report must contain not only clear conclusions with supporting data, but also a reasoned medical explanation connecting the two a remand is necessary for a medical opinion. See Nieves- Rodriguez v. Peake, 22 Vet. App. 295 (2008); Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007). The matters are REMANDED for the following action: 1. Acquire updated VA and/or private treatment records. If such records are unavailable, the Veteran’s claim file must be clearly documented to that effect and the Veteran notified in accordance with 38 C.F.R. § 3.159(e). 2. Obtain an addendum medical opinion from a medical professional with appropriate expertise. The examiner should review the Veteran’s claims file. If the examiner determines that an opinion cannot be provided without an examination, the Veteran should be scheduled for one. Based on a review of the record, and a new examination if necessary, the examiner must address the following: (a.) Whether it is at least as likely as not (a 50 percent or greater probability) that the Veteran’s lumbar spine condition and bilateral radiculopathy is related to his active service or is caused by or aggravated by military service. The examiner must consider and address the following: 1) The April 1972 service treatment records for the motor vehicle accident; 2) the May 24, 1972 report of bilateral leg pain and back pain; and 3) the Veteran’s testimony that he has had continued pain in his back since service and received treatment from a chiropractor in the early 1970s (the records are no longer available). In all opinions rendered, the examiner is advised that the Veteran is competent and credible to report his symptoms and treatment history including his credible reports of back pain due to his in-service injury with continued symptoms to the present. The examiner must specifically consider and discuss the Veteran’s lay statements and the opinion and rationale should reflect such consideration. If a negative opinion is offered based primarily on the length of time between separation and the current diagnosis the examiner should explain the medical significance of this fact, i.e., why this is indicative that any current back condition is not related to service. A complete rationale containing clear conclusions with supporting data and a reasoned medical explanation connecting the two is required for all medical opinions. The examiner should also identify and explain the relevance or significance, as appropriate, of any history, clinical findings, medical knowledge or literature, etc., relied upon in reaching the conclusion(s). If the medical professional cannot provide an opinion without resorting to mere speculation, he or she shall provide a complete explanation for why an opinion cannot be rendered. In so doing, the medical professional shall explain whether the inability to provide a more definitive opinion is the result of a need for additional information, or that he or she has exhausted the limits of current medical knowledge in providing an answer to that particular question(s) G. A. WASIK Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Prinsen, Samantha 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.