Citation Nr: 21027000 Decision Date: 05/04/21 Archive Date: 05/04/21 DOCKET NO. 17-63 181 DATE: May 4, 2021 REMANDED Entitlement to service connection for a back disorder is remanded. Entitlement to service connection for a neck disorder is remanded. Entitlement to service connection for an acquired mental disorder, to include post-traumatic stress disorder (PTSD), to include as secondary to a back disorder, is remanded. REASONS FOR REMAND The Veteran served on active duty in the United States Army Reserves from May 1999 to October 1999 and from February 2003 to June 2004. This matter comes before the Board of Veterans' Appeals (Board) on appeal from August 2016 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO). In February 2021, the Veteran testified at a hearing before the undersigned Veterans Law Judge (VLJ); a transcript is of record. 1. Entitlement to service connection for a back disorder. The Veteran asserts that her back condition is related to her active military service, which included lifting heavy mail bags. Upon review of all evidence of record, the Board finds that additional development is needed prior to adjudication of the claim. In this regard, the Veteran has not yet been afforded a VA examination for her back condition. See McClendon v. Nicholson, 20 Vet. App. 79 (2006); see also 38 U.S.C. § 5103A(d)(2); 38 C.F.R. § 3.159(c)(4)(i). The Veteran's treatment records show a diagnosis of chronic low back pain, upper back pain and thoracic spine pain. See February 2015 private treatment records. The Veteran's service treatment records (STR) do not show any treatment or diagnosis for the Veteran's back. However, the Veteran reported back pain on her post-deployment health assessment. The Board also notes that the Agency of Original Jurisdiction (AOJ) was unable to obtain the Veteran's complete STRs. See July 2016 VA Notice Letter; October 2017 Statement of the Case (SOC). At the February 2021 Board hearing, the Veteran testified that she has been experiencing back pain since her separation from active service. The Veteran also submitted a statement from her mother, describing her observations of the Veteran's back pain symptoms since active service. The Board notes that the evidence of record indicates that the Veteran was involved in a post-service motor vehicle accident, resulting in back pain/strain. See private treatment records. The Veteran submitted a January 2019 private opinion, attributing her chronic back condition to her military service. The Board finds the private opinion inadequate for adjudication purposes as the examiner did not provide a rationale for his opinion. Nor did he take into consideration the evidence of record indicating that the Veteran's condition may be related to her post-service motor vehicle accident. As such, an adequate medical opinion is needed prior to adjudication of the Veteran's claim. Based on the foregoing, the Board finds that the low threshold of McLendon is met and on remand the Veteran should be afforded a VA examination to determine whether her back condition is related to her active military service. 20 Vet. App. at 83-86. 2. Entitlement to service connection for a neck disorder. The Veteran further asserts that her neck condition is related to her active military service, which included lifting heavy mail bags. Upon review of all evidence of record, the Board finds that additional development is needed prior to adjudication of the claim. Specifically, as with the back condition, the Veteran has not yet been afforded a VA examination for her neck condition. See McClendon, supra. The Veteran's treatment records show a diagnosis of chronic neck pain. See January 2019 private treatment record. The available Veteran's STRs do not show complaints, treatment or a diagnosis of a neck condition in service. The Veteran submitted a January 2019 private opinion, attributing her neck condition to her military service. The Board finds the private opinion inadequate for adjudication purposes as the examiner did not provide a rationale for his opinion. Accordingly, as the low threshold of McLendon is met, an adequate medical opinion is needed prior to adjudication of the Veteran's claim. See, supra. 3. Entitlement to service connection for an acquired mental disorder, to include PTSD and as secondary to a back disorder. The Veteran asserts that her mental disability is related to her military service, to include as secondary to her back condition. See February 2021 Board hearing transcript. The issue of entitlement to service connection for the Veteran's acquired mental disability is inextricably intertwined with the issue of entitlement to service connection for back disorder, because the outcome of the claim may have a bearing on the Veteran's entitlement to service connection on secondary basis. See Harris v. Derwinski, 1 Vet. App. 180 (1991) (two issues are "inextricably intertwined" when they are so closely tied together that a final decision on one issue cannot be rendered until a decision on the other issue has been rendered). These matters are REMANDED for the following action: 1. Ask the Veteran to complete a VA Form 21-4142 for Kaiser, Piedmont Healthcare, or any other identified facility to obtain any outstanding pertinent reports associated with the Veteran's lower back, neck, and mental disorder. Make two requests for the authorized records unless it is clear after the first request that a second request would be futile. 2. Schedule the Veteran for a VA examination to determine the nature and etiology of her back condition. The claims file and a copy of this remand must be made available to the reviewing examiner, and the examiner should indicate in the report that the claims file was reviewed. The examination should include any diagnostic testing (including X-rays) or evaluation deemed necessary for the specific claimed disability. The VA examiner should respond to the following inquiries: (a) Whether the Veteran has a current diagnosis of a back condition or any impairment in her earning capacity due to back pain. (b) If a diagnosis of a back condition is made, whether it is at least as likely as not (a 50 percent or greater probability) that the Veteran's back condition had its onset in, or is otherwise related to, active duty or active duty for training. (c) Whether it is at least as likely as not (a 50 percent or greater probability) that the Veteran's back condition is due to an injury sustained while on inactive duty for training. (d) If the Veteran's back pain is not attributable to a known clinical diagnosis, is it at least as likely as not that the reported symptom is a manifestation of an undiagnosed illness or part of a medically unexplained multi-symptom illness under 38 C.F.R. § 3.317. A complete rationale must be provided for all opinions expressed. The rationale must consider and discuss the pertinent evidence of record, to include the Veteran's and her mother's lay statements, which include attributing her condition to carrying heavy mail bags. In providing this opinion, the examiner should also address the Veteran's complaint of back pain on her post-deployment health assessment in the STRs, January 2019 private opinion and private treatment records indicating that the Veteran was involved in a post-service motor vehicle accident. 3. Schedule the Veteran for a VA examination to determine the nature and etiology of her neck condition. The claims file and a copy of this remand must be made available to the reviewing examiner, and the examiner should indicate in the report that the claims file was reviewed. The examination should include any diagnostic testing (including X-rays) or evaluation deemed necessary for the specific claimed disability. The VA examiner should respond to the following inquiries: (a) Whether the Veteran has a current diagnosis of a neck condition or any impairment in her earning capacity due to neck pain. (b) If a diagnosis of a neck condition is made, whether it is at least as likely as not (a 50 percent or greater probability) that the Veteran's neck condition had its onset in, or is otherwise related to, active duty or active duty for training. (c) Whether it is at least as likely as not (a 50 percent or greater probability) that the Veteran's neck condition is due to an injury sustained while on inactive duty for training. (d) If the Veteran's neck pain is not attributable to a known clinical diagnosis, is it at least as likely as not that the reported symptom is a manifestation of an undiagnosed illness or part of a medically unexplained multi-symptom illness under 38 C.F.R. § 3.317. A complete rationale must be provided for all opinions expressed. The rationale must consider and discuss the pertinent evidence of record, to include the Veteran's and her mother's lay statements, which include attributing her condition to carrying heavy mail bags. In providing this opinion, the examiner should also address the January 2019 private opinion and private treatment records indicating that the Veteran was involved in a post-service motor vehicle accident. 4. After completing the above, accomplish any development deemed necessary, e.g., scheduling a VA psychiatric examination to identify any disorder(s) present and to obtain a VA nexus medical opinion, and readjudicate the claim of entitlement to service connection for an acquired mental disability, to include PTSD, to include as secondary to a back disorder. C. CRAWFORD Veterans Law Judge Board of Veterans' Appeals Attorney for the Board A. Kuzniar, 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.