Citation Nr: 21027268 Decision Date: 05/05/21 Archive Date: 05/05/21 DOCKET NO. 14-22 398 DATE: May 5, 2021 REMANDED Entitlement to service connection for residuals of neck fracture is remanded. Entitlement to service connection for low back condition is remanded. REASONS FOR REMAND The Veteran served on active duty in the United States Marine Corps from September 1973 to January 1976. In July 2017, the Veteran testified at a Board hearing. The transcript is of record. In December 2019 the Board issued a decision denying the claim of entitlement to service connection for residuals of neck fracture and low back condition. The Veteran appealed that decision to the Court of Appeals of Veterans Claims (Court) and in an order dated November 2020, the Court issued a Joint Motion Remand (JMR) and remanded the issue for further development and readjudication. Pursuant to the JMR, the Board is remanding this case for further development. 1. Entitlement to service connection for residuals of neck fracture and low back condition A remand is necessary to ensure compliance with the Board's December 2017 remand instructions and to ensure that due process is met. Stegall v. West, 11 Vet. App. 268, 271 (1998). The Veteran contends his alleged neck injury occurred in-service during February or March 1974 and he sought treatment at the military hospital in Millington, Tennessee; however, the service treatment records do not include the military hospital records. The Board remanded the case in order to attempt to obtain these records but, the record does not indicate that any attempts were made to find the hospital records. As such, a remand is necessary for further development. The matters are REMANDED for the following action: 1. In remanding this case, the Board makes no credibility determination, expressed or implied, at this juncture. 2. Contact the Veteran and afford him 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, which must include the Millington, Tennessee military hospital records. All information obtained must be made part of the file. All attempts to secure this evidence must be documented in the claims file. If, after making reasonable efforts, the records cannot be obtained, notify the Veteran and his representative and (a) identify the specific records that cannot be obtained; (b) briefly explain the efforts made to obtain those records; and (c) describe any further action to be taken with respect to the claim. The Veteran must then be given an opportunity to respond. 3. After the above development is completed, 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 residuals of neck fracture and/or low back condition is related to his active service, or is caused by or aggravated by military service, to include due to the alleged 1974 pommel horse incident. The examiner must consider and address the following: 1) the Veteran's statements and testimony that he incurred his neck injury in-service in a pommel horse incident See Hearing Transcript; 2) the September 1975 complaint of back pain See Service Treatment Records; 3) the February 2010 neurology consultation by Dr. Pick See Medical Treatment Record Government Facility March 2010; and 4) the medical records revealing a history of motor vehicle accidents and neck injuries. The term "at least as likely as not" does not mean within the realm of medical possibility, but rather that the medical evidence both for and against a certain conclusion is so evenly divided that it is as medically sound to find in favor of such a conclusion as it is to find against it. In all opinions rendered, the examiner is advised that the Veteran is competent to report his symptoms and treatment history and the examiner must specifically consider and discuss the lay statements of record. If there is a medical basis to support or doubt the history provided, the examiner should explain why the lay statements or recollections are inconsistent with the medical evidence in this case, the medical principles relating to the onset and progress of the neck and/or back condition, and/or the specific medical findings of record. 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 neck or low back condition is not related to service. (Continued on the next page) 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 S. A. Prinsen 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.