Citation Nr: 21027379
Decision Date: 05/05/21	Archive Date: 05/05/21

DOCKET NO. 19-13 812
DATE: May 5, 2021

REMANDED

Entitlement to service connection for a lumbar spine disability is remanded.

REASONS FOR REMAND

The Veteran served on active duty from June 1965 to June 1968.

In January 2021, the Veteran testified in a virtual hearing before the undersigned Veterans Law Judge.  A copy of the hearing transcript is of record and has been reviewed. 

A remand is necessary to provide the Veteran with a new VA opinion prior to deciding the claim on the merits.

It is indisputable that the Veteran's sustained a back injury in service.  The August 2018 examiner opined that the currently diagnosed lumbar strain was less likely than not related to service given the normal separation examination and lack of chronicity until treatment decades later.  

Nevertheless, during the 2021 Board hearing, the Veteran testified that his back bothered him since the documented in-service injury.  Given that his lay reports that are deemed competent were not considered by the 2018 examiner, the Board finds that an additional opinion is necessary.  In addition, the examiner only rendered a diagnosis of a lumbar strain; however, it was noted that a Dual-energy X-ray absorptiometry showed evidence of osteopenia.  The examiner did not discuss this diagnosis or its relationship to the in-service injury.

The matters are REMANDED for the following action:

1.  Ensure all outstanding VA treatment records are associated with the claims file.

2.  Obtain an addendum as to the likely etiology of the current lumbar spine disability.  The claims file and a copy of this remand will be made available to the examiner, who will acknowledge receipt and review of these materials.

After a review of the record, the examiner is asked to respond to the following: 

Provide an opinion as to whether it is at least as likely as not (a 50 percent or higher probability) that the Veteran's lumbar strain AND osteopenia had their onset during service or is otherwise related to it, including the sacral contusion sustained in service.  

**In doing so, please address the Veteran's competent lay assertions of having had lumbar spine pain ever since the in-service injury.  Note: the absence of contemporaneous medical records does not serve as an "absolute bar" to the service connection claim and cannot be used as a sole rationale in providing a negative opinion.  

(Continued on the next page)

 

A complete rationale should be provided for all opinions.

3.  Thereafter, readjudicate the remanded claim.

 

 

S. B. MAYS

Veterans Law Judge

Board of Veterans' Appeals

Attorney for the Board	A. Yaffe, 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.