Citation Nr: 21027827 Decision Date: 05/06/21 Archive Date: 05/06/21 DOCKET NO. 16-43 554 DATE: May 6, 2021 THE ISSUES 1. Entitlement to service connection for a lumbar spine disability. 2. Entitlement to service connection for a headache disability (claimed as migraines). REMANDED Entitlement to service connection for a lumbar spine disability is remanded. Entitlement to service connection for a headache disability is remanded. REASONS FOR REMAND The Veteran served on active duty from April 1963 to January 1967. This matter comes before the Board of Veterans' Appeals (Board) on appeal from an October 2014 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in St. Paul, Minnesota. In January 2019, the Veteran, along with his wife, testified before the undersigned Veterans Law Judge (VLJ) at a travel Board hearing sitting in San Antonio, Texas. A transcript of the hearing is of record. These matters were previously before the Board in July 2020. In its decision, the Board remanded these matters in order to afford the Veteran VA examinations and opinions for his claimed disabilities. The Board finds that there has been substantial compliance with its remand directives and that the matters are once again properly before it. See Stegall v. West, 11 Vet. App. 268 (1998). 1. Entitlement to service connection for a lumbar spine disability is remanded. 2. Entitlement to service connection for a headache disability is remanded. The Veteran contends that he currently has a lower back condition as a result of a fall in service, and that he suffers from recurrent headaches since service. See January 2019 Board hearing. In the July 2020 Board decision, we remanded these matters in order to afford the Veteran VA examinations for his claimed disabilities. Such examinations were completed by a single examiner in October 2020. In the Veteran's lumbar spine examination, the examiner found that the Veteran currently had a lumbar strain. However, the examiner opined that the Veteran's current lumbar spine disability was not at least as likely as not related to his service and offered the following rationale: "There is no documentation of complaint of, evaluation for, or diagnosis of a back condition while in the service or in the year proximal to service." No further rationale was provided, and the examiner did not address the Veteran's contentions of symptoms since service. In the Veteran's headache examination, the examiner found the Veteran currently suffered from migraine headaches. However, the examiner opined that the Veteran's current headache disability was not at least as likely as not related to his service and offered the following rationale: "There is no documentation of complaint of, evaluation for, or diagnosis of a chronic headache condition while in the service." No further rationale was provided, and the examiner did not address the Veteran's contentions of symptoms since service. Once VA undertakes the effort to provide an examination when developing a claim, the examination must be an adequate one. See Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). It is the factually accurate, fully articulated, sound reasoning for the conclusion that contributes probative value to a medical opinion. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). A mere conclusion by a medical doctor is insufficient to allow the Board to make an informed decision as to what weight to assign to the doctor's opinion. Stefl v. Nicholson, 21 Vet. App. 120, 125 (U.S. 2007). The absence of documented treatment in service or thereafter is not fatal to a service connection claim, and the absence of evidence in the service treatment records is an insufficient basis, by itself, for a negative opinion. See Ledford v. Derwinski, 3 Vet. App. 87, 89 (1992). A significant lapse in time between service and post-service medical treatment may be considered a factor in the analysis, but that such absence of documented treatment, in and of itself, is not a basis for discrediting his lay statements of continuity. See Maxson v. Gober, 230 F.3d 1330 (Fed. Cir. 2000); Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006). Because the opinions above are conclusory and unsupported by adequate rationale, the Board finds that it is necessary to remand to obtain addendum opinions which address the Veteran's contentions of symptoms since service and adequately address whether the Veteran's above-listed disabilities were incurred in service. The matters are REMANDED for the following action: 1. Obtain any outstanding and relevant VA or private treatment records. If such exist, associate them with the claims file. 2. Thereafter, the Virtual VA/VBMS records, and a copy of this remand, must be returned to, and reviewed by the October 2020 examiner, or other suitable medical professional, to determine the etiology of the Veteran's lumbar spine and headache disabilities. The examiner must indicate on the examination report that the case was reviewed again. If, but only if, the examiner deems another examination essential to provide an opinion, one should be conducted. The examiner should provide opinions addressing the following questions: (a) Is the Veteran's diagnosed lumbar spine disability at least as likely as not related to an in-service injury, event, or disease? (b) Is the Veteran's diagnosed headache disability at least as likely as not related to an in-service injury, event, or disease? In addressing these questions, the examiner should consider the Veteran's claims of continuing symptoms since service as detailed in the January 2019 Board hearing. For all opinions, the examiner is reminded that the absence of documented treatment in service or thereafter is not fatal to a service connection claim, and the absence of evidence in the service treatment records is an insufficient basis, by itself, for a negative opinion. See Ledford v. Derwinski, 3 Vet. App. 87, 89 (1992). A significant lapse in time between service and post-service medical treatment may be considered a factor in the analysis, but that such absence of documented treatment, in and of itself, is not a basis for discrediting his lay statements of continuity. See Maxson v. Gober, 230 F.3d 1330 (Fed. Cir. 2000); Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006). The examiner is asked to explain the reasons behind any opinions expressed and conclusions reached. The examiner is reminded that the term "as likely as not" does not mean "within the realm of medical possibility," but rather that the evidence of record is so evenly divided that, in the examiner's expert opinion, it is as medically sound to find in favor of the proposition as it is to find against it. Any opinion provided must be sufficiently supported by medical knowledge and rationale, and therefore, not conclusionary in nature. See Jones v. Shinseki, 23 Vet. App. 382, 390 (2010). If the examiner is unable to offer the requested opinion, it is essential that the examiner offer a rationale for the conclusion that an opinion cannot be provided without resort to speculation, together with a statement as to whether there is additional evidence that might enable an opinion to be provided, or whether the inability to provide the opinion is based on the limits of medical knowledge. See Jones v. Shinseki, 23 Vet. App. 328 (2010). (Continued on next page.) 3. Upon completion of the above, and any additional development deemed appropriate, readjudicate the remanded issues. If the benefit sought remains denied, the Veteran should be provided with a supplemental statement of the case. The case should then be returned to the Board for appellate review if otherwise in order. Michael A. Pappas Veterans Law Judge Board of Veterans' Appeals Attorney for the Board R. E. Geary, 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.