Citation Nr: 21028150
Decision Date: 05/10/21	Archive Date: 05/10/21

DOCKET NO. 16-20 043
DATE: May 10, 2021

REMANDED

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

INTRODUCTION

The Veteran served on active duty in the United States Army from April 1968 to April 1970 and was awarded the Combat Infantryman Badge.

REASONS FOR REMAND

The Board is of the opinion that additional development is required before the claim on appeal is decided.  When VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate.  Barr v. Nicholson, 21 Vet. App. 303, 312 (2007).

The Veteran underwent a VA examination to assess his claimed lumbar spine disability in August 2013.  In the course of the examination, the examiner diagnosed the Veteran with lumbar spine degenerative disc disease (DDD), as well as a lumbar strain, status-post laminectomy and discectomy.  The examiner determined the Veteran's lumbar strain was incurred in service and had fully resolved, but failed to explain how or why he came to this conclusion.  To be considered adequate, medical examination reports must contain not only clear conclusions with supporting data, but also a reasoned medical explanation connecting the two.  See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008).

The examiner also found the Veteran's lumbar spine DDD was less likely as not caused by or the result of his military service.  In support of this conclusion, the examiner indicated the Veteran was noted to have a negative separation examination.  However, the Board observes the Veteran did in fact report ongoing back pain at the time of his April 1970 separation examination.  Further, the Veteran has reported ongoing back pain since that time.  An opinion based upon an inaccurate factual premise has no probative value.  Reonal v. Brown, 5 Vet. App. 458, 461 (1993).  Further, examiners cannot ignore a veteran's statements related to lay observable symptoms.  See Dalton v. Nicholson, 21 Vet. App. 23 (2007).  Based on the foregoing insufficiencies, the Board finds a new examination and medical opinion are necessary prior to final adjudication of this matter.

Accordingly, these matters are REMANDED for the following actions:

Afford the Veteran a VA examination by an examiner with sufficient experience and expertise, who has not previously examined this Veteran, to address the etiology of the Veteran's claimed lumbar spine disability.  All pertinent evidence of record must be made available to and reviewed by the examiner.  Any indicated studies should be performed.

(Continued on the next page)

 

Following a review of the relevant records and lay statements, the examiner should state an opinion with respect to whether any diagnosed lumbar spine disability, to specifically include degenerative disc disease and strain, at least as likely as not (a 50 percent probability or greater) originated during his period of active service or is otherwise etiologically related to his active service.

The examiner must specifically address the Veteran's reports relative to the etiology of the claimed disability.  If the examiner is unable to provide any required opinion, he or she should explain why.  If the examiner cannot provide an opinion without resorting to mere speculation, he or she shall provide a complete explanation as to why this is so.

 

 

T. REYNOLDS

Veterans Law Judge

Board of Veterans' Appeals

Attorney for the Board	G. Fraser, 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.