Citation Nr: 21028996 Decision Date: 05/12/21 Archive Date: 05/12/21 DOCKET NO. 16-40 644 DATE: May 12, 2021 REMANDED Entitlement to service connection for a low back disability is remanded. REASONS FOR REMAND The Veteran served on active duty in the Army from February 1992 to July 1992 and in the Air Force from December 2001 to March 2002 and from April 2003 to March 2004, with additional service in the Air Force Reserve until his retirement in June 2012. This matter is before the Board of Veterans' Appeals (the Board) on appeal from an October 2014 rating decision issued by a Department of Veterans Affairs (VA) Regional Office (RO). The Board previously remanded this matter in January 2019, for further development. Unfortunately, as explained below, the Board finds that additional development action is required. Entitlement to service connection for a low back disability is remanded. The Veteran seeks service connection for a low back disability which he contends is the result of an injury sustained during a period of active duty. The Veteran contends that he was on "30 day orders" in March 2003 when he injured his back. See July 2020 statement. The Veteran explained that he was "on orders for 30 days prior to [his] 1 year activation" and that "not all orders have a DD-214" associated with them. The Board remanded this matter for the RO to obtain the Veteran's complete service personnel records, and to verify all active duty for training and inactive duty training dates for alleged Air Force Reserve service from 2003 to 2012. The Board also directed the RO to obtain a VA examination to assess the nature and etiology of the Veteran's low back disability. A response from the Defense Personnel Records Information Retrieval System (DPRIS), indicates that for the period of March 16, 2003 to March 31, 2003, the Veteran was on "Active Duty Other," service. Accordingly, this information supports the Veterans contentions that he was on active duty for training (ACDUTRA) at this time. The Veteran's available service treatment records document the Veteran's complaints of, and treatment for, a "pulled back muscle" on March 18, 2003. He was assessed with acute lumbar spine strain. The Veteran provided a lay statement from a buddy describing the March 2003 back injury and the pain the Veteran endured after he sustained the injury as they were preparing for deployment. See June 2015 lay statement. On a post deployment self-assessment health questionnaire completed in February 2004, the Veteran noted that he experienced back pain during and after the deployment. See February 2004 VA treatment record. In October 2019, a VA examiner opined that the Veteran's current back disability was not related to service because her review of the file found he had service beginning on April 2003. He complained of back pain on March 18, 2003, before his re-enlistment period, so a nexus was not established. However, with the development above, which was not provided to the October 2019 VA examiner, the Veteran was on a period of ACDUTRA at the time of the March 18, 2003 service treatment record documenting the back pain and treatment. Hence, the opinion was based on inaccurate information and an addendum opinion on remand is required. The matter is REMANDED for the following actions: 1. Forward the claims file to the October 2019 VA examiner, if available or otherwise to a similarly qualified examiner to provide an addendum opinion regarding the nature and etiology of the Veteran's low back disability. Only if a VA examination is required to provide the requested opinion should one be scheduled. Thereafter, the examiner is asked to provide a fully-articulated opinion addressing the following: (a) Whether it is at least as likely as not (50 percent or greater probability) that any low back disability had its onset in or is related to any period of active service or any period of ACDUTRA (to include from March 16, 2003 to March 31, 2003). In providing this opinion, the examiner must specifically address, and attempt to reconcile, the evidence of record, to include: The Veteran's March 18, 2003 complaint of "pulled back muscle," and his provider's assessment of acute lumbar spine strain, as documented in his STRs The August 2013 private opinion from S.C., DC, stating that in his professional opinion, the degenerative changes in the Veteran's back more likely than not stem from injuries he sustained while serving in the Air Force, and the Veteran's fall which fit the profile for the precipitating trauma that has led to the Veteran's current condition The Veteran's April 2003 Self-Assessment Questionnaire response that he developed back pain during deployment and continued to have back pain at the time of the questionnaire June 2015 buddy statement from fellow serviceman D.S., stating that he observed the Veteran's back injury and that the Veteran has complained about back pain ever since. Reconcile the October 2019 VA opinion that the Veteran's current back disability was not related to service because the examiner's review of the file found he had service beginning on April 2003, and the Veteran had complained of back pain on March 18, 2003, before his re-enlistment period for active duty however, as noted above, on March 18, 2003, the Veteran was indeed in a period of ACDUTRA. The examiner is advised that the term "at least as likely as not" does not mean "within the realm of possibility." Rather, it means that the weight of the medical evidence both for and against the claim is so evenly divided that it is as medically sound to find in favor of the claim as it is to find against it. The examiner must provide a complete rationale for any opinions offered, citing to the examiner's own expertise, medical principals, and/or evidence in the Veteran's record, when necessary, to support the conclusion reached. If an opinion cannot be reached without resorting to speculation, the examiner must fully explain why that is so. LESLEY A. REIN Veterans Law Judge Board of Veterans' Appeals Attorney for the Board C. Gates 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.