Citation Nr: 21030035 Decision Date: 05/17/21 Archive Date: 05/17/21 DOCKET NO. 17-46 258 DATE: May 17, 2021 REMANDED Entitlement to service connection for a back condition is remanded. REASONS FOR REMAND The Veteran served on active duty in the United States Marines from August 2003 to August 2007. This September 2017 appeal comes before the Board of Veterans' Appeals (Board) from a November 2015 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO), in Phoenix, Arizona. The Veteran also initiated an appeal for service connection for tinnitus, however that issue was granted in a July 2017 rating decision which represents a full grant of benefits and therefore it is no longer before the Board. In the Veteran's September 2017 appeal, he requested a Board hearing by videoconference. The Veteran was afforded a Board hearing in June 2020 on the remaining issue on appeal. 1. Entitlement to service connection for a back condition is remanded. The Veteran claims his current back condition was caused by his active duty service. During a June 2017 VA examination for his back condition, the Veteran was diagnosed with a lumbar strain. He reported the onset of his back pain was during boot camp in 2003 due to increased running, lifting, and hiking. The Veteran denied any injury or trauma. The Veteran reported that his symptoms have progressed over the years and that now he has constant mild back pain with periods of increasing pain due to overuse or certain movements. The examiner noted that the Veteran's January 2006 x-rays indicated minimal upper dorsal scoliosis. The examiner opined the Veteran's back condition was less likely than not due to his active service because the Veteran's scoliosis was a developmental condition and the Veteran had not had chronic medical treatment for his back condition after discharge from service. Although the Veteran was diagnosed with congenital scoliosis, his entrance examination was silent for any congenital defect or disease. Further, the June 2017 VA examination does not include an opinion regarding whether the Veteran's congenital scoliosis is a congenital disease or defect. See Quirin v. Shinseki, 22 Vet. App. 390, 395 (2009) (where a congenital condition is at issue, a VA medical opinion may be needed to determine whether the condition is a disease or defect...). Therefore, the Board finds the examination is inadequate and an addendum medical opinion is necessary. The matters are REMANDED for the following action: 1. Obtain an addendum medical opinion from an appropriate medical professional regarding the Veteran's congenital scoliosis. The claims file should be made available for review, and the examination report should reflect that such review occurred. Following the review of the record, the examiner should respond to the following: a. Is the Veteran's scoliosis considered to be a congenital defect (more or less static in nature) or congenital disease (capable of improving or deteriorating) for VA purposes? (The examiner is advised that for the purposes of VA compensation, a "congenital defect or abnormality" is defined as a condition that is more or less stationary in nature, whereas a "congenital disease" is defined as a condition capable of improving or deteriorating.) b. If his scoliosis is a congenital defect, is it at least as likely or not (a 50 percent probability or greater) that there was a superimposed disease or injury in-service that resulted in an additional disability of the back? c. If his scoliosis is a congenital disease, is it clear and unmistakable that the Veteran's back was not aggravated in service? Please determine whether it is clear and unmistakable that there was no increase during service, or that it is clear and unmistakable that any increase in disability was due to the natural progression of the pre-existing condition. d. Are the Veteran's thoracic and lumbar lesions related to, or caused by, the Veteran's scoliosis? e. If the thoracic and lumbar lesions are not related to, or caused by, the Veteran's scoliosis, are they at least as likely or not (a 50 percent probability or greater) due to, or caused by, the Veteran's active service? It should be noted that the Veteran is competent to attest to observable symptomatology. The examiner's opinion must include a discussion regarding the Veteran's statements concerning the in-service onset of the claimed condition and the continuity of symptomatology he has experienced since service. The examiner is reminded that a medical opinion based solely on the absence of documentation in the record or that does not address the Veteran's reports of symptoms and history is inadequate. If there is a medical basis to support or doubt the history provided by the Veteran, the examiner should provide a fully reasoned explanation. A rationale for all opinions expressed should be provided as the Board is precluded from making medical findings. A discussion of the facts and the medical principles involved will be of considerable assistance to the Board, including citation to any supporting medical treatises. J. B. FREEMAN Veterans Law Judge Board of Veterans' Appeals Attorney for the Board C. Aubee, 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.