Citation Nr: 21030371 Decision Date: 05/18/21 Archive Date: 05/18/21 DOCKET NO. 16-06 927 DATE: May 18, 2021 REMANDED Entitlement to service connection for degenerative disc disease of the lumbar spine is remanded. Entitlement to special monthly compensation due to housebound status is remanded. REASONS FOR REMAND The Veteran served on active duty in the United States Air Force from September 1981 to December 1981. This matter comes to the Board of Veterans' Appeals (Board) on appeal of a VA RO rating decision. In July 2019, the Veteran testified in a videoconference hearing before the undersigned Veterans Law Judge. A transcript of the hearing is included in the electronic record and has been reviewed. This case was previously before the Board, most recently in October 2020, when remanded for VA medical opinions. 1. Entitlement to service connection for degenerative disc disease of the lumbar spine is remanded. Once VA undertakes to provide an examination, it must provide an adequate one. Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). In October 2020, the Board directed a VA examiner to "consider and discuss the November and December 1981 in-service complaints of back pain, the Veteran's lay statements reporting constant pain since his in-service injury and the post-service 1986 workplace injury." In November 2020, a VA examiner offered opinions that the Veteran's intervertebral disc syndrome, lumbar spine, foraminal stenosis, bulging disc condition was less likely than not (less than 50 percent probability) incurred in, caused by, or unmistakably aggravated beyond natural progression by an inservice injury, event, or illness. The opinion, however, does not consider all the relevant evidence of record, including lay statements. Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008); Dalton v. Nicholson, 21 Vet. App. 23 (2007). In December 2020, VA received additional medical evidence related to the Veteran's back condition, including treatment notes that did not appear to be a part of the record at the time the November 2020 VA examiner had an opportunity to review the medical evidence or record. More importantly, in January 2021, the Veteran submitted an additional statement providing clarification about back injuries and recovery from back injuries before, during, and after service. An addendum VA medical opinion addressing this evidence is warranted. 2. Entitlement to special monthly compensation due to housebound is remanded. Finally, because a decision on the remanded issue of entitlement to service connection for degenerative disc disease of the lumbar spine could significantly impact a decision on the issue of entitlement to special monthly compensation due to housebound, the issues are inextricably intertwined. A remand of the claims for entitlement to special monthly compensation due to housebound is required. The matters are REMANDED for the following action: 1. In remanding this matter, the Board makes no finding, implicit or otherwise, as to the credibility of the Veteran's assertions. Neither the Veteran's credibility nor any lack thereof should be presumed in this remand. 2. Acquire updated VA and private treatment records. If such records are unavailable, the Veteran's claim file must be clearly documented to that effect and the Veteran notified in accordance with 38 C.F.R. § 3.159(e). 3. Obtain an addendum opinion from an appropriate clinician regarding the Veteran's degenerative disc disease of the lumbar spine. The examiner must review the claims file, including a copy of this remand order, the evidence associated with the claims file in December 2020, and the Veteran's statement received in January 2021. The examiner is asked to provide a response to the following: (a.) Is degenerative disc disease of the lumbar spine at least as likely as not related to service, including a football injury? (b.) Did degenerative disc disease of the lumbar spine clearly and unmistakably (undebatable) preexist the Veteran's service? (c.) If the examiner finds it did clearly and unmistakably preexist service, was it clearly and unmistakably not aggravated by service? (d.) If the examiner finds that it either did not clearly and unmistakably preexist service, or was not clearly and unmistakably aggravated by service, the examiner must opine whether it is at least as likely as not related to service, including a football injury. (e.) Did the Veteran's back condition, which existed prior to service, at least as likely as not increase in severity during service? (f.) If so, was the increase in severity clearly and unmistakably (undebatable) due to the natural progress of the disease? Provide a rationale to support the opinions. The examiner should identify and explain the relevance or significance, as appropriate, of any history, clinical findings, medical knowledge or literature, etc., relied upon in reaching the conclusions. If the medical professional cannot provide an opinion without resorting to mere speculation, the medical professional shall provide a complete explanation for why an opinion cannot be rendered. In so doing, the medical professional shall explain whether the inability to provide a more definitive opinion is the result of a need for additional information, or that he or she has exhausted the limits of current medical knowledge in providing an answer to that particular question. In providing the requested opinion, consider the Veteran's description of in-service injury and symptoms as well as post-service symptoms. If there is any medical reason to accept or reject the proposition that the Veteran's reported injury and symptoms in service and thereafter represented the onset of current disability, this should be noted. Stated another way, do the Veteran's reports about symptoms align with how the currently diagnosed disability is known to develop or are the Veteran's reports generally inconsistent with medical knowledge or implausible? In all opinions rendered, the examiner is advised that the Veteran is competent to report symptoms, including symptoms after separation from service and before any intervening injuries. The examiner must consider and discuss the November and December 1981 in-service complaints of back pain, the Veteran's lay statements and sworn testimony reporting constant pain since the in-service injury and the post-service 1986 workplace injury. (Continued on the next page) The opinion and rationale must go beyond generalized statements that the evidence does not support the Veteran's claim. The rationale must reflect the specific facts and medical principles specific to the claim. If there is a medical basis to support or doubt the medical history provided by the Veteran, the examiner should so indicate and provide a fully reasoned explanation for this finding. 4. After the above development, and any additionally indicated development, has been completed, readjudicate the issue on appeal, including the inextricably intertwined issue of entitlement to special monthly compensation due to being housebound. If the benefit sought is not granted to the Veteran's satisfaction, send the Veteran and representative a Supplemental Statement of the Case and provide an opportunity to respond. If necessary, return the case to the Board for further appellate review. G. A. WASIK Veterans Law Judge Board of Veterans' Appeals Attorney for the Board James Hekel 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.