Citation Nr: 21031011
Decision Date: 05/20/21	Archive Date: 05/20/21

DOCKET NO. 16-42 643
DATE: May 20, 2021

REMANDED

Entitlement to service connection for a back disability is remanded.

REASONS FOR REMAND

The Veteran had active duty service with the U.S. Army from July 1984 to May 1987 and from February 1991 to February 1993.

This case comes before the Board of Veteran's Appeals (Board) on appeal from a June 2013 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO).

In November 2018 remand, the Board directed that the Veteran be afforded an examination to determine the etiology of any current back disability. The examiner was specifically directed to consider the Veteran's competent lay statements indicating that he first experienced back pain in service and that the pain had continued since that time. Unfortunately, the November 2019 VA examiner failed to discuss these lay statements, or even to acknowledge them, focusing instead on the absence of documentary medical evidence. The resulting opinion was based on an absence of medical treatment and is therefore inadequate and requires remand. Stegall v. West, 11 Vet. App. 268, 271 (1998).

The matters are REMANDED for the following action:

1. Obtain updated VA treatment records. 

2. Schedule the Veteran for a VA lumbar spine examination. The claims folder must be reviewed in conjunction with the examination. The examiner must opine as to whether it is at least as likely as not that the Veteran's back disability was caused or aggravated by service.

In forming the opinion, the examiner must address the Veteran's statements regarding the onset and continuity of symptoms.

3. Thereafter, readjudicate the remanded issues. If any benefit sought remains denied, issue a supplemental statement of the case. The case should then be returned to the Board for appellate review if otherwise in order.

 

 

WILLIAM H. DONNELLY

Veterans Law Judge

Board of Veterans' Appeals

Attorney for the Board	S. Baxter 

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 This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.