Citation Nr: 21031699 Decision Date: 05/24/21 Archive Date: 05/24/21 DOCKET NO. 15-26 487 DATE: May 24, 2021 REMANDED Entitlement to service connection for a cervical spine disability is remanded. REASONS FOR REMAND The Veteran served on active duty from July 1999 to March 2005. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a January 2014 and August 2015 rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO). This matter was previously remanded in January 2020 for additional development. The Board finds that more development is necessary prior to final adjudication of the claim on appeal. Notably, in its January 2020 remand, the Board found a November 2016 VA cervical spine examination report inadequate on the basis the VA examiner did not provide an adequate explanation for rejecting the Veteran's lay statements of cervical spine symptoms or why imaging of the Veteran's cervical spine was not warranted. As a result, the Board remanded this issue for additional development to obtain a medical opinion as to whether the Veteran had a current cervical spine disability that was related to his service. Per the January 2020 Board remand instructions, the Veteran underwent a VA examination in October 2020. However, the Board finds the October 2020 VA cervical spine examination provided in connection with the Veteran's claim for service connection for a cervical spine disability is inadequate. The Board notes that there is some question as to whether or not the Veteran has a current cervical spine disability. Notably, the October 2020 VA examiner determined that the Veteran did not have a current cervical spine disability based on the symptoms presented during evaluation. However, the examiner also remarked that "diagnostic findings on cervical spine MRI and/or electrodiagnostic studies suggesting a radicular pathologic process would be helpful in supporting [the Veteran's] claims. The Board notes that the October 2020 VA cervical spine examination did not include any imaging studies or an adequate explanation for why such studies were not conducted. Additionally, the VA examiner indicated that imaging results would be helpful in determining if the Veteran had a current cervical spine disability in related to the Veteran's self-reports of symptoms. Therefore, remand is necessary to obtain an adequate medical examination and medical opinion addressing the current nature of the Veteran's self-reported cervical spine disability condition. Barr v. Nicholson, 21 Vet. App. 303, 309 (2007). The matters are REMANDED for the following action: 1. The RO should take appropriate steps to confirm the Veteran's address, to include contacting the representative. Thereafter, the Veteran should be requested to provide the names, addresses and approximate dates of treatment of all medical care providers, VA and non-VA, who have treated him for the disability on appeal. After the Veteran has signed the appropriate releases, those records should be obtained and associated with the claims folder. 2. Provide the Veteran with an appropriate examination to determine the etiology of his claimed cervical spine disability. The entire claims file must be made available to and be reviewed by the examiner. X-rays or imaging studies of the cervical spine must be conducted. Any indicated tests and studies must be accomplished and all clinical findings must be reported in detail and correlated to a specific diagnosis. An explanation for all opinions expressed must be provided. (a.) The examiner must provide an opinion regarding whether it is at least as likely as not (50 percent or greater probability) that any diagnosed cervical spine disability had onset in, or is otherwise related to, active military service. (Continued on the next page) (b.) The examiner must specifically address the Veteran's assertions of an in-service cervical spine injury and continuing cervical spine symptoms since separation from service. Additionally, the examiner must address and discuss imaging results of the cervical spine in relation to any cervical spine diagnosis. 3. After the above development, and any additionally indicated development, has been completed, readjudicate the issue on appeal. If the benefit sought is not granted to the Veteran's satisfaction, send the Veteran and his 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. James A. DeFrank Acting Veterans Law Judge Board of Veterans' Appeals Attorney for the Board J. Dworkin, 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.