Citation Nr: 21041022 Decision Date: 07/07/21 Archive Date: 07/07/21 DOCKET NO. 16-55 448 DATE: July 7, 2021 REMANDED The issue of service connection for a lower back disability is remanded. REASONS FOR REMAND The Veteran served on active duty in the United States Army from September 1972 to September 1977. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a May 2015 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO). In November 2018, the Board remanded this matter for additional development. Service Connection for a Lower Back Disability is Remanded. The matters are REMANDED for the following action: 1. BACKGROUND FOR THE ADJUDICATOR The RO obtain an addendum opinion about the cause of the Veteran's lower back etiology in November 2019. However, this opinion misstates the facts of the record. The clinician indicated there are no active duty records documenting a back complaint or pathology. However, the Veteran reported the use of a back brace and recurrent back pain in a February 1976 report of medical history and in August 1976 the Veteran received treatment for low back pain that was diagnosed as a strain. Since the clinician's opinion was based on an inaccurate reading of the record, the opinion is inadequate. A remand is necessary to obtain an addendum opinion. The claims file indicates the Veteran is receiving disability benefits from the Social Security Administration (SSA). However, SSA records are not in the record. The RO must obtain and associate those records with the Veteran's claims file. The RO has incorrectly identified the Veteran's active service period in rating decisions, code sheets, and to clinicians as October 1974 to September 1977. The Veteran's military personnel records contain two DD-214s. One for the period of September 1972 to October 1974 and one for the period of October 1974 to September 1977. Upon remand, the RO should correctly identify the Veteran's service period in procedural documents and to clinicians. SPECIFIC REMAND DIRECTIVES FOLLOW. 2. Make any necessary changes to the Veteran's claims file to accurately reflect the Veteran's period of service as September 1972 to September 1977. 3. Request from the SSA relevant records, including determinations and medical records, regarding any claim for disability benefits. All attempts to fulfill this development should be documented in the claims file. If the records are unavailable, the Veteran should be informed of the reason and provided the opportunity to provide copies of the records the Veteran may possess. 4. Obtain copies of any outstanding VA treatment records. 5. Return the claims file to the November 2019 VA clinician, and request she again review the claims file and respond to the inquiry below. If the examiner is not available, arrange for another appropriately-qualified VA examiner to provide an addendum medical opinion to assist in determining the etiology of the Veteran's lower back disorder. All appropriate tests, studies and consultations should be accomplished, including a new medical examination if necessary, and all clinical findings should be reported in detail in the narrative portion of the examination report. THE EXAMINER MUST PROVIDE A COMPREHENSIVE EXPLANATION FOR HER OPINION A SUMMARY CONCLUSION IS NOT SUFFICIENT FOR APPELLATE REVIEW. The examiner must provide an opinion as to whether the Veteran's current low back disability is related to his active service, to include reports of recurrent back pain, use of a back brace, or lower back strain documented in service treatment records trauma THE EXAMINER MUST REVIEW THE ENTIRE RECORD IN CONJUNCTION WITH RENDERING THE REQUESTED OPINION. SPECIAL ATTENTION SHOULD BE PAID TO: *A FEBRUARY 1976 REPORT OF MEDICAL HISTORY THAT INDICATES THE VETERAN HAS RECURRENT BACK PAIN AND USES A BACK BRACE. *AN AUGUST 1976 SERVICE TREATMENT RECORD INDICATING THE VETERAN REPORTED LOWER BACK PAIN AND WITH AN IMPRESSION NOTED AS STRAIN. *A NOVEMBER 2015 VA TREATMENT RECORD INDICATING THE VETERAN REPORTS BACK PAIN FOR THE PAST 10 OR 15 YEARS. A thorough explanation must be provided for the opinion rendered. If the examiner cannot provide the requested opinion without resorting to speculation, s/he should expressly indicate this and provide supporting rationale as to why the opinion cannot be made without resorting to speculation. 6. Readjudicate the issue on appeal. If the benefit sought on appeal remains denied, the Veteran should be provided a supplemental statement of the case (SSOC). Vito A. Clementi Veterans Law Judge Board of Veterans' Appeals Attorney for the Board S. Reed, 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.