Citation Nr: 21041953 Decision Date: 07/10/21 Archive Date: 07/10/21 DOCKET NO. 17-02 733 DATE: July 10, 2021 REMANDED Entitlement to service connection for degenerative disc disease of the lumbar spine is remanded. REASONS FOR REMAND The Veteran served on active duty in the United States Army from October 1966 to October 1968, including extensive combat service in the Vietnam War. The Veteran was awarded several decorations for personal valor in combat, to include the Combat Infantryman Badge. This appeal comes before the Board of Veterans' Appeals (Board) from a May 2014 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO) in Columbia, South Carolina. In April 2021, the Veteran testified at a video conference hearing from Columbia, South Carolina, before the undersigned Veterans Law Judge sitting in the vicinity of the Central Office in Washington, D.C. A transcript of the hearing is available in the record. After the hearing, the Veteran request an additional 30 days to obtain supporting evidence. 6/03/2021 VA 21-4138. Shortly thereafter, the Veteran cancelled this request. 6/04/2021 VA 21-4138. Entitlement to service connection for degenerative disc disease lumbar spine is remanded. At his hearing before the Board, the Veteran testified that he developed recurrent lower back pain due to combat action during active military service, and that he sought treatment from a private chiropractor beginning approximately one year after his discharge in 1970. See April 2021 Hearing Transcript. The Veteran was afforded a VA examination in May 2013. The examiner documented the Veteran's lay reports of lower back injury during combat in Vietnam, which the examiner described as a lower back strain. The diagnosis was L5 compression deformity and degenerative disc disease. However, the examiner's opinion was limited to a conclusion that the back condition was not secondarily caused or aggravated by diabetes mellitus. The examiner did not address whether the Veteran's lower back condition was directly due to active service, or chronic since active service, other than noting that they are degenerative in nature. See May 2013 VA Examination. Once VA undertakes the effort to provide a medical examination or opinion, it must provide an adequate one. Barr v. Nicholson, 2 Vet. App. 303, 311-12 (2007). A medical opinion is adequate where it is based upon consideration of a veteran's prior medical history and examination, and describes the disability at issue in sufficient detail to allow the Board's evaluation of a claim to be a fully informed one. Stefl v. Nicholson, 21 Vet. App. 120, 123 (2007). Here, as the examiner's opinion did not address service connection on a direct basis, or on a presumptive basis due to chronicity of symptomatology, the opinion is not sufficient for the Board to render a decision on the issue on appeal at this time. As such, a remand is warranted for a VA examination and medical opinion. This matter is REMANDED for the following action: Schedule the Veteran for an appropriate VA examination to determine the nature and etiology of his lower back degenerative disc disease. The examiner should indicate review of the complete claim file, and provide answers to the following questions: (a.) Is it at least as likely as not (about 50 percent probability or greater) that the Veteran's lower back condition was caused by an in-service combat injury to his lower back? **The examiner's attention is invited to the finding at a VA examination in May 2013 that the Veteran suffered a lower back strain during combat in Vietnam. See 5/08/2013 VA Examination, at 3. At the 2021 hearing, the Veteran reported being blown off a hatch into the air and onto the ground as well as changing M-50 caliber machine guns that weight approximately 100 pounds. See 4/06/2021 Hearing Transcript, at 4. The examiner is to assume as true that the Veteran sustained such injury due to his combat service.** (b.) Is it at least as likely that the Veteran's lower back condition onset during service or within one year of his discharge from service and has continued since that time? In answering the above question, the examiner should address the Veteran's lay reports at his hearing that he experienced lower back pain during service and sought private chiropractic treatment in approximately 1970. The examiner must provide a complete rationale for his or her opinion(s) in the examination report. If any of the above requested opinions cannot be made without resort to speculation, the examiner must state this and provide a rationale for such conclusion. Paul Sorisio Veterans Law Judge Board of Veterans' Appeals Attorney for the Board J. Hermsdorfer, 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.