Citation Nr: 22012504
Decision Date: 03/04/22	Archive Date: 03/04/22

DOCKET NO. 17-04 137
DATE: March 4, 2022

REMANDED

Entitlement to service connection for a lower back condition is remanded.

REASONS FOR REMAND

The Veteran served on active duty from October 1968 to March 1974 and August 1983 to July 1985.

This matter comes before the Board of Veterans' Appeals (Board) on appeal from an April 2014 rating decision by the Department of Veterans Affairs (VA). This case was remanded in January 2019 and July 2021 for further development; it has since been re-assigned to the undersigned.

Entitlement to service connection for a lower back condition.

The Veteran reported a back injury when he fell on a pier in 1985 and pain since that time. See, e.g., December 2019 VA examination. Service treatment records (STRs) confirm the fall. See February 1985 STRs. STRs from January 1984 also reflect a back injury.

In July 2021, this matter was remanded for a new medical opinion due to noncompliance with the Board's prior remand directive. Specifically, a December 2019 VA medical opinion did not discuss September 2013 private medical opinions that are inadequate, but otherwise reflect that the Veteran's treating physician believed his current back condition was incurred during service.

In October 2021, a VA examiner opined it was less likely than not that the Veteran's degenerative arthritis and degenerative disc disease were related to service. However, the examiner again did not discuss the September 2013 private medical opinions in his rationale. Moreover, the examiner did not discuss the Veteran's report of continued back pain after he fell from the pier during service. As a result, the opinion is inadequate, and remand for a new opinion is necessary. See Stegall v. West, 11 Vet. App. 268, 271 (1998).

The matter is REMANDED for the following action:

1. The AOJ should obtain copies of VA treatment records from November 2021 to the present.

2. After the above development is completed, the AOJ should arrange for a VA medical opinion, with examination or telehealth interview of the Veteran only if deemed necessary by a medical professional, to determine the nature and likely cause of any lumbar spine disability. The examiner should review the claim file (including this remand) and note such review was conducted. Based on review of the record, the examiner should provide an opinion with detailed rationale that responds to the following:

For each lumbar spine disability diagnosed, is it at least as likely as not (50% or greater probability) that such disability was either incurred in or otherwise related to the Veteran's military service? Please explain why. The examiner must consider the Veteran's report that his back pain began in service and continued from that time. The examiner must discuss the September 2013 private medical opinions that the Veteran's back condition was incurred during service. The examiner may not rely solely on the absence of evidence in STRs or records immediately after service.

3. If upon completion of the above action the issue remains denied, the case should be returned to the Board after compliance with appellate procedures.

 

 

E. I. VELEZ

Veterans Law Judge

Board of Veterans' Appeals

Attorney for the Board	J. Sandler, 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.