Citation Nr: 22014145 Decision Date: 03/11/22 Archive Date: 03/11/22 DOCKET NO. 15-10 435A DATE: March 11, 2022 ORDER Entitlement to service connection for cervical spine spondylolysis with partial facetectomy, and foraminotomy (hereinafter "cervical spine disability") is granted. REMANDED Entitlement to service connection for an eye disability is remanded. FINDING OF FACT Resolving reasonable doubt in the Veteran's favor, his cervical spine disability is proximately due to his service-connected disabilities. CONCLUSION OF LAW The criteria for entitlement to service connection for a cervical spine disability are met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.310. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty in the United States Air Force from February 1973 to April 1976. This matter comes to the Board of Veterans' Appeals (Board) from a May 2013 rating decision of a Department of Veterans Affairs (VA) Veterans Benefits Administration (VBA). The Board remanded these issues to VBA for additional development in July 2018, March 2021, and August 2021. The Board finds that, with respect to the claim for a cervical spine disability, VBA substantially complied with remand directives, and the issue is ready for adjudication. Stegall v. West, 11 Vet. App. 268 (1998). Unfortunately, the Board finds that a Remand is warranted as the October 2021 VA medical opinion and December 2021 VA addendum opinion are inadequate. Barr v. Nicholson, 21 Vet. App. 303 (2007). The Board notes that in a November 2021 correspondence, the Veteran's then-attorney withdrew as his representative. See 38 C.F.R. §§ 14.631(c). The Veteran was made aware of the withdrawal and has not appointed another representative; the Board does not recognize any representation at this time. Entitlement to service connection for a cervical spine disability. The Veteran contends his cervical spine disability is caused or aggravated by his service-connected disabilities. The Board agrees. The November 2021 neck VA examination report shows the Veteran has a current disability of the cervical spine. The record reflects that in a November 2021 rating decision, VBA granted service connection for the Veteran's left shoulder. Review of the November 2021 shoulder VA examination report notes the examiner's opinion that the Veterans' left shoulder was caused by a fall the Veteran sustained in 2007 at work after his right knee gave way while carrying a skid down a flight of stairs. The Board notes that this incident has been repeatedly reiterated by the Veteran throughout VA and private treatment as the cause of his shoulder, neck, and knee pain. The Board has no reason to doubt the veracity of the Veteran's statements as he has consistently asserted that his neck pain began after this fall and being that this was the basis of service connection being granted for the Veteran's left shoulder, the Board finds it also reasonable to conclude that the same accident caused his cervical spine disability. Further, the medical evidence of record notes the Veteran's cervical spine disability worsened since the 2007 fall and he had to undergo surgery for his disability in 2010. Accordingly, after resolving all doubt in favor of the Veteran, the Board finds that service connection for a cervical spine disability is warranted. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. REASONS FOR REMAND Entitlement to service connection for an eye disability is remanded. Unfortunately, there has not been substantial compliance with the Board's previous remand directives regarding the issue. Another remand is required. Stegall v. West, 11 Vet. App. 268, 271 (1998). Here, the Board instructed VBA in its August 2021 decision, to afford the Veteran an additional VA examination and obtain a medical opinion on the Veteran's eye disabilities on a secondary basis. The examiner was specifically instructed to address a December 2011 outpatient treatment note and July 2012 and December 2019 VA examinations reports and provide a complete rationale for the opinions. Review of the October 2021 VA medical opinion reflects the examiner did not consider any of the identified medical evidence and did not provide any rationale for the opinion. The examiner simply stated that the Veteran's cataracts were most likely age related, Fuchs dystrophy is a genetic dystropy and exophoria was present most of the Veteran's life and none of the disorders were aggravated by a service connected disability. Additionally, the examiner found that the Veteran also suffered from pseudophakia of both eyes but failed to address the etiology of this condition. VBA acknowledged that the October 2021 medical opinion was inadequate and attempted to obtain an adequate medical opinion prior to adjudicating the claim. In December 2021, VBA requested the same examiner provide a complete rationale for the opinions noted in the October 2021 medical opinion. The examiner still failed to address the medical evidence the Board specifically noted in its August 2021 decision, and the examiner did not provide any rationale for the opinions but merely restated the same conclusions from the October 2021 medical opinion without addressing the etiology of the new diagnosis of pseudophakia. As such, the Board finds remand is required to comply with previous remand directives. The matter is REMANDED for the following action: 1. Schedule the Veteran for an appropriate VA examination to determine the nature and etiology of his eye disabilities. The electronic claims file must be reviewed by the examiner. All indicated tests and studies should be performed and the clinical findings should be reported in detail. The examiner should address the following: (a.) The examiner must address the following evidence: (1) the December 2011 outpatient treatment note indicating that exophoria is the "likely cause of reading difficulty and diplopia;" (2) the July 2012 and December 2019 VA examinations indicating that changes in vision and sensitivity to light are migraine symptoms. (b.) The examiner must opine as to whether it is at least as likely as not (an approximate balance of positive and negative evidence) that the Veteran's eye disability, to include Fuchs' endothelial corneal dystrophy, cataracts, exophoria, or pseudophakia is CAUSED OR AGGRAVATED (worsened) beyond its natural progress by the Veteran's service-connected migraines. If aggravation of any eye disability by service-connected migraines is shown, the examiner should objectively quantify, to the extent possible, the degree of aggravation beyond the level of impairment, had no aggravation occurred. A complete rationale must be provided for all expressed opinions. A clearly stated rationale must include a discussion of medical principles and must not be based solely on lack of documentation or records. The reasons for any opinion must include a discussion of the relevant evidence. If the clinician cannot provide a requested opinion without resorting to speculation, it must be so stated, and the clinician must provide the reasons why. 2. Thereafter, readjudicate the claim on appeal. If the benefit sought remains denied, issue the Veteran a supplemental statement of the case and provide a reasonable opportunity to respond before returning the matter to the Board for further appellate review. K.A. KENNERLY Veterans Law Judge Board of Veterans' Appeals Attorney for the Board K. McDuffie, 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.