Citation Nr: 22014240 Decision Date: 03/11/22 Archive Date: 03/11/22 DOCKET NO. 19-36 259A DATE: March 11, 2022 REMANDED Entitlement to service connection for thoracolumbar spine degenerative arthritis is remanded. REASONS FOR REMAND The Veteran served on active duty from February 1954 to October 1957. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a September 2018 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO). 1. Entitlement to service connection for thoracolumbar spine degenerative arthritis is remanded. The Veteran asserts that his diagnosed thoracolumbar spine degenerative arthritis is related to service. Specifically, he asserts that he injured his back after suffering a motor vehicle accident in service in the summer of 1955. See August 2017 Statement in Support of Claim. He submitted a photocopy of an article which is largely illegible, however the words "motorist", "collision", and the Veteran's full name are decipherable. See October 2018 Correspondence. Unfortunately, the Veteran's Service Treatment Records (STRs) were unable to be located by the RO. See November 2019 Correspondence. However, in a June 2010 VA medical treatment note, the Veteran reported that he receives treatment from private doctors and will continue to do so. He also stated that he received a laminectomy at Adena Hospital in 2009. On remand, these private medical records must be obtained. Additionally, the most recent VA Medical Records date back to May 2017. On remand, his complete VA medical treatment records must be obtained. The Veteran was afforded a VA examination in June 2018, where he was diagnosed with degenerative arthritis of the spine. A VA medical opinion was obtained by a different VA examiner in September 2018, who stated that the Veteran's degenerative arthritis of the spine was not related to service. The VA examiner explained that the Veteran's available records did not show complaints or treatment of a back condition during service, a back injury visit was not noted during service, degenerative arthritis was diagnosed the day of the VA examination more than 60 years after service, and thus concluded that his low back disability was related to advanced age. The Board finds the September 2018 VA medical opinion inadequate for a number of reasons. Firstly, the VA examiner bases her opinion largely on the fact that there was no documented injury in service. As noted above, the Veteran's STRs were deemed irrecoverable, therefore it would be impossible to have a documented in-service injury. Additionally, the VA examiner incorrectly states that the Veteran was first diagnosed with degenerative arthritis on the day of the June 2018 VA examination. To the contrary, VA medical treatment records show a notation of degenerative disc disease of the spine as early as June 2010, and as noted above, relevant medical records are missing from the Veteran's file, thus making it possible that he was diagnosed with a lower back condition much earlier than "greater than 60 years post service..." Finally, the September 2018 VA medical examiner did not address the Veteran's competent lay statements regarding his in-service injury at all. When VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). Accordingly, a new medical opinion is warranted. The matters are REMANDED for the following action: 1. Ask the Veteran to identify all outstanding treatment records relevant to his claim. All identified VA records should be added to the claims file, to include VA records dated since May 2017. All other properly identified records should be obtained if the necessary authorization to obtain the records is provided by the Veteran, to include private treatment records regarding his October 2009 laminectomy at Adena Hospital. If any records are not available, or the Veteran identifies sources of treatment but does not provide authorization to obtain records, appropriate action should be taken (see 38 C.F.R. § 3.159(c)-(e)), to include notifying the Veteran of the unavailability of the records. 2. Thereafter, obtain an addendum opinion from an appropriate clinician to determine the nature and etiology of the Veteran's low back disability. The entire file must be made available to the examiner, to include the new records noted above, and the examiner must note review of the file in his or her report. The examiner must provide an opinion as to whether it is at least as likely as not (i.e., 50 percent or greater probability) that the Veteran's low back disability is causally or etiologically related to service, to include the motor vehicle accident in the summer of 1955. In offering this opinion, the examiner must discuss the Veteran's competent and credible lay statements. The examiner cannot base a negative nexus on the mere lack of a documented in-service injury. If the examiner finds that the Veteran's low back disability is not related to service, the examiner must offer an alternate etiology for the disability. The examiner must provide a complete rationale for all opinions provided as adjudicators are precluded from making medical determinations. ROBERT N. SCARDUZIO Acting Veterans Law Judge Board of Veterans' Appeals Attorney for the Board T. Mohammad 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.