Citation Nr: 22014698 Decision Date: 03/14/22 Archive Date: 03/14/22 DOCKET NO. 18-38 148 DATE: March 14, 2022 REMANDED Entitlement to service connection for a left shoulder condition is remanded. REASONS FOR REMAND The Veteran served on active duty in the United States Army from January 1967 to January 1969. This matter comes before the Board of Veterans Appeals (Board) on appeal from an April 2018 decision by a Department of Veterans Affairs (VA) Regional Office (RO). In October 2021, the Veteran testified before the undersigned Veterans Law Judge (VLJ). A transcript of the hearing is of record. The Board finds it necessary to remand for further development, as the last VA examination for the claimed condition is inadequate. VA has a duty to ensure that any medical examination or opinion it provides is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). A medical opinion is adequate where it is based upon consideration of the full medical history and describes a disability in sufficient detail so that the Board's evaluation will be fully informed. Stefl v. Nicholson, 21 Vet. App. 120, 123 (2007). The medical opinion must support its conclusions with sufficient data and reasoning. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 301-304 (2008). If a medical examination is inadequate, a remand is warranted to obtain an adequate examination. The Veteran underwent VA examinations for his left shoulder in January 2018 and June 2018. The January 2018 examination found that the Veteran's left shoulder condition was not caused by his service-connected posttraumatic stress disorder (PTSD), while the June 2018 examination added that PTSD did not aggravate his left shoulder condition. The January 2018 examination offered the following opinion: His shoulder pain was well documented with multiple surgeries before his fall, it is not directly associated with PTSD. PTSD did not cause shoulder conditions. He has a long history (decades) of bilateral shoulder condition including bilateral shoulder surgeries 1990s, 2002, and 2004, which preceded his most recent event. Therefore, the Veteran's current left shoulder condition is less likely than not proximately due to or the result of the Veteran's service connected condition. The Veteran's representative noted during his October 2021 hearing that the January 2018 examiner does not distinguish between the left and right shoulder conditions in their opinion, and the Board agrees that this is a problemspecifically, because the Veteran's right shoulder condition is service-connected secondary to PTSD, and it is not the place of the examiner to relitigate that finding. The Board needs to know whether, conceding that the Veteran's right shoulder condition is service connected, his left shoulder condition is as well. The January 2018 examiner also does not explain why a "long history" of shoulder conditions cannot be caused by the Veteran's service-connected PTSD. While the Veteran's PTSD was not service connected until 2006, the 1990s were three decades after his separation from active service, and the examiner did not address when the Veteran's PTSD actually had its onset (and whether this is likely to have been before it was formally diagnosed). The June 2018 opinion found that the Veteran's left shoulder condition was not aggravated beyond its natural progression, either by PTSD or by his right shoulder condition. The main reason for this conclusion was that the examiner could not determine a baseline level of severity, but it is not entirely clear why not; the examiner cited lack of radiographic evidence in the record, and also said: A reference baseline of functioning for the left shoulder prior to and following his diagnosis of PTSD cannot be established as the Veteran underwent left shoulder surgeries on two remote occasions, one of which was related to an industrial accident. But the examiner did not explain why a baseline could not be established from the (by the examiner's own admission) "well-documented" reports of left shoulder pain in the Veteran's medical records throughout the years. While establishing a baseline of severity is a requirement for proving an aggravation claim, see 38 C.F.R. § 3.310(b), that does not mean it is acceptable to deny a Veteran's claim based on conclusory findings that a baseline "cannot be established." The matters are REMANDED for the following action: Obtain an opinion from an appropriate clinician, who has not already provided an opinion in this case, regarding the nature and etiology of the Veteran's left shoulder pain. If the clinician believes an in-person or telehealth examination is necessary, one should be scheduled. After reviewing the entire claims file, the examiner should answer the following: (a) Is it at least as likely as not (50 percent or greater probability) that the Veteran's left shoulder condition is related to an in-service injury, disease, or event? (b) Is it at least as likely as not (50 percent or greater probability) that the Veteran's left shoulder pain was caused or aggravated by a service-connected condition, to include PTSD and a right shoulder condition? (The examiner should specifically address the Veteran's testimony about falling in bed due to PTSD, and overuse of his left arm due to his right shoulder injury.) If the examiner cannot determine a baseline level of severity for the purpose of providing an aggravation opinion, the examiner must explain why. (c) If the Veteran's left shoulder pain is unrelated to his military service, what is its likely etiology? The examiner must review the entire claims file, and the opinion must reflect consideration of Veteran's full medical history and the record as a whole. The examiner must provide a complete rationale for all opinions, supported by evidence and citing any records or medical literature relied upon. If any of the above requested opinions cannot be made without resorting to speculation, the examiner must explain why. DELYVONNE M. WHITEHEAD Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Shermila Sundquist 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.