Citation Nr: 22017162 Decision Date: 03/24/22 Archive Date: 03/24/22 DOCKET NO. 16-56 309 DATE: March 24, 2022 REMANDED Entitlement to service connection for a lumbar spine condition is remanded. Entitlement to service connection for a sinus condition is remanded. REASONS FOR REMAND The Veteran served on active duty in the Navy from September 1982 to April 1984. This case comes before the Board of Veterans' Appeals (Board) on appeal from the November 2014 and March 2015 rating decisions issued by the Department of Veterans Affairs (VA) Regional Office (RO). In December 2018, the Board issued a decision denying the Veteran's service connection claims. The Veteran appealed the Board's denial to the United States Court of Appeals for Veterans Claims (CAVC), resulting in the February 2020 Joint Motion for Partial Remand (JMPR). In the February 2020 Order, CAVC granted the JMPR, thereby partially vacating the December 2018 Board decision, and remanding the issue for readjudication consistent with the JMPR. In August 2020 and December 2021, the Board remanded the Veteran's claims for additional development. The Board notes that there was not substantial compliance with its August 2020 remand directives. See Stegall v. West, 11 Vet. App. 268, 271 (1998); D'Aries v. Peake, 22 Vet. App. 97, 105 (2008). 1. Entitlement to service connection for a lumbar spine condition is remanded. 2. Entitlement to service connection for a sinus condition is remanded. As noted above, in August 2020, the Board remanded the Veteran's claims for further development, specifically requesting that the Veteran be provided VA examinations and medical opinions regarding the current nature and etiology of his claimed conditions. Within the medical opinions, the examiner(s) were specifically directed to consider and discuss all lay statements and assertions provided by the Veteran, to include his contentions of an in-service fall and twisting injury causing his lumbar spine condition, and the multiple notations of in-service treatment for sinus conditions and/or bronchitis. See BVA Decision, August 2020. In April 2021, the Veteran was provided VA examinations and medical opinions, in response to the Board's August 2020 remand. For each claim, the examiner provided unfavorable nexus opinions as to the Veteran's claimed conditions being related to his active service. Nevertheless, the Board finds these medical opinions to be inadequate, as the examiner failed to discuss the Veteran's lay statements of the in-service causation of his lumbar spine condition and the onset and continuity of symptomatology of both conditions. Moreover, the examiner failed to discuss the in-service notations of medical treatment for sinus conditions and/or bronchitis. Instead, the examiner improperly relied on the lack of objective evidence in-service of complaints, treatment, or diagnosis of the claimed conditions as a sole basis for providing the negative opinions. Therefore, based on the above, the Board finds that the Veteran should be provided addendum VA medical opinions that adequately address the etiology of his claimed conditions, in accordance with VA's duty to assist and in compliance with Stegall. Accordingly, a remand is necessary to address the matters discussed above. The matters are REMANDED for the following action: 1. Request the Veteran to identify all medical providers (VA and private) from whom he has received treatment for his lumbar spine condition and sinus condition, and obtain any outstanding records and associate them with the Veteran's claims file. 2. After associating all newly acquired records with the claims file, provide the Veteran with addendum VA medical opinions by appropriate clinicians to determine the nature and etiology of the Veteran's lumbar spine condition and sinus condition. The entire claims file, including a copy of this remand, must be made available to the examiner, and note review of the record in the examination report. All pertinent medical complaints, symptoms, and clinical findings must be reported in detail. The Veteran should be scheduled for another examination(s) if deemed necessary by the person providing the addendum report to address the following: (a) Opine whether it is at least as likely as not (50 percent or greater probability) that any of the Veteran's diagnosed lumbar spine conditions had its onset during any period of active duty service, within a year of discharge, or is otherwise etiologically related to his active duty service, to include the assertion of an in-service fall and twisting injury. (b) Opine whether it is at least as likely as not (50 percent or greater probability) that any of the Veteran's diagnosed sinus conditions had its onset during any period of active duty service, or is otherwise etiologically related to his active duty service, to include the in-service notations of medical treatment for sinus conditions and/or bronchitis. (c) All opinions should include a detailed rationale. The examiner should consider the entire claims file and discuss the Veteran's lay statements regarding the nature and onset of symptoms. The examiner is advised that the Veteran is competent to report symptoms, and that he is reports must be considered in formulating the requested opinion. An opinion solely based on the absence of a diagnosis or documented symptoms in service is insufficient for these purposes. (d) If the examiner(s) is unable to offer the requested opinion(s), it is essential that the examiner offer a rational for the conclusion that an opinion could not be provided without resorting to speculation, together with a statement as to whether there is additional evidence that could enable an opinion to be provided, or whether the inability to provide the opinion is based on the limits of medical knowledge. See Jones v. Shinseki, 23 Vet. App. 382. (2010). DELYVONNE M. WHITEHEAD Veterans Law Judge Board of Veterans' Appeals Attorney for the Board B. Carter, 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.