Citation Nr: 22017392 Decision Date: 03/24/22 Archive Date: 03/24/22 DOCKET NO. 18-50 056A DATE: March 24, 2022 REMANDED Entitlement to service connection for a lumbar spine disability is remanded. Entitlement to service connection for left lower extremity radiculopathy is remanded. REASONS FOR REMAND The Veteran served in the Army National Guard with verified periods of active service from June 1983 to August 1983 and November 1990 to April 1991, with additional periods of active duty, active duty for training (ACDUTRA) and inactive duty for training (INACDUTRA). He testified at a videoconference hearing before the undersigned in November 2021. A transcript of the hearing is associated with the claims file. At the hearing, the Veteran's attorney requested an additional 60 days within which to submit additional evidence. Evidence was submitted prior to the expiration of the 60-day period, and correspondence received with the evidence indicated that all remaining evidence had been submitted and that the Veteran wished for a decision to be made by the Board. The Board also notes that the Veteran also testified at a hearing in February 2018 before a different Veterans Law Judge (VLJ). The issues addressed at that hearing will be addressed by separate decision. Regrettably, the Board finds that remand of the instant claims is necessary. The Agency of Original Jurisdiction (AOJ) denied the claims based on the findings of an October 2017 VA medical examiner, who opined against a relationship between the Veteran's back/radiculopathy disabilities and service because there was no mention of back pain in the emergency room records associated with a May 1997 injury, to which the Veteran attributes his current back disability. However, the Board finds that the October 2017 opinion of record is insufficient to adjudicate the Veteran's claims. Indeed, the examiner appeared to base the negative nexus opinion largely on an observation that documented treatment after the Veteran's in-service fall involved only the wrist, and did not involve the back. While that may be true, the contemporaneous service records do document that the Veteran fell on both his wrist and his back in May 1997, and the Veteran has since reported ongoing back pain stemming from that injury. He has also submitted several statements of others who know him attesting to his ongoing back pain, and discussion of back injury during service. The October 2017 opinion provider did not discuss why, from a medical standpoint, an absence of documented care specifically for back issues after the fall informed the opinion. On remand, a new opinion should be obtained. The matters are REMANDED for the following action: 1. Obtain an addendum opinion addressing the etiology of the Veteran's current lumbar spine disability and associated left lower extremity radiculopathy. It is left to the discretion of the selected examiner whether an in-person examination is necessary. After a review of the claims file, the examiner should answer the following: Is it at least as likely as not (approximately 50 percent probability) that any currently diagnosed lumbar spine disability with left lower extremity radiculopathy, had onset in, or is otherwise related to the Veteran's period of service? In providing a response, the examiner should assume as true that the Veteran fell on his back in May 1997. The examiner should consider the various lay statements submitted in support of the Veteran's appeal. If there are medical reasons that either support, or call into question the Veteran's report of history of back pain since his May 1997 fall, these should be well explained. 2. Thereafter, readjudicate the issues on appeal. V. Chiappetta Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Polly Johnson, 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.