Citation Nr: 22017560 Decision Date: 03/25/22 Archive Date: 03/25/22 DOCKET NO. 15-33 496 DATE: March 25, 2022 REMANDED Entitlement to service connection for a lumbar spine disability is remanded. REASONS FOR REMAND The Veteran served on active duty from May 1966 to March 1969. This matter comes before the Board of Veterans' Appeals (Board) on appeal from an August 2012 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO). This matter was remanded by the Board in February 2019 for further development. 1. Entitlement to service connection for a lumbar spine disability is remanded. The Veteran asserts that his lumbar spine disability is related to service. Specifically, he asserts that he began to suffer severe chronic back pain after an injury playing flag football at Fort Irwin, as well as an injury on a diving board during active duty. See March 2020 Statement in Support of Claim. The Veteran stated that he received Social Security disability benefits for his chronic back pain from the mid-1980s to 1988. See September 2020 Correspondence. On remand, these records must be obtained. Pursuant to the February 2019 Board remand, the Veteran was afforded a VA examination in December 2019, where the VA examiner stated that the Veteran's lumbar spine disability was not related to service. The VA examiner explained that the Veteran was treated for chronic back pain in service, his claimed injuries were not documented in his Service Treatment Records (STRs), and that his chart was silent until January 2005 when he was seen for back pain. The Board finds the December 2019 VA medical opinion inadequate for a number of reasons. Firstly, the VA examiner offered inconsistent and confusing rationale, stating "there was no treatment record regarding back pain only stated chronic back pain, the veteran continue to have back pain, tho there is a diagnosis of back pain while in the service as noted by the treatment on the STR..." The VA examiner also cited factually inaccurate information, including that the Veteran was in traction for only 4 days in service, and that the Veteran's chart was silent for treatment until 2005. The Veteran's STRs show that he was in traction on two separate occasions, in September 1966 and November 1966, both for several days at a time. Furthermore, the VA examiner himself noted that the Veteran sought treatment for back pain in prison in 1997. The Veteran's VA medical records note that he has a history of back pain since 1966. See January 2005 VA Medical Treatment Record. Finally, the Veteran noted that he rarely saw a doctor unless while being incarcerated because he did not have medical coverage; he stated that he self-medicated with marijuana and aspirin during these times. See March 2020 Statement in Support of Claim. Finally, the December 2019 VA medical examiner did not address the Veteran's competent lay statements regarding his in-service injury and that he suffered chronic back pain ever since. 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. Obtain the Veteran's Social Security Administration disability records. In particular, the Veteran stated that he received Social Security benefits for his chronic back pain from the mid-1980s to 1988. See September 2020 Correspondence. 2. Thereafter, obtain an addendum medical opinion by an appropriate clinician to determine the nature and etiology of the Veteran's lumbar spine disability. The examiner must opine whether it is at least as likely as not related to an in-service injury, event, or disease. The entire claims file and a copy of this REMAND must be made available to the examiner in conjunction with the examination. The examiner must note in the examination report that the evidence in the claims file has been reviewed. The examiner must specifically discuss the following: (a.) The Veteran's STR's showing that he was treated for his back, to include being placed in a traction for several days on two separate occasions, and diagnosed with chronic back pain. See September 1966, November 1966 STRs. (b.) The Veteran's lay testimony that he began experiencing severe chronic back pain after an in-service playing flag football injury at Fort Irwin, as well as an injury on a diving board during active duty, and that his pain has continued ever since. See March 2020 Statement in Support of Claim. (c.) The Veteran's VA medical records which note that he has a history of back pain since 1966. See January 2005 VA Medical Treatment Record. (d.) The Veteran's attempts to get treated for back pain while he was incarcerated, to include in 1997. (e.) The Veteran's statement that he rarely saw a doctor unless while being incarcerated because he did not have medical coverage; he stated that he self-medicated with marijuana and aspirin during these times. See March 2020 Statement in Support of Claim. A sufficient rationale must be provided for all conclusions reached. If the VA examiner concludes that the Veteran's lumbar spine disability is not related to service, the VA examiner must offer an alternate etiology for the Veteran's disability. P.M. DILORENZO 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.