Citation Nr: 22018356 Decision Date: 03/29/22 Archive Date: 03/29/22 DOCKET NO. 16-08 790 DATE: March 29, 2022 REMANDED Entitlement to service connection for a lumbar spine disability is remanded. REASONS FOR REMAND The Veteran served on active duty in the United States Army from April 1978 to July 1978 and from July 1979 to September 1980. This matter initially came before the Board of Veterans' Appeals (Board) on appeal from a rating decision issued by the Agency of Original Jurisdiction (AOJ). The Veteran testified before the undersigned Veterans Law Judge at a March 2018 videoconference hearing. A copy of the hearing transcript has been associated with the claims file. In June 2019, the Board remanded the issues of entitlement to service connection for a left knee disability and lumbar spine disability for further development. In January 2021, the Board denied entitlement to service connection for a left knee disability and entitlement to service connection for a lumbar spine disability. The Veteran then appealed the portion of the Board's decision, that denied entitlement to service connection for a lumbar spine disability, to the United States Court of Appeals for Veterans Claims (Court). In a December 2021 Order, the Court vacated the portion of the Board's decision that denied entitlement to service connection for a lumbar spine disability and remanded the matter to the Board for development consistent with the parties' November 2021 Joint Motion for Partial Remand (JMPR). The Court noted that the Veteran did not wish to disturb the portion of the Board's decision which denied entitlement to service connection for a left knee disability. Thus, this issue will not be addressed. With regard to the merits of the claim currently on appeal, the Board has reviewed the record and finds that remand is necessary. Entitlement to service connection for a lumbar spine disability In the November 2021 JMPR, the parties agreed that the Board erred by failing to address a reasonably raised theory of entitlement. More specifically, the parties stated that while the Board addressed whether the Veteran's low back disability was due to an in-service motor vehicle accident (which was raised in an attachment to a July 2018 VA Form 21-4138), the Board did not address the Veteran's March 2016 statement that he had "a fall in the military that initiated his ongoing back pain." The Board finds that this theory of entitlement was reasonably raised by the record and, as such, the Board finds that a medical opinion is necessary to determine whether such claimed incident proximately caused the Veteran's current low back disorder. The parties also agreed that the Board improperly relied on an inadequate VA medical examination, dated September 2019. In the September 2019 DBQ, the examiner diagnosed degenerative arthritis of the spine and concluded that it was less likely than not that the Veteran's back disorder was related to his claimed in-service motor vehicle accident. The examiner summarized the Veteran's statements regarding how he injured his back in service, noted that the Veteran stated that he had been treated at a hospital at the time, and reported that none of the Veteran's service treatment records, including his July 1980 separation examination, documented complaints of or treatment for back pain. Here, the Board finds that the examiner did not provide a reasoned medical explanation as to why the Veteran's current back problems were not attributable to the in-service motor vehicle accident. On remand, a new medical opinion should be obtained that offers sufficient rationale to support the examiner's conclusion of whether the Veteran's lumbar spine disability was caused by an in-service motor vehicle accident. The matters are REMANDED for the following action: 1. First, obtain any outstanding VA treatment records dated January 2020 to Present. 2. Then, schedule the Veteran for a VA examination to determine the nature and etiology of his low back disorder. The claims folder (including a copy of this remand) must be provided to and reviewed by the examiners as part of the examination. A notation to the effect that this review has taken place should be made in the evaluation report. All tests, studies, and evaluations should be performed as deemed necessary by the examiners, and the results of any testing must be included in the examination report. (a) After considering the pertinent information in the record in its entirety, the VA examiner should identify any present back disorders, to include degenerative arthritis of the spine. (b) Then, the examiner is asked to opine whether it is at least as likely as not (a probability of 50 percent or greater) that any back disorder(s) identified, was/were incurred in or was/were otherwise etiologically related to his active service, and if not, why. **In providing the above opinions, the examiner must take a detailed history from the Veteran regarding the onset of his back disorder, to include the Veteran's March 18, 2016 contention that he had a "fall in the military that initiated his ongoing back pain," as well as his contention that he injured his back in 1980 during an in-service motor vehicle accident. ** The examiner must also consider the Veteran's hearing testimony, as well as his lay statements of continuity of symptomatology. A clear explanation for all opinions based on specific facts for the case as well as relevant medical principles is needed. If the examiner determines that the requested opinion cannot be provided without resort to speculation, the examiner must provide a reasoned explanation for such conclusion. GAYLE STROMMEN Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Hanson, Tiffany 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.