Citation Nr: 22019293 Decision Date: 03/31/22 Archive Date: 03/31/22 DOCKET NO. 17-49 444 DATE: March 31, 2022 REMANDED Entitlement to service connection for a low back disability is remanded. Entitlement to a disability rating in excess of 20 percent disabling for service-connected intervertebral disc syndrome and degenerative disc disease of the cervical spine is remanded. REASONS FOR REMAND The Veteran served on active duty from September 1983 to October 1987, with additional service in the Reserves and National Guard. These matters come before the Board of Veterans' Appeals (Board) on appeal from June 2016 and October 2016 rating decisions of a Department of Veterans Affairs (VA) Regional Office (RO). The Board remanded these claims in October 2019 and September 2021 for further development. 1. Entitlement to service connection for a low back disability is remanded. The Veteran asserts that he has a low back disability related to service. He was afforded a VA examination in November 2021, where the examiner stated that the Veteran's low back condition was not related to service. The VA examiner largely based his negative nexus on the fact that there was no documented evidence of back pain or injury in the Veteran's service treatment records (STRs). The Board finds this explanation inadequate. In this regard, documented treatment for a disability is not required for service connection. The VA examiner did not discuss the Veteran's lay testimony that he began feeling low back pain after suffering a fall in service in 2010. Additionally, the VA examiner stated that a complaint of back pain was noted in the Veteran's STRs in 2013, but that this referred to his cervical spine. As noted by the Board in the September 2021 remand, a January 2013 STR notes that the Veteran had back pain in service; the Board noted that this same entry had a separate complaint for chronic pain in the right upper extremity and upper back, thus signaling that the Veteran likely had a unique complaint for lower back pain. See September 2021 Board Remand. The Board finds the November 2021 VA Examination inadequate. 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, an addendum medical opinion is warranted. 2. Entitlement to a disability rating in excess of 20 percent disabling for service-connected intervertebral disc syndrome and degenerative disc disease of the cervical spine is remanded. The Veteran asserts that he is entitled to a higher disability evaluation for his service-connected invertebral disc syndrome and degenerative disc disease of the cervical spine. At his November 2021 VA examination, the VA examiner noted the Veteran's active and passive range of motion (ROM) measurements but did not provide measurements for weight-bearing and non-weight bearing. The Board finds the November 2021 VA examination inadequate as it did not comply with the requirements of Correia v. McDonald, 28 Vet. App. 158 (2016). Therefore, the Veteran should be scheduled for an additional VA examination on remand. The matters are REMANDED for the following action: 1. Obtain an addendum medical opinion by an appropriate clinician to determine the nature and etiology of the Veteran's low back 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, including the Veteran's STRs showing complaints of back pain. See May 2011, January 2013 STR. Of note, a January 2013 STR notes that the Veteran had back pain in service; this same entry had a separate complaint for chronic pain in the right upper extremity and upper back, thus signaling that the Veteran likely had a unique complaint for lower back pain. The VA examiner must discuss the Veteran's lay testimony that he experienced low back pain after an in-service fall in 2010. The VA examiner may not base a negative nexus on a lack of documented treatment in the Veteran's STRs or medical records. Rather, the VA examiner must consider the Veteran's description of his in-service injury and symptoms as well as his post-service symptoms. If there is any medical reason to accept or reject the proposition that the Veteran's reported injury and symptoms in service and thereafter represented the onset of his current disability, this should be noted. Stated another way, do the Veteran's reports about his symptoms align with how the currently diagnosed disability is known to develop or are the Veteran's reports generally inconsistent with medical knowledge or implausible? 2. Arrange for a VA examination (or telehealth interview, review of the record, etc. if an in-person examination is not feasible) of the Veteran's service-connected invertebral disc syndrome and degenerative disc disease of the cervical spine to assess the severity of the disability for the entire period on appeal. The entire claims file and a copy of this REMAND must be made available to the examiner in conjunction with the examination. In the examination report, the examiner must include all of the following: Correia factors: A. Active range of motion testing results. B. Passive range of motion testing results. C. Weightbearing range of motion testing results. D. Non-weightbearing range of motion testing results. The examiner must provide a numerical range of motion result for each of the above. If the examiner is unable to conduct the required testing or concludes that the required testing is not necessary in this case, he or she should clearly explain why that is so. Flare-ups (Sharp): The examiner must elicit as much information as possible from the Veteran regarding the severity, frequency, and duration of flare-ups, their effect on functioning, and precipitating and alleviating factors. If the examination is not performed during a flare-up, the examiner must provide an estimate of additional loss of range of motion during a flare-up. If the examiner is unable to provide an estimate of additional loss of motion during a flare-up, the examiner must provide a specific explanation as to why the available information, including the Veteran's own statements, is not sufficient to make such an estimate. 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.