Citation Nr: 22040142 Decision Date: 07/13/22 Archive Date: 07/13/22 DOCKET NO. 16-61 640 DATE: July 13, 2022 REMANDED Entitlement to service connection for lumbar spine degenerative disc disease is remanded. Entitlement to service connection for hypertension, to include as secondary to lumbar spine degenerative disc disease, or alternatively, as due to exposure to contaminated water at Camp Lejeune, is remanded. REASONS FOR REMAND The Veteran served on active duty from August 1982 to July 1986. This matter comes to the Board of Veterans' Appeals (Board) on appeal from a May 2013 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Houston, Texas. When this matter was previously before the Board in May 2020 and February 2022, the Board remanded for further development. The matter has now returned to the Board for appellate review. The Board regrets any further delay in this matter, but finds additional development is required. 1. Entitlement to service connection for lumbar spine degenerative disc disease is remanded. The Veteran seeks service connection for a back disorder diagnosed as lumbar spine degenerative disc disease. The Veteran's service treatment records reflect complaints of lower back pain on several occasions and include a diagnosis of muscle spasms. At issue is whether the Veteran's current lumbar spine degenerative disc disease is etiologically related to the complaints of back pain noted in service (then diagnosed as muscle spasms). Of note, the Veteran has consistently stated that he has had lower back pain since service, and the Board has no reason to doubt the Veteran's credibility. As part of the development of the Veteran's claim for his back, the RO obtained VA examinations. The first VA examination was obtained in May 2013 and the examiner rendered a negative nexus opinion. However, as noted in the May 2020 Board Remand, this opinion was inadequate as the May 2013 VA examiner did not discuss the Veteran's lay statements in the context of the negative opinion. New medical opinions were obtained in May 2021and October 2021. However, as noted in the February 2022 Board Remand, none of the medical opinions addressed the Veteran's lay statements concerning his credible statements of continuing symptomatology since service. Instead, for the claimed back disability, the examiner focused solely on the Veteran's exit exam not mentioning a history of back condition, and that the earliest record of treatment for post-service back pain is dated in December 2004, roughly 18 years after service. On remand, the Board gave specific remand directives, including a directive that the examiner "must specifically and comprehensively discuss the Veteran's competent and credible reports regarding his continuous back pain from service to the present." The most recent medical opinion was obtained in March 2022. A negative nexus opinion was rendered, but the Board finds that this medical opinion is also inadequate as well. First, the March 2022 written opinion was difficult to follow, as the examiner's written opinion addressed both the claimed back disability and the claimed hypertension simultaneously, with repeating paragraphs, and overlapping information. The examiner seemed to indicate a negative nexus opinion was appropriate because (1) a "thoracolumbar strain would not cause degenerative disc disease"; and (2) "the Veteran's occupation as a postal worker is the most likely cause of his current back condition." However, the examiner did not specifically and comprehensively discuss the Veteran's report of continuous back pain from service to the present or provide a rationale for rejecting the Veteran's credible statements. A remand by the Board confers on the claimant a legal right to compliance with the remand orders. Stegall v. West, 11 Vet. App. 268, 271 (1998). A failure by the Board to ensure that its remand orders are complied with constitutes legal error. Id. On remand, a new medical opinion that address all of the Board's remand directives must be obtained. 2. Entitlement to service connection for hypertension, to include as secondary to pain from lumbar spine disability, or alternatively, as due to exposure to contaminated water at Camp Lejeune, is remanded. The Veteran seeks service connection for hypertension on two alternative theories of entitlement: (1) as secondary to the pain from his lumbar spine degenerative disc disease; or, (2) as due to exposure to contaminated water at Camp Lejeune. In the May 2020 Board Remand, the Board noted that the Veteran had not been afforded a VA examination and upon remand, the Veteran was to be afforded a VA examination to determine the nature and etiology of his hypertension. Medical opinions were obtained in May 2021 and October 2021. However, as noted in the February 2022 Board Remand, the examiner focused on the service treatment records lacking a diagnosis or treatment for hypertension, and the Veteran's known risk factors for hypertension. The examiner did not offer a sufficient rationale for the opinion that the Veteran's hypertension is not likely due to contaminated water exposure at Camp Lejeune, stating instead only that hypertension is not presumed to be related to such exposure and that the Veteran's file does not contain evidence to support such a finding. The Board found this conclusion to be unsupported by actual rationale or discussion of the evidence apparently relied upon, and ordered a new medical opinion be obtained. On remand, the Board gave specific remand directives, including a directive that the examiner "must specifically and comprehensively discuss the Veteran's contention that his hypertension may be related to exposure to contaminated water at Camp Lejeune. In addition, the examiner is to provide a well-reasoned opinion as to whether the Veteran's hypertension has been caused or aggravated by his low back disorder, to include any treatments therefore." New medical opinions were obtained in February 2022 and March 2022. A negative nexus opinion was rendered, but the Board finds that these medical opinions are also inadequate. First, the March 2022 written opinion was difficult to follow, as the examiner's written opinion addressed both hypertension and the claimed back disability simultaneously, with repeating paragraphs, and overlapping information. The examiner seemed to indicate a negative nexus opinion was appropriate because hypertension was not noted in service, is not among the list of diseases for which presumptive service connection can be granted for contaminated water at Camp Lejeune, and was not caused or aggravated by the claimed back disorder. However, the Board finds the March 2022 examiner's opinion was inadequate in several respects. First, the examiner used the same rationale to render a negative opinion for hypertension as he did for the back disorder, stating only that since the Veteran's back disorder is not likely related to service but is instead due to his post-service employment, his hypertension is also not likely related to service. The same rationale was used to find that hypertension did not begin within one year of service separation. As to whether hypertension was caused or aggravated by the claimed back disorder, the examiner provided a negative opinion, without supportive rationale, that was internally inconsistent on the issue of aggravation. Another opinion that appears to separately address whether hypertension was etiologically related to service was obtained in February 2022. This examiner tendered a negative nexus opinion but as part of the rationale also stated that "the medical literature is mixed regarding the effects of pain, both acute and chronic, and the effects on blood pressure, and the argument for and against are equipoise." As such, the Board finds this medical opinion to be internally inconsistent with the negative opinion tendered. 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). The matters are REMANDED for the following action: 1. Obtain an addendum medical opinion from a qualified clinician to determine the nature and etiology of the Veteran's lumbar spine disability. The Veteran's claims file, including a copy of this remand, must be made available to and reviewed by the examiner. The examiner must provide a well-reasoned opinion as to whether it is at least as likely as not that any currently diagnosed lower back disorder began during service, within one year of service separation, or is otherwise etiologically related to service. The examiner is advised that the Veteran is competent to report history and symptoms, including his credible reports of back pain during service and continuing thereafter. The examiner must specifically and comprehensively discuss the Veteran's competent and credible reports regarding his continuous back pain from service to the present. If the examiner rejects the Veteran's credible reports, the examiner must provide a rationale for doing so. The examiner is also reminded that a lack of treatment is not itself a sufficient reason to find a disability is not related to service. The examiner must provide a comprehensive report including complete rationales for all opinions and conclusions reached, citing the objective medical findings leading to the conclusions. A thorough rationale is required for adjudication. 2. Obtain an addendum opinion from a qualified clinician to determine the nature and etiology of the Veteran's hypertension. The Veteran's claims file, including a copy of this remand, must be made available to and reviewed by the examiner. The examiner must provide a thorough, well-reasoned opinion as to whether it is at least as likely as not that the Veteran's hypertension: began in service, within one year of service separation, or is otherwise related to the Veteran's service, to include his acknowledged exposure to contaminated water at Camp Lejeune; Was caused by his low back disorder, to include any treatments therefor; Was aggravated by his low back disorder, to include any treatments therefor. In providing these opinions, the examiner must consider and address the Veteran's lay statements concerning the onset of his symptomatology. If the examiner rejects the Veteran's credible statements, the examiner must provide a rationale for doing so. The examiner must specifically and thoroughly discuss the Veteran's contention that his hypertension is related to exposure to contaminated water at Camp Lejeune. The examiner must provide a comprehensive report including complete rationales for all opinions and conclusions reached, citing the objective medical findings leading to the conclusions. A thorough rationale is required for adjudication. Caroline B, Fleming Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Bess, T. 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.