Citation Nr: 23014170 Decision Date: 03/08/23 Archive Date: 03/08/23 DOCKET NO. 18-25 803 DATE: March 8, 2023 REMANDED Entitlement to compensation under 38 U.S.C. § 1151 for a left shoulder disorder is remanded. REASONS FOR REMAND The Veteran served on active duty from February 1973 to February 1976. This matter comes to the Board of Veterans' Appeals (Board) on appeal from a September 2017 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO). Jurisdiction of this appeal is currently with the RO in Des Moines, Iowa. In July 2020, the Veteran withdrew his request for a Board hearing. Compensation Under 38 U.S.C. § 1151 for a Left Shoulder Disorder The Veteran seeks entitlement to compensation under 38 U.S.C. § 1151 for a left shoulder injury that occurred following a fall due to ice in a parking lot on January 3, 2017 at the Des Moines, Iowa VAMC, and due to negligent treatment and/or lack of treatment by VA at that time, namely the failure the properly treat and/or diagnose the left shoulder injury at that time. See e.g., VA Form 21-4138 Statement in Support of Claim, July 19, 2017. The Veteran was afforded a VA examination in August 2017. At that time, the VA examiner opined the Veteran's current disability of a left shoulder injury resulted from a fall in the wintertime. The VA examiner noted the Veteran was immediately evaluated, treated, and underwent physical therapy for months until reaching his goal; his last physical therapy treatment note noted that his left shoulder pain had mostly resolved. The VA examiner noted further physical treatment notes at the termination of his physical therapy, and found that the Veteran's acute left shoulder injury was treated, improved, and was expected to continue to perform well if complaint with treatment recommendations. The VA examiner furthered that the disability was caused by a fall and improved by treatment at VA; not caused or became worse as a result of VA treatment, as documented. There was no additional disability. The VA examiner noted that there was no failure on the part of VA to timely diagnose and/or properly treat the claimed disability that allowed the disability to continue to progress. The VA examiner noted the Veteran was treated timely and with standard of care; the condition did not progress; and the condition improved with physical therapy. The Board finds the August 2017 VA examination opinions incomplete to decide the claims because the examiner did not provide supporting rationale for the conclusions reached. Namely, the VA examiner provided the above opinions without further elaboration. This opinion is therefore insufficient to decide the claim. Where VA provides the Veteran with an examination in a service connection claim, the examination must be adequate. Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). The Board regrets the additional delay, but an adequate VA examination is needed before the Board can render a decision on this issue. Accordingly, the Board concludes that an addendum opinion is required. The matters are REMANDED for the following action: 1. The Veteran should be given the opportunity to identify any outstanding private or VA treatment records relevant to the claim on appeal. After obtaining any necessary authorization from the Veteran, all outstanding records should be obtained, to include updated VA treatment records. For private treatment records, make at least two (2) attempts to obtain records from any identified sources. If any such records are unavailable, inform the Veteran and his representative and afford him an opportunity to submit any copies in his possession. For federal records, all reasonable attempts should be made to obtain such records. If any records cannot be obtained after reasonable efforts have been made, issue a formal determination that such records do not exist or that further efforts to obtain such records would be futile, which should be documented in the claims file. The Veteran must be notified of the attempts made and why further attempts would be futile, and allowed the opportunity to provide such records, as provided in 38 U.S.C. § 5103A(b)(2) and 38 C.F.R. § 3.159(e). 2. Following the receipt of outstanding records, obtain a medical opinion addressing the Veteran's claim for entitlement to compensation under 38 U.S.C. § 1151 for a left shoulder disorder. Further physical examination is left to the discretion of the examiner. After reviewing the claims file, please answer the following questions: (A) Did the Veteran experience any additional disability caused by VA treatment and/or lack of treatment or follow up for a shoulder injury following a fall due to ice in a VA parking lot on January 3, 2017 in Des Moines, Iowa VAMC? In answering this question, the examiner should specifically consider his treatment on January 3, 2017 by the physical therapist, primary care physician, and emergency room providers. The examiner is reminded that, to determine whether a veteran has an additional disability, VA compares the veteran's condition immediately before the medical care or treatment in question to the veteran's condition after such care has stopped. (B) If it is found that additional disability was caused by the VA treatment or lack of treatment in January 2017, the examiner should opine as whether any such additional disability was proximately caused by carelessness, negligence, lack of proper skill, error in judgment, or similar instance of fault on the part of VA in furnishing the therapy in question. When making this determination, please discuss if VA failed to exercise the degree of care that would be expected of a reasonable health care provider. (C) If it is found that additional disability was caused by the VA treatment or lack of treatment in January 2017, the examiner should also provide an opinion as to whether any identified additional disability was due to an event that was reasonably foreseeable or an event not reasonably foreseeable, to include consideration of the Veteran's contention that his left shoulder disorder is the result of the VA physician's failure to undertake preventive treatment or properly diagnose the injury on the date of injury. That is, was the event the type of risk that a reasonable health care provider would have disclosed in connection with informed consent procedures? (D) If it is found that additional disability was caused by the VA treatment or lack of treatment in January 2017, the examiner should also provide an opinion as to whether any identified additional disability was aggravated due to the failure on the part of VA to timely diagnose and/or treat and allow the disability to progress. A rationale should be provided for any opinion offered. If it is not possible to provide a specific opinion regarding the above questions, the examiner must state whether the need to speculate is due to a deficiency in the state of general medical knowledge (no one could respond given medical science and the known facts), a deficiency in the record (additional facts are required), or the examiner (does not have the knowledge or training). (Continued on the next page) The medical opinion must support the conclusions reached with an analysis that is adequate to consider and weigh against other evidence of record; medical opinions must contain not only clear conclusions with supporting data, but also a reasoned medical explanation connecting the two. If an opinion cannot be expressed without resort to speculation, ensure that the clinician so indicates and discusses why an opinion is not possible, to include whether there is additional evidence that could enable an opinion to be provided, or whether the inability to provide the opinion is based on the limits of medical knowledge and explain why this is so. M. Schlickenmaier Acting Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Mariah N. Sim, 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.