Citation Nr: A25041286 Decision Date: 05/06/25 Archive Date: 05/06/25 DOCKET NO. 240731-464008 DATE: May 6, 2025 REMANDED Entitlement to service connection for degenerative arthritis of the cervical spine is remanded. Entitlement to service connection for a left hip disability is remanded. Entitlement to service connection for a right hip disability is remanded. INTRODUCTION The Veteran served on active duty in the U.S. Air Force from August 1995 to November 1999, with subsequent service in the U.S. Army Reserves. In October 2023 and January 2024, the Regional Office (RO) issued rating decisions which addressed the above-noted issues. Thereafter, in July 2024, the Veteran submitted a VA Form 10182, Decision Review Request: Board Appeal (Notice of Disagreement) (NOD), wherein he sought to appeal the claims in the Appeals Modernization Act (AMA) System. He selected the Direct Review option; therefore, the Board may only consider the evidence of record at the time the RO issued the October 2023 and January 2024 rating decisions. 38 C.F.R. § 20.301. However, because the Board is remanding the above-referenced claims, any evidence the Board could not consider will be considered by the RO in the readjudication of those claims. 38 C.F.R. § 3.103 (c)(2)(ii). REASONS FOR REMAND Pursuant to 38 C.F.R. § 20.802, unless an issue on appeal can be granted in full, the Board shall remand the appeal to the agency of original jurisdiction for correction of an error on the part of the agency of original jurisdiction to satisfy its duties under 38 U.S.C. § 5103A, if the error occurred prior to the date of the agency of original jurisdiction decision on appeal. The Board may remand for correction of any other error by the agency of original jurisdiction in satisfying a regulatory or statutory duty, if correction of the error would have a reasonable possibility of aiding in substantiating the appellant's claim. Under 38 C.F.R. § 3.159 the Department of Veterans Affairs must provide assistance in developing a veteran's claim. Under certain circumstances, this regulation requires the Administration obtain a VA examination or medical opinion. When VA undertakes to provide a VA examination or obtain an opinion, it must ensure that the examination or opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). The failure to provide the above-noted assistance constitutes a due process violation. The Veteran has asserted his cervical spine degenerative arthritis and bilateral hip disabilities are consequentially related to his military occupation. He has also claimed his bilateral hip disabilities were caused or aggravated by his low back disability. The Board notes the Veteran's claim for entitlement to service connection for his low back disability, with bilateral lower extremity sciatica is also presently in appellate status and will be addressed under separate correspondence. In January 2023, the Veteran underwent a VA neck conditions examination to assess his cervical spine disability. Following that examination, the examiner diagnosed the Veteran with a cervical strain, and concluded the disability was related to his military service. Thereafter, the RO service-connected the Veteran's cervical strain. However, the Veteran continues to assert he has degenerative arthritis of the cervical spine, which was also caused by his military service. Following the January 2023 examination, the Veteran underwent radiological testing of his neck in April 2023. Though the January 2023 examiner reviewed those tests and stated the Veteran's cervical spine was normal, the Board finds the x-ray results were rather ambiguous. Following his April 2023 x-rays, the reading physician indicated the Veteran had no "significant" degenerative changes of his cervical spine. This statement does not indicate the Veteran's cervical spine was normal, rather it may indicate he had minimal or mild degenerative changes. Apparently noting this ambiguity, the RO obtained a second VA examination in January 2024; however, that examiner failed to conduct additional diagnostic x-ray testing to confirm or rule out the existence of degenerative arthritis of the cervical spine. Based on the foregoing, the Board finds the RO committed a pre-decisional error in failing to obtain an adequate examination to address this matter. Additionally, the Board notes the Veteran underwent a VA hip conditions examination in January 2023. Following that examination, he was diagnosed with a bilateral hip strain with degenerative arthritis of the right hip. Though the examiner indicated his conditions were "due to wear and tear from military service," she wholly failed to explain how or why she came to that conclusion. As such, this opinion is of low probative value. The Veteran then underwent a second VA hip conditions examination in September 2023. During this examination, the Veteran reported he initially experienced hip pain following an incident in service when a tire bead blew out causing him significant injury. A review of the Veteran's active duty records indicates he was involved in a tire blowout incident in September 1999. His records also show he incurred a line of duty (LOD) injury to his hip in November 2003 while performing training with the Army Reserves. The September 2003 examiner concluded the Veteran's current disabilities were less likely than not incurred in service. Here, the examiner cited to a 2019 lumbar spine x-ray, which indicated the Veteran's sacroiliac joints were unremarkable. The examiner also cited to an absence of "documented" hip issues following the Veteran's 1997 injury, but curiously failed to acknowledge or discuss the Veteran's November 2003 LOD. Though the 2019 lumbar spine x-ray may speak to the presence or absence of degenerative changes, this test would not be valid for diagnosing a strain. Further, a medical examiner is not free to simply ignore a veteran's lay statements recounting symptoms or events and base his or her opinion that there is no relationship to service on the absence of corroborating medical records. Dalton v. Nicholson, 21 Vet. App. 23 (2007); see also Buchanan v. Nicholson, 451 F.3d 1331, 1337 (Fed. Cir. 2006). Finally, a medical examination report must contain not only clear conclusions with supporting data, but also a reasoned medical explanation connecting the two. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). Based on the foregoing pre-decisional duty to assist errors, the Board finds a remand is necessary. Accordingly, these matters are REMANDED for the following actions: Afford the Veteran a VA examination by an examiner with sufficient expertise to address the etiology of the Veteran's claimed cervical spine degenerative arthritis and bilateral hip disabilities. All pertinent evidence of record must be made available to and reviewed by the examiner. Any indicated studies should be performed, to specifically include x-ray or other diagnostic testing to confirm or rule out the presence of cervical spine degenerative arthritis. Following a review of the relevant records and lay statements, the examiner should state an opinion as to whether the Veteran's cervical spine degenerative arthritis, if present, and bilateral hip disabilities at least as likely as not (likelihood is approximately balanced or nearly equal, if not higher) originated during his period of active service or are otherwise etiologically related to his active service. The examiner should state an opinion as to whether the Veteran's hip disabilities at least as likely as not (likelihood is approximately balanced or nearly equal, if not higher) are consequentially related to his November 2003 line of duty injury with the Army Reserves. The examiner should also state an opinion with respect to whether the Veteran's bilateral hip disabilities at least as likely as not (likelihood is approximately balanced or nearly equal, if not higher): a) were caused by his lumbar spine disability; or b) were worsened to any degree by his lumbar spine disability. Finally, the examiner is asked to state whether the Veteran's cervical spine degenerative arthritis, if diagnosed, at least as likely as not (likelihood is approximately balanced or nearly equal, if not higher): a) was caused by his service-connected cervical strain; or b) was worsened to any degree by his service-connected cervical strain. (Continued on the next page) ? For these opinions, the examiner should note veterans are generally competent to attest to factual matters of which they have first-hand knowledge, including events and symptoms. The examiner is asked to consider and expressly discuss the Veteran's reports relative to the nature and etiology of his claimed disabilities. If the examiner finds any reports provided by the Veteran to lack reliability, the examiner should state why. The examiner must provide a complete rationale for all opinions offered. If the examiner is unable to provide any requested opinion, he or she should explain why. If the examiner cannot provide an opinion without resorting to mere speculation, he or she shall provide a complete explanation as to why this is so. If the inability to provide a more definitive opinion is the result of a need for additional information, the examiner should identify the additional information that is needed. T. REYNOLDS Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Fraser, Gordon 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.