Citation Nr: A26013169 Decision Date: 02/12/26 Archive Date: 02/12/26 DOCKET NO. 241127-498356 DATE: February 12, 2026 ORDER Entitlement to service connection for a lumbar spine condition is granted. Entitlement to service connection for a cervical spine condition is granted. REMANDED Entitlement to service connection for posttraumatic stress disorder is remanded. FINDINGS OF FACT 1. The Veteran's lumbar spine condition is related to his active military service. 2. The Veteran's cervical spine condition is related to his active military service. CONCLUSIONS OF LAW 1. The criteria for entitlement to service connection for a lumbar spine condition have been met. 38?U.S.C. §§?1110, 1131, 5107;?38?C.F.R. §§ 3.102,?3.303. 2. The criteria for entitlement to service connection for a cervical spine condition have been met. 38?U.S.C. §§?1110, 1131, 5107;?38?C.F.R. §§ 3.102,?3.303. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from November 1993 to June 1994. The rating decisions on appeal were issued in September 2024 and November 2024. In the decisions, the agency of original jurisdiction (AOJ) denied service connection for a lumbar and cervical spine condition and posttraumatic stress disorder. In November 2024, the Veteran filed VA Form 10182, Decision Review Request: Board Appeal (Notice of Disagreement) and elected the Evidence Submission docket. The Board may only consider the evidence of record at the time of the September 2024 and November 2024 AOJ decisions on appeal, as well as any evidence submitted by the Veteran or his representative with, or within 90 days from receipt of, the VA Form 10182. 38 C.F.R. § 20.303. If evidence was submitted either (1) during the period after the AOJ issued the decision on appeal and prior to the date the Board received the VA Form 10182, or (2) more than 90 days following the date the Board received the VA Form 10182, the Board did not consider it in its decision. 38 C.F.R. §§?20.300, 20.303, 20.801. As to the granted claims, if the Veteran would like VA to consider any evidence that was submitted that the Board could not consider, the Veteran may file a Supplemental Claim (VA Form 20-0995) and submit or identify this evidence. 38 C.F.R. §?3.2501. If the evidence is new and relevant, VA will issue another decision on the claim, considering the new evidence in addition to the evidence previously considered. Id. Specific instructions for filing a Supplemental Claim are included with this decision. However, as to the remanded claim, because the Board is remanding the claim, any evidence the Board could not consider will be considered by the AOJ in the adjudication of the claim. 38 C.F.R. § 3.103(c)(2)(ii). SERVICE CONNECTION The Veteran seeks entitlement to service connection for a lumbar spine condition and a cervical spine condition that he contends is due to his active-duty service. See April 2024 VA Form 21-526EZ, Fully Developed Compensation Claim. Applicable Law Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active service. 38?U.S.C. §§?1110, 1131; 38?C.F.R. §?3.303. Service connection generally requires evidence of: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the current disability and the in-service disease or injury. Shedden v. Principi, 381 F.3d 1163, 1166-67 (Fed. Cir. 2004). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. Analysis As to current disabilities, the AOJ favorably found the Veteran has been diagnosed with lumbosacral strain and degenerative disc disease of the neck. See September 2024 Rating Decision; see also November 2024 Rating Decision. The Board is bound by the favorable findings. See 38 C.F.R. § 3.104 (c). As to an in-service incurrence, the Veteran complained of back pain during service. See March 16, 1994, Screening Note of Acute Medical Care. Furthermore, the Veteran's brother submitted a lay statement stating the Veteran came home from AIT in 1994 for two weeks after their father had a heart attack. The Veteran was in severe pain, and after question, the Veteran informed that he had a fall during training and hurt his neck and back but was afraid to tell anyone because he did not want to be kicked out on medical discharge. See May 2024 Buddy Lay Statement. The Board has no reason to question the veracity of the buddy lay statement. Thus, resolving all doubt in favor of the Veteran, the Board finds there is credible evidence of the in-service incurrence.? As to the final element of service connection, a nexus, or link, there are opinions against and for the claim. Against the claim, there is an opinion that the Veteran's lumbar spine condition and cervical spine condition were less likely than not incurred in or caused by the claimed in-service injury, event, or illness. As a rationale regarding the lumbar spine condition, the first examiner stated that besides the Veteran's March 1994 in-service complaints, there were no other documented symptoms of the claimed disorder, there was no chronicity, and the Veteran did not report injury to his back during military service. See May 2024 VA Medical Opinion. The second examiner stated that there were no available service treatment records or health provider visits suggesting the Veteran was seen and examined for back pain. See October 2024 VA Medical Opinion. As a rationale regarding the cervical spine condition, the examiner stated that a review of the Veteran's military medical records revealed no complaint, diagnosis, or treatment of the claimed condition or its associated symptoms and that the evidence did not show an event, disease, or injury in service. See May 2024 VA Medical Opinion. When VA undertakes to obtain an evaluation, it must ensure that the evaluation is adequate.? See Barr v. Nicholson, 21?Vet. App.?303, 312 (2007).? After careful review and consideration, the Board finds the May 2024 and October 2024 medical opinions inadequate because the examiner failed to address the lay statement regarding the Veteran's in-service fall that led to severe back and neck pain. For the claim, there is an opinion that the Veteran's lumbar spine condition and cervical spine condition were at least as likely as not caused by his service. The examiner stated that the opinion was based on review of the Veteran's medical history, including VA medical records, military service treatment records, DD Form 214, self-reported symptoms, and current medical literature. As a rationale regarding the lumbar spine condition, the examiner stated that the Veteran experienced a fall during training that initiated his ongoing struggle with his lumbar spine condition and chronic pain which progressively worsened over the years and significantly impacted his daily life. The examiner detailed the Veteran's daily struggles and discussed the pathophysiological link between the Veteran's fall during miliary training and his current condition. The examiner explained that the fall in service caused acute injuries to the structures of the lumbar spine and over time, the body's response included inflammation, micro-tears, and degeneration of the spinal components. Citing medical literature, the examiner discussed how physical demands and injuries directly contributed to the development of the Veteran's lumbar spine condition which resulted in long-term spinal instability and pain. See February 2025 T.L.M., DPT, PT, LAT, ATC, CSCS Medical Opinions. As a rationale regarding the cervical spine condition, the examiner stated that the Veteran fell from a height of 10 feet, landing on his neck and back during basic training, which began his long-term cervical spine condition. The examiner detailed the Veteran's daily struggles and discussed the pathophysiological link between the Veteran's fall during miliary training and his current condition. Citing medical literature, the examiner discussed how physical demands and injuries contributed to the development of the Veteran's cervical spine condition. See id. Satisfying the final element for service connection, the Board finds there is a nexus between the Veteran's lumbar spine condition and active military service and between the Veteran's cervical spine condition and active military service.? The February 2025 opinions are logical, well-reasoned, and thorough. In this instance, the Board affords the medical opinions?substantial probative weight. See Nieves-Rodriguez v. Peake, 22?Vet. App.?295, 301 (2008) (explaining that a medical examination report must contain clear conclusions with supporting data and a reasoned medical explanation connecting the two).?? In sum, as all three elements for service connection have been met, the Board resolves all doubt in favor of the Veteran and finds entitlement to service connection for a lumbar spine condition and for a cervical spine condition is granted.? See 38?U.S.C. §?5107;?38?C.F.R. §?3.102; Lynch,?21 F.4th at 776. REASONS FOR REMAND The Veteran seeks entitlement to service connection for posttraumatic stress disorder that he contends is related to his active military service. See June 2024 VA Form 21-526EZ, Fully Developed Compensation Claim. For the following reasons, the Board remands?the Veteran's claims to correct pre-decisional duty to assist errors under the provisions of?38?C.F.R. §?20.802.??? As to a current disability, the AOJ favorably found the Veteran has a posttraumatic stress disorder diagnosis. See September 2024 Rating Decision. As to an in-service incurrence, the Veteran stated that his father had a major heart attack and he had to go home during military training. He explained that while he was home, he learned that his wife cheated on him with multiple men. He further explained an incident, the weekend following the foregoing, where he and other members of his training were in a car wreck and pulled out of the car at gunpoint. See June 2024 Statement in Support of Claim. The Veteran's brother submitted a lay statement explaining that the Veteran returned home for two weeks in 1994 after their father had a heart attack. The brother stated that he observed the Veteran's change in behavior since his time in the Army including severe mood swings, and irritability in crowds or in public. He also stated that the Veteran's behavior persisted and the Veteran declined to talk to him about it. See May 2024 Buddy Lay Statement. Finally, the Veteran's roommate submitted a lay statement explaining that he was roommates with the Veteran before the Veteran went into the Army and when the Veteran returned from the Army. The roommate stated that when the Veteran returned from training, he noticed a change in his anger and being in crowds or around groups of people. The roommate stated that the Veteran did not have those behaviors prior to going into the Army. See June 2024 Buddy Lay Statement. VA must provide an examination when there is competent evidence of a disability (or persistent or recurrent symptoms of a disability) that may be associated with an in-service event, injury, or disease, but there is insufficient information to make a decision on the claim. 38 U.S.C. § 5103A (d); McLendon v. Nicholson, 20 Vet. App. 79, 81 (2006). Here, even though there is evidence of posttraumatic stress disorder and in-service incurrence, the Veteran has not been afforded a VA examination as required by McLendon. Based on the foregoing, a remand is required to correct the pre-decisional duty to assist error of failing to afford the Veteran an examination and obtaining the necessary medical opinion. The matters are REMANDED for the following action: Schedule the Veteran for an examination with an appropriate clinician to determine the nature and etiology of his posttraumatic stress disorder. The entire claims file should be made available to and reviewed by the examiner.? Following review of the entire record, the examiner should opine whether is it at least as likely as not (likelihood is at least approximately balanced or nearly equal, if not higher) the Veteran's posttraumatic stress disorder is due to his military service. If the examiner bases any portion of the opinion on a gap in documented medical treatment (i.e., the time between the in-service injury and the first medical report of treatment sought) the examiner should explain why or how, from a medical perspective, that gap in documented medical treatment informs the medical opinion. The medical professional should consider and comment on the Veteran's lay statements. All opinions should be supported with a complete and thorough explanation or rationale and should be based on consideration of all pertinent lay and medical evidence. JIMMY L. BARDIN Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Ti'a Smith, Associate 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.