Citation Nr: 18139626
Decision Date: 09/28/18	Archive Date: 09/28/18

DOCKET NO. 16-27 635
DATE:	September 28, 2018
REMANDED
Entitlement to service connection for intervertebral disc syndrome (IVDS) is remanded.
Entitlement to service connection for interstitial lung disease (ILD) with chronic obstructive pulmonary disease (COPD) is remanded.
REASONS FOR REMAND
The Veteran served on active duty from October 1978 to February 1979, from August 1986 to October 1992 and from August 2007 to December 2010.  This matter comes before the Board of Veterans Appeals (Board) on appeal from an August 2014 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) denying service connection for IVDS and COPD.
1. Entitlement to service connection IVDS is remanded.
The Veteran claims that he was injured during service and has submitted a buddy statement reporting that the Veteran sustained a back injury lifting a drink cooler while serving in Afghanistan.  The Veteran contends that this injury caused his current back disabilities, to include IVDS.  
The Veteran submitted an October 2016 statement from Dr. M.J. opining that the Veteran sustained trauma in service which exacerbated a pre-existing back injury.  The statement from M.J. also opined that the complete diagnosis for the Veteran’s claimed back disability was not limited to IVDS, and identified at least five separate back disabilities, including disabilities which pre-existed the Veteran’s active duty service.  
Dr. M.J.’s statement did not contain sufficient rationale to support his opinion.  See Stefl v. Nicholson, 21 Vet. App. 120, 124-25 (2007) (a medical opinion must “support its conclusion with an analysis that the Board can consider and weigh against contrary opinions[;]” see also Nieves-Rodriguez, 22 Vet. App. 295, 304 (2008) (concluding that a medical opinion is not entitled to any weight if it does not contain a rationale that adequately connects data and conclusions). In addition, the opinions lack any discussion of the Veteran’s contentions as to onset and continuity of symptomatology. See Dalton v. Nicholson, 21 Vet. App. 23 (2007).  as he does not indicate which records he reviewed and the scope of any examination he performed.  
Furthermore, it does not appear that records from Dr. M.J. have been associated with the claims file.  As those records may provide further support for Dr. M.J.’s opinions, a remand is necessary for VA to attempt to obtain those records.  
If new records are received, VA should obtain an addendum opinion regarding the nature and etiology of any current back disabilities.
2. Entitlement to service connection for ILD with COPD is remanded.
The Veteran contends that his respiratory disability was worsened by his service, to include exposure to jet fuel while in service.  Significantly, the Veteran has three periods of service.  Entrance examinations in July 1978 and August 1986 reflect the lungs and chest were normal.  A report of medical history in connection with his entrance to his third period of service completed in November 2006 reflects the Veteran reported a history of bronchitis and indicated he had been prescribed an inhaler.  He also indicated he had an open lung biopsy and pneumonia.  Examination on the same date described the lungs and chest as normal but noted the history of open lung biopsy, pneumonia and use of an inhaler. It also noted asthma as through February 2006.  As the Veteran was examined prior to each period of service and officially assessed as normal, he is presumed sound at entrance.
A December 2013 medical record indicated that the Veteran was diagnosed with ILD in 2004.  A September 2007 medical record indicates that the Veteran was reportedly told by a doctor that he possibly had ILD, but did not indicate the name of the doctor or the date when he was told that he possibly had ILD.  A remand is necessary to obtain all of the Veteran’s private and government treatment records related to his claimed lung disabilities, as the history of the Veteran’s lung disabilities is unclear from the evidence in the record.
Additionally, the Veteran underwent a VA examination in July 2014.  The VA examiner opined that the Veteran’s COPD “probably” pre-existed service, and that the Veteran’s military service did not aggravate the Veteran’s COPD.  
This opinion is inadequate as it does not express whether there is clear and unmistakable evidence that the Veteran’s disability was both preexisting and not aggravated by service.  See Wagner v. Principi, 370 F.3d 1089, 1096 (Fed. Cir. 2004).
As there is not sufficient medical evidence in the claims file to decide this issue, a remand is necessary to obtain the Veteran’s complete treatment records and to obtain an addendum opinion from a VA examiner.
The matters are REMANDED for the following action:
1. Ask the Veteran to complete a VA Form 21-4142 for each physician or facility where the Veteran has sought treatment for his claimed back disabilities to include Dr. J.M.  Make two requests for the authorized records from each facility or physician identified by the Veteran unless it is clear after the first request that a second request would be futile.
2. Ask the Veteran to complete a VA Form 21-4142 for each physician or facility where the Veteran has sought treatment for any claimed lung disability.  Make two requests for the authorized records from each facility or physician identified by the Veteran unless it is clear after the first request that a second request would be futile.
3. Schedule the Veteran for a VA examination to determine the relationship between the Veteran’s ILD and COPD and his service, to include exposure to jet fuel during service. The examiner should provide an opinion as to the following:
a) it is “at least as likely as not” (50 percent or greater probability) that any current lung disability was caused by or aggravated by an in-service injury, event or disease during his period of service from October 1978 until February 1979 or his second period of service from October 1986 until October 1992?
b) Did a lung disability, to include ILD and COPD, “clearly and unmistakably” (obviously or manifestly) exist prior to the Veteran’s entry into his third period of service from August 2007 until December 2010? 
c) If a lung disability, to include ILD and COPD, clearly and unmistakably existed prior to his period of service from August 2007 until December 2010, was it “clearly and unmistakably” (obviously or manifestly) not aggravated by military service? In this special context, “aggravation” has occurred where there is an increase in disability beyond the natural progress of the disability. 
d) If the answer to either question above is no, then answer whether it is “at least as likely as not” (50 percent or greater probability) that any current lung disability was caused by or aggravated by an in-service injury, event or disease during his period of service from August 2007 until December 2010? 
A clear rationale for all opinions is required.
4. Schedule the Veteran for a VA examination to determine the relationship between the Veteran’s IVDS and his service, to include the Veteran’s reported injury during service. The examiner should provide an opinion as to the following:
a) whether it is “at least as likely as not” (50 percent or greater probability) that any current back disability was caused by or aggravated by an in-service injury, event or disease, during any period of service to include the Veteran’s reported in-service back injury? The examiner must comment on the opinion of Dr. M.J.
(Continued on the next page)
 
A clear rationale for all opinions is required.
 
H. SEESEL
Veterans Law Judge
Board of Veterans’ Appeals
ATTORNEY FOR THE BOARD	A. Boal, Associate Counsel

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