Citation Nr: 1327699 Decision Date: 08/29/13 Archive Date: 09/05/13 DOCKET NO. 12-08 921 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Roanoke, Virginia THE ISSUES 1. Entitlement to an initial evaluation in excess of 10 percent for low back intervertebral disc syndrome, with degenerative arthritis. 2. Entitlement to an initial in excess of 10 percent for right sciatic neuropathy. REPRESENTATION Appellant represented by: African American PTSD Association ATTORNEY FOR THE BOARD D. Schechter, Counsel INTRODUCTION The Veteran served on active military duty from August 1980 to August 2002. The appeal comes before the Board of Veterans' Appeals (Board) from a March 2011 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Roanoke, Virginia. The appeal is remanded to the RO via the Appeals Management Center (AMC), in Washington, DC. REMAND The Veteran asserts in a July 2011 statement that the examiner in June 2011 examined him at 2:00 p.m. on a Friday afternoon, for approximately two minutes, and that no x-rays were obtained. The Veteran asserted that his back disorder had increased in severity, and did not believe that the examiner took the time to adequately evaluate this disorder. If an examination report does not contain sufficient detail, it is incumbent upon the rating board to return the report as inadequate for rating purposes. 38 C.F.R. § 4.2 (2012). A new examination is thus warranted based on the inadequacy of the April 2011 examination. Accordingly, the case is remanded for the following action: 1. The AMC must contact the Veteran and afford him the opportunity to identify or submit any additional pertinent evidence in support of his claims. Based on his response, the AMC must attempt to procure copies of all records which have not previously been obtained from identified treatment sources. All attempts to secure this evidence must be documented in the evidence of record by the AMC. If, after making reasonable efforts to obtain named records the AMC is unable to secure same, the AMC must notify the Veteran and (a) identify the specific records the AMC is unable to obtain; (b) briefly explain the efforts that the AMC made to obtain those records; (c) describe any further action to be taken by the AMC with respect to the claim; and (d) that he is ultimately responsible for providing the evidence. The Veteran and his representative must then be given an opportunity to respond. 2. The Veteran must be afforded an orthopedic examination to determine the current severity of his service-connected intervertebral disc syndrome, with degenerative arthritis. The claims file and all electronic records, to include on Virtual VA, must be made available to the examiner, and the examiner must specify in the examination report that these records have been reviewed. The examiner must specify the dates encompassed by the electronic records that were reviewed. All indicated testing must be conducted. The examiner must conduct full range of motion studies on the service-connected intervertebral disc syndrome, with degenerative arthritis. The examiner must first record the range of motion on clinical evaluation, in terms of degrees with a goniometer. If there is clinical evidence of pain on motion, the examiner must indicate the specific degree of motion at which such pain begins. The same range of motion studies must then be repeated after at least three repetitions and after any appropriate weight-bearing exertion. Then, after reviewing the Veteran's complaints and medical history, the examiner must render an opinion as to the extent to which the Veteran experiences functional impairments, such as weakness, excess fatigability, lack of coordination, or pain due to repeated use or flare-ups, etc. Objective evidence of loss of functional use can include the presence or absence of muscle atrophy and/or the presence or absence of changes in the skin indicative of disuse due to the service-connected intervertebral disc syndrome, with degenerative arthritis. 3. The Veteran must be afforded a neurologic examination to determine the current severity of his service-connected intervertebral disc syndrome, with right sciatic neuropathy. The claims file and all electronic records, to include on Virtual VA, must be made available to the examiner, and the examiner must specify in the examination report that these records have been reviewed. The examiner must specify the dates encompassed by the electronic records that were reviewed. The examiner must also report all associated neurological complaints and findings attributable to the Veteran's service-connected intervertebral disc syndrome, including any radiating pain to the lower extremities. If necessary to evaluate the complaints, nerve conduction studies and/or electromyography studies must be conducted. The specific nerve(s) involved must be identified. The examiner must state whether there is complete or incomplete paralysis of the sciatic nerve, and if there is incomplete paralysis, the examiner must state whether the paralysis is mild, moderate, moderately severe, or severe with marked muscular atrophy. All neurologic abnormalities associated with the Veteran's intervertebral disc extrusion with radiculopathy, including, but not limited to, bowel or bladder impairment, must be reported. With regard to the Veteran's intervertebral disc syndrome, the examiner must state whether the Veteran experienced incapacitating episodes that required bedrest prescribed by a physician and treatment required by a physician, and the frequency and total duration of such episodes over the course of the past 12 months. 4. The AMC must notify the Veteran that it is his responsibility to report for the examinations, and to cooperate in the development of the claim. The consequences for failure to report for a VA examination without good cause may include denial of the claim. 38 C.F.R. §§ 3.158, 3.655 (2012). In the event that the Veteran does not report for the scheduled examinations, documentation must be obtained and associated with the Veteran's claims file that shows that notices scheduling the examinations were sent to his last known address. Documentation must be also be obtained and associated with the Veteran's claims file demonstrating any notice that was sent was returned as undeliverable. 5. After completing the above actions, and any other development as may be indicated by any response received as a consequence of the actions taken above, the claims on appeal must be readjudicated. If any issue on appeal remains denied, a supplemental statement of the case must be provided to the Veteran and his representative. After the Veteran and his representative have had an adequate opportunity to respond, the appeal must be returned to the Board for appellate review. No action is required by the Veteran until he receives further notice; however, he may present additional evidence or argument while the case is in remand status at the AMC. Kutscherousky v. West, 12 Vet. App. 369 (1999). _________________________________________________ JOY A. MCDONALD Veterans Law Judge, Board of Veterans' Appeals Under 38 U.S.C.A. § 7252 (West 2002), only a decision of the Board of Veterans' Appeals is appealable to the United States Court of Appeals for Veterans Claims. This remand is in the nature of a preliminary order and does not constitute a decision of the Board on the merits of your appeal. 38 C.F.R. § 20.1100(b) (2012).