Citation Nr: 1335302 Decision Date: 11/04/13 Archive Date: 11/13/13 DOCKET NO. 08-15 389 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Houston, Texas THE ISSUE Entitlement to service connection for a left shoulder disability. ATTORNEY FOR THE BOARD Luke Pelican, Associate Counsel INTRODUCTION The Veteran served on active duty in the United States Army from September 2003 to December 2006. The Veteran had service in Iraq from November 2005 to November 2006, for which he received a Combat Action Badge, among other awards. This matter comes before the Board of Veterans' Appeals (the Board) on appeal from an April 2007 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Houston, Texas. The Board notes that, in addition to the paper claims file, there is a Virtual VA electronic claims file associated with the Veteran's claim. The Board has considered the records contained in the electronic claims file and the paper claims folder in reviewing this appeal. The appeal is REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. VA will notify the Veteran if further action is required. REMAND The Veteran was afforded a VA examination in July 2008, the report of which indicates that, with respect to his left shoulder, the Veteran complained of minor episodic symptoms of dull, aching pain. After a physical examination of the Veteran, the examiner rendered a diagnosis of the left shoulder as a stable joint with a normal examination result. However, the examiner referred the Veteran for an MRI of his left and right shoulders, stating that it was imperative to utilize the MRI technique to substantiate the Veteran's claim of a shoulder pathology. Nevertheless, the record before the Board contains only MRI examination results for the right shoulder, not the left one. The results of the left shoulder MRI examination, if they exist, should be obtained and made part of the record. If such results cannot be obtained or do not exist, the Veteran must be scheduled for a new VA examination of his left shoulder. The examination should include an MRI of the Veteran's left shoulder, or an explanation as to why one is not required, and any accompanying opinion should be supported by a rationale. Accordingly, the case is REMANDED for the following actions: 1. Obtain a copy of any VA MRI examination results dated in July 2008 or thereafter with respect to the left shoulder. If such a report is not located, this should be documented for the record. 2. If the left shoulder MRI examination results are located and made part of the record, then forward the claims file to the July 2008 examiner or a suitable substitute. The clinician should review the claims file, and provide an addendum opinion as to whether any left shoulder disability is at least as likely as not (a probability of 50 percent or greater) related to the Veteran's military service. In this regard, the examiner's attention is directed to the July 2008 examination findings of limitation of motion on flexion (145 degrees), abduction (150 degrees) and internal rotation (75 degrees). Any opinion offered must be accompanied by supporting rationale. 3. If the left shoulder MRI examination results cannot be found or do not exist, then schedule the Veteran for another examination of his left shoulder by an appropriate VA examiner. The claims file should be made available to the examiner. The examiner should review the claims file as well as conduct any indicated evaluations, studies, and tests, including an MRI examination, in order to identify the nature and severity of any left shoulder disability. If an MRI examination is not deemed necessary by the examiner, the reasons therefore should be explained. In this regard, the examiner's attention is directed to the July 2008 examiner's notation that "it is imperative to utilize MRI technique to substantiate his claim of a shoulder pathology." The examiner should opine as to whether any left shoulder disability is at least as likely as not (a probability of 50 percent or greater) related to the Veteran's military service. In this regard, the examiner's attention is directed to the July 2008 examination findings of limitation of motion on flexion (145 degrees), abduction (150 degrees) and internal rotation (75 degrees). Any opinion offered must be accompanied by supporting rationale. 4. Ensure completion of the foregoing and any other development deemed necessary, then readjudicate the Veteran's claim. If the claim remains denied, the Veteran should be provided with a supplemental statement of the case and an opportunity to respond. The case should then be returned to the Board for appropriate appellate consideration. The Veteran has the right to submit additional evidence and argument on the matter the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2013). _________________________________________________ S.S. TOTH 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) (2013).