Citation Nr: 18139898 Decision Date: 10/01/18 Archive Date: 10/01/18 DOCKET NO. 15-31 484A DATE: October 1, 2018 REMANDED A disability rating in excess of 20 percent for status post herniated nucleus pulposus with arthritis (formerly arthritis lumbar spine with degenerative disc disease L4-5) is remanded. A total disability rating based on individual unemployability due to service-connected disability (TDIU) is remanded. REASONS FOR REMAND The Veteran had active service from July 1943 to January 1946 and from August 1952 to August 1971. This matter is on appeal from a September 2013 rating decision. A January 2018 rating decision denied a TDIU. The Veteran did not initiate an appeal of that rating decision. However, the TDIU issue was raised as a component of the increased rating claim on appeal. Thus, it is presently in appellate status before the Board. See Rice v. Shinseki, 22 Vet. App. 447 (2009). 1. A disability rating in excess of 20 percent for status post herniated nucleus pulposus with arthritis (formerly arthritis lumbar spine with degenerative disc disease L4-5) is remanded. The Veteran has not been examined by VA since April 2014. That examination did not comply with the requirements in Correia v. McDonald, 28 Vet. App. 158, 168 (2016) or Sharp v. Shulkin, 29 Vet. App. 26, 34-36 (2017). Therefore, the Veteran should be provided an opportunity to report for a VA examination to ascertain the current severity and manifestations of the disability. The Veteran’s updated VA medical records, plus his records from the Social Security Administration (SSA) and any further private medical records, should also be obtained. 2. A total disability rating based on individual unemployability due to service-connected disability (TDIU) is remanded. The development and decision on the remanded increased rating issue will significantly impact a decision on the TDIU issue. Therefore, the issues are inextricably intertwined, and a remand of the TDIU issue is required. The matters are REMANDED for the following action: 1. Ask the Veteran to complete a VA Form 21-4142 for any private (non-VA) medical provider(s) or facility having additional relevant medical records. Make two requests for any authorized records, unless it is clear after the first request that a second request would be futile. 2. Obtain the Veteran’s federal records from the Social Security Administration. Document all requests for information as well as all responses in the claims file. 3. Obtain the Veteran’s outstanding VA treatment records. 4. Schedule the Veteran for an examination of the current severity of his lumbar spine disability. The examiner must test the Veteran’s active motion, passive motion, and pain with weight-bearing and without weight-bearing. The examiner must also attempt to elicit information regarding the severity, frequency, and duration of any flare-ups, and the degree of functional loss during flare-ups. To the extent possible, the examiner should identify any symptoms and functional impairments due to the lumbar spine alone and discuss the effect of the Veteran’s disability on any occupational functioning and activities of daily living. If it is not possible to provide a specific measurement, or an opinion regarding flare-ups, symptoms, or functional impairment without speculation, the examiner must state whether the need to speculate is due to a deficiency in the state of general medical knowledge (no one could respond given medical science and the known facts), a deficiency in the record (additional facts are required), or the examiner (does not have the knowledge or training). The examiner is also asked to comment on and describe the functional impairment caused solely by the service-connected disabilities as it pertains to the Veteran’s ability to function in an occupational environment. The examiner should, for instance, describe the limitations and restrictions imposed by his service-connected impairments on routine work activities for up to six hours per day, such as interacting with customers/coworkers and using technology, plus other physical activities such as sitting, standing, walking, lifting, carrying, pushing, and pulling, and mental activities such as understanding and remembering instructions, and sustained concentration. The examiner is asked to identify, to the extent possible, the date on which any change in degree of impairment first occurred. C. CRAWFORD Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD C. Bosely, Counsel