Citation Nr: 18141219 Decision Date: 10/10/18 Archive Date: 10/09/18 DOCKET NO. 15-24 252 DATE: October 10, 2018 REMANDED Entitlement to an initial evaluation in excess of 10 percent disabling for service-connected s/p anterior cervical fusion with scar, claimed as cervical spine condition, is remanded. REASONS FOR REMAND The Veteran served on active duty from January 1977 to April 1981, and from March 1983 to March 1999. In September 2018, the Veteran appeared before the undersigned Veterans Law Judge at a videoconference hearing. Entitlement to an initial evaluation in excess of 10 percent disabling for service-connected s/p anterior cervical fusion with scar, claimed as cervical spine condition, is remanded. The Board finds that additional development is needed prior to final adjudication of the issue on appeal. First, the Board finds that there are outstanding treatment records that must be obtained and associated with the claim file. At the September 2018 hearing, the Veteran indicated that there are outstanding Tricare and VA treatment records, and that he received treatment at Edwards AFB. The Board will remand to obtain these records. In addition, the Veteran has stated that his disability has worsened since his last VA examination and that he experiences neurological symptoms, such as tingling and numbness in his arms. Under these circumstances, VA cannot rate the service-connected disability without further medical clarification. Hence, the Veteran is entitled to a new VA examination. See, e.g., Snuffer v. Gober, 10 Vet. App. 400 (1997); Caffrey v. Brown, 6 Vet. App. 377 (1994); VAOPGCPREC 11-95 (1995). The matter is REMANDED for the following action: 1. After securing any necessary consent forms from the Veteran, obtain any outstanding treatment records, to include any VA and/or private treatment records, pertaining to the issue on appeal, to include any outstanding Tricare and VA treatment records, such as treatment at Edwards AFB. All attempts to obtain these records should be documented in the claim file. If any records could not be obtained, this should be noted in the claim file. 2. Upon completion of the above, schedule the Veteran for a VA examination, in order to determine the current severity of the service-connected disability on appeal. The claim folder and all pertinent treatment records should be made available to the examiner for review, and review of such records should be noted in any subsequent report. All necessary diagnostic testing should be performed. If the examiner is unable to conduct the required testing or concludes that the required testing is not necessary in this case, he or she should clearly explain why that is so. The examiner is asked specifically to provide range of motion testing (ROM) for active motion, passive motion, weight-bearing, and nonweight-bearing. In addition, the examiner must discuss pain for ROM movements on active, passive, and repetitive use testing. The examiner is asked to address the following questions: (a) Are any ROM movements painful on active, passive, and repetitive use testing? If yes, identify whether active, passive, and repetitive use. (b) If yes (there are painful movements), does the pain contribute to functional loss or additional limitation of ROM? Please further describe the functional loss or additional limitation of ROM. (c) If no (the pain does not contribute to functional loss or additional limitation of ROM), explain why the pain does not contribute. In addition, the examiner must discuss pain when used in weight-bearing or in nonweight-bearing. The examiner is asked to address the following questions: (a) Is there pain when the joint is used in weight-bearing or nonweight-bearing? If yes, identify whether weight-bearing or nonweight-bearing. (b) If yes (there is pain when used in weight-bearing or nonweight-bearing), does the pain contribute to functional loss or additional limitation of ROM? Please further describe these limitations. (c) If no (the pain does not contribute to functional loss or additional limitation of ROM), explain why the pain does not contribute. Finally, the examiner is asked to address the Veteran’s contentions with regard to neurological symptoms, specifically that he experiences tingling and numbness in his arms. Upon remand, the examiner is asked to address the Veteran’s contentions. 3. If upon completion of the above action the issue is denied, the case should be returned to the Board after compliance with appellate procedures. E. I. VELEZ Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD K. Foster, Associate Counsel