Citation Nr: 18141685 Decision Date: 10/11/18 Archive Date: 10/11/18 DOCKET NO. 16-26 910 DATE: October 11, 2018 REMANDED Entitlement to a rating in excess of 20 percent for degenerative joint disease, lumbar spine is remanded. Entitlement to a rating in excess of 10 percent for bilateral sensorineural hearing loss is remanded. REASONS FOR REMAND The Veteran served on active duty from December 1977 to July 1984 and from February 2003 to December 2004. In January 2011 the Veteran filed for an increase in his lumbar spine disability rating. Similarly, in April 2014, the Veteran filed for an increase in his hearing loss disability rating. 1. Entitlement to a rating in excess of 20 percent for degenerative joint disease, lumbar spine is remanded. A review of the evidence of record reveals the record is incomplete and additional examination is warranted. A May 2011 treatment record indicates that there may be outstanding and relevant Social Security Administration (SSA) records. A remand is required to allow VA to request these records. The Veteran was provided VA examinations for this claim in May 2011 and January 2015. As part of this appeal, the Veteran contends symptoms related to his bilateral upper and lower extremities and neck are due to his lumbar spine disability, but these contentions were not addressed by the VA examiners. See August 2013 noticed of disagreement and June 2016 substantive appeal. Additionally, the examiner found the Veteran to have radiculopathy of the lower extremities, but did not know the date of diagnosis. This indicates the examiner relied on the Veteran’s self-report rather than the evidence of record. A review of the evidence of record reveals the Veteran has been found to suffer from diabetic polyneuropathy in addition to radiculopathy. See, e.g., March 10, 2009 and November 22, 2010 private treatment records. Moreover, at least one clinician has attributed a portion of the Veteran’s nerve issues to a gunshot wound for which the Veteran was denied service connection. See June 2, 2009 private treatment record (chronic sciatic nerve injury which corresponds to gunshot wound above right knee). In light of the above, additional examination and opinion is needed to determine if the Veteran’s reported symptoms, including radiculopathy, are attributable to his service connected lumbar spine disability or other diseases and injuries. 2. Entitlement to a rating in excess of 10 percent for bilateral sensorineural hearing loss is remanded. In addition to the missing SSA records, remand is warranted in order for the Veteran to be provided another evaluation of his hearing loss disability. The Veteran was last provided a VA examination in April 2012. In his notice of disagreement, the Veteran reported his “hearing is about 80% gone.” Similarly, in his substantive appeal the Veteran reported that he could hardly hear. The Board interprets these statements as a contention that the Veteran’s hearing loss disability has worsened since his April 2012 VA examination. When the evidence of record “does not adequately reveal the current state of the claimant’s disability . . ., the fulfillment of the statutory duty to assist requires a thorough and contemporaneous medical examination.” Caluza v. Brown, 7 Vet. App 498, 505-506 (1995); Schafrath v. Derwinski, 1 Vet. App. 589, 595 (1991). Therefore, remand for an additional examination is warranted. The matters are REMANDED for the following action: 1. Obtain outstanding records of VA treatment and evaluation since June 2012. 2. Obtain the Veteran’s federal records from SSA. Document all requests for information as well as all responses in the claims file. 3. Schedule the Veteran for an examination by an appropriate clinician to determine the current severity of his service-connected lumbar spine disability. The examiner should ask the Veteran to clarify what symptoms he feels are attributable to his lumbar spine disability. The examiner should provide a full description of the disability and report all signs and symptoms necessary for evaluating the Veteran’s disability under the rating criteria, and opine whether it is at least as likely as not the Veteran’s reported symptoms are attributable to his service connected lumbar spine disability. A complete rationale is required.   4. Schedule the Veteran for an examination by an appropriate clinician to determine the current severity of his service-connected bilateral sensorineural hearing loss disability. H. N. SCHWARTZ Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD Gregory T. Shannon, Associate Counsel