Citation Nr: 18142524 Decision Date: 10/17/18 Archive Date: 10/16/18 DOCKET NO. 16-28 626 DATE: October 17, 2018 REMANDED The issue of entitlement to an evaluation in excess of 10 percent for right lower extremity radiculopathy is remanded. The issue of entitlement to an evaluation in excess of 20 percent for lumbar disc herniation with intervertebral disc syndrome (IVDS) is remanded. The issue of entitlement to a total rating for compensation purposes based on unemployability due to service-connected disabilities (TDIU) is remanded. REASONS FOR REMAND The Veteran served on active duty from September 1981 to September 1987. These matters come to the Board of Veterans’ Appeals (Board) on appeal from an April 2016 rating decision by a Regional Office (RO). A Notice of Disagreement was submitted in May 2016; a Statement of the Case was issued in June 2016; and a VA Form 9 was received in October 2016. Lumbar Spine and Right Lower Extremity Radiculopathy The Veteran was most recently afforded a VA examination for the lumbar spine disability and associated right lower extremity radiculopathy in April 2016. In subsequent statements of record, he indicated that he was “in more pain than before,” and that he was unable to perform daily activities, sit or stand for more than 15 minutes, or obtain employment as a result of his lumbar spine and associated radiculopathy disabilities. See NOD and VA Form 9. Based on evidence of possible worsening, the issue must be remanded to afford him a contemporaneous VA examination to assess the severity of his lumbar spine disability, to include joint testing for pain on both active and passive motion, in weight-bearing and nonweight-bearing, as well as the associated radiculopathy. See Snuffer v. Gober, 10 Vet. App. 400 (1997); see also Correia v. McDonald, 28 Vet. App. 158 (2016); VAOPGCPREC 11-95 (1995), 60 Fed. Reg. 43186 (1995). The evidence also reflects that the Veteran has received private medical treatment for his lumbar spine disability throughout the course of this appeal. See August 2015 VA Treatment Records (referencing a private EMG/NCS and medications prescribed by a private physician). Thus, while on remand, VA should obtain all outstanding, pertinent private and VA treatment records, to include those from his PCP, Dr. Maziak (or Majchrzak)(sp?). Lastly, the record reflects that the Veteran is in receipt of disability benefits from SSA on account of his lumbar spine disability. To date, the SSA records have not been obtained. VA has a duty to obtain potentially relevant SSA records. Golz v. Shinseki, 590 F.3d 1317 (Fed. Cir. 2010). Accordingly, the RO must obtain all available SSA records on remand. TDIU The Veteran has indicated he is unable to work due to his service-connected lumbar spine and radiculopathy disabilities. See VA Form 9 and NOD. As such, the issue is raised with the increased rating claims. Rice v. Shinseki, 22 Vet. App. 447 (2009). As this issue is intertwined with the remanded claims, its adjudication is deferred. The matters are REMANDED for the following action: 1. Obtain complete VA treatment records from May 2016 to the present. 2. After securing any necessary authorization, obtain any private treatment records as the Veteran may identify relevant to his claims, including treatment records from his PCP, Dr. Maziak (or Majchrzak)(sp?). 3. Request a copy of any SSA decision awarding disability benefits for the Veteran, copies of all treatment records upon which any such SSA disability benefit award was based, and a copy of any medical records associated with any subsequent disability determinations by SSA. 4. Schedule the Veteran for an examination of the current severity of his lumbar disc herniation with IVDS and right lower extremity radiculopathy. All necessary testing must be performed. 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 lumbar strain with IVDS and radiculopathy alone and discuss the effect of the Veteran’s lumbar strain with IVDS and radiculopathy 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). DEBORAH W. SINGLETON Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD H. Hoeft, Counsel