Citation Nr: 18144117 Decision Date: 10/23/18 Archive Date: 10/23/18 DOCKET NO. 16-28 062 DATE: October 23, 2018 REMANDED Entitlement to a disability rating greater than 20 percent for degenerative disc disease of the spine from November 1, 2012 to April 27, 2015 and beginning July 1, 2015 is remanded. Entitlement to a disability rating greater than 20 percent for radiculopathy in the left lower extremity is remanded. An extension of temporary total evaluation past November 1, 2012, based on convalescence after lumbar fusion surgery is remanded. Entitlement to a total disability rating for compensation based on individual unemployability (TDIU) due to service connected disabilities is remanded. REASONS FOR REMAND Although the Board regrets the additional delay, a remand is necessary to ensure that due process is followed and that there is a complete record upon which to decide the Veteran’s claim so that he is afforded every possible consideration. The Veteran had active service in the United States Air Force from February 1976 to November 1996, including over 5 years of foreign service. For his meritorious service, the Veteran was awarded (among other decorations) the Air Force Commendation Medal, the Meritorious Service Medal, and the Southwest Asia Service Medal. This matter comes before the Board of Veterans’ Appeals (Board) from the June 2013 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in St. Petersburg, Florida. In a March 2016 rating decision, the Regional Office (RO) changed the Veteran’s original rating for the evaluation of his degenerative disc disease of the lumbosacral spine with radiculopathy of the left leg from a single 40 percent evaluation to individual ratings for the Veteran’s back disability and bilateral radiculopathy in the lower extremities. First, with regard to the Veteran’s claim for an increased rating for his back disability, the Veteran submitted a Disability Benefits Questionnaire from a private treatment provider in May 2017. This DBQ reflects symptoms much more severe than reflected on his most recent VA examination of August 2012. Importantly, though, this DBQ diagnosed the Veteran as suffering from psoriatic arthritis, while the Veteran is specifically service-connected for degenerative disc disease of the lumbar spine. It is not clear to the Board whether this diagnosis represents a separate disability or whether the symptoms found are manifestations of the Veteran’s service-connected back disability. The clarity of a VA examination is needed. As the Veteran’s claim is being remanded, updated VA treatment records must also be obtained. As the Board is seeking updated VA treatment records, any decision on the Veteran’s claim for an increased rating for his radiculopathy and for an extension of his temporary total rating would be premature at this time. Finally, with respect to the Veteran’s claim for a TDIU, the Veteran has separately sought and been denied this benefit in the past. However, as the evidence continues to indicate that the Veteran may be unable to work on account of his service-connected disabilities, the claim for a TDIU is once again raised by the record and must be remanded. Of particular note here: the RO has denied the Veteran’s claim for a TDIU in the past based in part on his not returning the formal application for a TDIU (VA Form 21-8940) provided to him by the RO. Ultimately, the resolution of a TDIU depends on many factors, including the Veteran’s work and educational history. The information required to resolve this claim is included on the VA Form 21-8940, and for both the RO and the Board to be able to make an informed decision on this question, it is imperative that the Veteran return this form in as complete a manner as possible. Thus, on remand, the Veteran must be provided a copy of this application. The Veteran is also specifically instructed that a failure to complete this form may result in a denial of his claim. The matters are REMANDED for the following action: 1. Provide the Veteran with a copy of VA Form 21-8940 (Application for Increased Compensation Based on Unemployability). 2. Obtain VA treatment records dated from July 2015 and thereafter and associate those documents with the Veteran’s claims file. 3. Schedule the Veteran for a VA examination to determine the current nature and severity of his service connected back disability. The examination should include all studies, tests, and evaluations deemed necessary by the examiner. The examiner should report all manifestations related to the service connected disability. The examiner is directed to answer whether or not the Veteran has ankylosis of the thoracolumbar or entire spine. The examiner must also address the private May 2017 DBQ submitted by the Veteran and state whether the symptoms and findings in that examination are consistent with his service-connected lumbar spine disability. All opinions provided must be thoroughly explained and an adequate rationale for any conclusions reached must be provided. If any requested opinion cannot be provided without resort to speculation, the medical professional should state and explain why an opinion cannot be provided without resort to speculation. 4. Following completion of the above, and a review of any additional evidence received, the RO should also undertake any other development it deems to be necessary, to include, if warranted, an addendum medical opinion which considers any newly received evidence and possible submission of the Veteran’s TDIU claim to the Director, Compensation Service for extraschedular consideration. Evan M. Deichert Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD S. Mountford, Associate Counsel