Citation Nr: 18145073 Decision Date: 10/26/18 Archive Date: 10/25/18 DOCKET NO. 16-31 434 DATE: October 26, 2018 REMANDED Entitlement to service connection for mitral valve prolapse is remand. Evaluation of cervical degenerative disc disease, currently rated at 10 percent prior to September 25, 2014, at 20 percent from September 25, 2014 to April 7, 2016, and at 10 percent thereafter is remanded. Evaluation of systemic lupus erythematous, currently rated at 10 percent is remanded. Evaluation of status-post hemorrhoidectomy, currently rated as noncompensable is remanded. Evaluation of migraine headaches, currently rated as noncompensable prior to September 25, 2014, as 30 percent from September 25, 2014 to April 7, 2016, and as noncompensable thereafter is remanded. Entitlement to service connection for urinary tract infection is remanded. REASONS FOR REMAND The Veteran served on active duty from February 1991 to February 2011. This matter came before the Board of Veterans Appeals (Board) on appeal from a June 2012 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO). An April 2016 Decision Review Officer (DRO) decision increased the rating for the Veteran’s cervical degenerative disc disease from 10 to 20 percent for the period from September 25, 2014 to April 7, 2016 and assigned a rating of 10 percent for the period after April 7, 2016. The DRO decision also increased the rating for migraines from noncompensable to 30 percent for the period from September 25, 2014 to April 7, 2016 and assigned a noncompensable rating for the period after April 7, 2016. Because higher ratings for these disabilities are assignable during the relevant period and the Veteran is presumed to seek the maximum available benefit, the issues remain on appeal. See AB v. Brown, 6 Vet. App. 35, 38 (1993). The Board notes that the Veteran’s July 2013 Notice of Disagreement (NOD) also included the issues of service connection for bilateral plantar fasciitis, obstructive sleep apnea, left ankle tendonitis, right ankle tendonitis and right knee patellofemoral pain syndrome. Service connection for these disabilities was granted in the April 2016 DRO decision. As this constituted a full grant of the issues on appeal, they are not before the Board. REASONS FOR REMAND 1. Entitlement to service connection for mitral valve prolapse The Veteran contends that she has a current disability of mitral valve prolapse that began in service. June 2016 VA treatment records document a cardiology consult, at which cardiac testing was performed and showed overall normal systolic function and a mild anterior mitral valve prolapse with trace mitral regurgitation. The Board also notes that service treatment records document a June 1995 diagnosis of mild mitral valve prolapse but that the September 2011 VA general medical examination found that the Veteran did not have mitral valve prolapse at the time of the examination. As the Veteran has been diagnosed with mitral valve prolapse with trace mitral regurgitation since the last VA examination in September 2011, remand for a new examination is required. 2. Evaluation of cervical degenerative disk disease, currently rated at 10 percent prior to September 25, 2014, at 20 percent from September 25, 2014 to April 7, 2016, and at 10 percent thereafter is remanded. 3. Evaluation of systemic lupus erythematous, currently rated at 10 percent is remanded. 4. Evaluation of status-post hemorrhoidectomy, currently rated as noncompensable is remanded. 5. Evaluation of migraine headaches, currently rated as noncompensable prior to September 25, 2014, as 30 percent from September 25, 2014 to April 7, 2016, and as noncompensable thereafter is remanded. In a July 2017 statement, the Veteran’s representative contended that her service-connected disabilities have worsened since the last VA examinations in 2015 and 2016. Specifically, the July 2017 statement noted increased functional loss due to her cervical spine disability, multiple exacerbations of lupus and that the migraines are worse with frequent prostrating attacks. In her June 2016 Formal Appeal, the Veteran also stated that her hand swelling was constant, not intermittent, and ulcers were recurring monthly or bimonthly. As the evidence of record suggests her service-connected disabilities have increased in severity since the most recent VA examination in 2016, the Board finds that the Veteran should be afforded new examinations. See Snuffer v. Gober, 10 Vet. App. 400 (1997). The Board also notes that since the September 2011, September 2014 and April 2016 VA cervical spine examinations, the U.S. Court of Appeals for Veteran’s Claims (the Court) has issued the decision in Correia v. McDonald, 28 Vet. App. 158, 166 (2016) concerning the adequacy of VA orthopedic examinations. The Court in Correia held that the final sentence of 38 C.F.R. § 4.59 requires that VA examinations include joint testing for pain on both active and passive motion, in weight-bearing and non-weight-bearing and, if possible, with range of motion measurements of the opposite undamaged joint. The Board’s review indicates that the VA cervical spine examinations of record did not include the testing required under Correia and that remand for a new cervical spine examination is required. 6. Entitlement to service connection for urinary tract infection In her June 2013 NOD, Veteran reported a June 2013 diagnosis of urinary tract infection. The Board’s review indicates that VA treatment records do not contain evidence of such a diagnosis. However, May 2013 VA treatment records note that a private provider had conducted urinalysis and found white blood cells in the Veteran’s urine. The VA provider determined that as there were no urinary symptoms no acute care was needed, but noted that the Veteran had private doctors and had been treated with ciprofloxacin, an antibiotic. The Board’s review indicates that referenced private records have not yet been associated with the claim file. As the record indicates that there are outstanding records relevant to the issue on appeal, remand is required. The matters are REMANDED for the following action: 1. Ask the Veteran to complete a VA Form 21-4142 for all private providers, including any provider who treated a May or June 2013 urinary tract infection. Make two requests for the authorized records from all identified providers unless it is clear after the first request that a second request would be futile. 2. Obtain the Veteran’s VA treatment records for the period from March 2018 to the Present. 3. Schedule the Veteran for an appropriate VA examination to determine the nature and etiology of her mitral valve prolapse. The claim file should be made available to the examiner and the examination report must state a review of the file was conducted. A complete rationale for all opinions expressed must be provided. For any current mitral valve disability found to be diagnosed, the examiner should provide an opinion as to whether it is at least as likely as not (50 percent or greater probability) that any such disability is related to the Veteran’s active service. Attention is requested to September 1995 service treatment records noting a diagnosis of mild mitral valve prolapse. In providing the opinion, the examiner should consider and discuss any lay statements of record, to include the Veteran’s statements regarding the onset and persistence of her symptoms. 4. Schedule the Veteran for an appropriate VA examination to determine the current severity of her cervical spine disability. The claim file should be made available to and reviewed by the examiner and the examination report should state a review of the file was completed. The examiner should identify all cervical spine pathology found to be present. The examiner should conduct all indicated tests and studies, to include range of motion studies. The joints involved should be tested in both active and passive motion, in weight-bearing and non-weight-bearing and, if possible, with range of motion measurements of the opposite undamaged joint. 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 should describe any pain, weakened movement, excess fatigability, instability of station and incoordination present. If pain is noted, the point during range of motion at which pain starts must be clearly indicated. The examiner should also state whether the examination is taking place during a period of flare-up. If not, the examiner should ask the Veteran to describe the flare-ups she experiences, including: frequency, duration, characteristics, precipitating and alleviating factors, severity and/or extent of functional impairment she experiences during a flare-up of symptoms and/or after repeated use over time. Based on the Veteran’s lay statements and the other evidence of record, the examiner should provide an opinion estimating any additional degrees of limited motion caused by functional loss during a flare-up or after repeated use over time. If the examiner cannot estimate the degrees of additional range of motion loss during flare-ups or after repetitive use without resorting to speculation, the examiner should state whether the need to speculate is caused by a deficiency in the state of general medical knowledge (i.e. no one could respond given medical science and the known facts) or by a deficiency in the record or the examiner (i.e. additional facts are required, or the examiner does not have the needed knowledge or training). 5. Schedule the Veteran for an appropriate VA examination to determine the current level of severity of her lupus. The examiner should review the file and provide a complete rationale for all opinions expressed. 6. Schedule the Veteran for an appropriate VA examination to determine the current level of severity of her hemorrhoids. The examiner should review the file and provide a complete rationale for all opinions expressed. 7. Schedule the Veteran for an appropriate VA examination to determine the current level of severity of her migraines. The examiner should review the file and provide a complete rationale for all opinions expressed. CONTINUED ON NEXT PAGE 8. If upon completion of the above action the appeal remains 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 A. Arnold, Associate Counsel