Citation Nr: 18145225 Decision Date: 10/26/18 Archive Date: 10/26/18 DOCKET NO. 15-28 444 DATE: October 26, 2018 REMANDED Entitlement to an increased disability rating in excess of 20 percent prior to July 21, 2010, for chronic AC separation of the left shoulder with associated degenerative changes and tendonitis status post-surgical repair, and an evaluation in excess of 30 percent therefrom, is remanded. Entitlement to a total disability rating based on individual unemployability due to service-connected disability (TDIU) is remanded. REASONS FOR REMAND The Veteran had active service from February 1994 to May 2001. This matter is on appeal from a March 2010 rating decision. A July 2015 rating decision granted a 30 percent rating for the left shoulder disability effective July 21, 2010. This partial grant, which did not award the maximum allowable benefit, did not resolve the appeal. In August 2010, a private attorney filed an informal notice of disagreement (NOD) on the Veteran’s behalf as it pertained to a denial of TDIU. The NOD did not identify the decision being appealed, and the claims file does not reflect a prior denial of a TDIU at that time. Rather, a rating decision was not issued on the TDIU issue until January 2011, after which the Veteran did not file a second NOD for the issue. Nonetheless, the TDIU issue is currently on appeal as it has been raised as a component of the rating claim on appeal. Thus, it is presently in appellate status before the Board. See Rice v. Shinseki, 22 Vet. App. 447 (2009). A misfiled document was discovered by the Board in this Veteran’s claims file. The misfiled record consisted of a notification letter pertaining to a different Veteran. This misfiled record appears to have been mistakenly included in this Veteran’s file, but does not appear to have had any impact in the instant appeal. Accordingly, action was taken by the Board in October 2018 to associate it with the correct Veteran’s claims file. 1. Entitlement to an increased disability rating in excess of 20 percent prior to July 21, 2010, for chronic AC separation of the left shoulder with associated degenerative changes and tendonitis status post-surgical repair, and an evaluation in excess of 30 percent therefrom, is remanded. The Veteran was last examined by VA in August 2010. Since that time, a June 2016 VA Telephone Nursing note indicates a second surgery in 2012 by a private (non-VA) doctor. On this basis, the isuse is remanded to (1) obtain the private medical records, and (2) arrange for a new VA examination, including one compliant with Correia v. McDonald, 28 Vet. App. 158, 168 (2016), and Sharp v. Shulkin, 29 Vet. App. 26, 34-36 (2017). 2. Entitlement to a TDIU is remanded. This issue is intertwined with the left shoulder issue. The matters are REMANDED for the following action: 1. Ask the Veteran to complete a VA Form 21-4142 for all providers and/or medical facilities having additional records pertinent to the left shoulder disability, including surgery by Dr. Dunteman in 2012. Make two requests for the authorized records, unless it is clear after the first request that a second request would be futile. 2. Obtain the Veteran’s ongoing VA treatment records. 3. Schedule the Veteran for an examination of the current severity of his left shoulder disability. 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 the left shoulder disability alone and discuss the effect of the Veteran’s left shoulder disability 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). The examiner is also asked to comment on and describe the functional impairment caused solely by the service-connected disability as it pertains to the Veteran’s ability to function in an occupational environment. The examiner should, for instance, describe the limitations and restrictions imposed by his service-connected left shoulder on routine work activities for up to six hours per day, such as interacting with customers/coworkers and using technology, plus other physical activities such as sitting, standing, walking, lifting, carrying, pushing, and pulling, and mental activities such as understanding and remembering instructions, and sustained concentration. The examiner is asked to identify, to the extent possible, the date on which any change in degree of impairment first occurred. C. CRAWFORD Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD C. Bosely, Counsel