Citation Nr: 18147744 Decision Date: 11/07/18 Archive Date: 11/06/18 DOCKET NO. 16-31 602 DATE: November 7, 2018 REMANDED The issue of service connection for a generalized anxiety disorder is remanded. The issue of service connection for a recurrent gastrointestinal disorder to include gastroesophageal reflux disease (GERD) is remanded. The issue of service connection for a recurrent urological disorder to include voiding dysfunction is remanded. The issue of service connection for a recurrent prostate disorder is remanded. The issue of service connection for a recurrent anterior cruciate nerve disorder is remanded. The issue of service connection for erectile dysfunction is remanded. The issue of a rating in excess of 10 percent for the period prior to October 17, 2017, and in excess of 50 percent for the period on and after October 17, 2017, for the Veteran’s “other specified trauma and stressor related” disorder is remanded. The issue of an effective date prior to July 5, 2013, for the award of service connection for Type II diabetes mellitus is remanded. The issue of an initial rating in excess of 20 percent for the Veteran’s left (minor) subscapularis tear repair residuals arthroscopic debridement residuals, open biceps tenodesis, and degenerative joint disease is remanded. REASONS FOR REMAND The Veteran had active service from June 1971 to August 1974. 1. The issues of service connection for a generalized anxiety disorder, a recurrent gastrointestinal disorder to include GERD, a recurrent urological disorder to include voiding dysfunction, a recurrent prostate disorder, a recurrent anterior cruciate nerve disorder, and erectile dysfunction; a rating in excess of 10 percent for the period prior to October 17, 2017, and in excess of 50 percent for the period on and after October 17, 2017, for the Veteran’s “other specified trauma and stressor related” disorder; and an effective date prior to July 5, 2013, for the award of service connection for Type II diabetes mellitus are remanded. The Veteran has submitted timely notices of disagreement with the denial of service connection for a generalized anxiety disorder, a recurrent gastrointestinal disorder to include GERD, a recurrent urological disorder to include voiding dysfunction, a recurrent prostate disorder, a recurrent anterior cruciate nerve disorder, and erectile dysfunction; a rating in excess of 10 percent for the period prior to October 17, 2017, and in excess of 50 percent for the period on and after October 17, 2017, for the Veteran’s “other specified trauma and stressor related” disorder; and an effective date prior to July 5, 2013, for the award of service connection for Type II diabetes mellitus. A statement of the case that addresses that issue has not been issued to the Veteran. Where a veteran has submitted a timely notice of disagreement with an adverse decision and no statement of the case has been issued, the Board should remand for issuance of a statement of the case. Manlincon v. West, 12 Vet. App. 238 (1999). 2. The issue of an initial rating in excess of 20 percent for the Veteran’s left (minor) subscapularis tear repair residuals arthroscopic debridement residuals, open biceps tenodesis, and degenerative joint disease is remanded. The Veteran asserts that an initial rating in excess of 20 percent for the service connected left shoulder disability is warranted. The reports of a January 2016 VA upper extremity examination and a March 2016 VA upper extremity examination do not include findings for left upper extremity and passive range of motion and non-weight-bearing maneuvers for the opposite, undamaged joint as required. See Correia v. McDonald, 28 Vet. App. 158 (2016). The Department of Veterans Affairs’ (VA) duty to assist includes, in appropriate cases, the duty to conduct a thorough and contemporaneous medical examination which is accurate and fully descriptive. McLendon v. Nicholson, 20 Vet. App. 79 (2006); Green v. Derwinski, 1 Vet. App. 121, 124 (1991). When VA undertakes to obtain an evaluation, it must ensure that the evaluation is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). Therefore, the Board of Veterans’ Appeals (Board) concludes that further VA upper extremity evaluation is necessary. Clinical documentation dated after May 2018 is not of record. VA should obtain all relevant VA and private treatment records which could potentially be helpful in resolving the Veteran’s claims. Murphy v. Derwinski, 1 Vet. App. 78 (1990); Bell v. Derwinski, 2 Vet. App. 611 (1992). The matter is REMANDED for the following action: 1. Ask the Veteran to complete a VA Form 21-4142 for each private healthcare provider who has treated the service connected left shoulder disabilities. Make two requests for any authorized records from all identified healthcare providers unless it is clear after the first request that a second request would be futile. 2. Obtain the Veteran’s VA treatment records associated with treatment after May 2018. 3. Schedule the Veteran for a VA orthopedic examination in to assist in determining the current severity of the service-connected left shoulder disabilities. The examiner must review the record and should note that review in the report. A rationale for all opinions should be provided. The examiner should: (a) Provide ranges of motion for passive and active motion, and for weight-bearing and nonweight-bearing, of both the shoulders. The examiner should state whether there is any additional loss of left shoulder function due to painful motion, weakened motion, excess motion, fatigability, incoordination, or on flare up. (b) Provide an opinion as to the impact of the left shoulder disabilities on the Veteran’s vocational pursuits. (Continued on the next page)   4. Issue a statement of the case which addresses the issues of entitlement to service connection for a generalized anxiety disorder, a recurrent gastrointestinal disorder to include GERD, a recurrent urological disorder to include voiding dysfunction, a recurrent prostate disorder, a recurrent anterior cruciate nerve disorder, and erectile dysfunction; a rating in excess of 10 percent for the period prior to October 17, 2017, and in excess of 50 percent for the period on and after October 17, 2017, for the Veteran’s “other specified trauma and stressor related” disorder; and an effective date prior to July 5, 2013, for the award of service connection for Type II diabetes mellitus. Notify the Veteran of his appeal rights and that he must submit a timely substantive appeal to receive appellate review of that claim. If a timely substantive appeal is received, return those claims to the Board. J. T. HUTCHESON Acting Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD P. Franke, Associate Counsel