Citation Nr: 18149040 Decision Date: 11/08/18 Archive Date: 11/08/18 DOCKET NO. 16-29 904 DATE: November 8, 2018 REMANDED Entitlement to an increased rating for degenerative disc disease of the lumbar spine, currently evaluated as 10 percent disabling, is remanded. REASONS FOR REMAND The Veteran served on active duty from August 1971 to August 1973. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from an April 2014 rating decision. The Veteran was most recently afforded a VA spine examination in March 2014. In his June 2016 substantive appeal, the Veteran reported that his range of motion in his lumbar spine was very limited and worse than reported in the April 2014 VA examination report. Thus, his statement suggests that his disability may have worsened since the last VA examination. When a claimant asserts that the severity of a disability has increased since the most recent rating examination, an additional examination is appropriate. VAOPGCPREC 11-95 (April 7, 1995); see also Snuffer v. Gober, 10 Vet. App. 400 (1997); Caffrey v. Brown, 6 Vet. App. 377 (1994). Moreover, in light of a decision issued by the United States Court of Appeals for Veterans Claims (Court), an additional examination is required. In Correia v. McDonald, 28 Vet. App. 158, 169 (2016), the Court held that the final sentence of § 4.59 creates a requirement that the examination should record the results of range of motion testing “for pain on both active and passive motion [and] in weight-bearing and nonweight-bearing.” Correia v. McDonald, 25 Vet. App. 158 (2016). In this case, the April 2014 VA examination report did not include all of these findings. For these reasons, the Board finds that an additional VA examination is needed. The matter is REMANDED for the following action: 1. The Agency of Original Jurisdiction (AOJ) should request that the Veteran provide the names and addresses of any and all health care providers who have provided treatment for his service-connected degenerative disc disease of the lumbar spine. After acquiring this information and obtaining any necessary authorization, the AOJ should obtain and associate these records with the claims file. The AOJ should also secure any outstanding VA medical records. 2. After completing the foregoing development, the Veteran should be afforded a VA examination to ascertain the severity and manifestations of his service-connected lumbar spine disability. Any and all studies, tests, and evaluations deemed necessary by the examiner should be performed. The examiner is requested to review all pertinent records associated with the claims file. The examiner should note that the Veteran is competent to attest to factual matters of which he has first-hand knowledge, including observable symptomatology. If there is a medical basis to support or doubt the history provided by the Veteran, the examiner should provide a fully reasoned explanation. The examiner should report all signs and symptoms necessary for rating the lumbar spine disability under the rating criteria. In particular, the examiner should provide the range of motion in degrees of the lumbar spine. In so doing, the examiner should test the Veteran’s range of motion in active motion, passive motion, weight-bearing, and nonweight-bearing. 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 so in the report. The examiner should also indicate whether there is any form of ankylosis. In addition, the examiner should state the total duration of incapacitating episodes over the past 12 months and identify all neurological manifestations of the disability. The presence of objective evidence of pain, excess fatigability, incoordination and weakness should also be noted, as should any additional disability (including additional limitation of motion) due to these factors. Further, the VA examiner should comment as to whether range of motion measurements for active motion, passive motion, weight-bearing, and/or nonweight-bearing can be estimated for the other VA examination conducted during the appeal period in March 2014. If the examiner is unable to provide a retrospective opinion as to these specific range of motion findings, he or she should clearly explain so in the report. A clear rationale for all opinions would be helpful and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. Because it is important “that each disability be viewed in relation to its history[,]” 38 C.F.R. § 4.1, copies of all pertinent records in the appellant’s claims file, or in the alternative, the claims file, must be made available to the examiner for review. J.W. ZISSIMOS Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD K. Osegueda, Counsel