Citation Nr: 18153813 Decision Date: 11/28/18 Archive Date: 11/28/18 DOCKET NO. 16-46 040 DATE: November 28, 2018 REMANDED Entitlement to a compensable evaluation for right ring finger status post fracture with scar and hand osteoarthritis is remanded. Entitlement to a compensable evaluation for sinusitis is remanded. Entitlement to a compensable evaluation for gastroesophageal reflux disease (GERD) (claimed as ulcerated esophagus) is remanded. Entitlement to an increased evaluation for muscle contraction headaches, currently rated at noncompensable (0 percent) is remanded. REASONS FOR REMAND At the outset, the Veteran had several claims filed within the two years leading up to this current issuance, and the Regional Office (RO) decisional decided those matters. The Veteran has the remainder of the one-year appeal periods to file a Notice of Disagreement to initiate an appeal of those claims. 1. Entitlement to a compensable evaluation for right ring finger status post fracture with scar and hand osteoarthritis is remanded. 2. Entitlement to a compensable evaluation for sinusitis is remanded. 3. Entitlement to a compensable evaluation for gastroesophageal reflux disease (GERD) (claimed as ulcerated esophagus) is remanded. 4. Entitlement to compensable evaluation for muscle contraction headaches is remanded. Having had the opportunity for overview of the appellate record, the last relevant VA Compensation and Pension examinations for the denotated service-connected conditions were all from over 6 years ago, and it is therefore essential that the Veteran is reexamined for contemporaneous findings. See Palczewski v. Nicholson, 21 Vet. App. 174, 181-82 (2007), citing Caluza v. Brown, 7 Vet. App. 498, 505-06 (1998) (“Where the record does not adequately reveal the current state of the claimant’s disability...the fulfillment of the statutory duty to assist requires a thorough and contemporaneous medical examination.”). Additionally, the Veteran himself through ongoing correspondence (this provided upon several statements given upon copies of VA Form 9) stated that the prior 2012 examiner’s medical evaluation was mostly cursory. The Veteran noted some other issues with the rated disorders at issue; for one, having recently had constant sinus infections resulting in two surgeries. Further, the right ring finger demonstrated lost mobility that reportedly affected the Veteran’s capacity to do his job. regarding gastrointestinal problems, the Veteran contends that the reflux symptoms are out of control. These considerations should be taken into account during the upcoming re-examinations. The Veteran has further identified by medical records authorization form that he had treatment by a private neurologist, and this becomes additionally significant in that the headache and sinusitis conditions are considered to have had a similar etiology, and information bearing on one could clarify the whole picture. The matters are REMANDED for the following action: 1. Contact the Veteran and request that he complete a medical authorization form (VA Form 21-4142) to request treatment records from a Dr. A. Maloon, neurologist, for the evaluation and treatment of headaches and/or sinusitis. Then obtain further treatment records available based upon the information provided. 2. Obtain the Veteran’s most recent VA outpatient treatment records and associate them with the claims folder. 3. After the development in paragraphs 1 and 2 is complete, schedule the Veteran for VA examination to determine the severity of his service-connected muscle contraction headaches and sinusitis. The claims file must be provided to and reviewed by the examiner in conjunction with the examination. The VA examiner is requested to indicate all present symptoms and manifestations from the Veteran’s service-connected muscle contraction headaches, in accordance with the rating criteria in 38 C.F.R. § 4.124a, Diagnostic Code 8100. This should include an assessment of occupational functioning. The examiner should define prolonged, frequent, and/or prostrating as those terms apply to the Veteran’s clinical picture. Also provide clinical findings in regard to the Veteran’s service-connected sinusitis under 38 C.F.R. § 4.97, Diagnostic Code 6517. The examiner should consider the Veteran’s lay statement that he recently underwent two surgical procedures to the sinus region. The examiner should provide a complete rationale for all opinions provided. 4. After the development in paragraphs 2 is complete, schedule the Veteran for VA examination to determine the severity of his GERD. The claims file must be provided to and reviewed by the examiner in conjunction with the examination. The VA examiner is requested to indicate all present symptoms and manifestations from the Veteran’s service-connected GERD, as rated in accordance with 38 C.F.R. § 4.114, Diagnostic Code 7346. The examiner is requested to consider the Veteran’s assertion that reflux was the primary problem with the condition. The examiner should provide a complete rationale for all opinions provided. 5. Then readjudicate the claims on appeal based upon all evidence of record. If any benefit sought on appeal is not granted, the Veteran and his attorney should be furnished with a Supplemental Statement of the Case (SSOC) and afforded an opportunity to respond. REBECCA N. POULSON Acting Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD Jason A. Lyons