Citation Nr: 18154373 Decision Date: 11/29/18 Archive Date: 11/29/18 DOCKET NO. 16-46 019A DATE: November 29, 2018 REMANDED Entitlement to service connection for glaucoma is remanded. Entitlement to service connection for sleep apnea is remanded. Entitlement to service connection for a heart disability is remanded. Entitlement to service connection for hypertension is remanded. Entitlement to service connection for hepatitis C is remanded. Entitlement to service connection for diabetes mellitus is remanded. Entitlement to service connection for a headache disability is remanded. Entitlement to service connection for a psychiatric disorder, to include posttraumatic stress disorder (PTSD) and depression, is remanded. Entitlement to a rating in excess of 40 percent for chronic low back strain with degenerative changes and bulging of multiple lumbar vertebrae with lumbar radiculopathy, is remanded. Entitlement to a rating in excess of 10 percent for chondromalacia patella of the left knee with laxity, is remanded. Entitlement to a rating in excess of 10 percent for anterior cruciate ligament (ACL) deficiency post-arthroscopic surgery with degenerative changes of the left knee, is remanded. REASONS FOR REMAND The Veteran served in the Army Reserve from February 1980 to March 1989. He had periods of active duty for training (ACDUTRA), including from February 1980 to July 1980. This case comes before the Board of Veterans’ Appeals (Board) on appeal from a March 2015 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Milwaukee, Wisconsin. A review of the record indicates that the Veteran applied for disability benefits from the Social Security Administration (SSA). Because those records may be relevant to the Veteran’s appeal, the Board finds that a remand is necessary so that they may be obtained and reviewed by the Agency of Original Jurisdiction (AOJ). Golz v. Shinseki, 590 F.3d 1317 (Fed. Cir. 2010). In addition, a review of the record indicates that VA treatment records dated from June 1996 to January 1999, and from February 2001 to April 2005 have not been associated with the claims file. The record also indicates that the Veteran was hospitalized in October 2004 at the Milwaukee VA Medical Center; however, those records have not been associated with the claims file. Therefore, the Board finds that a remand is necessary to obtain any outstanding VA treatment records. Regarding the claims for increased ratings for left knee and low back disabilities, the most recent VA examination reports do not include detailed range of motion findings or findings regarding functional loss, per the recent precedential decisions of Correia v. McDonald, 28 Vet. App. 158 (2016), and Sharp v. Shulkin, 29 Vet. App. 26 (2017). Therefore, the Board finds that a remand is necessary for additional VA examinations. The matters are REMANDED for the following action: 1. Identify and obtain any pertinent, outstanding VA and private treatment records and associate them with the claims file. This should include VA treatment records dated from June 1996 to January 1999, from February 2001 to April 2005, and any hospitalization records dated in October 2004. 2. Obtain and associate with the claims file the Veteran’s SSA disability benefits records, to include the claim, any decision, and any medical records. 3. Then, schedule the Veteran for an appropriate VA examination to determine the current level of severity of all impairment resulting from his service-connected left knee disability. All indicated tests should be performed and all findings should be reported in detail. The examiner should provide all information required for rating purposes, to specifically include range of motion in active motion, passive motion, weight bearing, and non-weight 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 why that is so. The examiner must report whether there is a lack of normal endurance or functional loss due to pain and pain on use, including that experienced during flare ups; whether there is weakened movement, excess fatigability, incoordination; and the effects of the service-connected disability on the Veteran’s ordinary activity. The examiner should also ask the Veteran to identify the severity, frequency, duration, precipitating and alleviating factors, and extent of functional impairment resulting from flare-ups. The examiner should identify the extent of the Veteran’s functional loss during flare-ups and offer range of motion estimates based on that information. If the examiner cannot provide any of the requested findings without resorting to speculation, the examiner must state why that is so and provide a detailed rationale as to the reason why the requested findings could not be provided. 4. Then, schedule the Veteran for an appropriate VA examination to determine the current level of severity of all impairment resulting from his service-connected low back disability. All indicated tests should be performed and all findings should be reported in detail. The examiner should provide all information required for rating purposes, to specifically include range of motion in active motion, passive motion, weight bearing, and non-weight 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 why that is so. The examiner must report whether there is a lack of normal endurance or functional loss due to pain and pain on use, including that experienced during flare ups; whether there is weakened movement, excess fatigability, incoordination; and the effects of the service-connected disability on the Veteran’s ordinary activity. The examiner should also ask the Veteran to identify the severity, frequency, duration, precipitating and alleviating factors, and extent of functional impairment resulting from flare-ups. The examiner should identify the extent of the Veteran’s functional loss during flare-ups and offer range of motion estimates based on that information. The examiner should also state whether the functional impairment resulting the Veteran’s low back disability, including during flare-ups, is equivalent to unfavorable ankylosis. If the examiner cannot provide any of the requested findings without resorting to speculation, the examiner must state why that is so and provide a detailed rationale as to the reason why the requested findings could not be provided. 5. Confirm that the VA examination reports and all opinions provided comport with this remand and undertake any other development found to be warranted. 6. Then, readjudicate the issues on appeal. If a decision is adverse to the Veteran, issue a supplemental statement of the case and allow appropriate time for response. Then, return the case to the Board. Kristin Haddock Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD S. Mishalanie, Counsel