Citation Nr: 18154432 Decision Date: 11/29/18 Archive Date: 11/29/18 DOCKET NO. 16-59 494 DATE: November 29, 2018 REMANDED Entitlement to a rating in excess of 10 percent degenerative joint disease of the cervical spine is remanded. Entitlement to a rating in excess of 20 percent for cervical radiculopathy is remanded. Entitlement to a total disability rating based on individual unemployability (TDIU) is remanded. REASONS FOR REMAND The Veteran served on active duty from June 1984 to September 2004. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a November 2013 rating decision. The issue of entitlement to a TDIU is under the Board’s jurisdiction as part and parcel of the appeal from the rating assigned for the underlying disability. Rice v. Shinseki, 22 Vet. App. 447 (2009). The Veteran raised this issue in his November 2014 notice of disagreement and again in his December 2016 substantive appeal.   1. Entitlement to a rating in excess of 10 percent degenerative joint disease of the cervical spine is remanded. 2. Entitlement to a rating in excess of 20 percent for cervical radiculopathy is remanded. 3. Entitlement to a TDIU. The Veteran last underwent a VA examination for his cervical spine disability in October 2013. Since then, he has submitted lay statements that suggest a worsening of his symptoms. In detail, he has stated that in November 2014 he had to quit work altogether due to issues with his neck, shoulder, and arm. See December 2016 substantive appeal. As such, the Veteran should be provided an opportunity to report for a VA examination to ascertain the current severity and manifestations of his cervical spine disability, to include radiculopathy. The examination report should include a discussion of how the Veteran’s service-connected neck, shoulder, and arm disabilities impact his ability to do both physical and sedentary work. As already mentioned, the Veteran has asserted that he had to stop working due to these disabilities. Id. In his December 2016 substantive appeal, the Veteran indicated that he was being treated at the Shaw Air Force Base Hospital for sharp pain in his arm. This statement indicates that there may be outstanding and relevant Air Force treatment records. A remand is required to allow VA to request these records. In November 2014, the Veteran submitted the report of a June 2014 cervical myelogram. The report identifies the provider as the Tuomey Healthcare System. Additionally, a June 2014 VA treatment records indicates that an outside orthopedist had scheduled the myelogram. See VBMS: 06/28/2016, CAPRI, at 43. This evidence also indicates that there may be outstanding and relevant private treatment records. A remand is required to allow VA to request these records.   The matters are REMANDED for the following actions: 1. Obtain the Veteran’s treatment records from the medical facility at Shaw Air Force Base. Document all requests for information as well as all responses in the claims file. 2. Ask the Veteran to complete a VA Form 21-4142 for any relevant private treatment providers. Make two requests for the authorized records from any identified sources, unless it is clear after the first request that a second request would be futile. 3. After completing #1 and #2, schedule the Veteran for an examination by an appropriate clinician to determine the current severity of his service-connected cervical spine disability, to include radiculopathy. The examiner should provide a full description of the disability and report all signs and symptoms necessary for evaluating the Veteran’s disability under the rating criteria. The examiner must attempt to elicit information regarding the severity, frequency, and duration of any flare-ups, and the degree of functional loss during flare-ups or after repetitive use. To the extent possible, the examiner should identify any symptoms and functional impairments due to the service-connected neck, shoulder, and arm disabilities alone and discuss the effect of these disabilities on any occupational functioning and activities of daily living. The examiner should discuss how the Veteran’s service-connected neck, shoulder, and arm disabilities impact his ability to do both physical and sedentary work. 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). Paul Sorisio Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD P. López, Associate Counsel