Citation Nr: 18155677 Decision Date: 12/04/18 Archive Date: 12/04/18 DOCKET NO. 16-53 354A DATE: December 4, 2018 REMANDED Entitlement to a compensable rating for scarring status post right ankle scar associated with status post, right ankle dislocation is remanded. REASONS FOR REMAND The Veteran served in the Army from August 1990 to September 1995. He is a Gulf War Era Veteran. This appeal comes before the Board of Veterans’ Appeals (Board) from an October 2015 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) that granted service connection for scarring status post right ankle with an evaluation of zero percent from July 13, 2015. As a preliminary matter, the Board notes that the Veteran did not perfect all issues from October 2015 rating decision in his appeal to the Board. The Veteran initially filed a notice a disagreement in November 2015 as to claims for a higher rating for a status-post ankle scar and status-post right ankle dislocation with fracture to the right calcaneus and degenerative joint disease. In September 2016, the RO issued Statement of the Case denying an initial rating in excess of zero percent for scarring status post right ankle and denying an increase in excess of 10 percent for status post right ankle dislocation with fracture to right calcaneus and degenerative joint diseases. Subsequently, in November 2016, the Veteran submitted substantive appeal only appealing the initial rating of zero percent for scarring status post right ankle. Entitlement to a compensable rating for scarring status post right ankle scar associated with status post, right ankle dislocation is remanded. The Veteran contends that his right ankle scar warrants a 10 percent rating because it is painful and/or unstable. In his November 2016 substantive appeal, the Veteran referred to attached VA progress notes that stated that he has two or more scars that are painful and unstable. A review of the record does not reveal the referenced VA progress notes and the Veteran did not describe the contents of these progress notes or provide the relevant dates. On remand, the Veteran should be asked to provide the copies of the VA progress notes he submitted with the November 2016 substantive appeal or provide the dates of these VA progress notes so they could be obtained. In addition, the Veteran contends that his scars are painful and unstable in a November 2016 substantive appeal. As the evidence of record indicates that the Veteran’s symptoms may have increased in severity since he was last evaluated on examination in October 2015, the Board finds that a remand is warranted to afford the Veteran a new VA examination to assess the current severity of his right ankle scar. See Snuffer v. Gober, 10 Vet. App. 400, 403 (1997); see also Green v. Derwinski, 1 Vet. App. 121, 124 (1991) (VA has a duty to provide the Veteran with a thorough and contemporaneous medical examination). On remand, the Veteran should be asked to furnish, or to furnish an authorization to enable VA to obtain, any additional private treatment records from providers who treated him for his claimed disability. Finally, given the time that will elapse on remand, updated VA treatment records should be obtained. The matter is REMANDED for the following action: 1. Request that the Veteran provide copies of the VA progress notes submitted with his November 2016 substantive appeal or that he identify the dates of the treatment and medical facilities that provided the treatment referenced in the VA progress notes. The Veteran should also be given an opportunity to identify any outstanding private or VA treatment records relevant to the claim on appeal. After obtaining any necessary authorization from the Veteran, all outstanding records should be obtained. These VA treatment records include updated VA treatment records dated from June 2018 to the present. For private treatment records, make at least two (2) attempts to obtain records from any identified sources. If any such records are unavailable, inform the Veteran and afford her an opportunity to submit any copies in his possession. For federal records, all reasonable attempts should be made to obtain such records. If any records cannot be obtained after reasonable efforts have been made, issue a formal determination that such records do not exist or that further efforts to obtain such records would be futile, which should be documented in the claims file. The Veteran must be notified of the attempts made and why further attempts would be futile, and allowed the opportunity to provide such records, as provided in 38 U.S.C. § 5103A (b)(2) and 38 C.F.R. § 3.159(e). 2. Schedule the Veteran for an examination by an appropriate clinician to determine the current severity of the Veteran’s service-connected right ankle scar. The examiner should specifically indicate whether the Veteran’s scar is painful or unstable. KRISTY L. ZADORA Acting Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD M. Iglesias, Law Clerk