Citation Nr: 18155703 Decision Date: 12/06/18 Archive Date: 12/04/18 DOCKET NO. 15-31 361A DATE: December 6, 2018 REMANDED Entitlement to a rating in excess of 20 percent for a cervical strain (neck disability) is remanded. REASONS FOR REMAND The appellant is a Veteran who served on active duty from September 1995 to April 1999. This matter is before the Board of Veterans’ Appeals (Board) on appeal from a July 2014 rating decision which continued a 20 percent rating for the Veteran’s neck disability. In November 2018 a videoconference hearing was held before the undersigned. Entitlement to a rating in excess of 20 percent for a neck disability is remanded. The most recent VA examination to assess the severity of the Veteran’s neck disability was conducted in July 2014, when the diagnosis was cervical strain. In a January 2015 statement, the Veteran reported that his neck “condition continues to become worse.” At the November 2018 Board hearing, he testified that he has since received a diagnosis of cervical disc disease, suggesting that the nature of his neck disability has evolved. Considering the allegation of worsening and the length of the intervening period since he was last examined, a contemporaneous examination to assess the neck disability is necessary. The record reflects that pertinent records of private treatment remain outstanding. On April 2013 VA neck examination, the Veteran reported that he was “being seen by his primary care provider for the pain in his neck.” Records of such treatment are not associated with the Veteran’s record but are material (and may be dispositive) evidence in this claim for increase, and should be obtained on remand. It is not clear whether the Veteran has received any VA treatment for neck disability during the period for consideration; as VA treatment records are constructively of record, and any existing are likely to contain pertinent information, they also must be sought. The matter is REMANDED for the following: 1. Secure for the record updated (to the present, those not already associated with the record) complete clinical records of all VA evaluations and treatment the Veteran has received for his neck disability since April 2013 (when the most recent VA treatment records in the record are dated). Ask the Veteran to provide identifying information regarding all private evaluations or treatment he has received for his neck disability and submit authorizations for VA to secure complete clinical records from all providers identified. Obtain those records. 2. When the development requested above is completed, arrange for an orthopedic examination of the Veteran to assess the nature and current severity of his service-connected cervical spine disability. The Veteran’s record (to include this remand and all records received pursuant to the development sought above) must be reviewed by the examiner in conjunction with the examination. All pertinent findings should be described in detail. The examiner should note whether or not there have been incapacitating episodes of disc disease (and if so, their frequency and duration) and whether the spine is ankylosed. The examiner should also note whether there are any associated neurological symptoms (and if so identify them, describing all manifestations). Considering the Veteran’s reports of flare-ups on prior VA examinations, describe the functional impairment due to the neck disability during flare-ups, accounting for pain, incoordination, weakened movement, and excess fatigability on use, and, to the extent possible, report such impairment in terms of additional degrees of limitation of motion. [If an opinion cannot be provided without resort to speculation, indicate 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), or a deficiency in the record or the examiner (additional facts are required, or the examiner does not have the needed knowledge or training).] GEORGE R. SENYK Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD J. Dupont, Associate Counsel