Citation Nr: 18155799 Decision Date: 12/06/18 Archive Date: 12/06/18 DOCKET NO. 08-36 543 DATE: December 6, 2018 REMANDED Entitlement to an increased rating for post-operative right total knee arthroplasty prior to October 27, 2017, and on or after December 1, 2018, is remanded. Entitlement to a total disability evaluation based upon individual unemployability due to service-connected disability (TDIU) is remanded. REASONS AND BASES FOR REMAND The Veteran served on active duty from September 1970 to May 1972. This case comes before the Board of Veterans’ Appeals (Board) on appeal from an August 2009 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO). The Veteran testified at a hearing before the undersigned Veterans Law Judge in December 2007. A transcript is of record. The Board remanded the case for further development in September 2009, June 2014, and July 2017. The case has since been returned to the Board for appellate review. In the July 2017 remand, the Board directed the Agency of Original Jurisdiction (AOJ) to afford the Veteran a VA examination in compliance with the requirements of Correia v. McDonald, 28 Vet. App. 158 (2016). Thereafter, the Veteran was scheduled for a VA examination on October 31, 2017; however, the AOJ noted that he failed to report because he underwent right knee surgery on October 27, 2017. There was no attempt made to reschedule the Veteran for a VA examination or to obtain a retrospective medical opinion regarding the Correia findings. See Chotta v. Peake, 22 Vet. App. 80 (2008) (when there is an absence of medical evidence during a certain period of time, a retroactive medical evaluation may be warranted). Therefore, in order to ensure compliance with the prior remand, the AOJ should attempt to obtain a retrospective opinion concerning the Correia requirements prior to October 27, 2017, and provide an additional VA examination to ascertain the current severity and manifestations of the service-connected disability for the period beginning on December 1, 2018. Moreover, the Veteran's increased rating claim being remanded could impact adjudication of his TDIU claim. Therefore, these claims are inextricably intertwined. See Harris v. Derwinski, 1 Vet. App. 180, 183 (1991) (holding that two issues are inextricably intertwined when they are so closely tied together that a final Board decision on one issue cannot be rendered until the other issue has been considered). The matter is REMANDED for the following action: 1. The AOJ should request that the Veteran provide the names and addresses of any health care providers who have provided treatment for his service-connected right knee disability. After acquiring this information and obtaining any necessary authorization, the AOJ should obtain and associate these records with the claims file. The AOJ should also secure any outstanding VA treatment records. 2. The AOJ should request that the Veteran complete a VA Form 21-8940. 3. After completing the foregoing development, the Veteran should be afforded a VA examination to ascertain the current severity and manifestations of his service-connected right knee disability. The examiner is requested to review all pertinent records associated with the claims file. It should be noted that the Veteran is competent to attest to factual matters of which he has first-hand knowledge, including observable symptomatology. If there is a medical basis to support or doubt the history provided by the Veteran, the examiner should provide a fully reasoned explanation. The examiner should report all signs and symptoms necessary for evaluating the Veteran's disability under the rating criteria. In particular, the examiner should provide the range of motion of the left and right knees in degrees on active motion, passive motion, weight-bearing, and nonweight-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 provide an explanation for this determination in the report. The examiner should also state whether the Veteran has prosthetic replacement of the right knee joint with chronic residuals consisting of severe painful motion or weakness in the affected extremity. He or she should also indicate whether the Veteran has intermediate degrees of residual weakness, pain, or limitation of motion and whether there is any ankylosis, loss of extension, or malunion or nonunion of the tibia and fibula. The presence of objective evidence of pain, excess fatigability, incoordination, and weakness should also be noted, as should any additional disability due to these factors (including any additional loss of motion). Further, the VA examiner should comment as to whether range of motion measurements for active motion, passive motion, weight-bearing, and/or nonweight-bearing can be estimated for the other VA examinations conducted during the appeal period. See, e.g., August 2007, July 2010, and May 2016 VA examination reports. If the examiner is unable to provide a retrospective opinion as to these specific range of motion findings, he or she should clearly explain so in the report. In addition, the examiner should address how the Veteran’s service-connected right disability results in functional impairment and comment on the Veteran’s ability to function in an occupational environment. In so doing, he or she should consider the Veteran’s assertions that his right knee pain requires daily medication of narcotics. A clear rationale for all opinions would be helpful and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. 3. The AOJ should notify the Veteran that it is his responsibility to report for any scheduled examination, to cooperate in the development of the claim, and that the consequences for failure to report for a VA examination without good cause may include denial of the claims. 38 C.F.R. §§ 3.158, 3.655. In the event that the Veteran does not report for any scheduled examination, documentation which shows that notice scheduling the examination was sent to the last known address should be associated with the file. It should also be indicated whether any notice that was sent was returned as undeliverable. 5. The AOJ should review the examination report to ensure that it is in compliance with this remand. If a report is deficient in any manner, the AOJ should implement corrective procedures. 6. After completing these actions, the AOJ should conduct any other development as may be indicated by a response received as a consequence of the actions taken in the preceding paragraphs J.W. ZISSIMOS Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD B. Kuczynski