Citation Nr: 18156245
Decision Date: 12/07/18	Archive Date: 12/07/18

DOCKET NO. 18-45 368
DATE:	December 7, 2018
REMANDED
Entitlement to a rating in excess of 20 percent for moderate facet arthropathy of lumbar spine (lumbar spine disability) is remanded.
REASONS FOR REMAND
The Veteran served on active duty from January 1963 to August 1966 and September 1967 to September 1971.
On his September 2018 Substantive Appeal (VA Form 9), the Veteran stated that he was unable to bend then stand up or sometimes bend.  He further stated that he should be awarded a 100 percent due to unfavorable ankylosis.  In his November 2018 Appellate Brief, the Veteran, through his representative, stated that the currently assigned evaluation does not accurately reflect the severity of the Veteran’s lumbar spine disability.  The representative also stated that the available evidence is too old to adequately evaluate the state of the Veteran’s condition.  Based on the Veteran’s contention that his disability has gotten worse, the Board finds that a remand is necessary to afford him a new VA examination.  38 U.S.C. § 5103A(d); 38 C.F.R. § 3.159.


The matter is REMANDED for the following action:
1.   Obtain and associate all outstanding VA treatment records with the claims file.
2.   Contact the Veteran and request that he identify all private providers who have treated him for his lumbar spine disability.  After obtaining authorization, obtain all outstanding, non-duplicative records.  If the records are unavailable, document the claims file and notify the Veteran in accordance with 38 C.F.R. § 3.159(e).
3.   Thereafter, schedule a VA examination to determine the current severity of the Veteran’s lumbar spine disability.  The complete record, to include a copy of this remand and the claims folder, must be made available to and reviewed by the examiner in conjunction with the examination.  The examination report must include a notation that this record review took place.  All clinical findings should be reported in detail to include the functional impact on daily activities and employment.
All indicated studies, including x-rays, range of motion (ROM) studies in degrees must be conducted, and all findings must be reported in detail.  To the extent possible, the examiner is asked to opine as to the ROM and note any pain (and the point during ROM that pain is reported), pain on use, weakness, incoordination, or excess fatigability. 
In accordance with Correia v. McDonald, 28 Vet. App. 158 (2016), the ROM for the Veteran’s lumbar spine disability should be tested on active and passive motion, in weight-bearing and non-weight-bearing, and after repetitive use.  The examiner should consider the Veteran’s lay statements regarding his decreased ROM.  
The examiner should also express an opinion concerning whether there would be additional functional impairment on repeated use or during flare-ups.  The examiner should further assess the additional functional impairment on repeated use or during flare-ups in terms of the degree of additional ROM loss.  The examiner should consider all procurable and assembled data by obtaining all tests and records that might reasonably illuminate the medical analysis, to include the Veteran’s statements regarding the extent of functional loss during flare-ups.  
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 supporting rationale for all opinions expressed must be provided.

 
MICHAEL LANE
Veterans Law Judge
Board of Veterans’ Appeals
ATTORNEY FOR THE BOARD	T. Henry, Associate Counsel