Citation Nr: 18157240 Decision Date: 12/12/18 Archive Date: 12/12/18 DOCKET NO. 17-00 822 DATE: December 12, 2018 REMANDED Entitlement to a rating in excess of 20 percent for degenerative disc disease of the lumbar spine is remanded. Entitlement to a rating in excess of 10 percent for radiculopathy of the right leg is remanded. Entitlement to a total disability evaluation based upon individual unemployability due to service-connected disabilities (TDIU) is remanded. REASONS FOR REMAND The Veteran served in the Missouri Army National Guard and had a period of active duty from 2004 to October 2005 This case comes before the Board of Veterans’ Appeals (Board) on appeal from an April 2015 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO). During the course of the appeal, the Veteran reported that he is unemployed due to his service-connected disabilities. As such, the issue of entitlement to TDIU has been raised and is on appeal. See Rice v. Shinseki, 22 Vet. App. 447, 453 (2009). The Veteran indicated in a January 2017 VA Form 9 that he receives treatment at the Kansas City VA Medical Center (VAMC). He noted that his most recent treatment at that time had been in December 2016. However, the claims file does not contain any VA treatment records dated since September 2016. Thus, on remand, the Agency of Original Jurisdiction should attempt to obtain any outstanding VA medical records. Moreover, with regard to the Veteran’s service-connected lumbar spine disability, an additional examination is necessary in light of a decision issued by the United States Court of Appeals for Veterans Claims (Court). In Correia v. McDonald, 28 Vet. App. 158, 169 (2016), the Court held that the final sentence of § 4.59 creates a requirement that the examination should record the results of range of motion testing “for pain on both active and passive motion [and] in weight-bearing and nonweight-bearing.” Correia v. McDonald, 25 Vet. App. 158 (2016). In this case, the VA examination report from April 2015 does not include these findings. The Board also notes that the Veteran indicated in his December 2015 notice of disagreement that his right leg pain is worse than mild with shooting pain sometimes causing him to almost fall. Such a statement suggests a possible worsening since the April 2015 VA examination, and he also challenged the examiner’s findings. Therefore, the Board finds that an additional VA examination is needed to ascertain the current severity and manifestations of the Veteran’s service-connected radiculopathy of the right leg. In addition, the Veteran has repeatedly claimed that he cannot work due to his service-connected disabilities, including degenerative disc disease of the lumbar spine and his medications used to treat the disabilities. Therefore, the issue of entitlement to TDIU is inextricably intertwined with the increased rating claims. See Harris v. Derwinski, 1 Vet. App. 180, 183 (1991) (noting that two issues are inextricably intertwined when the adjudication of one issue could have significant impact on the other issue). The matters are REMANDED for the following action: 1. The Agency of Original Jurisdiction (AOJ) should request that the Veteran provide the names and addresses of any and all health care providers who have provided treatment for his service-connected disabilities that are not already of record. 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 obtain any updated VA treatment records, to include records from the Kansas City VAMC and records dated since September 2016. 2. After completing the foregoing development, the Veteran should be afforded a VA examination to ascertain the current severity and manifestations of his service-connected lumbar spine degenerative disc disease. Any studies, tests, and evaluations deemed necessary by the examiner should be performed. 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 thoracolumbar spine in degrees on active motion, passive motion, weight-bearing, and nonweight-bearing, using the appropriate measuring tool such as a goniometer. 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 state whether there is any form of ankylosis. He or she should also state the total duration of any incapacitating episodes over the past 12 months and identify any neurological manifestations of the disability other than radiculopathy of the right leg. 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). 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. Copies of all pertinent records in the Veteran’s claims file, or in the alternative, the claims file, must be made available to the examiner for review. 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 radiculopathy of the right lower extremity. Any and all studies, tests, and evaluations deemed necessary by the examiner should be performed. The examiner is requested to review all pertinent records associated with the claims file. The examiner should report all signs and symptoms necessary for rating the Veteran’s radiculopathy under the rating criteria. In particular, the examiner identify the affected nerves, describe the symptoms and impairment of the disability, and address the level of paralysis attributable to the Veteran’s service-connected right lower extremity. 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. Because it is important “that each disability be viewed in relation to its history[,]” 38 C.F.R. § 4.1, copies of all pertinent records in the appellant’s claims file, or in the alternative, the claims file, must be made available to the examiner for review. 4. After completing the foregoing development, the AOJ should schedule the Veteran for a VA examination to determine the combined effects of his service-connected disabilities and any resulting impairment. The examiner should address how the Veteran’s service-connected disabilities and any medications used to treat them result in functional impairment and comment on the Veteran’s ability to function in an occupational environment. If possible, he or she should also indicate if there is any form of employment that the Veteran could perform, and if so, to please define what type. A written copy of the report should be associated with the electronic claims folder. 5. The AOJ should conduct any other development that may be indicated as a consequence of the actions taken in the preceding paragraph. J.W. ZISSIMOS Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD B. Kuczynski