Citation Nr: 18157587
Decision Date: 12/13/18	Archive Date: 12/12/18

DOCKET NO. 17-56 022A
DATE:	December 13, 2018
REMANDED
Entitlement to a rating in excess of 20 percent for degenerative disc disease status post lumbar laminectomy and discectomy (hereinafter a “low back disability”) is remanded.
REASONS FOR REMAND
The Veteran had active service from in the United States Navy (USN) from April 1951 to April 1955. 
Disability Evaluation – Low Back Disability 
The Board finds that additional development is necessary before the claim on appeal can be decided. 
The Board notes that in a decision the United States Court of Appeals for Veterans Claims (Court) found that 38 C.F.R. § 4.59 requires that VA examinations include joint testing for pain on both active and passive motion, in weight-bearing and nonweight-bearing and, if possible, with range of motion measurements of the opposite undamaged joint.  In other words, if there is not a discussion of those measurements in a VA examination report, the examination is inadequate, unless the examiner determines that those range of motion testing listed could not be conducted.  Correia v. McDonald, 28 Vet. App. 158 (2016).  A review of the record shows that the Veteran was afforded a VA examination for his low back disability in December 2016.  A review of that examination reports fails to show findings that are consistent with the holding in Correia.
Moreover, VA treatment records indicate that the Veteran’s low back disability may have worsened since his last VA examination.  In this regard, an August 2017 VA treatment record indicates the Veteran reported he had chronic low back pain that severely interfered with his activities of daily living.   
Therefore, the Veteran should be afforded a new VA examination to determine the current level of severity of all impairment resulting from his service-connected low back disability.
Additionally, current treatment records should be identified and obtained before a decision is made in this case.
The matter is REMANDED for the following action:
1. Identify and obtain any pertinent, outstanding VA and private treatment records and associate them with the claims file.
2. Schedule the Veteran for a VA examination by an examiner with sufficient expertise to determine the current level of severity of all impairment resulting from his service-connected low back disability.  The claims file must be made available to, and reviewed by the examiner.  All indicated tests and studies must be performed.  The examiner must provide all information required for rating purposes.
In assessing the severity of the low back disability, the examiner should test for pain on both active and passive motion, in weight-bearing and non-weight bearing.
3. Confirm that the VA examination report and any medical opinion provided comport with this remand, and undertake any other development found to be warranted.
4. Then, readjudicate the issue on appeal.  If the decision is adverse to the Veteran, issue a supplemental statement of the case and allow appropriate time for response.  Then, return the case to the Board.
 
YVETTE R. WHITE
Veterans Law Judge
Board of Veterans’ Appeals
ATTORNEY FOR THE BOARD	Mariah N. Sim, Associate Counsel