Citation Nr: 1817794 Decision Date: 03/22/18 Archive Date: 04/03/18 DOCKET NO. 16-54 252 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUES 1. Entitlement to a rating in excess of 20 percent after June 1, 2015 for a service-connected left shoulder disability. 2. Entitlement to service connection for residuals of dental trauma. REPRESENTATION Appellant represented by: Francisco J. Reyes, Attorney ATTORNEY FOR THE BOARD M. G. Perkins, Associate Counsel INTRODUCTION The Veteran served on active duty from July 1953 to July 1955 and from January 1957 to March 1975. This matter comes to the Board of Veterans' Appeals (Board) on appeal from April 2014 (denied the dental claim) and January 2015 (assigned a temporary total rating for the left shoulder from May 25, 2014, and a 20 percent rating from July 1, 2015) rating decisions by the St. Petersburg, Florida, Regional Office (RO) of the Department of Veterans Affairs (VA). In an October 2016 rating decision, the RO found clear and unmistakable error in the prior rating decision with regard to the effective dates assigned for the 100 percent and 20 percent evaluations for left shoulder disability. As a result, the 100 percent evaluation was assigned from April 25, 2014; the 20 percent rating was assigned from June 1, 2015. This appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2017). 38 U.S.C. § 7107(a)(2) (2012). The appeal is REMANDED to the Agency of Original Jurisdiction (AOJ). VA will notify the appellant if further action is required. REMAND The Veteran contends that the assigned rating for his service connected left shoulder disability should be higher than 20 percent. He underwent a total prosthetic shoulder replacement in April 2014 and was assigned a 100 percent convalescent care until June 1, 2015, at which time the 20 percent rating was effective. The evidence currently of record does not include adequate information to adjudicate the claim. Both a January 2015 VA examination and March 2015 private orthopedic treatment records include findings during the time period in which the temporary total rating was in effect; there is no evidence pertinent to the period after June 1, 2015. Thus, remand is necessary to obtain a current examination that will include consideration of all pertinent criteria, including range of motion and the functional impact of any reported flare-ups. See Correia v. McDonald, 28 Vet. App. 158 (2016); Sharp v. Shulkin, 29 Vet. App. 26 (2017). For the claimed dental disability, the Veteran contends that while in basic training he suffered an injury to his mouth where his teeth were broken and required dental repair. He claims that his current dental issues are residuals of that injury. The Veteran's service treatment records reflect that in July 1954, approximately two months after the Veteran's induction examination, he had extensive dental work performed. On remand, the RO should schedule the Veteran for a VA dental examination to determine whether the Veteran's July 1954 dental records document an in-service injury that establishes a nexus between an in-service incident and the Veteran's current dental condition. Additionally, the RO, with the Veteran's assistance, should obtain all private dental records since the Veteran left service. Accordingly, the case is REMANDED for the following action: (Please note, this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c). Expedited handling is requested.) 1. Obtain the names and addresses of all medical care providers who treated the Veteran for dental complaints since service. After securing the necessary release, take all appropriate action to obtain these records. 2. After completion of the foregoing, schedule the Veteran for an appropriate VA dental examination to determine whether the July 1954 in-service dental records substantiate the Veteran's contention that he experienced a dental injury during basic training. The claims folder and copies of all pertinent electronic records should be made available to the examiner. After an examination and thorough file review, the examiner is asked to answer the following: (a) Do the Veteran's dental records, in his service treatment records (STRs), show any evidence of any injuries to the Veteran's teeth during service? In answering this question, the examiner's attention is directed to (i) the Veteran's May 1954 induction examination where no entries are made to the dental section, providing the Veteran with the Veteran with the presumption of soundness regarding his dental health; (ii) STR Record documenting dental treatment from July 1954 to March 1955 (on Form 16-20622-3) in claims file document labeled STR-Medical with a receipt date of July 17, 1953. (b) If the answer to (a) is yes, is it at least as likely as not that the Veteran's in-service dental injury is causally related to his current dental condition. The examiner is requested to provide a rationale for any opinion expressed. The rationale must comment on the Veteran's reports of continuous/recurring symptoms since service/injury therein and post service medical treatment records confirming scoliosis. If the examiner cannot provide an opinion without resort to speculation, the examiner should provide an explanation as to why this is so and note what, if any, additional evidence would permit such an opinion to be made. 3. Schedule the Veteran for an appropriate VA examination to determine the current severity of his left shoulder disability. Copies of all pertinent records should be made available to the examiner for review. The examiner is requested to delineate all symptomatology associated with, and the current severity of, the left shoulder disability. The appropriate DBQs should be filled out for this purpose, if possible. The examiner should specifically test the Veteran's left shoulder ranges of motion in active motion, passive motion, weight-bearing, and nonweight-bearing. If the examiner is unable to conduct the required testing or concludes that the Veteran is unable to complete any tests listed in the DBQ, the examiner should clearly explain why this is so. The examiner(s) should attempt to estimate additional functional loss of the left shoulder due to repetitive use and/or flare-ups. In making this determination the examiner is specifically directed to ascertain adequate information-i.e., frequency, duration, characteristics, severity, or functional loss-regarding the Veteran's flares by any available means, to include the Veteran's lay statements and all other evidence of record. 4. Thereafter, readjudicate the Veteran's claims. If any benefit sought on appeal remains denied, provide the Veteran and her representative with a supplemental statement of the case and an opportunity to respond. Then return the case to the Board for further appellate review, if otherwise in order. The Veteran has the right to submit additional evidence and argument on the matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C. §§ 5109B, 7112 (2012). ______________________________________________ M. E. LARKIN Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs