Citation Nr: 20003589 Decision Date: 01/16/20 Archive Date: 01/15/20 DOCKET NO. 16-09 751 DATE: January 16, 2020 REMANDED An increased rating greater than 10 percent from February 1, 2013 for residuals of a stroke is remanded. REASONS FOR REMAND The Veteran honorably served in the United States Navy on active duty from April 1966 to April 1986. The Board is grateful for the Veteran’s long and distinguished service to this nation. This matter is back before the Board of Veterans’ Appeals (Board) on appeal from a February 2014 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO). This matter was previously remanded in a September 2018 Board remand. 1. An increased rating greater than 10 percent from February 1, 2013 for residuals of a stroke is remanded. Although the Board sincerely regrets the additional delay, a remand is necessary to ensure that there is a complete and accurate record upon which to decide the Veteran’s claim so that every possible consideration is afforded. The Veteran’s most recent VA examination for his stroke disability occurred in October 2015. Since the previous remand, the medical records reflect additional and worsening symptoms that were not reflected in the prior VA examination. Compare October 2015 VA Examination (reflecting full strength in the left side and noting that “main disability is loss of sensation on the left upper and lower extremity.”) with March 2019 Primary Care Note (Veteran reporting that he is unable to use his left side and reflecting left upper and lower extremity weakness) and August 2018 Psychiatry Note (reflecting an assessment of visual hallucinations, unlikely psychiatric in origin, with a plan to rule out primary ophthalmologic disability vs. neurological pathology). Because it has been over four years since the last VA examination, remand for a contemporaneous examination is required to assess the current severity of his service-connected disability. See Green v. Derwinski, 1 Vet. App. 121 (1991); see also Snuffer v. Gober, 10 Vet. App. 400, 403 (1997). The matters are REMANDED for the following action: 1. Send a letter to the Veteran requesting that he identify any relevant outstanding private treatment records and any other relevant evidence pertaining to his claim of increased rating for residuals of a stroke. This may include medical evidence relating to visual hallucinations and/or visual disturbances from an ophthalmologist. He should be invited to submit this evidence himself or to request that VA to obtain it on his behalf. Authorized release forms (VA Form 21-4142) should be provided for this purpose. If the Veteran properly fills out and returns any authorized release forms for private records identified by him, reasonable efforts should be made to obtain such records and associate them with the claims file. At least two such efforts should be made unless it is clear from the private provider’s response to the first request that a second effort would be futile. If attempts to obtain any records identified by the Veteran are not successful, he MUST be notified of this fact and all efforts to obtain them must be documented and associated with the claims file. 2. Schedule the Veteran for an examination by an appropriate clinician to determine the current severity of his service-connected stroke residuals. The examiner should provide a full description of the disability and report all signs and symptoms necessary for evaluating the Veteran’s disability under the rating criteria. The examiner should also provide an opinion as to whether it is at least as likely as not (defined as a 50% or better probability) that the Veteran’s visual hallucinations are residuals of his stroke. In forming any opinions, the Board emphasizes that the Veteran is competent to report what his symptoms are and when they began. If the Veteran’s statements are inconsistent with the medical evidence, the examiner must provide a comprehensive report including a complete explanation (rationale) for all opinions and conclusions reached, citing the objective medical findings or other evidence leading to the conclusion that his statements are inconsistent with the medical evidence. Detailed rationale and reasoning for all opinions and conclusions provided is required BY LAW. Providing an opinion without a thorough explanation will delay processing of the claim and may result in a clarification being requested. If it is not possible to provide any of the requested information, the examiner must state whether this is because of a deficiency in the state of general medical knowledge (that is, no one could respond, given medical science and the known facts), a deficiency in the record (that is, additional facts are required), or the examiner (that is, the examiner does not have the required knowledge or training). If the examiner cannot provide answers because further information or diagnostic studies are required, all reasonable steps to obtain this information or diagnostic studies should be exhausted before concluding that the answer cannot be provided. VICTORIA MOSHIASHWILI Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board S. Lambert The Board’s decision in this case is binding only with respect to the instant matter decided. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.