Citation Nr: 20006549 Decision Date: 01/28/20 Archive Date: 01/27/20 DOCKET NO. 15-14 236 DATE: January 28, 2020 REMANDED 1. Entitlement to service connection for a right shoulder rotator cuff tear is remanded. 2. Entitlement to service connection for a lumbar spine disability is remanded. REASONS FOR REMAND The Veteran had active service from April 1954 to March 1956. These matters come before the Board of Veterans’ Appeals (Board) on appeal from an October 2014 rating decision by a Department of Veterans Affairs (VA) Regional Office (RO). The Board previously considered this case in January 2018, when it remanded for additional development, to include new shoulder and back examinations. The Board notes that a September 2019 rating decision granted entitlement to service connection for bilateral hearing loss, tinnitus, and GERD (also claimed as hiatal hernia and stomach condition). As this represents full grants of the benefits sought, the Board will not address these issues any further. Preliminarily, the Board notes that there are outstanding private treatment records that have yet to be associated with the claims file. As detailed below, these records relate to a 1995 shoulder surgery. A February 2017 Statement in Support of the Claim written in Spanish appears to identify a source of medical documents. On remand, the RO should translate this document and seek to associate the relevant medical records with the claims file. The Board notes that there are four other entries in the medical records that have not been translated. The medical entries date from June 2017, related to audiology testing, and from December 2019, related to psychiatric visits and an emergency room visit related to mental health. These records have no bearing on the issues for consideration. Accordingly, the Veteran is not prejudiced by the Board’s adjudication of his appeal at this time. See Soyini v. Derwinski, 1 Vet. App. 540, 546 (1991). 1. Entitlement to service connection for a right shoulder rotator cuff tear is remanded. The Veteran was provided VA examinations in June 2017 and August 2018. Both VA examiners noted that the Veteran had surgery in 1995 on his right shoulder. Both VA examiners elicited some medical history, but they did not obtain information from the Veteran as to the onset and continuity of his current shoulder symptoms. Furthermore, neither VA examiner addressed the significance, if any, of the October 1996 radiology showing degeneration in the right shoulder joint. Accordingly, the Board finds that these examinations are inadequate for decision making purposes. In the January 2018 remand order, the Board instructed the RO to obtain a new VA examination. A remand confers on the appellant the right to compliance with that order. See Stegall v. West, 11 Vet. App. 268, 271 (1998). Accordingly, the Board finds that remand is required to obtain the relevant medical records and an adequate VA examination. 2. Entitlement to service connection for a lumbar spine disability is remanded. The Veteran was provided VA examinations for his back in June 2017 and August 2018. Both VA examiners opined that the Veteran’s lumbar spine condition was less likely than not related to his active service, but rather was related to the normal processes of aging. However, neither VA examiner addressed the significance, if any, of the lumbar compression fracture documented in the VA treatment records. Indeed, the Veteran has submitted copies of his VA medical records with manual underlining to highlight that fact. Furthermore, the VA examiners did not obtain adequate information from the Veteran as to the history of any back injury and the onset and continuity of his current symptoms. Accordingly, the Board finds that these examinations are inadequate for decision making purposes. In the remand order, the Board instructed the RO to obtain a new VA examination. A remand confers on the appellant the right to compliance with that order. See Stegall v. West, 11 Vet. App. at 271. Accordingly, the Board finds that remand is required to obtain the relevant medical records and an adequate VA examination. Accordingly, this matter is REMANDED for the following action: 1. With the Veteran’s assistance, and any authorization deemed necessary for VA to obtain such records, attempt to locate medical records of his 1995 shoulder surgery and associate them with the claims file. In this regard, the RO should translate the February 2017 Statement in Support of the Claim and attempt to locate the medical records identified by the Veteran. 2. Schedule the Veteran for shoulder and lumbar spine VA examinations with suitably qualified examiners. The entire claims file and a copy of this remand must be provided to the examiners. Following review of the record, the examiners should opine as to: (a) Whether it is at least as likely as not (50 percent probability or more) that the Veteran has a lumbar spine disability related to active service. Rationale must be provided for the opinion proffered. The examiner must ask the Veteran to describe any history of back injuries. The examiner must also ask the Veteran when his back symptoms began, and whether they have been continuous since that time. The examiner must address the significance, if any, of the L1 vertebral compression fracture documented in the VA treatment records. (b) Whether it is at least as likely as not (50 percent probability or more) that the Veteran has a right shoulder disability related to active service. Rationale must be provided for the opinion proffered. The examiner must ask the Veteran when his shoulder symptoms began, and whether they have been continuous since that time. The examiner must address the significance, if any, of the October 1996 radiology diagnosing degeneration in the right shoulder joint. 3. After completion of the above, review the expanded record, including the evidence entered since the most recent supplemental statement of the case, and readjudicate the issues on appeal. If any benefit sought remains denied, furnish the Veteran and his representative   with a supplemental statement of the case. The appropriate period should be allowed for response before the appeal is returned to the Board. U. R. POWELL Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board S. Frasch 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.