Citation Nr: 20072018 Decision Date: 11/06/20 Archive Date: 11/06/20 DOCKET NO. 19-35 946 DATE: November 6, 2020 REMANDED Entitlement to a rating in excess of 40 percent for degenerative disk disease lumbosacral spine (back condition) is remanded. REASONS FOR REMAND The Veteran served on active duty from August 1962 to November 1983. This matter comes before the Board of Veterans’ Appeals (Board) from a November 2015 rating decision issued by a Department of Veterans Affairs (VA) Regional Office (RO). The Veteran testified at a Central Office Board hearing before the undersigned Veterans Law Judge in August 2020. The Veteran’s wife, B.C., was present as a witness. A transcript of the hearing is of record. Entitlement to a rating in excess of 40 percent for degenerative disk disease lumbosacral spine (back condition) is remanded. Initially, the Board notes that at the August 2020 Board hearing, the Veteran stated that he received private treatment from Dr. M, about 3 years ago, and additional treatment from Peninsula Orthopedics in Salisbury about 2 years ago. The Board notes that private records up to 2016 for Dr. M are of record; however, the Board finds that an additional search for any outstanding records from Dr. M is necessary, since 3 years ago would have been 2017. Additionally, there are no records from Peninsula Orthopedics in Salisbury. Therefore, efforts must be made to obtain missing records of medical treatment. The Board also notes that the Veteran last underwent VA examination for his back condition in November 2015. In the March 2016 notice of disagreement and at the August 2020 Board hearing, the Veteran indicated that his back condition had worsened. Regarding the November 2015 VA examination, the Board also finds that the VA examiner did not provide range of motion measurements for non-weight bearing and passive motion, as well as did not provide range of motion measurements during periods of functional loss and flare ups. Therefore, given the Veteran’s statements concerning worsening, as well as recent Court holdings in Correia v. McDonald, 28 Vet. App. 158 (2016) and Sharp v. Shulkin, 29 Vet. App. 26, 33 (2017), additional VA examination is required. The matters are REMANDED for the following actions: 1. Obtain any outstanding VA and private treatment records, that are relevant to the back condition claim. Specifically, locate any additional records from Dr. M, from 2016 to the present, and any relevant time frame of records from Peninsula Orthopedics in Salisbury and associate those records with the file. The RO should notify the Veteran and his representative of any attempts made to locate these records, as well as any notice of inability to locate these records. 2. Then, schedule the Veteran for a VA examination with an appropriate examiner to determine the current severity of the Veteran’s back condition. The claims file and a copy of this remand must be made available for review. All necessary tests and studies must be conducted. The examination must include range of motion testing in active motion, passive motion, weight-bearing, and non-weight-bearing. See Correia. The examiner is also asked to describe whether pain, weakness, fatigue and/or incoordination significantly limits functional ability during flares or repetitive use, and if so, the examiner must estimate range of motion during flares or repetitive use. If the examination does not take place during a flare, the examiner should have the Veteran describe and/or demonstrate the extent of motion loss during flares or repetitive use and provide the extent of motion loss described in terms of degrees. If there is no pain and/or no limitation of function, such facts must be noted in the report. The examiner should comment as to whether there is any medical reason to accept or reject the Veteran’s description of reduced range of motion during flares or repetitive use. See Sharp. A clear rationale must be provided for all opinions expressed. The examiner must consider the Veteran’s lay statements. 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 clearly explain why that is so. (Continued on the next page)   The examiner should identify any neurologic complications of the service-connected lumbosacral spine disability, if any. 3. Thereafter, readjudicate the claim on appeal. If the benefit sought remains denied, issue the Veteran and his representative a supplemental statement of the case and provide a reasonable opportunity to respond before returning the matter to the Board for further appellate review. MICHAEL MARTIN Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Saudiee Brown 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.