Citation Nr: 20021733 Decision Date: 03/26/20 Archive Date: 03/26/20 DOCKET NO. 15-08 236 DATE: March 26, 2020 REMANDED Entitlement to a disability rating in excess of 20 percent from August 25, 2015, for a lumbar spine disability is remanded. Entitlement to a disability rating in excess of 10 percent from August 25, 2015, for right hip osteomalacia (“right hip disability”) is remanded. REASONS FOR REMAND The Veteran served on active duty from January 1998 to August 2002. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from an April 2013 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO). This matter was previously before the Board in July 2018. The claim was remanded for the RO to review additional evidence, to include VA treatment records. The Board’s decision specifically ordered the RO to conduct any additional development deemed necessary, such as the procurement of a VA examination. The January 2020 supplemental statement of the case (SSOC) does not identify how the additional VA treatment records were evaluated in rendering their decision. The Board finds that the RO has not complied with the July 2018 Board remand directive and that the matter must be remanded again. Stegall v. West, 11 Vet. App. 268 (1998). 1. Entitlement to a disability rating in excess of 20 percent from August 25, 2015, for a lumbar spine disability The Veteran contends her lumbar spine disability is more severe than is currently contemplated by her 20 percent disability rating. The Veteran’s lumbar spine disability is rated as degenerative arthritis of the spine under 38 C.F.R. § 4.71a, Diagnostic Code 5242. This disability is evaluated either upon application of the General Rating Formula for Diseases and Injuries of the Spine (“General Formula”), or as intervertebral disc syndrome (IVDS) under the Formula for Rating IVDS Based on Incapacitating Episodes (“IVDS Formula”), whichever method results in the higher evaluation when all disabilities are combined under 38 C.F.R. § 4.25. See VBA Training Letter 02-04 (October 24, 2002). The rating criteria under the General Rating Formula provides a separate evaluation for any associated objective neurologic abnormalities, including, but not limited to, bowel or bladder impairment. 38 C.F.R. § 4.71a, Diagnostic Codes 5235 to 5243 (2017) (Note 1). In July 2017 VA treatment records, an MRI of the spine revealed an impression of mild degenerative change. The Veteran complained of back pain and an inability to “get up from the toilet.” She alleged that medical personnel at the ER told her that the problems with urine were related to her back. However, in a July 2017 addendum, the nurse noted incontinence of urine could be stress incontinence. In August 2017 VA treatment records, an assessment revealed the Veteran had low back pain with radicular symptoms. The Veteran’s last VA examination was in February 2013. The Board finds a new VA examination is warranted given the fact that the last examination was 7 years ago and there is evidence of worsening since that examination. See Proscelle v. Derwinski, 2 Vet. App. 629, 632 (1992) (holding that, where the veteran claims a disability is worse than when originally rated and the evidence is too old to adequately evaluate the current state of the condition, the VA must provide a new examination). Additionally, the August 2017 medical records note back pain with radicular symptoms, which indicates worsening symptoms and could warrant a separate evaluation. See 38 C.F.R. § 4.71a, Diagnostic Codes 5235 to 5243 (2017) (Note 1). Therefore, a new VA examination is warranted to accurately evaluate the Veterans current disability. 2. Entitlement to a disability rating in excess of 10 percent from August 25, 2015 for a right hip osteomalacia disability The Veteran contends that her right hip disability should be rated higher than the currently assigned 10 percent. In December 2015, a VA physical examination revealed normal internal range of motion for the right hip. In December 2019, VA treatment records noted painful motion on movement for the hip joint as a medical problem. The Veteran’s last VA examination was in February 2013. In light of the December 2019 VA treatment records noting painful motion on movement for the hip joint as a medical problem and the fact that 7 years has elapsed since the most recent VA examination, with indications of worsening since that examination, a remand for a new VA examination is necessary. See Proscelle, 2 Vet. App. at 632. Based on the evidence of record, the Board is unable to render a decision. Therefore, a new VA opinion is required that is supported by a clear, concise opinion and rationale, that considers all evidence of record. The matters on appeal are REMANDED for the following action: 1. Obtain and associate with the claims file any additional medical evidence that may have come into existence but has not been associated with the record. 2. Schedule the Veteran for an examination(s) in order to determine the current severity of her service-connected lumbar spine and right hip disabilities. 3. When the development requested above has been completed, readjudicate the issues on appeal. The Veteran has the right to submit additional evidence and argument on the matter that the Board has remanded. See Kutscherousky v. West, 12 Vet. App. 369, 372 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded for additional development or other appropriate action by the Board or United States Court of Appeals for Veterans Claims must be handled in an expeditious manner. 38 U.S.C. §§ 5109B, 7112. JONATHAN B. KRAMER Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board B. Jackman, Associate Counsel 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.