Citation Nr: 20046944 Decision Date: 07/14/20 Archive Date: 07/14/20 DOCKET NO. 18-08 347 DATE: July 14, 2020 REMANDED The claim of entitlement to an evaluation higher than 20 percent for degenerative disc disease of the lumbosacral spine is remanded. REASONS FOR REMAND The Veteran had active service from September 1974 to September 1979. This matter comes before the Board from a June 2017 rating decision by the agency of original jurisdiction (AOJ), that increased the evaluation of the Veteran’s low back disability to 20 percent, effective April 13, 2017, the date of receipt of his claim for increase. A Board hearing was held in February 2020. A transcript is of record. During the February 2020 hearing, the Veteran identified various sources of treatment by non-VA providers. He stated his belief that records of this treatment were in the VA claims file; however, review of the record reveals that the providers mentioned by the Veteran are not included. The Veteran should be afforded the opportunity to provider appropriate releases so that records from these providers might be obtained. In August 2019, the Veteran indicated that he had received treatment from the Atlanta VA Medical Center (VAMC) from 2009 to the present. There are no VA treatment records in the claims folder dating beyond May 2017. Updated records should be obtained. The Veteran’s low back disability was most recently examined in May 2017. During the February 2020 hearing, the Veteran and his fiancée described the severity of his back disability. The transcript indicates that the Veteran presented in a wheelchair, and he stated that he used it during flare-ups. Notably, the May 2017 examiner indicated that the Veteran occasional used a brace, but did not identify any other assistive device. Both the testimony and the fact that the Veteran presented in a wheelchair suggests worsening of the Veteran’s back disability. The Board therefore concludes that a current examination is necessary. The matter is REMANDED for the following action: 1. Schedule the Veteran for an examination to determine the severity of his service-connected low back disability. The claims file must be made available to the examiner. All necessary tests and studies should be accomplished, and all clinical findings should be reported in detail. All pertinent symptomatology and findings referable to the Veteran’s low back disability should be reported in detail, including range of motion (ROM) testing. The examiner should set forth the Veteran’s range of motion findings and note any pain, pain on use (to include the point during range of motion at which the Veteran reports pain), weakness, incoordination, or excess fatigability. If feasible, the examiner should portray any additional functional limitation of the spine due to these factors in terms of degrees of additional loss of motion. If not feasible, this should be stated and discussed in the examination report. If the Veteran does not have pain or any of the other factors, that fact should also be noted. The examiner should also test the range 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 required testing is not necessary in this case, he or she should clearly explain why that is so. 2. Then, readjudicate the Veteran’s claim, with application of all appropriate laws, regulations, and case law, and consideration of any additional information obtained as a result of this remand. If the decision remains adverse to the Veteran, he and his representative should be furnished a supplemental statement of the case (SSOC) and afforded an appropriate period within which to respond thereto. MICHAEL LANE Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board J. Barone, 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.