Citation Nr: 20056563 Decision Date: 08/26/20 Archive Date: 08/26/20 DOCKET NO. 20-20 639 DATE: August 26, 2020 REMANDED Entitlement to a rating in excess of 20 percent for intervertebral disc syndrome (IDVS) and degenerative arthritis of the thoracolumbar spine (herein after spine disability) is remanded. REASONS FOR REMAND The Veteran served on active duty from June 1961 to June 1981. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a rating decision of a Department of Veterans Affairs (VA) Regional Office (RO). On April 26, 2018, VA received the Veteran’s claim for a rating in excess of 20 percent for his spine disability. The Board finds that remand is required as the medical evidence of record is inadequate to decide the appeal. Barr v. Nicholson, 21 Vet. App. 303 (2007). Although a VA examination was provided in May 2018, the Board finds that the examination report is inadequate for adjudication purposes as it did not fully address the duration of any incapacitating episodes caused by IVDS that required bed rest prescribed by a physician and contains incongruous findings as to ankylosis. Barr v. Nicholson, 21 Vet. App. 303 (2007). Here, the VA examination report shows that the Veteran had episodes of acute signs and symptoms due to IVDS that required bed rest prescribed by a physician and treatment by a physician in the past 12 months. However, it does not specify if bed rest was prescribed by a physician as the rating schedule requires. Regarding the duration of the bed rest, the report listed the Veteran’s 2017 back surgery but not the duration of any physician prescribed bed rest. Notably, a higher rating for IVDS is warranted for incapacitating episodes having a total duration of at least 4 weeks during the past 12 months, and which requires bed rest prescribed by a physician and treatment by a physician. Also, the May 2018 VA examination report contains seemingly incongruous information to the lay reader insofar as, under the heading “Additional factors contributing to disability,” the report shows “Less movement than normal due to ankylosis, adhesions, etc., Disturbance of locomotion, Interference with sitting, Interference with standing.” However, there is a later notation, under the heading of “Ankylosis” that indicates there is no ankylosis of the spine. While the notation of “Less movement than normal due to ankylosis, adhesions, etc., Disturbance of locomotion, Interference with sitting, Interference with standing” may represent merely examples not specific to the Veteran, the report is simply not clear and may be reasonably construed as showing incongruous findings. Given the above, an addendum medical opinion to the May 2018 VA examination report is necessary to decide the appeal. Lastly, a review of the Veteran’s VA treatment records discloses that he has a non-VA primary care provider and that he has also obtained non-VA medical services through the VA Choice program. Although copies of some records were provided by the Veteran and associated with his claims file, they do not appear to be substantially complete. As any outstanding records may be relevant to the pending appeal, on remand, the Veteran should be afforded an opporunity to provide a release of the non-VA treatmetn records to VA for consideraion in this appeal. 38 C.F.R. § 3.159(c). Accordingly, the matter is REMANDED for the following action: 1. Obtain the Veteran’s VA treatment records for the period from January 2020 to the Present. 2. Ask the Veteran to complete a VA Form 21-4142 for all non-VA medical providers seen for his back/spine since April 2017 to include Texas Health Center and Texas Back Institute. Make two requests for the authorized records from all identified sources], unless it is clear after the first request that a second request would be futile. 3. Obtain an addendum to the 2018 VA examination report that addresses (1) the duration of any incapacitating episodes caused by IVDS that required bed rest prescribed by a physician and treatment by a physician since April 2017; and (2) reconciles the notation under “Additional factors contributing to disability” indicating “Less movement than normal due to ankylosis, adhesions, etc., Disturbance of locomotion, Interference with sitting, Interference with standing” and the later notation under “Ankylosis” indicating that there is no ankylosis of the spine. The clinician should consider VA and non-VA treatment records along with the May 2018 VA examination report in providing the addendum to the May 2018 VA examination report. Another examination is not required unless deemed necessary by the provider of this addendum or otherwise ordered by the originating agency. C.A. SKOW Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Thaddaeus J. Cox, 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.