Citation Nr: 21000953 Decision Date: 01/06/21 Archive Date: 01/06/21 DOCKET NO. 19-37 437 DATE: January 6, 2021 REMANDED Entitlement to service connection for a right shoulder disorder is remanded. Entitlement to service connection for a left shoulder disorder is remanded. Entitlement to service connection for a neck disorder is remanded. Entitlement to service connection for a back disorder is remanded. Entitlement to service connection for bilateral hearing loss is remanded. Entitlement to service connection for tinnitus is remanded. Entitlement to a rating in excess of 20 percent for left index, middle, ring and little finger injury residuals is remanded. Entitlement to a total disability rating based on individual unemployability (TDIU) is remanded. REASONS FOR REMAND The Veteran served on active duty from September 1963 to October 1967. These matters are before the Board of Veterans’ Appeals (Board) on appeal of an August 2015 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO). In December 2020, the undersigned held a virtual hearing. Potentially relevant to all the claims on appeal, identified records have not been obtained. Specifically, at his December 2020 Board hearing the Veteran reported receiving treatment at Fitzsimons Army Medical Center from 1969 until 1999. Additionally, in his October 2014 claim, the Veteran reported receiving treatment through Tricare. There is no indication that relevant medical records from Fitzsimons Army Medical Center or Tricare have been requested. Remand is required to ensure adequate measures to obtain these identified outstanding records. Entitlement to service connection for neck and back disorders is remanded. In his August 2016 notice of disagreement, the Veteran disagreed with the denials of entitlement to service connection for neck and back disorders in an August 2015 rating decision. A statement of the case (SOC) has not yet been issued regarding these issues nor is there any indication that the appeal is currently being processed by the Agency of Original Jurisdiction (AOJ). A remand is required for the AOJ to issue a SOC addressing these issues. 38 C.F.R. § 20.200; Manlincon v. West, 12 Vet. App. 238, 240-241 (1999). Entitlement to service connection for bilateral shoulder disorders is remanded. The Veteran has not been provided a VA examination regarding his claimed shoulder disorders. He has competently reported shoulder, neck and back symptoms, and asserts that these disorders were caused or aggravated by his service-connected left index, middle ring and little finger injury residuals. The Veteran must be provided a VA examination to address the nature and etiology of his claimed shoulder disorders. Entitlement to service connection for bilateral hearing loss and tinnitus is remanded. The Veteran was provided a VA examination to address the nature and etiology of his claimed hearing loss and tinnitus in May 2015. The examiner declined to provide an opinion as to whether hearing loss and tinnitus were related to active-duty service on the basis that the Veteran did not undergo audiological testing at the time of separation. However, the Veteran’s service treatment records do contain audiometric testing which was conducted in May 1967. Moreover, the examiner did not clearly explain why an opinion could not be provided based on the available evidence of record, to include the evidence of in-service acoustic trauma. On remand, new VA examinations should be provided to address the nature and etiology of the claimed bilateral hearing loss and tinnitus. Additionally, July and August 2016 VA treatment records noted that audiological testing was conducted. The specific results of that testing were not associated with the record, although it was noted that the documents could be viewed ‘using the “AudiogramDisplay” option under the “Tools” menu.’ As this medical evidence is relevant to the Veteran’s claim for service connection for hearing loss it must be obtained. Entitlement to a rating in excess of 20 percent for left index, middle, ring and little finger injury residuals is remanded. The Veteran was last provided a VA examination regarding the severity of his left index, middle, ring and little finger injury residuals in June 2015. The examiner did not expressly note consideration of pain on both active and passive motion as required under Correia v. McDonald, 28 Vet. App. 158 (2016). Remand is required to obtain a VA examination which includes consideration of pain on active and passive motion. Entitlement to a TDIU is remanded. When entitlement to a TDIU is raised in connection with an increased rating claim for one or more of those service-connected disabilities, the Board has jurisdiction over the issue because it is part of the claim for increased compensation. Rice v. Shinseki, 22 Vet. App. 447 (2009). In his August 2016 notice of disagreement, the Veteran stated that his left hand disability precluded any form of employment. Thus, the claim is included in the current appeal. The matters are REMANDED for the following action: 1. Obtain any available medical treatment records from the Fitzsimons Army Medical Center and Tricare, to include from any appropriate records repositories. If the AOJ cannot locate such records, it must specifically document the attempts that were made to locate them and explain in writing why further attempts to locate or obtain any government records would be futile. The AOJ must then: (a) notify the claimant of the specific records that it is unable to obtain; (b) explain the efforts VA has made to obtain that evidence; and (c) describe any further action it will take with respect to the claims. The claimant must then be given an opportunity to respond. 2. Obtain the results of the July and August 2016 VA audiological testing. 3. After the development in #1, schedule the Veteran for an examination by an appropriate clinician to determine the nature and etiology of any bilateral shoulder disorders. The examiner should state: (a.) What diagnosed right and left shoulder disorders have been present at any time since October 6, 2014? (b.) For each such right and left shoulder disorder, is it at least as likely as not proximately due to the left index, middle, ring and little finger injury residuals? (c.) For each such right and left shoulder disorder, is it at least as likely as not aggravated beyond its natural progression by the left index, middle, ring and little finger injury residuals? 4. After the development in #1 and #2, schedule the Veteran for an examination by an appropriate clinician to determine the nature and etiology of any hearing loss and tinnitus. The examiner should state: (a.) What diagnosed hearing loss and tinnitus have been present at any time since October 6, 2014? (b.) For each such hearing loss and tinnitus, is it at least as likely as not related to in-service acoustic trauma? For the purpose of providing this opinion, the examiner should accept that the Veteran was exposed to acoustic trauma in service. A complete, well-reasoned rationale must be provided for any opinion offered. If the requested opinion cannot be rendered without resorting to speculation, the examiner must state whether the need to speculate is caused by a deficiency in the state of general medical knowledge, i.e., no one could respond given medical science and the known facts, or by a deficiency in the record or the examiner, i.e., additional facts are required, or the examiner does not have the needed knowledge or training. 5. Schedule the Veteran for an examination by an appropriate clinician to determine the current severity of his service-connected left index, middle, ring and little finger injury residuals. The examiner should provide a full description of the disability and report all signs and symptoms necessary for evaluating the Veteran’s disability under the rating criteria. (a.) The examiner must test the Veteran’s active motion, passive motion, and pain with weight-bearing and without weight-bearing. If any requested testing cannot be completed, the examiner should state why that is the case. (b.) The examiner must also attempt to elicit information regarding the severity, frequency, and duration of any flare-ups, and the degree of functional loss during flare-ups. If it is not possible to provide a specific measurement based on direct observation, the examiner should provide an estimate, if at all possible, of the additional impairment due to flare-ups based on the other evidence of record and the Veteran’s statements. If it is not possible to provide a specific measurement without speculation, the examiner must state whether the need to speculate is due to a deficiency in the state of general medical knowledge (no one could respond given medical science and the known facts), a deficiency in the record (additional facts are required), or the examiner (does not have the knowledge or training). 6. Send the Veteran and his representative an SOC that addresses the issues of entitlement to service connection for neck and back disorders. LAURA E. COLLINS Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Paul J. Bametzreider 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.