Citation Nr: 21002306 Decision Date: 01/13/21 Archive Date: 01/13/21 DOCKET NO. 15-23 694 DATE: January 13, 2021 REMANDED Entitlement to an initial rating higher than 10 percent prior to November 4, 2019, and higher than 20 percent as of that date, for a right shoulder disability is remanded. REASONS FOR REMAND The Veteran served on active duty from November 1965 to November 1968. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a March 2013 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Cheyenne, Wyoming. The Board remanded the matter in September 2015 and March 2019. Entitlement to an initial rating higher than 10 percent prior to November 4, 2019, and higher than 20 percent as of that date, for a right shoulder disability is remanded. The November 2019 VA examination report does not contain sufficient information to determine whether a higher rating may be assigned based on additional functional impairment of the right shoulder during flare-ups. See DeLuca v. Brown, 8 Vet. App. 202, 206-07 (1995); Sharp v. Shulkin, 29 Vet. App. 26, 35 (2017). For the same reason, it does not comply with the Board’s March 2019 remand directives. See Stegall v. West, 11 Vet. App. 268, 271 (1998). More specifically, the November 2019 VA examination report states that the Veteran endorsed flare-ups, during which he would rest his arm. However, the examiner did not specify the frequency, duration, and severity of the flare-ups, as instructed by the Board’s remand, and as required under Sharp. See Sharp, 29 Vet. App. at 35. Moreover, the examiner’s only explanation for not estimating the additional loss of range of motion during flare-ups was that the Veteran stated he would rest his arm until the flare subsided. That is not a sufficient explanation. See id. While the Veteran may choose to rest his arm, the issue is whether he continues to have some range of motion of the shoulder, and to what degree. On remand, the examiner who conducted the November 2019 examination should be requested to provide the above information. If the examiner is not available, or cannot provide the information given the amount of time that has passed since the November 2019 examination, a new examination should be performed. The matter is REMANDED for the following action: 1. Add to the file the Veteran’s outstanding VA treatment records, if any, dated since May 2020. 2. Request the examiner who conducted the November 2019 examination to provide the information requested below. If the examiner is no longer available, or is unable to provide the requested information given the amount of time that has passed the examination was performed, a new examination should be arranged, which may include a virtual “telehealth” examination, if warranted. The claims file must be made available to the examiner for review. To the extent possible, the examiner must provide a full description of the severity, frequency, and duration of any flare-ups, their effect on functioning, and precipitating and alleviating factors. The examiner must also provide an estimate of additional loss of range of motion, if any, during a flare-up or on repeated use over time. In this regard, the examiner should state, to the extent possible, whether during flare-ups or with repeated use over time flexion or abduction of the arm would be limited to midway between the side and shoulder level (about 45 degrees) or to 25 degrees from the side, or would the Veteran continue to be able to lift the arm to shoulder level (i.e. to 90 degrees). A more exact estimate need not be provided. If the examiner is unable to provide such an estimate, the examiner must explain why the available information, including the Veteran’s statements, medical history, and the examination findings, is not sufficient for that purpose. P.M. DILORENZO Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board J. Rutkin, 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.