Citation Nr: 21002837
Decision Date: 01/15/21	Archive Date: 01/15/21

DOCKET NO. 16-40 607
DATE: January 15, 2021

REMANDED

A rating in excess of 20 percent for right shoulder disability is remanded.

REASONS FOR REMAND

The Veteran served on active duty in the United States Marine Corps from October 1987 to January 2001 and from February 2001 to April 2014, including combat service in Iraq and his decorations include a Combat Action Ribbon.  The Veteran also served in Afghanistan.

This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a May 2015 rating decision that was issued by the Department of Veterans Affairs (VA) Regional Office (RO).

In a November 2018 decision, the Board denied a rating in excess of 20 percent for his right shoulder disability.  The Veteran appealed the Board’s decision to the United States Court of Appeals for Veterans Claims (CAVC), resulting in a February 2020 Joint Motion for Partial Remand (JMPR) by the parties. A February 2020 CAVC Order remanded the matter for compliance with the JMPR instructions.  

In July 2020, the Board remanded this case for additional development.

Subsequently, the Veteran was afforded a VA examination on November 2020. However, the Board finds that another medical examination is warranted since the latest examination is inadequate. The examiner failed to examine the existence, severity and nature of all muscular, neurologic or orthopedic injuries or conditions present in his right shoulder. Further, the examiner did not provide a complete rationale for his statements. Therefore, the Board finds that this issue must be remanded for another VA examination where the examiner takes into consideration all muscular, neurologic and orthopedic injuries or conditions present in the Veteran’s right shoulder. Additionally, the examiner must provide a complete rationale for his statements and acknowledge the medical and lay evidence in record. Therefore, the Board finds that a medical evaluation is necessary to determine the Veteran’s current severity and impact of his right shoulder condition. 

As there is no adequate examination to determine the current severity of his right shoulder condition, a remand is necessary to have the Veteran examined and for an examiner to review his claims folder and provide opinions necessary to adjudicate this appeal.

The matter is REMANDED for the following action:

1.  Obtain complete VA and Non-VA medical treatment records of the Veteran’s right shoulder condition, to include all muscular, neurologic and orthopedic conditions present.

2.  Notify the Veteran that he may submit additional lay statements from himself and from other individuals who have first-hand knowledge, and/or were contemporaneously informed of his condition, extent, impact and severity of his right shoulder disability. 

The Veteran should be provided an appropriate amount of time to submit this lay evidence.

3.  Schedule a VA examination (or telehealth interview, review of the record, etc. if an in-person examination is not feasible) to determine the manifestations, impact and severity of his right shoulder condition. 

The examiner should provide a full description of all his right shoulder conditions, to include all muscular, neurologic and orthopedic conditions present, and report all signs and symptoms. 

 

 

STEVEN D. REISS

Veterans Law Judge

Board of Veterans’ Appeals

Attorney for the Board	M. Alvarado- 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.