Citation Nr: 21003081 Decision Date: 01/19/21 Archive Date: 01/19/21 DOCKET NO. 09-11 321A DATE: January 19, 2021 REMANDED Entitlement to an initial rating in excess of 30 percent for status-post left medial occipital stroke with congruous right upper quadrantanopia and simple headaches (visual/headaches disability) is remanded. Entitlement to an initial compensable rating for right shoulder recurrent strain with rotator cuff tendonitis (right shoulder disability) prior to May 7, 2013 and a rating in excess of 20 percent thereafter, is remanded. Entitlement to an initial rating in excess of 10 percent for adjustment disorder with anxiety prior to July 6, 2020 and a rating in excess of 30 percent thereafter is remanded. REASONS FOR REMAND The Veteran served on active duty in the U.S. Air Force from September 1994 to April 2006 and December 2011 to September 2012. The Veteran also served in the Air Force Reserves both prior to after her period of active duty. This appeal arises from an August 2007 rating decision, which granted service connection for her visual/headaches disability and assigned an initial 10 percent disability rating; granted service connection for her right shoulder disability and assigned an initial 0 percent disability rating; and granted service connection for adjustment disorder with anxiety and assigned an initial 0 percent disability rating, all effective April 2, 2006. The Veteran appealed for higher initial ratings. A December 2013 rating decision increased the rating for the Veteran’s right shoulder disability from 0 to 10 percent, effective from May 7, 2013. In January 2013, October 2015 and April 2017, the Board remanded the case to the AOJ for additional development and consideration. On remand, a September 2020 rating decision increased the rating for the Veteran’s visual/headaches disability from 10 to 30 percent, effective from April 2, 2006 (date of service connection); increased the rating for the Veteran’s right shoulder disability from 10 to 20 percent, effective from May 7, 2013; and increased the rating for the Veteran’s for adjustment disorder with anxiety from 0 to 10 percent, effective April 2, 2006 (date of service connection), and to 30 percent, effective July 6, 2020. The file is again before the Board for further appellate review. 1. Entitlement to an initial rating in excess of 30 percent for visual/headaches disability. 2. Entitlement to an initial compensable rating for right shoulder recurrent strain with rotator cuff tendonitis prior to May 7, 2013, and a rating in excess of 20 percent thereafter. 3. Entitlement to an initial rating in excess of 10 percent for adjustment disorder with anxiety prior to July 6, 2020 and a rating in excess of 30 percent thereafter. The Board’s April 2017 remanded this case for the AOJ to obtain outstanding Reserve service treatment records and to schedule the Veteran for VA examinations to assess the current severity of her disabilities on appeal. On remand, the AOJ provided requested VA headaches, shoulder and neurological examinations on August 17, 2020, and VA eye and mental disorder examinations in July 2020. However, the Veteran indicates she was most recently in the Reserves from 2006 through 2019. See Veteran’s August 2020 email correspondence. Yet, the Veteran’s Reserves service treatment records for the period of 2013 to 2019 were not associated with the claims until August 19, 2020, following the above examinations. So, the relevant VA examiners did not appear to have access to pertinent medical records during the pendency of the appeal. When VA undertakes to examine a Veteran, VA is obligated to ensure that that examination is adequate. See Barr v. Nicholson, 21. Vet. App. 303 (2007). Inadequate medical examinations include examinations that contain only data and conclusions, do not provide an etiological opinion, are not based upon a review of medical records, or provide unsupported conclusions. Nieves- Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008); Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007). Moreover, in the Veteran’s August 2020 email correspondence, she alerted the AOJ to potentially outstanding private treatment records, stating, “I have also seen some civilian providers as well.” It does not appear that the AOJ followed up with her to identify such records. On remand, the AOJ should ask the Veteran to identify such records, and if she does, attempt to obtain them. After associating any additional medical records, the VA examiners should provide addendum opinions to update the findings of their examinations. The matters are REMANDED for the following action: 1. Ask the Veteran to provide the names and addresses of any medical provider, VA or private, who has treated the Veteran for her visual, neurological, headache, shoulder and psychiatric problems. After securing any necessary releases, request any relevant records identified that are not duplicates of those already contained in the claims file. Obtain VA treatment records, if any. If any requested records are unavailable, the claims file should be annotated as such and the Veteran and her representative notified of such. 2. Then, obtain an updated addendum opinion by the July 2020 eye and mental health examiners and August 2020 VA headaches, shoulder and neurological examiners (or if any are not available, a similarly qualified clinician(s)) for consideration of additional Reserve service treatment records and any additional private treatment records. The examiner should indicate that the record was reviewed. If the examiner determines that another in-person examination is required, then such an examination should be scheduled. On review of the record, the examiner should update and/or confirm the findings recorded in the respective VA examination. Rationale must be provided for the opinions proffered. C. CRAWFORD Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Biswajit Chatterjee, 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.