Citation Nr: 21003227 Decision Date: 01/21/21 Archive Date: 01/21/21 DOCKET NO. 15-04 125 DATE: January 21, 2021 REMANDED Entitlement to an increased rating in excess of 40 percent for lumbar spine disability is remanded. Entitlement to an increased rating in excess of 20 percent for radiculopathy of the left lower extremity is remanded. Entitlement to an increased rating in excess of 20 percent for radiculopathy of the right lower extremity is remanded. REASONS FOR REMAND The Veteran served on active duty in the United States Army from August 1991 to March 1999. In February 2019, the Veteran was provided a hearing with the undersigned Veterans Law Judge and a transcript of the proceeding is of record. Entitlement to an Increased Rating: Lumbar Disability and Bilateral Radiculopathy of the Lower Extremities The Veteran contends that his service-connected lumbar disability, radiculopathy of the left lower extremity, and radiculopathy of the right lower extremity are more severe than the ratings provided. In February 2019, the Veteran was provided a hearing. The Veteran reported that despite his examination showing a forward flexion to 30 degrees, he is not able to move his back a lot. He reported constant pain and flare-ups that are worse than his normal baseline. He reported that at times his muscle spasms are so bad that he is incapacitated and cannot work for three to four days. He further reported an increase in numbness and pain in his legs, to include often needing help off the toilet due to not being able to feel his feet. He reported often losing his balance and needing help in and out of the shower. Due to the Veteran reporting worsening symptoms, as well as it being almost three years since his last examination, the Board finds that a remand is required in order to obtain a new examination to determine the current severity of the Veteran’s conditions. See Weggenmann v. Brown, 5 Vet. App. 281 (1993). The matters are REMANDED for the following action: 1. Obtain and associate with the Veteran’s electronic claims file any outstanding VA and private treatment records relevant to the Veteran’s claimed conditions. 2. Schedule the Veteran for an examination to determine the current severity of his lumbar spine disability and radiculopathy of the bilateral lower extremities. The claims file should be reviewed in conjunction with the examination and a copy of this remand should be provided to the examiner. The examiner should discuss all findings in terms of the Schedule of Ratings for Musculoskeletal System, specifically the General Rating Formula for Diseases and Injuries of the Spine, Diagnostic Code 5242, as well as the Schedule of Ratings for Diseases of the Peripheral Nerves, Diagnostic Code 8520. The pertinent rating criteria must be provided to the examiner, and the findings reported must be sufficiently complete to allow for a rating under all alternate criteria. The examiner should further determine whether any lumbar spine disability is manifested by weakened movement, excess fatigability, incoordination, flare-ups, or pain. If feasible, the examiner must assess the additional functional impairment on repeated use or during flare-ups in terms of the degree of additional range of motion loss, using lay observations specifically elicited from the Veteran for each disability. The examiner should also determine whether the Veteran’s additional impairment on flare-ups or repetitive use is the functional equivalent of ankylosis of the lumbar or thoracic spine. The examiner should also determine whether any bilateral lower extremity radiculopathy involving the sciatic nerve is mild, moderate, moderately severe, or severe. In offering any opinion, the examiner must consider the full record, to include the lay statements regarding symptoms and the opinion should note that consideration. A clearly stated rationale must be provided for any opinion offered. JENNIFER HWA Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board J. Negron, 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.