Citation Nr: 21003301 Decision Date: 01/21/21 Archive Date: 01/21/21 DOCKET NO. 15-31 415A DATE: January 21, 2021 REMANDED Entitlement to an initial rating in excess of 20 percent prior to July 28, 2014, and in excess of 40 percent thereafter for service-connected degenerative disc disease of the lumbosacral spine (lumbar spine disability) is remanded. Entitlement to an initial compensable rating prior to May 14, 2012, in excess of 10 percent from May 14, 2012, to December 25, 2019, and in excess of 20 percent thereafter, for service-connected radiculopathy, left lower extremity is remanded. Entitlement to a total disability rating based on individual unemployability (TDIU) due to service-connected disabilities is remanded. REASONS FOR REMAND The Veteran served on active duty from May 1970 to December 1971. The most recent VA examination to assess the nature and severity of the Veteran’s service-connected lumbar spine disability was in December 2019. Subsequently, the Veteran’s VA treatment records indicate that his condition may have worsened. For example, a January 2020 VA treatment record notes that the Veteran was seen at the emergency room following a fall, and he complained of worsening low back pain since the fall, as well as right hip pain. Subsequently, the Veteran underwent surgery to repair a fractured right hip. An August 2020 VA treatment record indicates that the Veteran fell again in May 2020, and the treatment record noted that he was now urinating on himself. In order to ascertain the current nature and severity of the Veteran’s lumbar spine disability, to include any possible neurological manifestations such as any bladder impairment, the Board finds that a more contemporaneous examination is needed. See Allday v. Brown, 7 Vet. App. 517 (1995); Caffrey v. Brown, 6 Vet. App. 377 (1994); Snuffer v. Gober, 10 Vet. App. 400 (1997). As noted in the Board’s July 2020 remand, the Veteran’s claim for a TDIU is inextricably intertwined with his claim for higher ratings. As such, the Board will defer consideration of that issue at this time. On remand, the agency of original jurisdiction (AOJ) should associate with the record any outstanding VA treatment records that are not currently associated with the claims file. Additionally, the Veteran should be given the opportunity to identify any outstanding pertinent evidence. The matters are REMANDED for the following action: 1. Associate with the Veteran’s claims file any VA treatment records dated from October 22, 2020, to the present. 2. Give the Veteran an additional opportunity to identify any outstanding pertinent evidence that has not already been associated with the claims file. The AOJ should then attempt to obtain those records if the Veteran provides the appropriate authorization. 3. After completing the above development, the Veteran should be scheduled for an appropriate VA examination by a competent medical professional to determine the current nature and severity of his service-connected lumbar spine disability and radiculopathy, left lower extremity. The entire record must be made available to and be reviewed by the examiner. The examiner should take a history from the Veteran as to the progression of his service-connected lumbar spine disability, to include any neurological manifestations in his lower extremities and/or any associated bladder impairment. Any indicated evaluations, studies, and tests should be conducted. The examiner must address each of the following inquiries: a) The examiner should describe all pertinent orthopedic and neurologic symptoms associated with the Veteran’s service-connected lumbar spine disability and radiculopathy. In doing so, please address the August 2020 VA treatment record noting that the Veteran was urinating on himself and indicate whether such is a neurological manifestation associated with his lumbar spine disability. The examiner should also ask the Veteran to provide a history as to the nature and severity of his service-connected lumbar spine disability. b) With regard to the lower extremity radiculopathy, the examiner should indicate whether there is complete or incomplete paralysis of the affected nerve(s) and, if so, the examiner should describe the severity of the impairment as mild, moderate, moderately severe, or severe with marked muscular atrophy. c) The examiner should also address the impact that the Veteran’s service-connected lumbar spine disability and radiculopathies have on activities of daily living, including employment. 4. Thereafter, and after any further development deemed necessary, the issues on appeal, including entitlement to a TDIU, should be readjudicated. With regard to the rating assigned to the Veteran’s service-connected lumbar spine disability, consideration must be given to both the former (pre-September 26, 2003) and current (post-September 26, 2003) rating criteria for evaluating general diseases and injuries of the spine. For all times prior to September 26, 2003, only the former rating criteria can be applied. For all times from September 26, 2003, both the former and current rating criteria for evaluating general diseases and injuries of the spine are applicable. The more favorable criteria should be applied. V. Chiappetta Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board James R. Springer, 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.