Citation Nr: 21003394 Decision Date: 01/21/21 Archive Date: 01/21/21 DOCKET NO. 17-12 229 DATE: January 21, 2021 REMANDED Entitlement to a rating in excess of 10 percent for low back disability and related bilateral lower extremity radiculopathy is remanded. Entitlement to a compensable rating for hypertension is remanded. Entitlement to service connection for a myocardial infarction, to include as secondary to hypertension, is remanded. REASONS FOR REMAND The Veteran served on active duty in the United States Navy from April 1989 to January 1991. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a February 2016 rating decision by a Department of Veterans Affairs (VA) Regional Office (RO) in Newnan, Georgia. In March 2019, the Veteran testified before the undersigned Veterans Law Judge. A transcript of the hearing is associated with the claims file. 1. Entitlement to a rating in excess of 10 percent for low back disability and related bilateral lower extremity radiculopathy is remanded. The Veteran contends that her low back disability and related bilateral lower extremity radiculopathy warrants a rating in excess of 10 percent. She testified that her low back disability has worsened, ton include flare-ups, stiffness, inability to sit for extended periods or walk more than a quarter of a block. She utilizes heating pads and a custom chair. She further testified that she is unable to bend over and touch her toes. Since her last examination, she stated that she has experienced and symptoms from her back disability which limit her sleep and causes excruciating pain down into the lower right side of her leg. In addition to functional limitations caused by her back disability, she testified that medication used to treat her back has caused limiting side effects. The Board regrets the further delay but finds that, given that she was last examined January 2016, the Veteran should be provided a current and contemporaneous examination to determine the nature and severity of her back disability and related bilateral lower extremity. The new examiner is necessary based on the testimony of increased severity since the prior examination. See Caffrey v. Brown, 6 Vet. App. 377 (1994); Snuffer v. Gober, 10 Vet. App. 400 (1997). 2. Entitlement to a compensable rating for hypertension is remanded. The Veteran contends that her hypertension warrants a compensable rating. She testified that since her last evaluation almost three decades ago, the condition has become more severe. She further testified that she has been treated with multiple medications and has experienced more headaches, shortness of breath, and chest pains within the last four or five years. See March 2016 Hearing Transcript. The Board regrets the further delay but finds that, given that she was last examined January 2016, the Veteran should be provided a current and contemporaneous examination to determine the nature and severity of her hypertension. See Caffrey v. Brown, 6 Vet. App. 377 (1994); Snuffer v. Gober, 10 Vet. App. 400 (1997). 3. Entitlement to service connection for a myocardial infarction, to include as secondary to hypertension, is remanded. The Veteran contends that her myocardial infarction is related to service, to include as secondary to hypertension. She testified that she suffered a heart attack as a result of a blood pressure reading of 200. She also testified that she has had headaches and been treated with heart medication. The Board regrets the further delay but finds that a remand is necessary because the record does not reveal a medical opinion for her heart disability. Accordingly, a duty to assist attaches to this appeal to provide the Veteran with an examination for an opinion that determines the nature and etiology of her myocardial infarction. The matters are REMANDED for the following action: 1. Update VA treatment records. 2. After completion of directive #1, schedule the Veteran for an examination with an appropriate clinician to determine the nature and etiology of her myocardial infarction. The examiner should opine on the following: Is it at least as likely as not (50 percent or greater probability) that the Veteran’s myocardial infarction is related to her service? Is it at least as likely as not (50 percent or greater probability) that the Veteran’s myocardial infarction is proximately due to or caused by her hypertension? Is it at least as likely as not (50 percent or greater probability) that the Veteran’s myocardial infarction is aggravated, beyond its natural progression, by her hypertension? 3. After completion of directive #1, schedule the Veteran for an examination with an appropriate clinician to determine the current severity of her low back disability, to include the presence and severity of any associated neurologic abnormalities (to include the previously rated right sciatic nerve radiculopathy). 4. After completion of directive #1, schedule the Veteran for an examination with an appropriate clinician to determine the current severity of her hypertension. The examiner should review the entire record, to include the Veteran’s testimony regarding her symptoms. All opinions should include a detailed rationale. Nathaniel J. Doan Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board K. Wilson, 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.