Citation Nr: 21004329 Decision Date: 01/26/21 Archive Date: 01/26/21 DOCKET NO. 14-29 019A DATE: January 26, 2021 REMANDED Entitlement to a disability evaluation in excess of 20 percent for a low back disability is remanded. REASONS FOR REMAND The Veteran served on active duty from April 2004 to October 2006. This matter come before the Board of Veterans’ Appeals (Board) on appeal from rating decisions of a Department of Veterans Affairs (VA) Regional Office (RO). The matter was previously before the Board in April 2018, at which time it was remanded for development. It has been returned to the Board for appellate review. 1. Entitlement to a disability evaluation in excess of 20 percent for a low back disability is remanded. Although it regrets the additional delay, the Board finds that a remand is necessary in order to afford the Veteran an adequate VA medical examination in connection with his claim for increase. The VA examiner with whom the Veteran met in February 2019 indicated that the Veteran endorsed weekly flareups of low back symptoms, as well as functional loss with repetitive use of the low back over time. However, the examiner did not indicate what degree of functional loss, if any, would be expected under either condition, which assessment is necessary in order properly to evaluate the current nature and severity of the Veteran’s service-connected low back disability. On remand, a new VA examination must be conducted, and the examiner must indicate what degree of functional loss would be expected during flareups or with repetitive use over time, even if the Veteran is not being examined under those conditions, and even if furnishing assessments of functional loss under those conditions would require a degree of speculation. The matters are REMANDED for the following action: 1. After obtaining the necessary authorization, obtain any outstanding VA and private treatment records relevant to the Veteran’s claim. 2. Then, schedule the Veteran for a VA examination to assess the severity of the service-connected lumbar spine disability. The record, including a copy of this remand, must be made available to the examiner, and the examination report should include discussion of the Veteran’s documented medical history and assertions. All indicated tests and studies should be accomplished (with all findings made available to the requesting examiner prior to the completion of his or her report), and all clinical findings should be reported in detail.   The examiner is asked to describe the current nature and severity of the Veteran’s lumbar spine disability. All pertinent symptomatology and findings should be reported in detail in accordance with VA rating criteria. Range of motion in active motion, passive motion, weight-bearing, and nonweight-bearing must be conducted. If the examiner is unable to conduct the required testing or concludes that the required testing is not necessary in this case, he or she should clearly explain why that is so. The rationale for all opinions expressed must be provided.  The examiner is specifically directed to estimate the degree of functional loss expected during flareups or with repetitive use of the low back over time, in terms of degrees of range of motion if possible. It is understood that assessments with respect to any condition not under direct observation may require a degree of speculation. 3. Review the opinions and any examination reports to ensure that they are in complete compliance with the directives of this remand. If any opinion or report is deficient in any manner, the AOJ must implement corrective procedures. GAYLE STROMMEN Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Z. Sahraie, 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.