Citation Nr: 21062987 Decision Date: 10/12/21 Archive Date: 10/12/21 DOCKET NO. 13-31 224A DATE: October 12, 2021 REMANDED Entitlement to a rating in excess of 20 percent for cervical spine degenerative disc disease is remanded. REASONS FOR REMAND The Veteran had active service from December 1981 to July 2002. Entitlement to a rating in excess of 20 percent for cervical spine degenerative disc disease is remanded. The report of a June 2019 cervical spine examination conducted for the Department of Veterans Affairs (VA) states that the Veteran complained of constant cervical spine pain which radiated down his right arm. On examination of the cervical spine, the Veteran exhibited forward flexion to 35 degrees, extension to 40 degrees, right lateral flexion to 20 degrees, left lateral flexion to 35 degrees, and lateral rotation to 60 degrees, bilaterally; pain with all ranges of motion; and "pain noted on exam but does not result in/cause functional loss." The examiner commented that the cervical spine did not impact the Veteran's ability to work. The nurse practitioner did not indicate the degree at which the Veteran experienced pain on motion of the cervical spine. In light of that deficiency, the Board of Veterans' Appeals (Board) finds that the functional loss associated with the service connected cervical spine disability is unclear and the examination report is of limited probative value. VA's duty to assist includes, in appropriate cases, the duty to conduct a thorough and contemporaneous medical examination which is accurate and fully descriptive. McLendon v. Nicholson, 20 Vet. App. 79 (2006); Green v. Derwinski, 1 Vet. App. 121 (1991). When VA obtains an evaluation, the evaluation must be adequate. Barr v. Nicholson, 21 Vet. App. 303 (2007). Given the cited deficiency in the June 2019 VA cervical spine examination, the Board finds that further VA cervical spine evaluation is needed. Clinical documentation dated after March 2021 is not of record. VA should obtain all relevant VA and private treatment records which could potentially be helpful in resolving the Veteran's claim. Murphy v. Derwinski, 1 Vet. App. 78 (1990); Bell v. Derwinski, 2 Vet. App. 611 (1992). The matters are REMANDED for the following action: 1. Ask the Veteran to complete a VA Form 21-4142 for each private healthcare provider who has treated the service connected cervical spine degenerative disc disease. Make two requests for the authorized records from all identified healthcare providers unless it is clear after the first request that a second request would be futile. 2. Obtain any VA treatment records not of record, to include those pertaining to treatment after March 2021. 3. Schedule the Veteran for a VA spine examination conducted by a medical doctor to assist in determining the current nature and severity of the service connected cervical spine degenerative disc disease. The examiner must review the record and should note that review in the report. A rationale for all opinions should be provided. The examiner should: (a) Provide ranges of motion for passive and active motion of the cervical spine for weight bearing and nonweight bearing. The examiner should indicate the degree of cervical spine motion at which any observed pain begins. The examiner should state whether there is any additional loss of cervical spine function due to painful motion, weakened motion, excess motion, fatigability, or incoordination. (b) Indicate to what extent the Veteran experiences functional loss of the cervical spine due to pain or any other symptoms during flare ups or with repeated use. (c) State whether or not there is any ankylosis of the spine or any segment of the spine. (d) Note any incapacitating episodes associated with the cervical spine disability and the duration. An incapacitating episode is a period of acute signs and symptoms that requires bed rest prescribed by a physician and treatment by a physician. (e) Describe any identified right or left upper extremity neurologic disabilities caused by the service-connected cervical spine disability. J. T. HUTCHESON Veterans Law Judge Board of Veterans' Appeals Attorney for the Board A. Smith, 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.