Citation Nr: 21063424 Decision Date: 10/14/21 Archive Date: 10/14/21 DOCKET NO. 17-44 966 DATE: October 14, 2021 REMANDED Entitlement to a rating in excess of 20 percent for chronic lumbar strain is remanded. Entitlement to a rating in excess of 20 percent for left lower extremity radiculopathy is remanded. Entitlement to a rating in excess of 20 percent for right lower extremity radiculopathy is remanded. REASONS FOR REMAND The Veteran served on active duty in the United States Army from June 1976 to June 1979. In February 2020, the Board remanded the case for further development, which has been completed. Stegall v. West, 11 Vet. App. 268, 271 (1998). 1. Entitlement to a rating in excess of 20 percent for right and left lower extremity radiculopathy 2. Entitlement to a rating in excess of 20 percent for chronic lumbar strain The evidence of record indicates that there are relevant outstanding private treatment records. The Veteran receives treatment from private providers for his lumbar spine strain and radiculopathy, to include pain management and physical and aquatic therapy. As the record reveals incomplete private treatment records, a remand is required to allow VA to obtain authorization and request the missing records. Additionally, the Veteran underwent a VA examination for his back condition in June 2019. The examiner reported that the Veteran's records were not available for review and indicated that other lower back conditions, and not his lumbar strain, were the cause of his surgery. Therefore, upon remand the examiner should review the records and identify all back conditions and distinguish which symptoms and effects on functioning are due to service-connected conditons. The matters are REMANDED for the following action: 1. In remanding this case, the Board makes no credibility determination, expressed or implied, at this juncture. 2. Contact the Veteran and afford him the opportunity to identify by name, address and dates of treatment or examination any relevant medical records, to include the Neurological Institute of Savannah, pain management, and physical and aquatic therapy records related to his treatment for lumbar strain and radiculopathy. Subsequently, and after securing the proper authorizations where necessary, make arrangements to obtain all the records of treatment or examination from all the sources listed by the Veteran which are not already on file. All information obtained must be made part of the file. All attempts to secure this evidence must be documented in the claims file. If, after making reasonable efforts, the records cannot be obtained, notify the Veteran and his representative and (a) identify the specific records that cannot be obtained; (b) briefly explain the efforts made to obtain those records; and (c) describe any further action to be taken with respect to the claim. The Veteran must then be given an opportunity to respond. 3. Obtain updated relevant VA treatment records. If such records are unavailable, the Veteran's claim file must be clearly documented to that effect and the Veteran notified in accordance with 38 C.F.R. § 3.159(e). 4. After the above development is completed, schedule the Veteran for a VA medical examination to determine the current severity of his service-connected lumbar spine and radiculopathy of the lower extremities with the examiner who provided the June 2019 VA examination. If that examiner is no longer available, provide the claims file to a qualified clinician. The electronic claims file must be reviewed in conjunction with the examination. The examiner should clarify the back conditions present during the period on appeal and identify all symptoms and functional impairments attributable to service-connected right lower extremity radiculopathy, left lower extremity radiculopathy and lumbar strain with arthritis and intervertebral disc syndrome. All necessary testing must be conducted. In particular, the examination must include tests of all applicable ranges of motion in active motion, passive motion, weight-bearing, and non- weight-bearing. 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 examiner must describe whether pain, weakness, fatigue and/or incoordination significantly limits functional ability during flares or repetitive use, and if so, the examiner must estimate range of motion during flares or repetitive use. If the examination does not take place during a flare or repetitive testing cannot be performed, the examiner should have the Veteran describe and/or demonstrate the extent of motion loss during flares or repetitive use and provide the extent of motion loss described in terms of degrees. If there is no pain and/or no limitation of function, such facts must be noted in the report. The examiner should comment as to whether there is any medical reason to accept or reject the Veteran's description of reduced range of motion during flares or repetitive use. The examiner must also provide an assessment of the Veteran's functional limitations due to his lumbar spine strain and radiculopathy as it may relate to his ability to function in a work setting and to perform work tasks. However, the examiner should refrain from commenting on the Veteran's employability. A complete rationale for all medical opinions is required. The examiner should identify and explain the relevance or significance, as appropriate, of any history, clinical findings, medical knowledge, or literature, etc., relied upon in reaching the conclusion(s). If the examiner feels that a requested opinion cannot be rendered without resorting to speculation, the examiner must state whether the need to speculate is caused by a deficiency in the state of general medical knowledge (i.e., no one could respond given medical science and the known facts) or by a deficiency in the record or the examiner (i.e., additional facts are required, or the examiner does not have the needed knowledge or training). G. A. WASIK Veterans Law Judge Board of Veterans' Appeals Attorney for the Board S. A. Prinsen 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.