Citation Nr: 21065075 Decision Date: 10/25/21 Archive Date: 10/25/21 DOCKET NO. 18-44 820 DATE: October 25, 2021 REMANDED Entitlement to a rating in excess of 20 percent for status post cervical spine injury is remanded. Entitlement to a rating in excess of 10 percent for degenerative joint disease (DJD) of the lumbar spine status post injury is remanded. REASONS FOR REMAND The Veteran served on active duty in the United States Army from June 1978 to January 2001. This matter comes before the Board of Veterans' Appeals (Board) on appeal from July 2017 rating decision issued by the Department of Veteran Affairs (VA) Regional Office (RO). In July 2021, the Veteran testified at a hearing before the undersigned Veterans Law Judge. A transcript of the hearing is associated with the record. During the July 2021 Board hearing, the Veteran testified that his disabilities worsened since his last VA examination in June 2017. He also stated he was able to do things, but he chose not to do them because of the pain he experienced. He was undergoing treatment through the Lima CBOC, for nerve burn treatment. He was referred to the facility by the VA and visits once a year. He received his prescriptions from a private facility, Blanchard Valley, that gave him Meloxicam and then Celebrex. He was also seeing a neurosurgeon for treatment but stopped going because they could no longer help him. At times, his back went out completely where he could not move, get up, or lay down. At those times, he consulted his doctors who provided him shots or Flexural. He is currently service connected for a cervical spine injury with a 20 percent rating. A higher evaluation of 30 percent was not awarded because evidence did not show forward flexion of the cervical spine 15 degrees or less or favorable ankylosis of the entire cervical spine. See July 2017 rating decision. He is also service connected for DJD of the lumbar spine with a 10 percent rating. A higher evaluation of 20 percent was not awarded because evidence did not show combined range of motion of the thoracolumbar spine not greater than 120 degrees or forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60degrees. Id. However, the Veteran made statements at the July 2021 Board hearing that suggest his disabilities have worsened since the time of his June 2017 VA examination. Therefore, the Veteran should be provided an opportunity to report for a VA examination to ascertain the current severity and manifestations of his service-connected disabilities. Snuffer v. Gober, 10 Vet. App. 400, 403 (1997). These matters are REMANDED for the following action: 1. Contact the Veteran for authorization to obtain private treatment records. Ask him to list all facilities and providers for which he received treatment for the disabilities on appeal. After receiving authorization, obtain outstanding medical treatment records from the VA as well as the records related to the Veteran's nerve burn treatment from Lima CBOC and prescribed medication from Blanchard Valley. 2. Then, schedule the Veteran for a VA examination with an appropriate clinician to determine the current severity of his cervical spine injury and lumbar spine injury. A complete copy of the Veteran's claim file, including a copy of this remand and newly obtained medical records, must be provided to the clinician for review. The clinician is asked review the file and included in the report detailed findings the about the severity level of the Veteran's disabilities. The examiner must complete the disability benefits questionnaire in its entirety. If the examiner cannot provide the requested opinion without resorting to speculation, it must be so stated, and the examiner must provide the reasons why an opinion would require speculation. The examiner must indicate whether there was any further need for information or testing necessary to make a determination. 3. After completing the above actions, readjudicate the claims on appeal. MICHAEL MARTIN Veterans Law Judge Board of Veterans' Appeals Attorney for the Board T. Harris, Attorney Advisor 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.