Citation Nr: 21066708 Decision Date: 11/01/21 Archive Date: 11/01/21 DOCKET NO. 18-09 021 DATE: November 1, 2021 REMANDED Entitlement to a disability evaluation in excess of 20 percent for thoracic multilevel degenerative arthritis, kyphosis with levoscoliosis, lumbar spondylosis, with bilateral thoracic neuritis (quiescent) and spinal fusion is remanded. REASONS FOR REMAND The Veteran served on active duty from July 2013 to April 2016. This matter comes before the Board of Veterans' Appeals (Board) on appeal from an August 2017 rating decision. The Veteran testified before the undersigned Veterans Law Judge in July 2021. 1. Entitlement to a disability evaluation in excess of 20 percent for thoracic multilevel degenerative arthritis, kyphosis with levoscoliosis, lumbar spondylosis, with bilateral thoracic neuritis (quiescent) and spinal fusion The Veteran was most recently provided with a VA back conditions examination in July 2017 where he reported flare ups and functional loss in the form of limited motion in his back. The Board notes that the examination does not comply with the requirements in Correia v. McDonald, 28 Vet. App. 158, 168 (2016). Specifically, the VA examination does not include passive range of motion testing. The Board also finds that the examination does not comply with the requirements in Sharp v. Shulkin, 29 Vet. App. 26, 34-36 (2017). Specifically, the examiner noted that the Veteran's flare-ups cause pain, fatigue, and lack of endurance but did not describe the functional loss in terms of range of motion. While the examiner stated that the Veteran's flare ups could not be described in terms of range of motion because the Veteran avoids motion, the examiner did not indicate that he could not provide a description in terms of range of motion due to the lack of knowledge within the medical community. Additionally, the Veteran testified at the July 2021 Board hearing that his back disabilty has worsened since the July 2017 VA examiantion as he now has severe pain in his back and has difficulty walking due to his radiculopathy. Accordingly, the Board finds that the Veteran should be provided an opportunity to report for a VA examination to ascertain the current severity and manifestations of his back disability. 38 C.F.R. § 3.159(c)(4). The matters are REMANDED for the following action: 1. Obtain the Veteran's VA treatment records for the period from October 2020 to the present. 2. Schedule the Veteran for an appropriate VA examination to determine the current severity of his back disability. His claims file must be made available to the examiner for review in connection with the examination. All pertinent symptomatology and findings must be reported in detail. The examiner should provide the range of motion of the Veteran's back and comment on the degree of functional loss due to such factors as pain on motion, weakened movement, excess fatigability, diminished endurance, or incoordination. The examiner should report (in degrees) the point at which pain is objectively recorded. In doing so, the examiner should offer an opinion as to whether pain could significantly limit functional ability during flare-ups or when the back is used repeatedly over a period of time. Such determinations should, if feasible, be portrayed in terms of the degree of additional range of motion loss due to pain on use or during flare-ups. This information must be derived from testing for pain on both active and passive motion, in weight-bearing and non-weight-bearing if possible. The examination report must confirm that all such testing has been made and reflect the results of the testing. 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. A fully articulated medical rationale for any opinion expressed must be set forth in the medical report. The examiner should discuss the particulars of this Veteran's medical history and the relevant medical science as applicable to this case, which may reasonably explain the medical guidance in the study of this case. M. Donohue Veterans Law Judge Board of Veterans' Appeals Attorney for the Board S. Morrad, 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.