Citation Nr: 21067990
Decision Date: 11/08/21	Archive Date: 11/08/21

DOCKET NO. 18-18 213
DATE: November 8, 2021

REMANDED

Entitlement to a rating in excess of 50 percent prior to March 12, 2019, and 70 percent on and after March 12, 2019, for posttraumatic stress disorder (PTSD) is remanded.  

Entitlement to a rating in excess of 10 percent prior to March 12, 2019; in excess of 20 percent from March 12, 2019 to May 12, 2019; and in excess of 40 percent on and after May 13, 2019, for lumbar spine degenerative arthritis is remanded.  

Entitlement to a rating in excess of 10 percent for right lower extremity radiculopathy is remanded.  

Entitlement to a rating in excess of 10 percent for left lower extremity radiculopathy is remanded.  

REASONS FOR REMAND

The Veteran had active service from May 1966 to May 1969 and from February 1976 to February 1999.  

Entitlement to a rating in excess of 50 percent prior to March 12, 2019, and 70 percent on and after March 12, 2019, for PTSD; a rating in excess of 10 percent prior to March 12, 2019; in excess of 20 percent from March 12, 2019 to May 12, 2019; and in excess of 40 percent on and after May 13, 2019, for lumbar spine degenerative arthritis; a rating in excess of 10 percent for right lower extremity radiculopathy; and a rating in excess of 10 percent for left lower extremity radiculopathy is remanded.  

In its September 2019 Remand instructions, the Board of Veterans' Appeals (Board) directed that treatment records from a Dr. Kohl, J. Moore, M.D., and J. Ball, M.D., should be requested for incorporation into the record.  Clinical documentation from Dr. Ball has not been requested.  The Agency of Original Jurisdiction's compliance with the Board's remand instructions is neither optional nor discretionary.  Stegall v. West, 11 Vet. App. 268 (1998).   

Clinical documentation dated after October 2019 is not of record.  VA should obtain all relevant VA and private treatment records which could potentially be helpful in resolving the Veteran's claims.  Murphy v. Derwinski, 1 Vet. App. 78 (1990); Bell v. Derwinski, 2 Vet. App. 611 (1992).  

The matters are REMANDED for the following action:

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1. Ask the Veteran to complete a VA Form 21-4142 for each private healthcare provider, including J. Ball, M.D., who treated him for the service connected PTSD, lumbar spine degenerative arthritis, right lower extremity radiculopathy, and the left lower extremity radiculopathy.  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.

 

 

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.