Citation Nr: 21068938 Decision Date: 11/16/21 Archive Date: 11/16/21 DOCKET NO. 15-06 388A DATE: November 16, 2021 REMANDED Entitlement to an evaluation higher than 10 percent for service-connected left ankle reflex sympathetic dystrophy is remanded. Entitlement to total disability rating based on individual unemployability (TDIU) is remanded. REASONS FOR REMAND The Veteran served on active duty from January 1981 to July 1989. This case comes before the Board of Veterans' Appeals (Board) on appeal from a March 2013 rating decision of the Department of Veteran Affairs (VA) Regional Office (RO). In April 2018, the Veteran presented testimony at a travel Board hearing before the undersigned Veterans Law Judge (VLJ). 1. Increased Evaluation- left ankle Remand is required to comply with the April 2019 remand directives. The Board is obligated by law to ensure that the RO complies with its directives. Stegall v. West, 11 Vet. App. 268, 271 (1998). RO compliance with remand directives is not optional or discretionary and the Board errs as a matter of law when it fails to ensure remand compliance. Stegall, 11 Vet. App. at 271. The appeal was remanded in April 2019 to assess the functional limitations of the Veteran's flare-ups. The Veteran received a July 2020 VA examination. The examiner stated the Veteran did not report flare-ups. However, in the description of the Veteran's history, the examiner noted left ankle aggravation with standing, walking, climbing, and running. The Veteran's statements regarding aggravation were similar during the July 2018 VA examination. Notably, the Veteran reported flare-ups with walking. The examiner's failure to address the functional impact of the Veteran's flare-ups does not comply with the April 2019 remand directives. Although a 2021 VA examination also noted the Veteran denied flare-ups, this does not cure the defect of prior findings. Thus, a retrospective medical opinion attempting to address the severity of the service-connected ankle disability would also aid in the resolution of the claim for a higher initial rating. Chotta v. Peake, 22 Vet. App. 80 (2008) (holding that VA's duty to assist may include a need to obtain a "retrospective medical opinion" to ascertain past severity of disability where a rating must be assigned for a long-ago period and insufficient evidence is presented to support rating the disability over that period) 2. TDIU Second, remand is required because entitlement to TDIU is inextricably interwined with the pending increased evaluation claim. See Harris v. Derwinski, 1 Vet. App. 180, 183 (1991) (holding that issues are inextricably intertwined and must be considered together when a decision concerning one could have a significant impact on the other). The matters are REMANDED for the following action: 1. Contact the appropriate VA Medical Center and obtain and associate with the claims file all outstanding records of treatment. If any requested records are not available, or the search for any such records otherwise yields negative results, that fact must clearly be documented in the claims file. Efforts to obtain these records must continue until it is determined that they do not exist or that further attempts to obtain them would be futile. The non-existence or unavailability of such records must be verified, and this should be documented for the record. Required notice must be provided to the Veteran and his representative. 2. Contact the Veteran and afford him the opportunity to identify by name, address and dates of treatment or examination any relevant medical records. 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, and if, after making reasonable efforts to obtain named records, they are not able to be secured, provide the required notice and opportunity to respond to the Veteran and his representative. 3. After any additional records are associated with the claims file, provide the Veteran with an appropriate examination to determine the severity of the service-connected left ankle. The entire claims file must be made available to and be reviewed by the examiner. Any indicated tests and studies must be accomplished, and all clinical findings must be reported in detail and correlated to a specific diagnosis. An explanation for all opinions expressed must be provided. The relevant Disability Benefits Questionnaire must be utilized. Obtain retrospective findings from an appropriate clinician to determine the severity of the Veteran's service-connected ankle disability for the below identified past examinations. If it is not possible to provide a specific measurement without speculation, the clinician must state whether the need to speculate is due to a deficiency in the state of general medical knowledge (no one could respond given medical science and the known facts), a deficiency in the record (additional facts are required), or the clinician (does not have the knowledge or training). (a) Provide an addendum retrospective opinion for the Veteran's service-connected left ankle disability to supplement the 2016 VA examination report that estimates the amount in degrees of ROM lost due to flare-ups experienced by the Veteran based on the evidence of record and the Veteran's statements. (b) Provide an addendum retrospective opinion for the Veteran's service-connected left ankle disability to supplement the September 2018 VA examination report that estimates the amount in degrees of ROM lost due to flare-ups experienced by the Veteran based on the evidence of record and the Veteran's statements. K. MILLIKAN Acting Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Bruton, Cherrelle M. 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.