Citation Nr: 21069322 Decision Date: 11/18/21 Archive Date: 11/18/21 DOCKET NO. 16-37 614 DATE: November 18, 2021 REMANDED Entitlement to a compensable rating prior to April 15, 2016, and in excess of 30 percent on and after April 15, 2016, for ulcerative colitis and gastroesophageal reflux disease (GERD) is remanded. Entitlement to an initial rating in excess of 10 percent for lumbosacral strain is remanded. REASONS FOR REMAND The Veteran had active service from January 2007 to February 2011. 1. Entitlement to a compensable rating prior to April 15, 2016, and in excess of 30 percent on and after April 15, 2016, for ulcerative colitis and GERD is remanded. In its May 2021 Remand instructions, the Board of Veterans' Appeals (Board) requested that the Veteran be afforded a Department of Veterans Affairs (VA) gastroenterological examination. The Board directed that the Agency of Original Jurisdiction should "schedule the Veteran for an examination by an appropriate clinician, preferably a gastroenterologist, to address the current severity of his service-connected gastrointestinal disability (currently noted to be ulcerative colitis and GERD)" and "the clinician should provide a full description of the disability and report all signs and symptoms necessary for evaluating the Veteran's disability under the rating criteria." The requested examination has not been scheduled. Instead, the Agency of Original Jurisdiction obtained September 2021 evaluations based solely on a review of the record and conducted for VA by a family nurse practitioner. 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). 2. Entitlement to an initial rating in excess of 10 percent for lumbosacral strain is remanded. The Veteran contends that a rating in excess of 10 percent is warranted for the service-connected lumbosacral strain. In his May 2020 VA Form 9, the Veteran asserted that VA examinations reports of record fail to adequately assess the lumbosacral strain. An August 2021 VA treatment record states that the Veteran complained of increasing non radiating mid low back pain of "a couple" months' duration. The treating VA physician noted "a significantly decreased lumbar lordosis." VA's duty to assist includes, in appropriate cases, the duty to conduct a thorough and contemporaneous medical examination which is accurate and fully descriptive. McLendon v. Nicholson, 20 Vet. App. 79 (2006); Green v. Derwinski, 1 Vet. App. 121, 124 (1991). The Veteran was last afforded a VA spine examination in March 2020. In light of the reported increase in severity of the Veteran's low back pain since that examination, the Board finds that further VA spine evaluation is needed. Clinical documentation dated after August 2021 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: 1. Ask the Veteran to complete a VA Form 21-4142 for each private healthcare provider who has treated the service connected ulcerative colitis, GERD, and lumbosacral spine disability. 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 August 2021. 3. Schedule the Veteran for a VA gastrointestinal examination conducted by a medical doctor in order to ascertain the current severity of the service connected ulcerative colitis and GERD. The examiner must review the record and should note that review in the report. A rationale for all opinions should be provided. 4. Schedule the Veteran for a VA spine examination conducted by a medical doctor to determine the current nature and severity of the service connected lumbosacral strain. The examiner must review the record and should note that review in the report. A rationale for all opinions should be provided. The examiner should: (a) Provide ranges of motion for passive and active motion of the lumbar spine for weight bearing and nonweight bearing. The examiner should specifically state at what degree of motion any observed pain began and whether there is any additional loss of lumbar spine function due to painful motion, weakened motion, excess motion, fatigability, incoordination, or on flare-up. (b) Indicate whether, and to what extent, the Veteran experiences functional loss of the spine due to pain or any other symptoms during flare-ups or with repeated use. (c) State whether there is any ankylosis of any segment of the spine. (d) Opine as to the impact of the service connected lumbosacral spine disability upon the Veteran's vocational pursuits. J. T. HUTCHESON Veterans Law Judge Board of Veterans' Appeals Attorney for the Board T. Douglas 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.