Citation Nr: 21069343 Decision Date: 11/18/21 Archive Date: 11/18/21 DOCKET NO. 17-48 037 DATE: November 18, 2021 REMANDED For the period prior to June 6, 2016, entitlement to an evaluation in excess of 20 percent for a lumbosacral strain is remanded. For the period from June 6, 2016, to November 9, 2020, entitlement to an evaluation in excess of 10 percent for a lumbosacral strain is remanded. For the period beginning on November 10, 2020, entitlement to an evaluation in excess of 20 percent for a lumbosacral strain is remanded. Entitlement to an evaluation in excess of 20 percent for left lower extremity radiculopathy is remanded. For the period prior to November 10, 2020, entitlement to an evaluation in excess of 10 percent for right lower extremity radiculopathy is remanded. For the period beginning on November 10, 2020, entitlement to an evaluation in excess of 20 percent for right lower extremity radiculopathy is remanded. REASONS FOR REMAND The Veteran served on active duty in the U.S. Air Force from September 1995 to June 2006. These matters come before the Board of Veteran's Appeals (Board) on appeal from February 2016 and July 2016 rating decisions by a Department of Veterans Affairs (VA) Regional Office (RO). In May 2020 and May 2021, the Board remanded the claims for further development. These matters are now returned to the Board for further appellate review. 1. For the period prior to June 6, 2016, entitlement to an evaluation in excess of 20 percent for a lumbosacral strain 2. For the period from June 6, 2016, to November 9, 2020, entitlement to an evaluation in excess of 10 percent for a lumbosacral strain 3. For the period beginning on November 10, 2020, entitlement to an evaluation in excess of 20 percent for a lumbosacral strain 4. Entitlement to an evaluation in excess of 20 percent for left lower extremity radiculopathy 5. For the period prior to November 10, 2020, entitlement to an evaluation in excess of 10 percent for right lower extremity radiculopathy 6. For the period beginning on November 10, 2020, entitlement to an evaluation in excess of 20 percent for right lower extremity radiculopathy The Veteran's lumbosacral strain is currently assigned a 20 percent rating effective December 12, 2014, a 10 percent rating effective June 6, 2016, and a 20 percent rating effective November 10, 2020. His associated left lower extremity radiculopathy is currently assigned a 20 percent rating. His associated right lower extremity radiculopathy is assigned a 10 percent rating prior to November 10, 2020, and 20 percent thereafter. He seeks increased ratings. Regarding the lumbosacral rating claim, a July 2015 rating decision granted service connection for the lumbosacral strain and assigned a 20 percent rating, effective December 12, 2014. In August 2015, the Veteran filed a claim for an increased rating. A February 2016 rating decision denied the increased rating claim, which the Veteran appealed to the Board. Meanwhile, a July 2016 rating decision reduced the lumbosacral strain rating from 20 to 10 percent, effective June 6, 2016. The Veteran filed an October 2016 notice of disagreement, a November 2020 statement of the case (SOC) was issued, but the Veteran did not file an appeal to the Board. Therefore, the rating reduction became final, and is not on appeal herein. Most recently, in May 2021, the Board remanded the claims because the November 2020 VA examination report noted that the Veteran experienced pain with weight bearing, but it was unclear whether the ranges of motion for the lumbosacral spine were weight bearing. The Board directed that the same VA examiner who prepared the November 2020 VA examination report provide an addendum to clarify whether the lumbosacral ranges of motion noted in the November 2020 VA examination report were weight bearing; if not, then a new VA examination was requested. A June 2021 addendum opinion was obtained, but it is not from the same examiner who prepared the November 2020 VA examination report. It was based on a record review and it is not clear how this new examiner could comment on the conduct of the previous examination. No new examination was performed. Therefore, the Board finds the claims should be remanded so that the same VA examiner who prepared the November 2020 VA examination report may be asked to provide clarification as to whether the lumbosacral ranges of motion noted in the November 2020 VA examination report were weight bearing; if not, or if that same VA examiner is unavailable, then a new VA examination should be performed. In light of the above, the Board defers decision on the rating claims for the bilateral lower extremity radiculopathy pending completion of the development directed herein. The matters are REMANDED for the following action: 1. Ask the same VA examiner who prepared the November 2020 VA examination report for the Veteran's back disability through QTC Medical Services - Ms. C.H., (N.P.) - to clarify whether the lumbosacral range of motion test results provided in the November 2020 report were weight bearing (it is not clear whether the lumbosacral spine is always in weight bearing position when upright due to the head, or whether weight bearing testing would involve other types of weight being used). Of importance is the most limiting reduced function. If not, then a new VA examination should be performed to address the current severity of the Veteran's lumbosacral strain disability and associated bilateral lower extremity radiculopathy. The claims folder should be made available to the examiner and pertinent documents therein should be reviewed by the examiner. All necessary tests and studies should be accomplished, and all clinical findings should be reported in detail. The examination must comply with the requirements of 38C.F.R. §4.59 involving measurements of passive and active range of motion - in both weight bearing and non-weight bearing. The examiner must explain why any of these clinical tests are not appropriate or could not be performed. A complete rationale for any opinions expressed should be provided. The examiner should be asked to note whether there is any weakened movement, excess fatigability, incoordination, or pain on use. If so, the examiner should note whether there are any additional degrees of loss of motion as a result (if it is not feasible to quantify, please explain). If flare-ups are noted, the examiner should note whether pain during flare-ups additionally limits functional ability. The examiner should note whether there are any additional degrees of loss of motion due to pain during flare-ups (if it is not feasible to quantify, please explain). Also, the examiner should ask the Veteran to describe in his own words whether there is any additional functional loss during flare-ups, and the examiner should note the frequency, duration, and severity of flare-ups. Any conclusions should be supported by a detailed rationale. J.W. FRANCIS Veterans Law Judge Board of Veterans' Appeals Attorney for the Board J. Juliano, 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.