Citation Nr: 21071398 Decision Date: 11/30/21 Archive Date: 11/30/21 DOCKET NO. 13-19 769 DATE: November 30, 2021 REMANDED Entitlement to an evaluation in excess of 20 percent disabling for a left shoulder disability is remanded. Entitlement to an increased rating for left upper extremity paresthesias evaluated at 20 percent, for the period prior to January 9, 2018, and in excess of 30 percent thereafter, is remanded. REASONS FOR REMAND The Veteran had active military service from September 1996 to May 1998. In March 2016, the Veteran testified at a Board hearing before the undersigned Veterans Law Judge. A transcript of that hearing is of record. The claims were most recently before the Board in October 2020. The Board denied the claim for increased rating for the left shoulder disability and remanded the claim for increased rating for the left upper extremity paresthesias. The Veteran appealed the denial to the United States Court of Appeals for Veterans Claims (CAVC). In a July 2021 Order, CAVC granted a Joint Motion for Partial Remand (JMPR), vacating and remanding the portion of the Board decision that denied the left shoulder claim. 1. Entitlement to an evaluation in excess of 20 percent disabling for a left shoulder disability is remanded. The claim is remanded to obtain an adequate medical examination that addresses at what point during the Veteran's range of motion of the left shoulder pain resulted in functional loss. The parties to the JMPR agreed that simply noting the presence of pain, without stating at what point during the range of motion the pain caused functional loss, prevented the Board from fully understanding the degree to which the Veteran's condition was disabling. The parties to the JMR agreed that the new opinion must state at what point, if any, the Veteran experiences pain resulting in functional loss on passive motion as well as active motion. 2. Entitlement to an increased rating for left upper extremity paresthesias evaluated at 20 percent, for the period prior to January 9, 2018, and in excess of 30 percent thereafter. The claim must be remanded as intertwined with the left shoulder claim and to obtain additional relevant treatment records. See 38 C.F.R. § 3.159. VA treatment include a May 2020 notation that the Veteran had a neurosurgery evaluation through Norvant two years prior. See October 2020 submission. The record does not include any treatment records from Norvant dated after 2014. The Veteran receives consistent treatment from VA. VA treatment records in July 2020 indicate that the Veteran received community care acupuncture and that documents were scanned. These records have not been associated with the record available to the Board for review. In addition, VA treatment records dated since October 2020 have not been associated with the claims file. The matters are REMANDED for the following action: 1. Take all appropriate action to obtain the Veteran's VA treatment records for the period from October 2020 to the present. 2. Take all appropriate action to obtain and associate with the record all treatment records scanned into VISTA Imaging. 3. Ask the Veteran to complete a I Form 21-4142 for all private providers, including Norvant. Make two requests for the authorized records from all identified providers unless it is clear after the first request that a second request would be futile. 4. Thereafter, schedule the Veteran for an examination (or telehealth interview, review of the record, etc., if an in-person examination is not feasible) to determine the current severity of his left shoulder. Copies of all pertinent records should be made available to the examiner for review. The examiner is requested to delineate all symptomatology associated with, and the current severity of, the left shoulder and left upper extremity disabilities. The appropriate DBQs should be filled out for this purpose, if possible. The examiner should specifically test the Veteran's left shoulder ranges of motion in active motion, passive motion, weight-bearing, and nonweight-bearing. The examiner should also specifically test the range of motion of the Veteran's right shoulder. 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 this is so. The examiner should attempt to estimate additional functional loss of the left shoulder due to repetitive use and/or flare-ups. In making this determination the examiner is specifically directed to ascertain adequate information-i.e., frequency, duration, characteristics, severity, or functional loss-regarding the Veteran's flares by any available means, to include the Veteran's lay statements and all other evidence of record. In discussing all range of motion testing results the examiner must identify at what point, if any, the Veteran experiences pain resulting in functional loss. 5. The AOJ should confirm that the VA medical opinion provided comports with this remand, and undertake any other development determined to be warranted. After the above development, and any additionally indicated development, has been completed, readjudicate the issues. M.E. LARKIN Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Robert J. Burriesci, 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.