Citation Nr: 21073397 Decision Date: 12/08/21 Archive Date: 12/08/21 DOCKET NO. 16-55 975 DATE: December 8, 2021 REMANDED Entitlement to separate compensable ratings for neurologic impairments, including urination difficulties and hand tremors, associated with the service connected lumbar spine intervertebral disc syndrome and spinal stenosis is remanded. REASONS FOR REMAND The Veteran had active service from January 1986 to October 1987. Entitlement to separate compensable ratings for neurologic impairments, including urination difficulties and hand tremors, associated with the service connected lumbar spine intervertebral disc syndrome and spinal stenosis is remanded. In its June 2021 Remand instructions, the Board of Veterans' Appeals (Board) noted that the private clinical documentation of record states that the Veteran was seen for complaints of difficulty with urination, right upper extremity numbness with tingling of the right hand, and hand tremors. The Board requested that the Veteran be scheduled for a Department of Veterans Affairs (VA) examination to identify all neurological abnormalities associated with the service connected lumbar spine disability including radiculopathy, other than that of the lower extremities, and bowel and bladder impairments. The Board directed that the examiner must address the Veteran's documented upper extremity and urological complaints and, "if the Veteran's reports are discounted, provide a reason for doing so." The report of an August 2021 lumbar spine examination conducted for VA states that the examiner was "unable to confirm a chronic diagnosis with current available records and/or today's exam" and "therefore no nexus or plausible secondary relationship is established." The nurse practitioner did not note or otherwise address the private clinical documentation reflecting that the Veteran was seen for complaints of difficulty with urination, right upper extremity numbness with tingling of the right hand, and hand tremors. 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). When VA undertakes to obtain an evaluation, it must ensure that the evaluation is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). 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). Therefore, the Board further VA evaluation is needed. VA clinical documentation dated in November 2019 indicates that the Veteran was in receipt of Social Security Administration (SSA) disability benefits. Documentation of the Veteran's SSA award of disability benefits and the evidence considered by the SSA in granting the Veteran's claim is not of record. VA's duty to assist the Veteran includes an obligation to obtain the records from the SSA. Masors v. Derwinski, 2 Vet. App. 181, 187 188 (1992). Clinical documentation dated after September 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 claim. Murphy v. Derwinski, 1 Vet. App. 78 (1990); Bell v. Derwinski, 2 Vet. App. 611 (1992). The matter is REMANDED for the following action: 1. Ask the Veteran to complete a VA Form 21-4142 for each private healthcare provider who has treated any upper extremity neurologic and urinary disabilities. 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. Associate with the record any VA medical records not already of record, including that provided after after September 2021. 3. Contact the SSA and request documentation of the Veteran's award of disability benefits and copies of all records developed in association with the decision for incorporation into the record. 4. Schedule the Veteran for a VA examination conducted by the appropriate medical doctor to assist in determining the current nature and severity of any neurological disabilities associated with the service connected lumbar spine intervertebral disc syndrome and spinal stenosis. The examiner must review the record, including the private clinical documentation reflecting that the Veteran was seen for complaints of difficulty with urination, right upper extremity numbness with tingling of the right hand, and hand tremors and the Veteran's written statements, and should note that review in the report. A rationale for all opinions should be provided. The examiner should (a) Describe any neurologic disabilities, including those of the upper extremity and the bladder, identified as associated with the lumbar spine disability, the nerves affected, and the level of impairment. (b) If no current neurological disabilities are identified, the examiner should specifically address the private clinical documentation reflecting that the Veteran was seen for complaints of difficulty with urination, right upper extremity numbness with tingling of the right hand, and hand tremors and the Veteran's written statements and opine whether such upper extremity and bladder symptoms were related to the service connected lumbar spine disability. J. T. HUTCHESON Veterans Law Judge Board of Veterans' Appeals Attorney for the Board K.R. Kardian, 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.