Citation Nr: 21077135
Decision Date: 12/28/21	Archive Date: 12/28/21

DOCKET NO. 17-11 781
DATE: December 28, 2021

REMANDED

Entitlement to an initial evaluation in excess of 10 percent for thoracic vertebra compression fracture residuals is remanded.

Entitlement to an initial compensable evaluation for right clavicle fracture residuals is remanded.

REASONS FOR REMAND

The Veteran served on active duty from August 1970 to August 1974.  This appeal comes before the Board of Veterans' Appeals (Board) from a June 2015 rating decision.

In August 2021, the Veteran testified at a Board videoconference hearing before the undersigned Veterans Law Judge.  A transcript of the hearing is included in the electronic claims file.

1. Entitlement to an initial evaluation in excess of 10 percent for thoracic vertebra compression fracture residuals is remanded.

2. Entitlement to an initial compensable evaluation for right clavicle fracture residuals is remanded.

Following the issuance of the February 2017 statement of the case (SOC) and certification of the appeal to the Board in July 2018, additional pertinent evidence was added to the record, to include VA treatment records dated from June 2015 to August 2021 that was developed by VA.  Neither the Veteran nor his representative waived review of this evidence.  38 U.S.C. § 7105(e); 38 C.F.R. § 20.1304(c).  Thus, a remand is required so that a supplemental statement of the case (SSOC) may be issued with consideration of all the evidence of record with regard to the claims on appeal.

During the August 2021 Board hearing, the Veteran and his representative essentially asserted that his service-connected thoracic spine and right clavicle disabilities have increased in severity since he was last examined by VA in June 2015.  The Veteran testified that his thoracic spine symptoms included increased pain, limitation of motion, muscle spasms, and instability and that his right clavicle symptoms included frequent dislocations, increased pain on use, and functional loss.  Based on the foregoing, the Veteran should be provided an opportunity to report for VA examinations to ascertain the current severity and manifestations of his service-connected thoracic spine and right clavicle disabilities.

Evidence of record further reflects that the Veteran received VA medical treatment for his service-connected thoracic spine and right clavicle disabilities from the Memphis VAMC and Jackson CBOC.  As evidence of record only includes treatment records dated up to August 2021 from those facilities, all pertinent VA treatment records should be obtained and properly associated with the record.  38 U.S.C. § 5103A(c) (2012); see also Bell v. Derwinski, 2 Vet. App. 611 (1992).

The matters are REMANDED for the following actions:

1. Obtain updated treatment records pertaining to the Veteran's service-connected thoracic spine and right clavicle disabilities from Memphis VAMC and Jackson CBOC dated from August 2021 to present.

2. Schedule the Veteran for VA examinations by appropriate clinicians to determine the current severity of his service-connected disabilities, thoracic vertebra compression fracture residuals and right clavicle fracture residuals.  Each examiner should provide a full description of each disability and report all signs and symptoms necessary for evaluating the Veteran's disabilities under the applicable rating criteria.

3. After completing the above actions and any other necessary development, the claims on appeal must be re-adjudicated, taking into consideration all relevant evidence associated with the record since the February 2017 SOC.  If any benefit on appeal remains denied, a SSOC must be provided to the Veteran and his representative.  After the Veteran has had an adequate opportunity to respond, the appeal must be returned to the Board for appellate review.

 

 

MICHAEL MARTIN

Veterans Law Judge

Board of Veterans' Appeals

Attorney for the Board	J. D. Deane, 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.