Citation Nr: 21006436 Decision Date: 02/04/21 Archive Date: 02/04/21 DOCKET NO. 15-27 434 DATE: February 4, 2021 REMANDED Entitlement to a separate rating for right knee instability, to include due to residuals of a right total knee arthroplasty is remanded. REASONS FOR REMAND The Veteran served on active duty from January 1966 to December 1968. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from an August 2009 rating decision by the Department of Veterans Affairs (VA). This case was remanded in August 2013 and March 2019 for further development; it has since been re-assigned to the undersigned. Entitlement to a separate rating for right knee instability, to include due to residuals of a right total knee arthroplasty The March 2019 Board decision requested a new VA examination regarding the Veteran’s right knee instability. A Supplemental Statement of the Case (SSOC) denied service connection for the above issue, stating that the Veteran had failed to report to the scheduled examination. However, upon review of the record, the Board cannot even be sure whether the requested VA examination was scheduled. Indeed, the record shows a VA examination request was made. This request was associated with the file on October 7, 2019. Thereafter, on October 10, 2019, a VA examination Request Clarification Response was added to the file which indicated that the requested examination had been suspended pending clarification of the request. It was noted that the Medical Opinion DBQ had not been associated with the request and an edited request that a Medical Opinion DBQ be added was requested. The same form also noted that the Medical Opinion DBQ was added as requested. However, a review of the file shows no documentation of the same. Indeed, the Exam Scheduling Request Clarification Response noted herein contained the same explanation of the examination request as the original request. Thereafter, associated with the file on October 31, 2019, is a notification that the exam had been cancelled as the Veteran did not show up. None of the documents noted a date on which the exam was scheduled for or even if the exam was indeed scheduled at all. Moreover, the record does not contain evidence of any notice that may have been provided to the Veteran regarding the time, date, and location of the scheduled examination. In fact, the record contains an inquiry showing that the nearest examination location did not conduct the type of exam being requested. Given the above, the Board cannot be certain that the Veteran was informed of the examination even less that an examination was indeed scheduled. Therefore, in order to ensure compliance with the duty to assist, the Board finds that another attempt should be made to schedule the requested examination. 38 U.S.C. § 5103A; 38 C.F.R. § 3.159. The matters are REMANDED for the following action: 1. The AOJ should obtain copies of VA treatment records from October 2019 to the present. 2. After the above development is completed, the AOJ should arrange for a VA examination of the Veteran to determine the severity of all residuals of the Veteran’s right total knee replacement. The examiner should review the claim file (including this remand) and note such review was conducted. All findings should be reported in detail. The examiner should conduct range of motion studies. The joints involved should be tested in both active and passive motion, in weight-bearing and non-weight-bearing and, if possible, with range of motion measurements of the opposite undamaged joint. 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 that is so. The examiner should describe any pain, weakened movement, excess fatigability, instability of station and incoordination present. If pain is noted, the point during range of motion at which pain starts must be clearly indicated. The examiner must specifically address whether right knee lateral instability has been present since February 16, 2015. The examiner should also state whether the examination is taking place during a period of flare-up. If not, the examiner should ask the Veteran to describe the flare-ups he experiences, including: frequency, duration, characteristics, precipitating and alleviating factors, severity and/or extent of functional impairment he experiences during a flare-up of symptoms and/or after repeated use over time. Based on the Veteran's lay statements and the other evidence of record, the examiner should provide an opinion estimating any additional degrees of limited motion caused by functional loss during a flare-up or after repeated use over time. If the examiner cannot estimate the degrees of additional range of motion loss during flare-ups or after repetitive use without resorting to speculation, the examiner should state whether the need to speculate is caused by a deficiency in the state of general medical knowledge (i.e. no one could respond given medical science and the known facts) or by a deficiency in the record or the examiner (i.e. additional facts are required, or the examiner does not have the needed knowledge or training). 3. If upon completion of the above action the issues remain denied, the case should be returned to the Board after compliance with appellate procedures. E. I. VELEZ Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board EJ Richardson 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.