Citation Nr: 21007130 Decision Date: 02/04/21 Archive Date: 02/08/21 DOCKET NO. 07-25 937 DATE: February 4, 2021 REMANDED Entitlement to service connection for coronary artery disease (CAD) is remanded. Entitlement to an increased initial rating for osteoarthritis of the cervical spine, rated as 10 percent disabling prior to November 29, 2007, and 30 percent thereafter is remanded. Entitlement to an increased initial rating for osteoarthritis of the right shoulder, rated as 20 percent disabling prior to February 27, 2017, and 30 percent thereafter is remanded. REASONS FOR REMAND The Veteran served on active duty from September 1967 to March 1991. These matters come to the Board of Veterans’ Appeals (Board) on appeal from a rating decision by a Regional Office (RO) of the Department of Veterans Affairs (VA). These matters were last before the Board in January 2018, when they were remanded for additional development. During the pendency of the remand, a September 2020 rating decision granted entitlement to a total disability rating based on individual unemployability, effective November 21, 2005. As November 21, 2005 was the date of claim for the Veteran’s pending increased rating claims, he has been granted a TDIU for the entire period on appeal. Thus, the issue of entitlement to TDIU is no longer before the Board. Harper v. Wilkie, 30 Vet. App. 356 (2018). 1. Entitlement to service connection for CAD is remanded. 2. Entitlement to an increased initial rating for osteoarthritis of the cervical spine, rated as 10 percent disabling prior to November 29, 2007, and 30 percent thereafter is remanded. 3. Entitlement to an increased initial rating for osteoarthritis of the right shoulder, rated as 20 percent disabling prior to February 27, 2017, and 30 percent thereafter is remanded. The evidence indicates there may be outstanding relevant VA treatment records. A May 21, 2018 VA treatment record indicates that the Veteran was to return for a follow up appointment in November 2018. VA treatment records subsequent to August 31, 2018 have not been associated with the claims file. A remand to obtain the outstanding records is required. Additionally, there has not been substantial compliance with the Board’s previous remand directives. In pertinent part, the January 2018 remand requested a VA opinion to determine whether the Veteran’s CAD was related to service. The remand directed that service treatment records, including one from July 19, 1973 be addressed in rendering the opinion. While an opinion was obtained in March 2020, the clinician did not address the service treatment record from July 19, 1973. Stegall v. West, 11 Vet. App. 268, 271 (1998). Also, while the examiner rendered an additional diagnosis of valvular heart disease, that diagnosis was not addressed in the opinion. Lastly, as the examiner indicated that the Veteran’s chest pain was due to anxiety and he is service connected for an unspecified anxiety reaction, the Board finds that a claim for secondary service connection is reasonably raised. Accordingly, another remand is required. The January 2018 remand also directed that the Veteran be provided a VA shoulder examination. The Veteran was provided a VA shoulder examination in March 2020. While the examiner noted that the Veteran had pain with active and passive flexion, abduction, and rotation, the examiner did not indicate where the pain started or ended. Accordingly, the Veteran should be provided a new VA examination, which complies with the requirements in Correia v. McDonald, 28 Vet. App. 158 (2016). Finally, the January 2018 remand directed that the RO request authorization from the Veteran and thereafter request copies of his Workman’s Compensation records. While a February 2020 letter requested that the Veteran submit copies of his Workman’s Compensation records, the RO did not request the Veteran to authorize VA to obtain those records on his behalf. Accordingly, another remand is required. Stegall v. West, 11 Vet. App. 268, 271 (1998). The matters are REMANDED for the following actions: 1. Ask the Veteran to provide the names and addresses of all medical care providers who have recently treated him for his claimed disabilities. After securing any necessary releases, the AOJ should request any relevant records identified. In addition, obtain updated VA treatment records dated since August 31, 2018. If any requested records are unavailable, the Veteran should be notified of such. 2. After receiving any necessary contact information and authorization from the Veteran, request copies of the Veteran’s Workman’s Compensation records. If the requested records are not available, the Veteran should be notified of such. 3. After records development is completed to the extent possible, forward the claims file to a VA clinician to obtain an addendum opinion regarding the Veteran's heart claim. If an examination is deemed necessary to respond to the questions presented, one should be scheduled. Following review of the claims file, the clinician should opine: (a.) Whether it is at least as likely as not (50 percent probability or greater) that any heart disability present during the pendency of the appeal had its onset during service or is otherwise related to service. In so opining, the clinician should address the Veteran’s treatment for chest pain on July 19, 1973, October 2, 1973, October 15, 1973, November 4, 1974, and November 1, 1977. (b.) Whether it is at least as likely as not (50 percent probability or greater) that any heart disability present during the pendency of the appeal was caused by the service-connected unspecified anxiety reaction? (c.) If not caused by the service-connected unspecified anxiety reaction, is it at least as likely as not that any heart disability present during the pendency of the appeal was aggravated by his service-connected anxiety disability? In rendering the above requested opinions, the clinician should address the March 2020 examiner’s statement that the Veteran’s complaints of chest pain were associated with anxiety and tension. A complete rationale should be provided for all opinions and conclusions expressed. 4. After the above record development is completed to the extent possible, schedule the Veteran for a VA shoulder examination to determine the current nature and severity of his service-connected right shoulder disability. The claims file should be reviewed in conjunction with the examination. All indicated tests should be conducted and the results reported. Range of motion testing should be undertaken, and should be tested actively and passively, in weight bearing, and after repetitive use. (a.) For each range of motion testing conducted for the right shoulder, the examiner must state where in the range of motion the Veteran reports that he begins to experience pain. If the examiner is unable to conduct any of 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. (b.) The examiner should also state whether there is likely to be additional range of motion loss due to flare-ups and due to pain, weakness, fatigability, or incoordination. If so, the examiner is asked to describe the additional loss, in degrees, if possible. In doing so, the examiner should elicit relevant information as to the Veteran's flares or ask him to describe the additional functional loss, if any, he suffered during flares and then estimate the Veteran's functional loss due to flares based on all the evidence of record, including the Veteran's lay information. (c.) If it is not possible to provide a specific measurement, or an opinion regarding flare-ups, symptoms, or functional impairment without speculation, the examiner must state whether the need to speculate is due to a deficiency in the state of general medical knowledge (no one could respond given medical science and the known facts), a deficiency in the record (additional facts are required), or the examiner (does not have the knowledge or training). 5. Then, readjudicate the claims on appeal. Romina A. Casadei Acting Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board J. Anderson 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.