Citation Nr: 21008971 Decision Date: 02/18/21 Archive Date: 02/18/21 DOCKET NO. 15-01 769 DATE: February 18, 2021 REMANDED Entitlement to a rating in excess of 10 percent for a left ankle disability is remanded. Entitlement to a rating in excess of 20 percent for a left foot disability is remanded. Entitlement to a rating in excess of 10 percent prior to December 29, 2014, for varicose veins of the right lower extremity (RLE). Entitlement to a rating in excess of 20 percent from December 29, 2014, for varicose veins of the RLE. Entitlement to a rating in excess of 10 percent prior to December 29, 2014, for varicose veins of the left lower extremity (LLE). Entitlement to a rating in excess of 20 percent from December 29, 2014, for varicose veins of LLE. REASONS FOR REMAND The Veteran served on active duty from January 1998 to October 2004. These matters come before the Board of Veterans’ Appeals (Board) on appeal from an August 2012 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO). A February 2019 Board decision, inter alia, remanded the claims to provide an examination to determine the current severity of his service-connected left ankle disability, left foot disability and bilateral lower extremity varicose veins. An October 2020 rating decision granted an increase to 20 percent rating for bilateral lower extremity varicose veins from December 29, 2014 (date of VA Form 9). As the award does not represent a full grant of the benefit sought on appeal, the claim remains in appeal status. See AB v. Brown, 6 Vet. App. 35 (1993). The Board acknowledges that the Veteran believes service connection is warranted for restless leg syndrome secondary to her service-connected bilateral lower extremity varicose veins. See Appellate Brief (February 2021). To the extent that the Veteran believes compensation is warranted for this condition, she is advised that all claims for benefits must be submitted on required forms. Effective on March 24, 2015, VA amended its rules as to what constitutes a claim for benefits; such now requires that claims be made on specific claim form prescribed by the Secretary and available online or at the local Regional Office. This provision effectively removed informal claims from VA’s processes. 1. Entitlement to a rating in excess of 10 percent for a left ankle disability. 2. Entitlement to a rating in excess of 20 percent for a left foot disability. 3. Entitlement to a rating in excess of 10 percent prior to December 29, 2014, for RLE varicose veins. 4. Entitlement to a rating in excess of 20 percent from December 29, 2014, for RLE varicose veins. 5. Entitlement to a rating in excess of 10 percent prior to December 29, 2014, for LLE varicose veins. 6. Entitlement to a rating in excess of 20 percent from December 29, 2014, for LLE varicose veins. Issues 1-6: The Veteran contends that she continues to have a lot of pain in the left foot and left ankle even with a brace; that her ankle constantly pops and is very painful when it does; and that she has difficulty walking, limps, and cannot do anything that requires long periods of walking. See Form 9 (December 2014). She also stated that her large veins ache and itch, and that her legs feel fatigued with or without prolonged standing and prevent her from sleeping well at night. Id. After careful review of the record, the Board finds that there are relevant outstanding treatment records that must be requested to ensure that VA has met its duty to assist the Veteran. The record includes VA treatment records through June 2012, and from December 2019 to July 2020. There is an unexplained gap in the VA treatment records in the claims file. Given the symptoms reported by the Veteran and this gap in the record, there is a strongly indicates that there are either outstanding additional VA treatment records or non-VA treatment records for the period intervening June 2012 and December 2019. Thus, VA treatment records should be obtained for the period between June 2012 and December 2019. Significantly, the Board notes that the January 2020 VA examination refer to treatment records from May 2015 and July 2019, which are not presently associated with the Veteran’s file. Any VA treatment records are within VA’s constructive possession, and are considered potentially relevant to the issue on appeal. See 38 U.S.C. § 5103A. See also Sullivan v. McDonald, 815 F.3d 786 (Fed. Cir. 2016). Further, a review of the Veteran’s VA treatment records confirms that, during the appeal period, the Veteran has been seen by a non-VA medical provider. See CAPRI (August 2012). The records have not been provided by the Veteran or requested by VA. Therefore, the Veteran must be afforded an opportunity to complete an authorization for release of the records to VA. See 38 C.F.R. § 3.159(c)(1). The matters are REMANDED for the following action: 1. Obtain the Veteran’s VA treatment records for the period from June 2012 and December 2019, and from July 2020 to the Present, if any. 2. Ask the Veteran to complete a VA Form 21-4142 for all non-VA medical providers seen for symptoms and/or treatment involving her left ankle, left foot, and varicose veins, to include from Tricare. Make two requests for the authorized records from all identified sources, unless it is clear after the first request that a second request would be futile. C.A. SKOW Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board E. M. Pesin 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.