Citation Nr: 21012449 Decision Date: 03/04/21 Archive Date: 03/04/21 DOCKET NO. 14-41 257 DATE: March 4, 2021 REMANDED Entitlement to an increased disability rating in excess of 50 percent prior to December 17, 2019, and in excess of 70 percent thereafter for service-connected posttraumatic stress disorder (PTSD) and major depressive disorder, associated with chronic low back pain with minimal ossifications at T10-11 (previously rated as adjustment disorder with mixed anxiety and depressed mood) is remanded. Entitlement to an increased disability rating in excess of 20 percent for service-connected lumbosacral intervertebral disc syndrome with grade 1 spondylolisthesis L5-S1 is remanded. REASONS FOR REMAND The Veteran had active duty service from April 1986 to November 1989. These matters are before the Board of Veterans’ Appeals (Board) on appeal from March 2013 and May 2013 rating decisions by a Department of Veterans Affairs (VA) Regional Office (RO). The Veteran’s claims were remanded in December 2018 in order to obtain new VA medical examinations to assess the current severity levels of his disabilities. 1. Entitlement to an increased disability rating in excess of 50 percent prior to December 17, 2019, and in excess of 70 percent thereafter for service-connected posttraumatic stress disorder (PTSD) and major depressive disorder, associated with chronic low back pain with minimal ossifications at T10-11 (previously rated as adjustment disorder with mixed anxiety and depressed mood) is remanded. Initially, the Board notes that pursuant to the December 2018 remand, the Veteran was scheduled for a PTSD VA examination in December 2019. However, per the record, the Veteran was scheduled again for a medical examination to assess the current severity level of his service-connected major depressive disorder. See December 2020 Exam Request. The Veteran expressed confusion as to why the examination was scheduled, but later conveyed that he was willing to report and asked that it be rescheduled. See December 2020 Report of General Information; January 2021 Report of General Information (“Veteran has clarification on why this appointment is needed and request for it to be rescheduled.”). The Board notes that there is no indication that the medical examination was conducted or rescheduled, and therefore, unfortunately, a remand is required to accomplish this additional development on the Veteran’s increased rating claim, as the medical findings could substantially impact its outcome. 2. Entitlement to an increased disability rating in excess of 20 percent for service-connected lumbosacral intervertebral disc syndrome with grade 1 spondylolisthesis L5-S1 is remanded. Upon remand, the Veteran was afforded a December 2019 VA examination. Per the report, the VA examiner indicated that the Veteran experienced pain with weightbearing; however, range of motion measurements were not provided as required by Correia. See Correia v. McDonald, 28 Vet. App. 158 (2016). The RO attempted to seek clarification from the VA examiner as to said omissions in the examination report, and yet the VA examiner did not address the Veteran’s range of motion relative to findings of him having experienced pain with weightbearing. See July 2020 Addendum to Examination Dated: 12/17/20. As such, the Board finds that another remand is unfortunately required to address the same. The matters are REMANDED for the following action: 1. Associate with the Veteran’s claims file any outstanding VA treatment records since December 2019. 2. Reschedule the Veteran for a VA examination to assess the current severity level of his service-connected PTSD and major depressive disorder. See January 2021 Report of General Information. 3. Obtain an addendum medical opinion from the December 2019 VA examiner, or an appropriate substitute if unavailable, as to whether the Veteran experiences any additional loss of range of motion or functional impairment relative to the medical findings of him having experienced pain with weightbearing. See December 2019 VA examination Report. If feasible, the medical opinion should address, not only the current severity, but also for the entire period since May 2010, and whether the Veteran suffered any additional loss of range of motion or functional impairment relative to the medical findings of him having experienced pain with weight bearing. See December 2018 Remand directives. If it is not feasible to offer any opinion to any degree of medical certainty without resort to speculation, the examiner must provide a specific explanation for why this is so. If such an opinion is not procurable based on a lack of knowledge, then the inability to offer such an opinion must be based on a lack of knowledge among the “medical community at large,” and not merely a lack of expertise, insufficient information, or unprocured testing on the part of the examiner. 4. Thereafter, readjudicate the claim on appeal. If the benefit sought remains denied, issue the Veteran and his representative a supplemental statement of the case and provide a reasonable opportunity to respond before returning the matter to the Board for further appellate review. Saudiee Brown Acting Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board S.R. Fey, Associate 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.