Citation Nr: 21012488 Decision Date: 03/04/21 Archive Date: 03/04/21 DOCKET NO. 16-09 403 DATE: March 4, 2021 REMANDED Entitlement to an initial rating in excess of 20 percent for left shoulder rotator cuff tear is remanded. REASONS FOR REMAND The Veteran served on active duty from August 1983 to November 1983, April 2002 to June 2002, April 2003 to June 2003, September 2007 to March 2008, April 2009 to August 2009, and August 2009 to August 2010, to include service in Southwest Asia. The Veteran’s awards and decorations for his service include a Bronze Star, Combat Action Badge, Purple Heart, and Legion of Merit, among many others. These matters come to the Board of Veterans’ Appeals (Board) on appeal from a June 2015 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) Philadelphia, Pennsylvania. In February 2019, the Board issued a decision denying entitlement to an increased rating for a left shoulder disorder. The Veteran subsequently appealed that decision to the United States Court of Appeals for Veterans Claims (Court). In a June 2020 Memorandum Decision, the Court vacated and remanded the case to the Board for action consistent with the Memorandum Decision. Increased Rating – Left Shoulder Rotator Cuff Tear As noted above, in its February 2019 Board decision, the Board denied entitlement to an increased rating for a left shoulder rotator cuff tear. In doing so, the February 2019 Board relied upon May 2015 and April 2016 VA examinations. However, the June 2020 Memorandum Decision found that the May 2015 VA examination report was unclear whether the Veteran’s various ranges of motion were limited by pain or whether the measurements taken included any limitation of motion caused by pain. Additionally, the June 2020 Memorandum Decision found that the February 2019 Board decision failed to provide an adequate statement of reasons or bases for relying on the April 2016 VA examination report and failed to address the portion of the VA examination report where the examiner noted that pain and functional loss on flare-ups or repetitive use limited the Veteran’s range of motion. Accordingly, and in accordance with the June 2020 Memorandum Decision, the Board concludes that the May 2015 and April 2016 VA opinions are incomplete to decide the claim, and the Veteran should be afforded a new VA examination to determine the current nature and severity of his left shoulder rotator cuff tear. The matter is REMANDED for the following action: 1. The Veteran should be given the opportunity to identify any outstanding private or VA treatment records relevant to the claim on appeal. After obtaining any necessary authorization from the Veteran, all outstanding records should be obtained, to include updated VA treatment records. For private treatment records, make at least two (2) attempts to obtain records from any identified sources. If any such records are unavailable, inform the Veteran and his representative and afford him an opportunity to submit any copies in his possession. For federal records, all reasonable attempts should be made to obtain such records. If any records cannot be obtained after reasonable efforts have been made, issue a formal determination that such records do not exist or that further efforts to obtain such records would be futile, which should be documented in the claims file. The Veteran must be notified of the attempts made and why further attempts would be futile, and allowed the opportunity to provide such records, as provided in 38 U.S.C. § 5103A(b)(2) and 38 C.F.R. § 3.159(e). 2. Then, schedule the Veteran for a VA examination to determine the current nature and severity of his service-connected left shoulder rotator cuff tear. The record, to include a copy of this Remand, should be made available to the examiner, and all indicated tests should be conducted. The examiner must address whether the Veteran’s various ranges of motion are limited by pain, and whether the measurements taken include any limitation of motion caused by pain. The examiner must address whether pain and functional loss on flare-ups or repetitive use limit the Veteran’s range of motion. (Continued on the next page)   The examiner should identify the nature and severity of all current manifestations of the Veteran’s service-connected left shoulder rotator cuff tear. A rationale for any opinion offered should be provided. KRISTY L. ZADORA Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Mariah N. Sim, 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.