Citation Nr: 21012855 Decision Date: 03/05/21 Archive Date: 03/05/21 DOCKET NO. 15-46 984 DATE: March 5, 2021 REMANDED Entitlement to service connection for bilateral shoulder disability, to include as secondary to service-connected lumbar spine disability, is remanded. Entitlement to an initial rating in excess of 10 percent prior to October 8, 2013, and from January 1, 2014 to April 2, 2018; in excess of 20 percent from April 2, 2018 to January 9, 2020; and in excess of 40 percent thereafter for lumbar spine degenerative arthritis with spinal fusion and IVDS (hereinafter “low back disability”) is remanded. Entitlement to a total disability rating based on individual unemployability (TDIU) is remanded. REASONS FOR REMAND The Veteran had active service from June 1980 to August 1984. This matter comes before the Board of Veterans’ Appeals (BVA or Board) from January 2013, December 2015, and April 2018 rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO). In September 2018, the Board remanded the issues for the claims for entitlement to a TDIU and initial increased rating for the service-connected low back disability for additional development. During the pendency of the remand development, in a May 2020 rating decision, the RO granted an increased evaluation of 40 percent for the low back disability, effective January 9, 2020. As this partial rating increase is not the maximum allowable for the entire period on appeal, this issue remains on appeal. AB v. Brown, 6 Vet. App. 35 (1993). A claim for service connection for right lower extremity radiculopathy was developed for appellate consideration in conjunction with the claims for entitlement to service connection for right and left shoulder disabilities. During the pendency of this appeal, a July 2020 rating decision granted entitlement to service connection for right lower extremity radiculopathy. The grant of service connection for right lower extremity radiculopathy was a full grant of the benefit sought. See AB v. Brown, 6 Vet. App. 35 (1993). Entitlement to service connection for bilateral shoulder disability is remanded. As highlighted and reiterated in the December 2020 correspondence from the Veteran’s representative, the Veteran claims that his right and left shoulder disabilities are related to his service-connected low back disability. See December 2020 Email Correspondence. Specifically, the Veteran contends that he improperly lifted, pushed, pulled, carried, and reached with his shoulders as a direct result of his low back disability while also simultaneously trying not to aggravate his back. A March 2018 VA treatment record noted the Veteran’s right shoulder pain and limited mobility that is consistent with a rotator cuff tendonitis/bursitis. See February 2020 CAPRI. A February 2020 VA treatment record noted an MRI of the left shoulder that revealed rotator cuff tear and mild to moderate AC joint degenerative joint disease. See April 2020 CAPRI. As a VA examination and etiological opinion has not been provided to determine whether the right and left shoulder disabilities are related to the service-connected low back disability, a remand is warranted to obtain such a VA examination and opinion. Entitlement to an initial rating in excess of 10 percent prior to October 8, 2013, and from January 1, 2014 to April 2, 2018, to a rating in excess of 20 percent from April 2, 2018 to January 9, 2020, and to a rating in excess of 40 percent thereafter for low back disability is remanded. Entitlement to a TDIU is remanded. Since the last supplemental statement of the case (SSOC) in May 2020, additional VA examinations and opinion pertinent to the claims for entitlement to a TDIU and initial increased rating for the service-connected low back disability were conducted and associated with the claims file in June 2020 and October 2020. See July 2020 C&P Exam and October 2020 C&P Exam. As such, a July 2020 letter was sent to the Veteran and his representative requesting waiver of AOJ review, however, no response was received within 45 days as to the AOJ waiver request. See July 2020 BVA Letter. Therefore, remand is necessary for the AOJ to issue a SSOC that considers any additional relevant evidence of record. The matters are REMANDED for the following action: 1. Obtain all updated VA treatment records. 2. After development #1 is completed, obtain a VA examination and opinion to evaluate his claim for bilateral shoulder disabilities. The claims folder should be made available to the examiner for review in connection with the examination and the examiner should acknowledge such review in the examination report. The examiner must complete the following: a. Confirm and identify any diagnosed bilateral shoulder disabilities near or during the entire period on appeal for these claims, from February 2018 to the present. b. Is it at least as likely as not (50 percent probability or greater) that any shoulder disability had its onset during active service, or is otherwise etiologically related to his period of service? Explain why or why not. c. Is it at least as likely as not (50 percent probability or greater) that any shoulder disability is proximately due to any of the Veteran’s service-connected disabilities, to include the low back disability? Explain why or why not. d. Is it at least as likely as not (50 percent probability or greater) that any shoulder disability is aggravated by any of the Veteran’s service-connected disabilities, to include the low back disability? Explain why or why not. 3. After the above development has been completed, review all evidence received since the May 2020 supplemental statement of the case and readjudicate the Veteran’s remaining claims on appeal as appropriate. If any claim on appeal remains denied, the Veteran and his representative should be furnished a supplemental statement of the case and be afforded the opportunity to respond. Thereafter, the case should be returned to the Board for appellate review, if in order. S. HENEKS Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board J. Cheng, 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.