Citation Nr: 21014066 Decision Date: 03/11/21 Archive Date: 03/11/21 DOCKET NO. 15-28 275 DATE: March 11, 2021 REMANDED Entitlement to a disability rating in excess of 30 percent for left (minor) shoulder strain, chronic, with degenerative changes, for the period from March 28, 2012 (excluding periods when temporary total evaluations are assigned) is remanded. Entitlement to a total disability rating based upon individual unemployability due to service-connected disabilities (TDIU) is remanded. REASONS FOR REMAND The Veteran served on active duty from June 1974 to June 1977. This appeal comes to the Board of Veterans’ Appeals (Board) from an October 2013 rating decision by a Department of Veterans Affairs (VA) Regional Office (RO). The Board remanded these matters in November 2018 and November 2020 for additional evidentiary development including obtaining outstanding relevant treatment records, affording the Veteran current and adequate VA examinations of his left shoulder disability, and referring these matters to the Director of Compensation Service for extraschedular consideration. In a January 2021 Statement in Support of Claim, the Veteran indicated that the severity of his left shoulder disability has worsened since his last VA examination and that there are outstanding relevant records from Fayetteville VA Medical Center and Fayetteville Orthopaedics. On remand, the Agency of Original Jurisdiction (AOJ) should obtain all outstanding relevant records and afford the Veteran a VA examination of the severity of his left shoulder disability under both the rating criteria in effect prior to February 7, 2021 as well as the revised rating criteria effective February 7, 2021 where applicable. See Schedule for Rating Disabilities: Musculoskeletal System and Muscle Injuries, 85 Fed. Reg. 76453 (Nov. 30, 2020) (to be codified at 38 C.F.R. § 4.71a). Thereafter, the AOJ should refer the matters to the Director of Compensation service for extraschedular consideration. The matters are REMANDED for the following action: 1. The AOJ should contact the Veteran and all current representatives and request their assistance in identifying any outstanding relevant records including additional records from the Fayetteville VA Medical Center and Fayetteville Orthopaedics. The AOJ should make reasonable attempts to obtain all identified outstanding records and associate them with the Veteran’s claims file. 2. After associating all outstanding identified relevant records with the Veteran’s claims file, the AOJ should schedule the Veteran for an examination by an appropriate clinician to determine the current severity of his service-connected left shoulder disability under both the rating criteria in effect prior to February 7, 2021 as well as the revised rating criteria effective February 7, 2021 where applicable. See Schedule for Rating Disabilities: Musculoskeletal System and Muscle Injuries, 85 Fed. Reg. 76453 (Nov. 30, 2020) (to be codified at 38 C.F.R. § 4.71a). The AOJ should ensure that the examiner provides a full description of the disability and reports all signs and symptoms necessary for evaluating the Veteran’s disability under the rating criteria. In so doing, the examiner must test the Veteran’s active motion, passive motion, and pain with weight-bearing and without weight-bearing. The examiner must attempt to elicit information regarding the severity, frequency, and duration of any flare-ups, and the degree of functional loss during flare-ups. If it is not possible to provide a specific measurement based on direct observation, the examiner should provide an estimate, if at all possible, of the additional impairment due to flare-ups based on the other evidence of record and the Veteran’s statements. If it is not possible to provide a specific measurement 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). 3. After completing the necessary evidentiary development, the AOJ should refer the Veteran’s claim for an increased rating for his service-connected left shoulder disability to the Director of Compensation Service for consideration of extraschedular ratings. The Director should determine if the Veteran’s left shoulder disability, rated as 30 percent disabling (except for periods when temporary total evaluations were assigned), warrants the assignment of an extraschedular rating at any point during the period of appeal. Simultaneously, the AOJ should refer the Veteran’s claim for entitlement to TDIU to the Director of Compensation Service for consideration of whether TDIU on an extraschedular basis is warranted. The AOJ should include a copy of this remand as well as a full statement as to the Veteran’s service-connected disabilities, employment history, educational and vocational attainment, and all other factors having a bearing on the issue. See 38 C.F.R. § 4.16(b). A. C. MACKENZIE Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Michael Duffy, 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.