Citation Nr: 21020731 Decision Date: 04/08/21 Archive Date: 04/08/21 DOCKET NO. 18-01 518 DATE: April 8, 2021 REMANDED The issue of entitlement to a disability rating in excess of 20 percent for lumbosacral strain is remanded. REASONS FOR REMAND The Veteran served on active duty in the Army from September 1990 to June 1994. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from an August 2017 rating decision by a Department of Veterans Affairs (VA) Regional Office (RO). In September 2020 the Veteran testified at a hearing before the undersigned Veterans Law Judge (VLJ) and the transcript is of record. VA has a duty to provide a contemporaneous examination when the evidence indicates that the current rating may be incorrect, including when a Veteran alleges that his condition has worsened since the last VA examination. Snuffer v. Gober, 10 Vet. App. 400 (1997). Here, the Veteran alleged that his lower back pain has worsened since 2017. Therefore, remand is necessary to provide him with a VA examination to assess the current state of his disability. Additionally, private treatment records are outstanding. During the September 2020 Board hearing the Veteran indicated that he obtained an MRI for his back disability from a private physician. Private treatment records have not been associated with the claims file. Because the records have not been requested, and because VA is on notice that additional records pertinent to the Veteran’s claim exist, those records should be requested. The matter is REMANDED for the following action: 1. Obtain the necessary authorization from the Veteran. Then, obtain private medical records dated from August 2017 and associate with the claims file. All attempts to secure these records must be documented in the claims folder. 2. Then, schedule the Veteran for an examination by an appropriate clinician to determine the current severity of his service-connected lumbosacral strain. The examiner should provide a full description of the disability and report 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. 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). The examiner must also attempt to elicit information regarding the severity, frequency, and duration of any flare-ups, and the degree of functional loss during flare-ups, throughout the entirety of the appeal period – that is, since May 2017. If it is not possible to provide a specific measurement based on direct observation, the examiner should provide an estimate, if 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). If the inability to provide an opinion without resorting to speculation is due to a deficiency in the record (additional facts are required), the AOJ should develop the claim to the extent it is necessary to cure any such deficiency. If the inability to provide an opinion is due to the examiner's lack of requisite knowledge or training, then the AOJ should obtain an opinion from a medical professional who has the knowledge and training needed to render such an opinion. S.C. Krembs Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Z. Sloley, 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.