Citation Nr: 21020955
Decision Date: 04/08/21	Archive Date: 04/08/21

DOCKET NO. 20-27 847
DATE: April 8, 2021

REMANDED

Entitlement to an increased evaluation in excess of 10 percent for degenerative arthritis of the lumbar spine is remanded.

REASONS FOR REMAND

The Veteran had active duty service from August 1976, to September 1993.  

Entitlement to an increased evaluation in excess of 10 percent for degenerative arthritis of the lumbar spine is remanded.

Review of the record reveals that the Veteran was assigned a 10 percent evaluation for degenerative arthritis of the lumbar spine.  The Veteran contends that the severity of his lumbar spine disorder has increased, and an evaluation in excess of 10 percent is warranted. The Veteran also reports that he underwent major back surgery in May 2020. These records need to be collected and evaluated by the regional office (RO).  Records of treatment leading up to the surgery need to be collected and reviewed.  In view of these findings, and the fact that the Veteran’s last VA back conditions examination occurred some time ago, the Board concludes that a current VA examination to assess the current severity of the Veteran’s service connected degenerative disorder of the lumbar spine is necessary.

The matters are REMANDED for the following action:

1. As necessary, ask the Veteran to identify, and provide appropriate releases for, any care providers who may possess new or additional evidence pertinent to the issue on appeal.  Any new or additional (i.e., non-duplicative) evidence received should be associated with the record.  If any of the records sought are not available, the record should be annotated to reflect that fact, and the Veteran and is representative should be notified.  All attempts to obtain records should be documented in the claims file. An effort should be made to collect any records associated with the Veteran’s reported May 2020 major back surgery and any treatments before and after the surgery thereafter.  These records may provide information on the condition of the back during a portion of the appeal period.

2. After the foregoing development has been completed to the extent possible, but whether or not the aforementioned records are obtained, schedule the Veteran for a VA back examination. The examiner should review the record.  All indicated tests should be conducted and the results reported.

After examining the Veteran and reviewing the record, together with the results of any testing deemed necessary, the examiner must provide a full description of all symptoms and manifestations associated with the Veteran’s lumbar spine. Functional or occupational impairments should be set out.

Please provide a complete rationale for all opinions entered.

If the examiner cannot provide any of the requested opinions, he/she must affirm that all procurable and assembled data was fully considered, and a detailed rationale must be provided for why an opinion cannot be rendered.

3. The AOJ must ensure that the examiner’s reports comply with this remand and answers the questions presented in the request.  The AOJ must also ensure that the examiner documents consideration of the electronic claims file, including any records contained in Virtual VA and VBMS.  If the report is insufficient, the AOJ must return it to the examiner for necessary corrective action as appropriate.

 

 

MICHAEL D. LYON

Veterans Law Judge

Board of Veterans’ Appeals

Attorney for the Board	M. Elliot Harris

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.