Citation Nr: 21022849 Decision Date: 04/19/21 Archive Date: 04/19/21 DOCKET NO. 13-00 470A DATE: April 19, 2021 REMANDED Entitlement to an evaluation in excess of 20 percent for status post left shoulder injury with subluxation (left shoulder disorder) (excluding a temporary total disability evaluation from July 17, 2018, to October 31, 2018) is remanded. Entitlement to an initial evaluation in excess of 30 percent for gastroparesis with gastroesophageal reflux disorder (GERD) and hiatal hernia is remanded. REASONS FOR REMAND The Veteran had active duty service from October 1994 to March 1997 and April 2005 to December 2006. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from an August 2010 rating decision from the Department of Veterans Affairs (VA) Regional Office (RO). The Board remanded the Veteran’s claims in December 2016. The December 2016 decision also included remands for claims for entitlement to a temporary total disability rating under 38 C.F.R. § 4.30 for treatment of a hernia, entitlement to service connection for a psychiatric disorder, and entitlement to a total disability rating based upon individual unemployability based on service-connected disabilities (TDIU). In a September 2018 rating decision, the RO subsequently assigned the Veteran’s left shoulder disorder a 100 percent evaluation from July 17, 2018, to October 31, 2018, based on surgical or other treatment necessitating convalescence. In a December 2019 decision, the Board then, in pertinent part, denied the issues of entitlement to an initial evaluation in excess of 30 percent for gastroparesis with GERD and an evaluation in excess of 20 percent for a left shoulder disorder. The Veteran then appealed the December 2019 decision to the United States Court of Appeals for Veterans Claims (Court). In a November 2020 order, the Court vacated that portion of the December 2019 Board decision and granted a joint motion for partial remand for above listed claims. A letter was then sent to the Veteran and his representative in December 2020 in which they were given 90 days from the date of the letter or until the date of the Board’s new decision, whichever came first, to submit additional argument or evidence in support of the appeal prior to the Board’s readjudication. The Veteran elected to hold the case open for the remainder of the 90-day period in order to submit additional evidence and submitted additional evidence in support of the appeal. The 90-day period expired after March 7, 2021. The Board notes that the December 2019 Board decision also remanded claims for entitlement to a temporary total rating for convalescence based on bilateral inguinal hernia laparoscopic surgery on October 24, 2011, entitlement to an initial rating in excess of 30 percent for depressive disorder, and entitlement to TDIU. The Veteran has opted into the modernized review system under the Appeals Modernization Act (AMA) with respect to these issues, by submitting VA Forms 20-0996 in May 2020 and June 2020, following the issuance of a May 2020 supplemental statement of the case and an April 2020 statement of the case. As such, these issues will be the subject of a separate AMA decision by the Board, if otherwise in order. Review of the Veteran’s medical records show that the Veteran underwent a surgical procedure for his left shoulder disorder in July 2018. As above, he was awarded a temporary 100 percent evaluation from July 17, 2018, through October 31, 2018, for treatment necessitating convalescence for that procedure. The Board notes that the Veteran was most recently afforded a VA examination for his left shoulder in September 2018, which was during that convalescence period. A VA examination was not performed following this procedure and convalescence period, as such, a VA examination is required in order to determine the severity and manifestation of the shoulder following the July 2018 surgery. The Board also finds that a VA examination and opinion are required for the Veteran’s gastroparesis disorder claim. In that regard, the Board notes that the Veteran’s representative has stated that the disorder has caused hundreds for hospital visits and a 30 lb. weight loss. A VA medical record dated February 2015 also mentions a 30 lb. weight loss over a one year period. However, VA examinations dated March 2010, September 2011, May 2012, and March 2018 do not indicate the presence of weight loss and/or indicate no changes in weight. As such, there is some conflicting evidence of record regarding the Veteran’s symptoms and another VA examination and opinion is required. Accordingly, the case is REMANDED for the following action: 1. The agency of original jurisdiction (AOJ) should request that the Veteran provide the names and addresses of any and all health care providers who have provided treatment for his left shoulder disorder and gastroparesis with GERD. After acquiring this information and obtaining any necessary authorization, the AOJ should obtain and associate these records with the claims file. Any outstanding VA medical records should also be obtained and associated with the claims file. 2. After the foregoing development has been completed, the Veteran should be afforded a VA examination to ascertain the severity and manifestations of his service-connected left shoulder disability. Any and all studies, tests, and evaluations deemed necessary by the examiner should be performed. The examiner is requested to review all pertinent records associated with the claims file, including the Veteran’s post-service medical records and assertions. The examiner should report all signs and symptoms necessary for rating the Veteran’s service-connected left disorder. In particular, the examiner should provide the range of motion in degrees and test the Veteran’s range of motion in active motion, passive motion, weight-bearing, and nonweight-bearing for both the right and left shoulders. If the examiner is unable to conduct the required testing or concludes that the required testing is not necessary in this case, he or she should clearly explain so in the report. The examiner should also indicate whether there is any form of ankyloses or impairment of the humerus, such as malunion, recurrent dislocation at the scapulohumeral joint, fibrous union, nonunion (false flail joint), and loss of head (flail shoulder). He or she should also indicate whether there is any impairment of the clavicle or scapula, such as malunion, nonunion with or without loose motion, or dislocation. The presence of objective evidence of pain, excess fatigability, incoordination, and weakness should also be noted, as should any additional disability due to these factors (including any additional loss of motion). A clear rationale for all opinions would be helpful and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. Copies of all pertinent records in the appellant’s claims file, or in the alternative, the claims file, must be made to the examiner for review. 3. After completing directive #1, the Veteran should be afforded a VA examination to ascertain the current severity and manifestations of his service-connected gastroparesis with GERD and hiatal hernia. Any and all studies, tests, and evaluations deemed necessary by the examiner should be performed. The examiner is requested to review all pertinent records associated with the claims file, including the Veteran’s service treatment records, post-service medical records, and assertions. The examiner should report all signs and symptoms necessary for rating the disability. In particular, he or she should address whether there is persistently recurrent epigastric distress with dysphagia, pyrosis, and regurgitation, accompanied by substernal or arm or shoulder pain, productive of considerable impairment of health. The examiner should also indicate whether there are symptoms of pain, vomiting, material weight loss and hematemesis or melena with moderate anemia; or other symptoms combinations productive of severe impairment of health. The examiner is asked to specifically address the conflicting evidence of record regarding any possible weight loss from June 2009 to present and opine as to whether or not any possible weight loss is related to the Veteran’s service-connected disorder. A clear rationale for all opinions would be helpful, and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. Copies of all pertinent records in the Veteran’s claims file, or in the alternative, the claims file, must be made available to the examiner for review. 4. After completing these actions, the AOJ should conduct any other development as may be indicated by a response received as a consequence of the actions taken in the preceding paragraphs. Nathaniel Doan Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board B. Rideout-Davidson, 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.