Citation Nr: 21025326 Decision Date: 04/27/21 Archive Date: 04/27/21 DOCKET NO. 15-18 560A DATE: April 27, 2021 REMANDED Entitlement to an evaluation in excess of 10 percent for service-connected status post lumbar fusion, low back pain with thoracolumbar spine degenerative disc disease (back disability) is remanded. REASONS FOR REMAND The Veteran served on active duty in the United States Marine Corps from July 1995 to November 2005. He was awarded the Combat Action Ribbon and Navy and Marine Corps Achievement Medal, among other decorations, for this service. This matter comes before the Board of Veterans' Appeals (Board) on appeal from an October 2012 rating decision of the St. Petersburg, Florida, Regional Office (RO). In November 2018, the Veteran testified before the undersigned Veterans Law Judge (VLJ). A copy of the transcript has been associated with the electronic claims file. In April 2019, the Board remanded the claim to the Agency of Original Jurisdiction (AOJ) for further development. For the reasons discussed below, the Board finds that there has not been substantial compliance with the development sought as part of the April 2019 remand. Stegall v. West, 11 Vet. App. 268 (1998). Finally, the Board notes recent correspondence to the Veteran’s representative has been returned as undeliverable, however, there is no indication of a change of address found in the record. Because the Board is remanding the claim for additional development, it finds no prejudice to the Veteran in doing so and the period of additional development will allow the Veteran and his counsel to update any necessary records. 1. Back Disability. On remand, the Veteran underwent a January 2020 VA examination. When VA undertakes to provide a medical examination, it must ensure that the examination and opinions therein are adequate. Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). Here, a remand is necessary to ensure an adequate record with which the Board can make a decision. Specifically, the lay and medical evidence indicates that the Veteran’s service-connected back disability may be more severe than is reflected in the January 2020 examination, including decreased range of motion and neurologic manifestations which were not discussed by the VA examiner. The matters are REMANDED for the following action: 1. Contact the Veteran and his representative and ask them to provide sufficient information and necessary authorization in order to obtain copies of any outstanding records of treatment by non-VA health care providers including any inpatient treatment for the claims on appeal. The letter should invite the Veteran and his representative to submit any pertinent medical evidence in support of his claim. If the Veteran or his representative provides the necessary information and authorizations, obtain any outstanding clinical records and incorporate them into the electronic claims file. 2. Associate any outstanding VA treatment records with the electronic claims file. 3. Schedule the Veteran for a VA orthopedic examination to determine the current severity of his back disability. The entire claims file, including any newly obtained treatment records, must be reviewed by the examiner and all necessary tests should be conducted. The VA examiner must comment on any neurologic and/or bowel and bladder symptoms secondary to the service-connected back disability. The VA examiner is also asked to comment on: 1. The Veteran’s acupuncture treatment records showing radiating pain into the legs. 2. The Veteran’s lay reports of radiating pain in the legs. 3. Notations in VA treatment records indicating potential lumbar radiculopathy. H. SEESEL Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board C. Teague, 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.