Citation Nr: 21025439 Decision Date: 04/28/21 Archive Date: 04/28/21 DOCKET NO. 16-19 774A DATE: April 28, 2021 REMANDED Entitlement to a disability rating in excess of 20 percent for service-connected right shoulder degenerative joint disease is remanded. Entitlement to a total disability rating based on individual unemployability due to service-connected disabilities (TDIU) is remanded. REASONS FOR REMAND The Veteran served on active duty from October 1964 to October 1968. 1. Entitlement to a disability rating in excess of 20 percent for service-connected right shoulder degenerative joint disease is remanded. While the record contains a January 2021 VA examination regarding the Veteran’s service-connected right shoulder degenerative joint disease, the examination does not comply with the requirements in Sharp v. Shulkin, 29 Vet. App. 26, 34-36 (2017). Notably, the examiner did not attempt to elicit relevant information regarding the description of the Veteran’s flare-ups and any additional functional loss suffered during flare-ups. The Board cannot make its own, independent medical judgment. See Colvin v. Derwinski, 1 Vet. App. 171, 175 (1991). It is therefore incumbent upon the Board to return, as inadequate for evaluation purposes, an evaluation report that lacks sufficient detail or requires clarification. 38 C.F.R. §§ 4.2, 19.9(a). Here, where the examiner determined that the examination was not being conducted during a flare-up, and that the Veteran’s flare-ups do limit functional ability, it is not clear why the estimated loss of motion during a flare-up is exactly the same as the actual loss of range of motion when measured at a time of non-flare-up. The examiner noted that flare-ups render the Veteran’s shoulder “unable to perform certain movements … due to pain and tightness.” It is not clear which movements are prohibited during the Veteran’s flare-ups. Without further clarification, the examiner’s range of motion estimation during flare-ups is inadequate. 2. Entitlement to a TDIU is remanded. The Veteran has the following disabilities that are service connected: right shoulder degenerative joint disease rated 20 percent from September 1986; and right little toe fracture and right shoulder scar, each rated noncompensable from September 1986. The Veteran does not meet the percentage standards set forth in § 4.16 (a). The Board may not consider his claim for a TDIU in the first instance but will refer it to the Director, Compensation Service, because there is a reasonable possibility that he is unemployable by reason of service-connected disabilities. 38 C.F.R. § 4.16 (b). In the January 2016 DRO hearing testimony, January 2016 TDIU application, and April 2021 informal hearing presentation, the Veteran and his representative indicated that he cannot work due to symptomatology associated with service-connected disabilities. Remand is required for referral of the claim to the Director, Compensation Service, for extraschedular consideration. The matters are REMANDED for the following action: 1. Schedule the Veteran for an examination by an appropriate clinician to determine the current severity of his service-connected right shoulder disability. 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 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). 2. Refer the Veteran’s claim for TDIU to VA’s Director of Compensation Service for extraschedular consideration. J. Komperda Acting Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board P.S. McLeod 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.