Citation Nr: 21025442 Decision Date: 04/28/21 Archive Date: 04/28/21 DOCKET NO. 14-32 468 DATE: April 28, 2021 REMANDED An initial rating in excess of 20 percent for cervical spine strain with degenerative disc disease (DDD).   REASONS FOR REMAND The Veteran served on active duty from March 1991 to April 2011. The case is on appeal from a June 2012 rating decision. Procedurally, in a May 2018 decision, the Board granted an increased initial cervical spine rating to 20 percent and denied a rating in excess of 20 percent. The Veteran appealed the decision to the United States Court of Appeals for Veterans Claims (Court). In an August 2019 Order, the Court granted a July 2019 Joint Motion for Partial Remand (JMR) and vacated the May 2018 Board denial. The claim was then remanded by the Board in January 2020 and, most recently, in October 2020 for further development. An initial rating in excess of 20 percent for cervical spine strain with DDD. In the July 2019 JMR, the parties agreed that the July 2017 VA examination was not adequate, specifically with regard to the Veteran’s reported flare-ups. During the examination, the Veteran reported flare-ups of the neck described as muscle cramping and muscles “not working.” He further stated his flare-ups cause “limits to movement.” The examiner noted the examination was not conducted during a flare-up, but that pain significantly limited functional ability during flare-ups. The parties to the July 2019 JMR found the opinion was inadequate because the examiner did not provide an estimate as to the loss of range of motion due to pain during flare-ups. Following the October 2020 Board remand, the Veteran was afforded a January 2021 VA examination in which the Veteran did not report flare-ups of the cervical spine. However, he did indicate he gets “generally a bit stiff and particularly motions to the left side are difficult.” The examiner noted the examination was not conducted during a flare-up and procured evidence does not suggest pain significantly limits functional ability with flare-ups. Additional testing revealed forward flexion of the cervical spine limited to 25 degrees with pain on left lateral flexion and rotation. The examiner reported the Veteran has pain with weight-bearing and no pain in nonweight-bearing. He indicated passive range of motion could not be performed, as it was not medically advisable to conduct because it may cause the Veteran severe pain. Further, ankylosis was not found. Initially, the Board finds the January 2021 VA examiner’s opinion fully satisfied the standard set forth in Correia v. McDonald, 28 Vet. App. 158 (2016) to test the joint for pain on both active and passive motion, and in weight-bearing and nonweight-bearing. However, an addendum opinion is needed from the January 2021 VA examiner with regard to potential additional functional loss during the reported flare-ups of the Veteran’s cervical spine. Moreover, an examination that fails to attempt to ascertain adequate information from relevant sources regarding frequency, duration, characteristics, severity, or functional loss during flare-ups will be considered inadequate. See Sharp v. Shulkin, 29 Vet. App. 26 (2017). Although flare-ups were not reported by the Veteran during the January 2021 VA examination, flare-ups were reported in the record previously, including during the July 2017 VA examination and the September 2017 representative’s statement. Additionally, as noted, in the July 2019 JMR the parties indicated the examiner must provide an estimate as to the loss of range of motion of the cervical spine due to pain during flare-ups, and such was not adequately provided in the January 2021 VA opinion. Thus, an addendum opinion is required to adequately address the Veteran’s flare-ups. The matters are REMANDED for the following action: Forward the claims file to the VA examiner who conducted the January 2021 VA examination to obtain an addendum opinion to address the severity of the Veteran’s cervical spine disorder. If this examiner is no longer available, forward the claims file to an appropriate medical profession for an addendum opinion. It is left to the examiner’s discretion whether to schedule the Veteran for an examination. The examiner should provide an opinion which estimates the functional loss that would occur during the Veteran’s flare-ups. The examiner should provide an estimate as to the loss of range of motion of the cervical spine that occurs due to pain during flare-ups. The examiner should address the flare-ups reported by the Veteran in the record, including during the July 2017 VA examination and September 2017 representative’s statement. The examiner should also ascertain adequate information from any relevant sources to provide the requested opinion. RYAN T. KESSEL Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board B. Isaacs, 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.