Citation Nr: 21026020 Decision Date: 04/29/21 Archive Date: 04/29/21 DOCKET NO. 16-31 332 DATE: April 29, 2021 REMANDED Entitlement to a disability rating in excess of 70 percent for service-connected major depressive disorder is remanded. Entitlement to a disability rating in excess of 30 percent for service-connected benign paroxysmal positional vertigo is remanded. Entitlement to a disability rating in excess of 20 percent prior to March 24, 2016, and in excess of 40 percent thereafter, for service-connected lumbar spine disability is remanded. Entitlement to a compensable disability rating for service-connected loss of teeth is remanded. REASONS FOR REMAND The Veteran served on active duty from September 1971 to July 1974. The issues on appeal are remanded to afford the Veteran procedural due process. Following the April 2016 statement of the case (SOC), additional evidence was added to the claims file, including VA treatment records. In February 2021, the Board sent a letter to the Veteran and his representative inquiring as to whether the Veteran was willing to waive agency of original jurisdiction (AOJ) consideration of the evidence in the first instance allowing the Board to proceed in adjudicating the issues on appeal, or whether he wished to have the issues remanded back to the AOJ. In March 2021 correspondence, the Veteran specifically requested that his case be sent back to the AOJ for review of the additional evidence that was submitted. Therefore, remand is required for AOJ review and issuance of a supplemental statement of the case (SSOC) that takes into consideration all evidence of record added to the claims file since the last adjudication in April 2016. A May 2019 VA treatment record notes the Veteran’s report of worsening pain in the lower back and radiating into both lower extremities. Since the Veteran’s most recent examination occurred in March 2016, the Veteran should be provided an opportunity to report for a VA examination to ascertain the current severity and manifestations of his lumbar spine disability. Finally, while on remand, the AOJ should obtain any new VA treatment records that have not already been associated with the claims file. The matters are REMANDED for the following action: 1. Obtain the Veteran’s VA treatment records for the period from June 2019 to the Present. 2. Thereafter, the Veteran should be scheduled for an appropriate VA examination by a competent medical professional to determine the current nature and severity of his service-connected lumbar spine disability. The entire record must be made available to and be reviewed by the examiner. The examiner should take a history from the Veteran as to the progression of his service-connected lumbar spine disability, to include any neurological manifestations in his lower extremities. Any indicated evaluations, studies, and tests should be conducted. The examiner must address each of the following inquiries: a) The examiner should describe all pertinent orthopedic and neurologic symptoms associated with the Veteran’s service-connected lumbar spine disability. In this regard, the Veteran’s VA treatment records reflect a diagnosis of lumbar radiculopathy. The examiner should also ask the Veteran to provide a history as to the nature and severity of his service-connected lumbar spine disability. b) If radiculopathy identified, the examiner should indicate whether there is complete or incomplete paralysis of the affected nerve(s) and, if so, the examiner should describe the severity of the impairment as mild, moderate, moderately severe, or severe with marked muscular atrophy. All examination findings/testing results, along with a complete, clearly-stated rationale for any opinion offered, must be provided. 3. After the above development, and any additionally indicated development, has been completed, readjudicate the issues on appeal. James Springer Acting Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board L. Bristow Williams, 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.