Citation Nr: 21027896 Decision Date: 05/07/21 Archive Date: 05/07/21 DOCKET NO. 15-15 320 DATE: May 7, 2021 REMANDED Initial evaluation for osteoarthritis, right hip, affecting ability to cross legs, in excess of 10 percent prior to May 1, 2017, and in excess of 20 percent from that date, is remanded. Initial compensable evaluation for osteoarthritis, right hip, affecting flexion, is remanded. Initial compensable evaluation for osteoarthritis, right hip, affecting extension, prior to May 1, 2017, and in excess of 10 percent from that date, is remanded. REASONS FOR REMAND The Veteran served on active duty from August 1958 to November 1982. The Board thanks the Veteran for his service to our country. A January 2019 Board decision, in part, denied the issues on appeal, then characterized as ratings in excess of those assigned for a right hip disability. The Veteran, in part, appealed the decision to the United States Court of Appeals for Veterans Claims (Court). In an Order dated in August 2020, the Court granted Joint Motion for Remand (JMR) of the parties (the Secretary of VA and the Veteran), and vacated the Board's decision, including with respect to the ratings assigned for the Veteran's right hip disability, and remanded the case to the Board for re-adjudication consistent with the JMR. In February 2020, the Board, in pertinent part, remanded the above listed issues, again characterized as ratings in excess of those assigned for a right hip disability, for additional development. They now return for appellate review. 1. Initial evaluation for osteoarthritis, right hip, affecting ability to cross legs, in excess of 10 percent prior to May 1, 2017, and in excess of 20 percent from that date, is remanded. 2. Initial compensable evaluation for osteoarthritis, right hip, affecting flexion, is remanded. 3. Initial compensable evaluation for osteoarthritis, right hip, affecting extension, prior to May 1, 2017, and in excess of 10 percent from that date, is remanded. The Board remands these issues for clarification of contradictory findings in the report of a January 2021 VA Hip and Thigh examination. The January 2021 report provides that on examination of passive range of motion, the Veteran exhibited pain on flexion, adduction and internal rotation. At the same time, the report subsequently provides the contradictory statement that there was no pain in passive adduction, and as a result the examiner did not respond whether the Veteran's previously noted pain was in weight-bearing, nonweight-bearing, active motion, passive motion, on rest/non-movement, caused functional loss or did not result in/cause functional loss. On remand, the Agency of Original Jurisdiction (AOJ) should obtain clarification from the January 2021 VA examiner as to these contradictory findings. If, and only if, clarification of these contradictory findings is not possible at this date, VA should provide the Veteran another VA examination to obtain consistent medical findings and opinions. In addition, the Board observes that the report of a June 2017 VA Hip and Thigh examination states that the Veteran's doctor ordered physical therapy for the Veteran's right thigh, and the Veteran underwent his first session the day before. A review of the Veteran's eFolder reveals that his treatment of the right thigh is from a private physician. However, the corresponding treatment records are dated only through May 3, 2017, and do not refer to physical therapy. On remand, the AOJ should provide the Veteran the opportunity to identify any outstanding relevant private treatment records dated after May 3, 2017, along with authorization to allow VA to request those records. Such records would be especially relevant in light of the fact that the Medical History section of the January 2021 VA examination report does not describe the Veteran's right thigh medical treatment over the prior few years. Additionally, the Board observes that the most recent VA outpatient treatment records are dated in August 2014, and was printed in May 2017. Since the claims are being remanded for other matters, the AOJ should update the eFolder to include any outstanding VA treatment records. The matters are REMANDED for the following actions: 1. Please obtain and associate with the Veteran's eFolder copies of all outstanding VA treatment records. 2. Please ask the Veteran to complete a VA Form 21-4142 for any private treatment of the right hip since May 3, 2017, to include physical therapy. Please make two requests for the authorized records from unless it is clear after the first request that a second request would be futile. 3. Please obtain an addendum opinion from the January 2021 VA examiner or an appropriate clinician clarifying the contradictory findings in the January 2021 VA examination regarding whether the Veteran exhibited pain on passive adduction. If the clinician clarifies that the Veteran did exhibit pain in passive adduction, the clinician should then indicate whether the pain was in weight-bearing, nonweight-bearing, active motion, passive motion, on rest/non-movement, caused functional loss or did not result in/cause functional loss. If, and only if, clarification of the contradictory January 2021 findings is not possible at this date, please provide the Veteran a VA examination (or telehealth interview, review of the record, etc., if an in-person examination is not feasible) to obtain consistent medical findings and opinions. 4. Please conduct any additional development indicated as a result of the additional materials received on remand, then readjudicate the issues on appeal. If any benefit sought is not granted, furnish the Veteran and his representative with a supplemental statement of the case and afford them an opportunity to respond before the record is returned to the Board. M. ESPINOZA Acting Veterans Law Judge Board of Veterans' Appeals Attorney for the Board J. Davitian, 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.