Citation Nr: 21029141 Decision Date: 05/12/21 Archive Date: 05/12/21 DOCKET NO. 13-33 743A DATE: May 12, 2021 REMANDED Entitlement to a rating in excess of 10 percent for low back strain with degenerative changes is remanded. REASONS FOR REMAND The Veteran served on active duty from February 1990 to February 1999, October 2001 to October 2002, and November 2009 to July 2012. He served honorably in the U.S. Air Force. The Board thanks the Veteran for his service to our country. The Veteran testified before the undersigned at a Board videoconference hearing in October 2015. A transcript of the hearing is of record. The Board previously remanded this case in April 2016 and April 2020 for additional development. The case has now returned to the Board for further appellate review. Entitlement to a rating in excess of 10 percent for low back strain with degenerative changes is remanded. A remand is warranted to ensure substantial compliance with the April 2020 Board decision. The Board errs when it fails to ensure substantial compliance with a Board remand. Stegall v. West, 11 Vet. App. 268, 271 (1998). In the April 2020 remand, the Board directed the clinician to indicate what the severity of the back disability might be when discounting the ameliorative effects of medication. However, in the September 2020 addendum opinion the clinician did not address the ameliorative effects of medication as the restatement of the requested opinion was incomplete. (The Board notes that a subsequent VA examination was canceled as the Veteran failed to RSVP, but observes that the request for physical examination did not instruct the examiner to indicate what the severity of the back disability might be when discounting the ameliorative effects of medication.) Accordingly, a remand is necessary. The Board further notes that federal medical records obtained pursuant to the April 2020 Board remand indicate that the Veteran's disability may have worsened since the June 2016 VA examination. Specifically, the Board notes an October 2018 note in which the provider rendered an assessment of lumbar radiculopathy and another October 2018 note indicating that there may be decreased range of motion. Accordingly, an examination should be scheduled for the Veteran as well. The Veteran is advised to confirm with VA his current contact information, including his phone number and address. The matters are REMANDED for the following action: 1. Please secure for the record (the Veteran's electronic benefits file) copies of complete updated clinical records (any not already of record) of all VA and non-VA treatment the Veteran has received for the disability on appeal. Please ask the Veteran to provide the releases necessary for VA to secure private treatment records. 2. After the action requested in paragraph 1 is complete, please schedule the Veteran for an examination and a medical opinion to assess the current severity of the low back disability. The Veteran's claims-file must be made available to and reviewed by the clinician. Any indicated tests or studies should be conducted. The examiner is specifically requested to provide an opinion as to the severity of the back disability when discounting the ameliorative effects of medication. The examiner must explain the rationale for all opinions and conclusions in detail, citing to supporting clinical data and/or medical literature, as appropriate. The examiner should take into consideration that the Veteran is competent to report post-service symptom experiences; other witnesses are competent to report observable symptoms. If the examiner cannot provide an opinion without resorting to speculation, the examiner should provide an explanation as to why this is so and note what, if any, additional evidence would permit such an opinion to be made. M. C. GRAHAM Veterans Law Judge Board of Veterans' Appeals Attorney for the Board M. Vashaw, Associate 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.