Citation Nr: 21030527 Decision Date: 05/19/21 Archive Date: 05/19/21 DOCKET NO. 14-24 724 DATE: May 19, 2021 REMANDED Entitlement to an initial disability rating in excess of 10 percent for carpal tunnel of the right, dominant hand, is remanded. REASONS FOR REMAND The Veteran served on active duty from December 2002 to December 2007. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a rating decision issued in March 2014 by the Department of Veterans Affairs (VA) Regional Office (RO) in San Diego, California. In April 2014, the Veteran submitted a notice of disagreement (NOD) and in June 2014, the RO issued a statement of the case (SOC). In July 2014, the Veteran filed his substantive appeal. In an August 2018 decision, the Board denied entitlement to a higher disability rating. Thereafter, the Veteran appealed to the United States Court of Appeals for Veterans Claims (Court). In a May 2020 Joint Motion for Remand (JMR), the Secretary of VA and the Veteran (the parties) moved the Court to vacate the August 2018 decision as to the issue on appeal. The Court granted the JMR in a May 2020 order and the matter is again before the Board for adjudication. 1. Entitlement to an initial disability rating in excess of 10 percent for carpal tunnel of the right, dominant hand. The Veteran is seeking a higher disability rating for his carpel tunnel syndrome. Specifically, he contends that his disability is more severe than reflected by his currently assigned rating. VA has a duty, when appropriate, to conduct a thorough and contemporaneous examination of the Veteran that takes into account records of prior examinations and treatment. See Green v. Derwinski, 1 Vet. App. 121 (1991). A review of the claims file reveals that the Veteran was afforded a VA examination to evaluate his carpel tunnel syndrome in January 2015, over six years ago. As such, the Board finds that a current examination is necessary. See Caffrey v. Brown, 6 Vet. App. 377, 381 (1995) (VA was required to afford a contemporaneous medical examination where examination report was approximately two years old). In addition, the most recent treatment records associated with the claims file are VA treatment records from June 2013 and private treatment records from August 2013. Furthermore, lay assertions from a July 2014 VA Form 9, have been associated with the record (on April 5, 2021). Accordingly, a remand for additional development is warranted. The matters are REMANDED for the following action: 1. The AOJ should obtain all outstanding VA treatment records and any private treatment records identified by the Veteran. All obtained records should be associated with the evidentiary record. 2. After all outstanding treatment records have been associated with the claims file, schedule the Veteran for an appropriate VA examination to determine the nature and severity of his right-hand carpel tunnel syndrome. The record, to include a copy of this Remand, must be made available to and be reviewed by the examiner, and the examination report should note that review. All testing deemed necessary to rate the disability under the criteria of the VA rating schedule must be conducted and the results reported in detail. 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. 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. In doing so, the examiner should review the Veteran's lay assertions in his July 2014 VA Form 9, associated with the claims file in April 2021. See May 2020 JMR. To the extent possible, the examiner should identify any symptoms and functional impairments due to carpal tunnel syndrome alone and discuss the effect of the Veteran's disability on any occupational functioning and activities of daily living. The examination report must include a complete rationale for all opinions expressed. If it is not possible to provide a specific measurement, or an opinion regarding flare-ups, symptoms, or functional impairment 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). 3. After completing the above, and any other development as may be indicated by any response received as a consequence of the actions taken in the preceding paragraphs, the Veteran's claim should be readjudicated based on the entirety of the evidence. If the benefit sought remains denied, furnish the Veteran a supplemental statement of the case (SSOC) and return the case to the Board. KRISTI L. GUNN Veterans Law Judge Board of Veterans' Appeals Attorney for the Board M. Kaufer, 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.