Citation Nr: 21032475
Decision Date: 05/27/21	Archive Date: 05/27/21

DOCKET NO. 14-26 204
DATE: May 27, 2021

REMANDED

A rating in excess of 20 percent for degeneration of the lumbar spine with spondylolisthesis.

Service connection for a left ankle disorder.

REASONS FOR REMAND

The Board remanded the issues in June 2018 and subsequently denied them in November 2019. The Veteran appealed to the Veterans Claims Court. In December 2020, the Court Clerk granted a joint motion for remand (JMR) and returned the case to the Board for further appellate action.

Based on the JMR, a remanded in needed in order to seek clarification of a March 2019 private medical opinion.  Further, estimated loss of range of motion during flare-ups is needed, including (per the JMR), a retrospective opinion as to range of motion determinations. Next, the JMR directed that a new opinion regarding the etiology of a claimed left ankle disorder was needed in order to reconcile a June 2019 VA examination finding no degenerative changes and a February 2014 VA X-ray report showing the degenerative changes with the left ankle.

In addition, the JMR found it was necessary to address whether a challenge to the competency of those that examined the Veteran was raised by the record. This will be addressed when the case returns from remand. 

The matters are REMANDED for the following actions:

1.  Seek clarification from the March 26, 2018, private clinician regarding the symptoms of a lumbar spine disability.  All attempts to obtain authorization for or the records themselves must be documented in the claims file.

2.  Refer the claims file to a clinician for the following retrospective opinions:

	Determine the loss of range of motion during flareups of the Veteran's lumbar spine disability as described and at the time of his January 2012 VA examination.

	Determine the loss of range of motion during flareups of the Veteran's lumbar spine disability as described and at the time of his February 2016 VA examination.

	Determine the loss of range of motion with repeated use over time of the Veteran's lumbar spine disability as described and at the time of his June 2019 VA examination.

If the clinician is unable to make any of these three determinations, they must explain whether the inability to portray the additional loss was due to their personal limitations, or the medical community at large.

3.  Refer the claims file to a clinician to determine the etiology of the Veteran's claimed left ankle disorder.  The clinician is asked to address the following:

	Does the Veteran have a current chronic left ankle disorder, and if so is it at least as likely as not (50 percent or more probability) that the current chronic disability was due to active duty?

The clinician is asked to specifically address the February 22, 2014 VA X-ray evidence showing degenerative changes in the Veteran's left ankle, and his lay statements regarding left ankle symptoms following separation from service.  

4. If the clinician determines that an examination is necessary in order to provide the requested opinions, then one should be scheduled.

 

 

L. HOWELL

Veterans Law Judge

Board of Veterans' Appeals

Attorney for the Board	Brendan A. Evans, 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.