Citation Nr: 21032672 Decision Date: 05/27/21 Archive Date: 05/27/21 DOCKET NO. 17-56 261A DATE: May 27, 2021 REMANDED Entitlement to an initial rating in excess of 30 percent for migraine headaches, as of May 17, 2018, is remanded. Entitlement to an initial rating in excess of 10 percent for migraine headaches, prior to May 17, 2018, is remanded. Entitlement to an initial rating in excess of 10 percent for a cervical spine disability, as of March 27, 2018, is remanded. Entitlement to an initial rating in excess of 20 percent for a cervical spine disability, as of August 5, 2016, to March 26, 2018, is remanded. Entitlement to an initial rating in excess of 10 percent for a cervical spine disability, prior to August 5, 2016, is remanded. Entitlement to an initial rating in excess of 10 percent for a low back disability is remanded. Entitlement to an initial rating in excess of 10 percent for a left knee disability is remanded. Entitlement to an initial rating in excess of 10 percent for a right ankle disability is remanded. REASONS FOR REMAND 1. Entitlement to an initial rating in excess of 30 percent for migraine headaches, as of May 17, 2018, is remanded. 2. Entitlement to an initial rating in excess of 10 percent for migraine headaches, prior to May 17, 2018, is remanded. 3. Entitlement to an initial rating in excess of 10 percent for a cervical spine disability, as of March 27, 2018, is remanded. 4. Entitlement to an initial rating in excess of 20 percent for a cervical spine disability, as of August 5, 2016, to March 26, 2018, is remanded. 5. Entitlement to an initial rating in excess of 10 percent for a cervical spine disability, prior to August 5, 2016, is remanded. 6. Entitlement to an initial rating in excess of 10 percent for a low back disability is remanded. 7. Entitlement to an initial rating in excess of 10 percent for a left knee disability is remanded. 8. Entitlement to an initial rating in excess of 10 percent for a right ankle disability is remanded. At a September 2020 Board hearing, the Veteran asserted that the disabilities on appeal had increased in severity since the most recent VA examination. The Veteran should be provided an opportunity to report for VA examinations to ascertain the current severities and manifestations of his disabilities. At the Septeember 2020 Board hearing, the Veteran identified relevant outstanding private treatment records, to particularly include records regarding chiropractic treatment. Remand is required to allow VA to obtain authorization and request these records. The VA treatment records currently in evidence contain notations indicating that a VA employee scanned medical records into a VA hospital's imaging system, but do not contain any copies of the scanned records. Any treatment records scanned into a VA hospital's imaging system are within VA's constructive possession and are considered potentially relevant to the issues on appeal. Remand is required to allow VA to obtain those records. The matters are REMANDED for the following action: 1. Obtain all outstanding VA treatment records. Specifically, obtain the most recent VA treatment records not included in the record of evidence and the records noted as having been scanned into the Vista imaging system by VA Medical Center personnel, as noted in the VA treatment records in evidence, dated February 9, 2015; and August 5, 2014. 2. Ask the Veteran to complete a VA Form 21-4142 for the treating chiropractor. Make two requests for the authorized records from the chiropractor's place of practice, unless it is clear after the first request that a second request would be futile. 3. Schedule the Veteran for a VA headaches examination by a qualified VA medical doctor examiner to determine the severity of the service-connected migraine headache disability without consideration of the ameliorating effects of any medication. The examiner must review the record and should note that review in the report. A rationale for all opinions should be provided. The examiner should: (a.) Report the number and frequency of characteristic prostrating attacks, if any, during all relevant periods and any associated economic inadaptability as a result of the headaches. (b.) Comment upon the frequency and severity of the headache disability without consideration of the ameliorating effects of any medication. (c.) In addition to the objective test results, the examiner must fully describe the functional effects caused by the Veteran's migraine headaches, including specifically, to what extent the migraine headaches decrease the Veteran's functioning in terms of performing daily activities as well as their impact on his occupational functioning. 4. Schedule the Veteran for a VA orthopedic examination by an orthopedist who has not previously examined the Veteran to determine the severity of the service-connected cervical spine, low back, left knee, and right ankle disabilities. All appropriate tests or studies, to include X-rays if considered to be necessary, should be accomplished, and all clinical findings should be reported in detail. The examiner must report the range of motion of the cervical spine, thoracolumbar spine, knees, and ankles, expressed in degrees, to include measurements for weight-bearing, nonweight-bearing, passive motion, and active motion. The examiner must make specific findings as to whether, during the examination, there is objective evidence of additional loss of function due to painful motion, weakened motion, excess motion, fatigability, incoordination, or on flare up. If pain on motion is observed, the examiner should indicate the point at which pain begins. The examiner should also indicate whether, and to what extent, the Veteran experiences functional loss of the affected joints or any other symptoms during flare-ups or with repeated use. To the extent possible, the examiner should express any additional functional loss in terms of additional degrees of limited motion. The examiner must also indicate whether the Veteran experiences recurrent subluxation or instability, or patellar instability of the left knee. The examiner should indicate whether the Veteran has been prescribed any assistive device due to his knee disability. Harvey P. Roberts Veterans Law Judge Board of Veterans' Appeals Attorney for the Board T.M. Gillett 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.