Citation Nr: 21040750 Decision Date: 07/06/21 Archive Date: 07/06/21 DOCKET NO. 16-40 754 DATE: July 6, 2021 REMANDED Entitlement to service connection for a right hip disability is remanded. Entitlement to an initial rating in excess of 10 percent for a cervical strain is remanded. Entitlement to a a rating in excess of 20 percent for a low back disability is remanded. Entitlement to an initial rating in excess of 10 percent for left lower extremity radiculopathy and alcoholic neuropathy is remanded. Entitlement to a rating in excess of 20 percent for a left shoulder disability is remanded. Entitlement to an increased rating for residuals of a left anterior cruciate ligament tear (left knee disability) is remanded. Entitlement to an increased rating for right bundle branch block with history of acute heart failure (heart disability) is remanded. Entitlement to a compensable rating for a bilateral hearing loss disability is remanded. Entitlement to a compensable rating for residuals of testicle surgery is remanded. Entitlement to a total disability rating based on individual unemployability due to service-connected disabilities (TDIU) prior to June 18, 2014, is remanded. REASONS FOR REMAND The Veteran had active service from January 1981 to January 1997. This case initially came before the Board of Veterans' Appeals (Board) on appeal from November 2013, September 2014, and May 2016 rating decisions issued by a Regional Office (RO) of the Department of Veterans Affairs (VA). In January 2019, the Board remanded the claims to the Agency of Original Jurisdiction (AOJ) for additional development. The case has since been returned to the Board. The Veteran also appealed the issues of entitlement to service connection for bilateral hand and feet disabilities. In a March 2020 rating decision, the AOJ granted service connection for alcoholic neuropathy of the upper and lower extremities, which constitutes a full award of the benefits sought on appeal. See Grantham v. Brown, 114 F. 3d 1156, 1158 (Fed. Cir. 1997). Thus, those matters are no longer in appellate status. REASONS FOR REMAND The Board finds that additional development is required before the claims on appeal are decided. In January 2019, the Board remanded the claims to obtain outstanding VA treatment records. The Veteran reported that he had received treatment from a VA facility since 1988; however, the earliest VA treatment record of record was dated in October 2006. In June 2019, the AOJ requested VA treatment records from 1988 to April 2004 (the first date records were seen electronically in CAPRI/VISTA). The AOJ instructed the VA facility to provide a negative response in writing if no records were found. In July 2019, the VA facility acknowledged the request; however, it is unclear what records, if any, were provided. The facility did not indicate that it was unable to locate records dated from 1988 to April 2004. Furthermore, the AOJ referenced VA treatment records dated since April 2004; however, the claims file does not contain any records dated prior to October 2006. Also missing are VA treatment records dated from December 2009 to August 2012, and from September 2013 to November 2013. Therefore, a remand is necessary to ensure that any relevant, outstanding VA treatment records are secured. Service Connection Right Hip The Veteran maintains that his right hip disability was incurred in or is related to service. Alternatively, he asserts that his right hip disability is caused or aggravated by his service-connected left knee disability. The Veteran's service treatment record indicated that he complained of right hip pain in September 1994. It was noted that he had radiating pain in the inguinal crease area. The assessment was tendon fasciitis syndrome versus fracture of the femoral head. A September 1994 X-ray showed that the joint space was well maintained. There was no fracture or subluxation noted. Smooth cortical outline of the right femoral head was noted. There was a partial separated well-corticated bony fragment at the superior aspect of the acetabulum, which was noted to most likely be an accessory ossicle or secondary to old trauma. In November 1994, a bone scan of the pelvis and both hips was normal. Post-service, a December 2007 VA treatment record indicated that the Veteran complained of right hip pain and requested a magnetic resonance imaging (MRI). The MRI showed early osteonecrosis of the right femoral head and right hip effusion; prominent marrow edema in the right acetabular roof with degenerative changes and osteophytes at the joint. In April 2008, an X-ray showed osteoarthritis of the right hip and fusion of the sacroiliac joints. It was noted that the right hip pain was most likely from osteoarthritis. He was given an injection of Lidocaine and scheduled for a total hip arthroplasty, which was performed in May 2008. A VA examination was conducted in October 2019. The examiner opined that the Veteran's right hip disability was less likely than not the result of or permanently aggravated beyond its natural progression by his service-connected knee disability. The examiner noted that he had a normal right hip X-ray and bone scan in 1994, and that the most likely cause was the normal aging process of an obese individual or a post-military service injury. The examiner, however, did not address the September 1994 X-ray findings of a bony fragment at the superior aspect of the acetabulum. In addition, although the examiner opined that the right hip disability was most likely due to the normal aging process and obesity, the examiner did not provide any rationale for why his left knee disability did not aggravate his right hip disability. Furthermore, the examiner indicated that the right hip disability might be due to a post military service injury; however, there is no evidence of such an injury between his separation from service in 1997 and the first documentation of a right hip disability in December 2007. For those reasons, the Board finds that the VA examiner's opinion is inadequate, and a remand is necessary for an additional VA medical opinion. Increased Rating Left Knee, Bilateral Hearing Loss, and Residuals of Testicle Surgery In January 2019, the Board remanded the claims for additional development. The Board instructed the AOJ to readjudicate the claims based on any additionally received evidence. If the decision was adverse to the Veteran, the Board instructed the AOJ to issue a supplemental state of the case (SSOC). As this was not done, a remand is necessary to ensure compliance. See Stegall v. West, 11 Vet. App. 268, 271 (1998). The matters are REMANDED for the following action: 1. Identify and obtain any pertinent, outstanding VA treatment records and associate them with the claims file, to include VA treatment records dated from 1988 to October 2006, from December 2009 to August 2012, and from September 2013 to November 2013. 2. Then, return the case to the VA examiner who conducted the October 2019 examination of the right hip for an addendum opinion regarding the nature and etiology of the Veteran's right hip disability. The claims file must be made available to, and reviewed by the examiner. After a review of the evidence of record, to include consideration of any newly received records, the examiner should provide an opinion as to whether it is at least as likely as not (50 percent or better probability) that any currently present right hip disability had its onset during the Veteran's active service, or is otherwise etiologically related to such service. In rendering the opinion, the examiner must address the September 1994 X-ray findings of a bony fragment at the superior aspect of the acetabulum, which was noted to most likely be an accessory ossicle or secondary to old trauma. The examiner should also provide an opinion as to whether it is at least as likely as not (50 percent or better probability) that any currently present right hip disability is caused or aggravated by the Veteran's service-connected left knee disability. In rendering the opinion, the examiner must include an explanation as to why the Veteran's left knee disability does or does not cause or aggravate his right hip disability. A rationale for all opinions expressed must be provided. 3. Confirm that the VA examination reports and all opinions provided comport with this remand and undertake any other development found to be warranted. 4. Then, readjudicate the issues on appeal. If a decision is adverse to the Veteran, issue a SSOC and allow appropriate time for response. Then, return the case to the Board. Kristin Haddock Veterans Law Judge Board of Veterans' Appeals Attorney for the Board S. Mishalanie, 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.