Citation Nr: 21040755 Decision Date: 07/06/21 Archive Date: 07/06/21 DOCKET NO. 15-01 679A DATE: July 6, 2021 REMANDED Entitlement to a rating in excess of 20 percent for right shoulder mild degenerative joint disease is remanded. Entitlement to a rating in excess of 20 percent for left shoulder degenerative changes is remanded. Entitlement to a total disability rating based on individual unemployability (TDIU) prior to February 15, 2006 is remanded. REFERRED The issue of entitlement to service connection for fibromyalgia was raised in a May 2021 correspondence and is referred to the Agency of Original Jurisdiction (AOJ) for any appropriate action. REASONS FOR REMAND The Veteran had active service from January 1994 to January 1998. This matter is before the Board of Veterans' Appeals (Board) on appeal of a September 2009 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO). In December 2017, the Veteran testified at a hearing before the undersigned Veterans Law Judge via video conference. A transcript of the hearing is associated with the record. In May 2018, the Board remanded this case for more development. In August of 2020, the Veteran requested that his previous withdrawal of a claim for TDIU at his Board hearing in December 2017 be retracted and that the issue be adjudicated. In November 2020, the Board remanded this matter for more development. The Board finds that the Regional Office (RO) substantially complied with the Board's remand instructions. See Stegall v. West, 11 Vet. App. 268 (1998). Regrettably, more development is still necessary for the Veteran's claims prior to adjudication. 1. Entitlement to a rating in excess of 20 percent for right shoulder mild degenerative joint disease is remanded. 2. Entitlement to a rating in excess of 20 percent for left shoulder degenerative changes is remanded. The Veteran seeks a higher rating for his bilateral shoulder disability. The Veteran contends that his private treatment providers have indicated that the only viable intervention at this point is for total shoulder replacements. However, the Board notes that the Veteran's VA treatment providers indicated that Duke declined operative intervention. See May 2021 Orthopedic Surgery Clinic Note. The Board notes that in the April 2017 VA examination the examiner noted that the Veteran had motion to 70 degrees (right) and 90 degrees (left). The Veteran was afforded a VA examination ins July 2020, but no range of motion measurements were records because the examiner stated that they were not recorded because the Veteran was in pain. The Veteran was afforded a second VA examination in April 2021, and again the examiner was not able to test the Veteran's range of motion, due to the Veteran having pain. In May 2021, the Veteran submitted a letter indicating that there are records that are available but have not been uploaded to the Veteran's claims file, including (x-rays, MRI's, CT's and PET scans). The Board cannot make a fully informed decision on the severity of the Veteran's shoulder claims until any outstanding records have been secured, and the Veteran is afforded a VA examination that determines the severity of the Veteran's bilateral shoulder disability. 3. Entitlement to a total disability rating based on individual unemployability (TDIU) prior to February 15, 2006 is remanded. A decision on the other remanded issues could significantly impact a decision on the issue of entitlement to a TDIU. Therefore, the issues are inextricably intertwined. A remand of the claim for entitlement to a TDIU is required. The matters are REMANDED for the following action: 1. Obtain all outstanding VA treatment records including (x-rays, MRI's, CT's, and PET scans) including but not limited to Kernersville VA from 2017 the present. See May 2021 Correspondence from the Veteran. 2. With any necessary assistance from the Veteran, obtain any relevant outstanding private treatment records, to include any from "Duke" where the Veteran reportedly underwent evaluation for a shoulder replacement. See May 2021 Correspondence from the Veteran. 3. After the development in #1 and #2, Schedule the Veteran for an examination as to the current severity of his service-connected right and left shoulder disabilities. The examiner must test the Veteran's active motion, passive motion, and pain with weight-bearing and without weight-bearing. The examiner must also attempt to elicit information regarding the severity, frequency, and duration of any flare-ups, and the degree of functional loss during flare-ups. In addition, the examiner is asked to explain, to the extent possible, any change in function since 2017. If the Veteran refuses to do range of motion testing, the examiner should opine whether there are sufficient objective findings on examination as well as on x-rays or MRI's that support the Veteran's claim of pain which completely restricts motion. 4. Thereafter, readjudicate the claim. If the benefits sought on appeal remain denied, issue a supplemental statement of the case to the Veteran and his representative. Then return the appeal to the Board for further appellate review. MICHAEL MARTIN Veterans Law Judge Board of Veterans' Appeals Attorney for the Board M. Quist 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.