Citation Nr: 21041787 Decision Date: 07/10/21 Archive Date: 07/10/21 DOCKET NO. 12-04 068 DATE: July 10, 2021 REMANDED Entitlement to a rating greater than 10 percent for degenerative disease thoracolumbar spine with thoracic scoliosis is remanded. REASONS FOR REMAND The Veteran served on active duty in the United States Army from June 1990 to October 2010, including foreign service in Iraq and Saudi Arabia. For his meritorious service, the Veteran was awarded (among other decorations) the Bronze Star Medal, Army Achievement Medal, Southwest Asia Service Medal with Bronze Service Star, and the Iraq Campaign Medal with Campaign Star. Historically, the Board denied this appeal in June 2020. However, the Court of Appeals for Veterans Claims (Court) approved a Joint Motion for Partial Remand (JMPR) in March 2021, thereby vacating the Board's decision and remanding the matter for further review. Briefly, the Board notes that there is a separate pending appeal regarding the Veteran's entitlement to a higher initial rating for his service-connected headaches. This matter was remanded by the Board in February 2021 for further development, which has not yet been completed. Thus, this appeal will be addressed in a subsequent Board decision, should such action be required. As to the instant matter, the Board hereby remands this appeal for action consistent with the parties' JMPR. Specifically, the parties found that the most recent VA back examination, conducted in March 2020, was inadequate for its failure to comply with the terms of Correia v. McDonald, 28 Vet. App. 158, 168 (2016), and the terms of an April 2018 Board remand. See Stegall v. West, 11 Vet. App. 268, 271 (1998). Also in March 2021, the Veteran provided VA Form 21-4142a authorizing the release of medical records from the Kuakini Medical Center and Island Urgent Care. On said form, the Veteran did not identify whether he received treatment for his back disability at either of these facilities. Thus, efforts to obtain these records on remand are required. The matter is REMANDED for the following actions: 1. Contact the Veteran and request that he identify all private providers of medical treatment for his back disability during the period on appeal, including whether he received treatment at the Kuakini Medical Center and/or Island Urgent Care. If private treatment is identified, request that the Veteran provide authorization for release of all identified private medical records to VA. All actions to obtain the requested records should be fully documented in the record. The RO must make two attempts to obtain any private records identified, unless the first attempt demonstrates that further attempts would be futile. If private records are identified, but not obtained, the RO must notify the Veteran of (1) the identity of the records sought, (2) the steps taken to obtain them, (3) that the claim will be adjudicated based on the evidence available, and (4) that if the records are later obtained, the claim may be readjudicated. If possible, the Veteran should attempt to obtain the records himself. 2. Thereafter, schedule the Veteran for a VA examination to assess the current severity of his service-connected back disability. The claims folder must be provided to the examiner in conjunction with the examination. All necessary tests and studies should be conducted. The examiner should offer an assessment of all pertinent symptomatology and findings, to be reported in detail in accordance with Diagnostic Code 5242 (both the old and amended versions). The examiner must test the range of motion in active motion, passive motion, weight-bearing, and non-weight-bearing. If the examiner is unable to conduct the required testing or concludes that the required testing is not necessary in this case, he or she should clearly explain why that is so. Further, the examiner must estimate any functional loss in terms of additional degrees of limited motion experienced during flare-ups and after repetitive use over time. If the examiner cannot provide the above-requested estimation without resorting to speculation, he or she should state whether all procurable medical evidence had been considered, to specifically include the Veteran's description as to the severity, frequency, duration of the flare-ups and his description as to the extent of functional loss during a flare-up and after repetitive use over time; whether the inability is due to the limits of medical community or the limits of the examiner's medical knowledge; and whether there is additional evidence, which if obtained, would permit the opinion to be provided. The VA examiner should also identify any neurological manifestations of the Veteran's thoracolumbar spine disability, and their severity. The VA examiner should describe the effect the thoracolumbar spine disability has on the Veteran's current level of occupational impairment. Evan M. Deichert Veterans Law Judge Board of Veterans' Appeals Attorney for the Board K. Kovarovic, 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.