Citation Nr: 21042183 Decision Date: 07/12/21 Archive Date: 07/12/21 DOCKET NO. 16-35 300 DATE: July 12, 2021 REMANDED Entitlement to an initial evaluation in excess of 30 percent disabling for hysterectomy is remanded. Entitlement to an initial evaluation in excess of 10 percent disabling for lumbosacral strain with degenerative arthritis prior to October 7, 2020, and in excess of 20 percent thereafter, is remanded. REASONS FOR REMAND The Veteran was a member of the United States Army Reserves with periods of active duty training from April to June 1982, March to June 1987, and October 1987 to February 1988. She then served on active duty from July 1993 to August 2015. These matters come to the Board of Veterans' Appeals (Board) on appeal from January 2016 and May 2016 rating decisions by a Regional Office (RO) of the United States Department of Veterans Affairs (VA). The Veteran testified at a July 2019 hearing at the RO held before the undersigned Veterans Law Judge (VLJ) via videoconference. A transcript of the hearing is associated with the electronic claims file. This appeal was previously before the Board in December 2019, at which time it was remanded for further development. VA back and gynecological conditions examinations were completed in October 2020. A subsequent development letter was mailed to the Veteran in December 2019, requesting that she submit any relevant private treatment records. Additional VA treatment records were also associated with the claims file. The matter is again before the Board. In a subsequent October 2020 rating decision, the Veteran was afforded a 20 percent evaluation for her lumbar spine condition, effective October 17, 2020, as well as a separate evaluation for left lower extremity radiculopathy effective the same date. Although this represents a partial grant of increased benefits, the claim for an increased evaluation remains on appeal for the entire period. A remand by the Board confers upon the Veteran, as a matter of law, the right to compliance with remand instructions, and imposes upon VA a concomitant duty to ensure compliance with the terms of the remand. See Stegall v. West, 11 Vet. App. 268, 271 (1998). The Agency of Original Jurisdiction (AOJ) did not substantially comply with the December 2019 remand directives. Another remand is warranted. Although updated VA treatment records have been associated with the claims file in accordance with the remand instructions, some records remain outstanding. Prior to the remand, the file included VA treatment records through June 2017. Following the remand, records were obtained beginning February 2019. However, it appears that there are missing records from the period between June 2017 and February 2019 that may be relevant. Specifically, these records indicate that the Veteran was seen by her VA physician for treatment pertaining to her back condition in May 2018. During her Board hearing, the Veteran also indicated that she had received a back MRI in 2018, although it is unclear whether this was completed at the VA or through a private provider. Accordingly, complete VA treatment records for the entire period on appeal should be obtained. Additionally, specifically regarding the claim for an increased evaluation for the hysterectomy, clarification is required as to whether the Veteran has current diagnoses for a vaginal vault and/or rectal prolapse. In the prior remand, it was noted that the Veteran's records indicate that she has a status post hysterectomy vaginal vault prolapse, and that she possibly suffers from a rectal prolapse. Accordingly, the examiner was instructed to identify whether these diagnoses are warranted, and if so, whether they are residuals of or otherwise related to the Veteran's hysterectomy. In the October 2020 gynecological conditions examination, the examiner noted that the Veteran did not have any pelvic organ prolapse due to injury, disease, or surgical complications of pregnancy. However, there appears to be conflicting contemporary information in the Veteran's VA treatment records. February 2020 VA treatment records include a VISTA Imaging scanned document from a February 2020 private provider gynecological visit, noting that the assessment plan included both cystocele with rectocele and prolapse of vaginal vault after hysterectomy. It is unclear exactly what was determined during this visit, as the full record has not been associated with the file. Accordingly, the VISTA Imaging scan that was associated with the Veteran's VA treatment records from this February 2020 gynecological visit must be associated with the claims file. Following this, an addendum opinion must be obtained in order for the VA examiner to clarify whether the Veteran has a diagnosis for a vaginal vault prolapse, or a rectal prolapse, and whether such is a residual of or otherwise related to her service-connected hysterectomy. The Board notes that the AOJ complied with directives regarding private treatment records, requesting proper releases from the Veteran, who did not respond. However, in light of the indications of highly relevant private treatment referred to in VA records, the Veteran should be given an additional opportunity to avail herself of VA assistance in substantiating her claim, as remand is required in any case. The matters are REMANDED for the following action: 1. Contact the Veteran and request properly executed releases for all private care providers who have treated her since 2016 for spine and gynecological conditions. Upon receipt of such, take appropriate action to contact the identified providers and request complete treatment records. The Veteran should be informed that in the alternative, she may obtain and submit these important records herself. 2. Obtain complete VA treatment records since June 2017, including VISTA imaging from the February 27, 2020 community care consult gynecology visit. 3. Obtain an addendum opinion regarding the Veteran's hysterectomy claim. The claims folder must be reviewed in conjunction with the opinion. An additional VA examination may be provided if deemed appropriate. Following review of the file, including private records and the February 2020 VISTA image note indicating that the Veteran has a prolapse of the vaginal vault following her hysterectomy, the examiner must state whether diagnoses of rectal prolapse or vaginal vault prolapses are warranted, and if so, whether such disabilities are residuals of or otherwise related to the Veteran's hysterectomy. 4. Then, readjudicate the claims. If the benefits sought remain denied, issue a supplemental statement of the case. The case should then be returned to the Board for appellate review if otherwise in order. WILLIAM H. DONNELLY Veterans Law Judge Board of Veterans' Appeals Attorney for the Board S.P. Faris 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.