Citation Nr: 21042495 Decision Date: 07/13/21 Archive Date: 07/13/21 DOCKET NO. 16-56 261 DATE: July 13, 2021 REMANDED Entitlement to an initial rating in excess of 0 percent for a rotator cuff tear of left shoulder with ORIF and arthroscopy is remanded. Entitlement to service connection for a low back disability is remanded. REASONS FOR REMAND The Veteran served on active duty from May 1984 to August 2014. These matters are before the Board of Veterans' Appeals (Board) on appeal from an August 2015 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Montgomery, Alabama. Although the Veteran originally requested a videoconference hearing on his November 2016 Form 9, he failed to report to his scheduled hearing in March 2020 and has not shown good cause nor timely requested rescheduling. His hearing request is deemed withdrawn. 38 C.F.R. §§ 20.702 (d), 20.704(d). Entitlement to a rating in excess of 0 percent for a rotator cuff tear of left shoulder with ORIF and arthroscopy is remanded. The Veteran asserts that the claimed shoulder disability is worse than what is currently contemplated by the assigned rating. The Veteran has not received a VA examination to check the severity level of his left shoulder disability since July 2015. As a result, further examination is needed to ascertain the current severity of the claimed disability. Entitlement to service connection for a low back disability The Veteran asserts that he is entitled to service connection for a low back disability because the claimed disability is the result of an in-service accident. Service treatment records noted complaints of back pain and evidence of bulging disc per an X-ray dated in June 1995. A July 2015 VA examiner found that the Veteran does not have a diagnosis of a low back disability. The examiner noted that the service medical records showed treatment for left lower extremity sciatica which was resolved, noted the Veteran had IVDS, and there were no surgeries or injections. Symptoms reported during the examination included stiffness. The examiner also indicated that there was no functional impairment caused to the Veteran by the claimed low back pain. The Veteran asserts the July 2015 VA examination was flawed as the examiner did not take the Veteran's in-service complaints and findings into consideration and the Board finds a new VA examination is warranted to assess the current disability as well as a nexus opinion. The matters are REMANDED for the following action: 1. Ask the Veteran to identify, and provide appropriate releases for, any care providers who may possess new or additional evidence pertinent to the issue(s) on appeal. If he provides the necessary release(s), assist him in obtaining the records identified, following the procedures set forth in 38 C.F.R. § 3.159. Any new or additional (i.e., non-duplicative) evidence received should be associated with the record. If any of the records sought are not available, the record should be annotated to reflect that fact and the Veteran should be notified. 2. Obtain copies of records pertaining to any VA treatment the Veteran has received since the time that such records were last procured, following the procedures set forth in 38 C.F.R. § 3.159. The evidence obtained, if any, should be associated with the record. 3. Then, schedule the Veteran for an examination by an appropriate clinician to determine the current severity of his service-connected left shoulder disability. The examiner should provide a full description of the disability and report all signs and symptoms necessary for evaluating the Veteran's disability under the rating criteria. In so doing, the examiner must test the Veteran's active motion, passive motion, and pain with weight-bearing and without weight-bearing. If it is not possible to provide a specific measurement without speculation, the examiner must state whether the need to speculate is due to a deficiency in the state of general medical knowledge (no one could respond given medical science and the known facts), a deficiency in the record (additional facts are required), or the examiner (does not have the knowledge or training). 4. Schedule a VA examination and opinion for the low back disability. The examiner must review the complete claims file, including this remand. Then, the examiner must address the following, with full supporting rationales: (Continued on the next page) Determine whether it is at least as likely as not that any current low back disability is related to an in-service injury, event, or disease. The examiner is asked to consider the Veteran's in-service back complaints and treatment. R. Costello Acting Veterans Law Judge Board of Veterans' Appeals Attorney for the Board K. Cross, 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.