Citation Nr: 21042623 Decision Date: 07/13/21 Archive Date: 07/13/21 DOCKET NO. 17-48 748 DATE: July 13, 2021 REMANDED Entitlement to an increased evaluation of osteoarthritis and meniscal tear with patellofemoral pain syndrome, right knee (claimed as temp 100% due to right knee surgery) is remanded. REASONS FOR REMAND The Veteran served on active duty from October 1990 to March 1998. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a March 2015 rating decision issued by the Department of Veterans Affairs (VA) regional office (RO) located in Phoenix, Arizona. The Veteran testified before the undersigned in April 2021; a transcript of the Veteran's testimony has been associated with the record. The Board notes that during the course of the appeal, the Veteran was awarded a temporary evaluation of 100 percent based on surgical or other treatment necessitating convalescence from June 3, 2016, to September 30, 2016, and from October 16, 2020, to December 31, 2020. As that is the maximum benefit available, these periods are no longer on appeal before the Board. Entitlement to an increased evaluation greater than 10 percent for osteoarthritis and meniscal tear with patellofemoral pain syndrome, right knee (excluding the periods from June 3, 2016, to September 30, 2016, and from October 16, 2020, to December 31, 2020) is remanded. The Board finds that this appeal must be remanded for additional development. In a claim for disability compensation, VA will make efforts to obtain the claimant's VA medical records or records of examination or treatment at non-VA facilities authorized by VA. VA will end its efforts to obtain records from a Federal department or agency only if VA concludes that the records sought do not exist or that further efforts to obtain those records would be futile. 38 C.F.R. § 3.159(c)(2)-(3). The Veteran's VA treatment records indicate that there may be additional relevant VA or private medical records in an information system, database, or other records depository named "VistA Imaging." See, e.g., VA treatment records received in February 2018 (with notes, in July 2017, for example, indicating that "SCANNED OUTSIDE MEDICAL RECORDS" may be accessed by "selecting [a] Tools menu, then select[ing] Vista Imaging Display"). The aforementioned evidence of record indicates that there may be relevant VA medical records, or private medical records in the custody of VA, that are missing from the claims file, and there is no indication that the AOJ has made any attempts to obtain those records or concluded that such records do not exist or that further efforts to obtain those records would be futile. The Board reminds the AOJ that the Board does not have access to the VistA Imaging system, or the Vista Imaging Display tool, so any documentation of the aforementioned records must be printed from those systems/tools and added to the Veteran's VBMS or Virtual VA file. The Board thus finds that this appeal must be remanded so that the AOJ can make sufficient attempts, as outlined in 38 C.F.R. § 3.159, to obtain all records in the Veteran's VA treatment records and/or in VA's related information systems. If the referenced records cannot be obtained and associated with the claims file for review, documentation to this effect must be clearly noted in the Veteran's claims file and the Veteran must be duly notified. Additionally, the Veteran was most recently afforded a VA examination in May 2017. He has since undergone another knee surgery, and the record reflects that his right knee disability may have worsened since that examination. 38 C.F.R. § 3.327; Snuffer v. Gober, 10 Vet. App. 400 (1997); Caffrey v. Brown, 6 Vet. App. 377 (1994) (finding that a 23-month-old VA examination was too remote in time where evidence of worsening symptoms was submitted in the interim). The record also reflects that arrangements have already been made to schedule the Veteran for another VA knee examination, but either the examination has not been performed yet, or the report of that examination has not yet been uploaded to the Veteran's claims file. Considering the foregoing, the Board finds that on remand, if the Veteran has not yet been scheduled for a VA examination to assess the current severity of his right knee condition, he should be scheduled for such an examination, and an opinion should be obtained on the current severity of this disability. The matters are REMANDED for the following action: 1. Obtain any outstanding VA treatment records, including any for the period from July 2018 to October 2020, and the period from May 2021 to present, along with any VA or private treatment records located in "VistA Imaging" or the "Vista Imaging Display" tool. The Board reminds the AOJ that the Board does not have access to the VistA Imaging system, or the Vista Imaging Display tool, so any documentation of the aforementioned records must be printed from those systems/tools and added to the Veteran's VBMS or Virtual VA file. 2. If the Veteran has not already been scheduled for another VA examination for the purpose of assessing the current severity of his right knee disability, schedule the Veteran for an examination by an appropriate clinician to determine the current severity of that 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. 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. If it is not possible to provide a specific measurement without speculation, or 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). Tiffany Dawson Veterans Law Judge Board of Veterans' Appeals Attorney for the Board C. Banks, 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.