Citation Nr: 22011825 Decision Date: 03/02/22 Archive Date: 03/02/22 DOCKET NO. 17-30 768 DATE: March 2, 2022 REMANDED Entitlement to a disability rating in excess of 20 percent for service-connected severe cervical spine injury with DDD at C5-6 & C6-7 (cervical spine disability) is remanded. Entitlement to a disability rating in excess of 20 percent for left shoulder injury due to strain with severe limitation of motion (left shoulder disability) is remanded. Entitlement to a disability rating in excess of 20 percent for radiculopathy of the left upper extremity and numbness of the medial left hand (left upper extremity radiculopathy) is remanded. REASONS FOR REMAND The Veteran served on active duty in the United States Air Force from October 1979 to June 1992. For his meritorious service, the Veteran was awarded (among other decorations) the Air Force Commendation and Achievement Medals. This matter is before the Board of Veterans' Appeals (Board) on appeal from a January 2016 rating decision issued by a Department of Veterans Affairs (VA) Regional Office (RO). The Veteran appeared at a Travel Board hearing before the undersigned Veterans Law Judge in October 2021. A transcript of the hearing is in the Veteran's file. On his June 2017 substantive appeal, the Veteran appeared to check a box indicating that he only wanted to appeal the issue of entitlement to an increased rating for his cervical spine disability. A review of the Veteran's complete substantive appeal, however, reveals that he expressed his disagreement and commented on all three issues listed on his statement of the case. Accordingly, the Board took testimony on all of these issues at the Veteran's October 2021 hearing, and the Board considers them all to be properly before it now. Entitlement to an evaluation greater than 20 percent for service-connected severe cervical spine injury with DDD at C5-6 & C6-7 (cervical spine disability) is remanded. Entitlement to a disability rating in excess of 20 percent for left shoulder injury due to strain with severe limitation of motion (left shoulder disability) is remanded. Entitlement to a disability rating in excess of 20 percent for radiculopathy of the left upper extremity and numbness of the medial left hand (left upper extremity radiculopathy) is remanded. The Veteran is seeking increased ratings for his service-connected cervical spine, left shoulder, and left upper extremity disabilities. The Veteran last underwent VA examinations pertinent to these issues in December 2015; at his October 2021 hearing, the Veteran testified that these disabilities have increased in severity since that time. Under the circumstances, the Veteran should be afforded a new VA examination to determine the current severity of his service-connected disabilities. See 38 U.S.C. § 5103A; 38 C.F.R. § 3.159; see also Green v. Derwinski, 1 Vet. App. 121, 124 (1991) (VA has a duty to provide the veteran with a thorough and contemporaneous medical examination); Weggenmann v. Brown, 5 Vet. App. 281 (1993) (VA has a duty to provide an examination when there is evidence that the disability has worsened since the previous examination). The Veteran has also presented testimony indicating outstanding VA medical records related to his service-connected disabilities. As such, further development is needed to obtain any outstanding medical records. The matters are REMANDED for the following actions: 1. Obtain the Veteran's VA treatment records for the period from December 2015 to the Present. 2. Thereafter, schedule the Veteran for a VA examinations to assess the current severity of his service-connected cervical spine disability, left shoulder disability, and left upper extremity disability. The claims folder must be provided to the examiner in conjunction with the examination. All necessary tests and studies should be conducted. For the cervical spine and left shoulder disabilities, 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 cervical spine disability, and their severity. Evan M. Deichert Veterans Law Judge Board of Veterans' Appeals Attorney for the Board J.R. Higgins 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.