Citation Nr: 22011967 Decision Date: 03/02/22 Archive Date: 03/02/22 DOCKET NO. 18-49 803 DATE: March 2, 2022 REMANDED Entitlement to a rating in excess of 10 percent for degenerative L5-S1 disc changes status post microdiscectomy is remanded. Entitlement to a rating in excess of 10 percent for right lower extremity radiculopathy is remanded. Entitlement to a compensable rating for eosinophilic esophagitis is remanded. REASONS FOR REMAND The Veteran served in the United States Air Force from October 1997 to October 2001. These matters come before the Board of Veterans' Appeals (Board) on appeal of a March 2017 rating decision by a Department of Veterans Affairs (VA) Regional Office (RO). The Veteran testified before the undersigned Veterans Law Judge in an October 2021videoconference hearing, and a transcript of this hearing is associated with the claims file. 1. Entitlement to a rating in excess of 10 percent for degenerative L5-S1 disc changes status post microdiscectomy is remanded. 2. Entitlement to a rating in excess of 10 percent for right lower extremity radiculopathy is remanded. The Veteran was afforded a VA back examination in December 2016. The Veteran reported experiencing symptoms of pain that travels from his low back down to his feet, and at times this pain travels to all of his lower joints. The Veteran also described experiencing tingling in both feet, intermittent in his left foot and constant in his right foot. He also described experiencing issues with bending and picking things up and said he could not stand, sit, or run for long periods of time. The Veteran also endorsed experiencing flare-ups, with the examiner noting these flare-ups relate to pain experienced in the lower extremity joints during increased low back pain. The examiner noted the Veteran's initial range of motion is as follows: forward flexion up to 70 degrees, with pain noted at 50 degrees; extension and right and left lateral flexion to 30 degrees; and right and left lateral rotation to 20 degrees. No additional loss of motion was noted after repetitive use or repeated use over time. The examiner noted the examination took place during a flare-up, but found that there was no additional loss of motion. Regarding radiculopathy symptoms, the Veteran reported experiencing mild intermittent pain and numbness in his right lower extremity. In his October 2021 hearing testimony, the Veteran described experiencing constant pain in his low back that extends to his sacrum, which he described as feeling like it was "bound up" and extremely painful. The pain in his sacrum makes it difficult for him to sit or to stand for long periods of time. He stated that his low back and right leg radiculopathy symptoms have impacted his ability to be as active as he used to be and prevent him from coaching his daughter's basketball team. The Veteran also endorsed experiencing flare-ups, especially after increased physical activity like mowing the lawn, where afterwards he is essentially knocked off his feet and experiences tingling, numbness, and burning sensations in his legs. He also experiences increased pain in his low back during flare-ups and feels the need to try and crack his back to relieve the pain. Additionally, the Veteran contends that the December 2016 examiner did not properly address his reported symptoms and instead was focused on merely "checking the boxes." The Board finds that the December 2016 examination is inadequate. In addition to the Veteran's contentions that the examiner failed to listen to and properly address his reported low back and right leg radiculopathy symptoms, the Veteran's October 2021 hearing testimony indicates his symptoms have worsened since this examination. While the Veteran provided additional statements concerning his low back and right leg radiculopathy symptoms after his December 2016 examination, these statements must still be taken into consideration when determining the severity of the Veteran's low back condition and right leg radiculopathy. Where VA provides the Veteran with an examination in a service connection claim, the examination must be adequate. Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). Remand is necessary in order to obtain a new examination. 3. Entitlement to a compensable rating for eosinophilic esophagitis is remanded. Regarding the claim of entitlement to a compensable rating for eosinophilic esophagitis, the Veteran submitted a timely notice of disagreement in February 2018. However, while the August statement of the case (SOC) addresses the Veteran's claims for increased ratings for a low back condition and right lower extremity radiculopathy, an SOC has not yet been issued addressing his claim for a compensable rating for eosinophilic esophagitis. A remand is required for the RO to issue an SOC addressing these issues. 38 C.F.R. § 20.200; Manlincon v. West, 12 Vet. App. 238, 240-41 (1999). The matters are REMANDED for the following action: 1. Schedule the Veteran for an examination with an appropriate examiner to address the current severity of his service-connected degenerative L5-S1 disc changes status post microdiscectomy. The examiner is to address all of the Veteran's reported symptoms and related contentions and is to note that the Veteran is competent and credible to report said symptoms. 2. Schedule the Veteran for an examination with a qualified examiner addressing the severity of his right lower extremity radiculopathy. The examiner is to address all of the Veteran's reported symptoms and related contentions and is to note that the Veteran is competent and credible to report said symptoms. 3. Send the Veteran and his representative a statement of the case that addresses the issue of entitlement to a compensable rating for eosinophilic esophagitis. If the Veteran perfects an appeal by submitting a timely VA Form 9, the issue should be returned to the Board for further appellate consideration. Caroline B. Fleming Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Gabrielle Ongies, Associate 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.