Citation Nr: 22013580 Decision Date: 03/10/22 Archive Date: 03/10/22 DOCKET NO. 15-38 026 DATE: March 10, 2022 REMANDED Entitlement to an evaluation in excess of 10 percent for insomnia disorder is remanded. Entitlement to an evaluation in excess of 0 percent for gout is remanded. Entitlement to an evaluation in excess of 0 percent for pes planus, bilateral is remanded. Entitlement to an evaluation in excess of 0 percent for lateral collateral ligament sprain, left ankle is remanded. REASONS FOR REMAND The Veteran served on active duty from May 1998 to July 2014. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a July 2015 rating decision issued by the Department of Veterans Affairs (VA) regional office (RO). 1. Entitlement to an evaluation in excess of 10 percent for insomnia disorder is remanded. 2. Entitlement to an evaluation in excess of 0 percent for gout is remanded. 3. Entitlement to an evaluation in excess of 0 percent for pes planus, bilateral is remanded. 4. Entitlement to an evaluation in excess of 0 percent for lateral collateral ligament sprain, left ankle is remanded. The Veteran was afforded VA examinations for gout, pes planus, and the left ankle collateral ligament sprain in May 2015. As shown on the May 2015 Non-Degenerative Arthritis and Dysbaric Osteonecrosis Disability Benefits Questionnaire (DBQ), the Veteran reported being under treatment for his gout, which involves multiple joints. These records have not been requested and are not in the claims file. VA has a duty to assist claimants in obtaining evidence, including medical and other records from VA medical facilities and from private medical care providers. See 38 C.F.R. § 3.159. No such assistance has yet been provided; accordingly, the Board finds that these issues must be remanded so attempts can be made to solicit additional information from the Veteran regarding any medical treatment for the pertinent disabilities and to obtain any records sufficiently identified and, if necessary, authorized to be released, by the Veteran. Further, the Non-Degenerative Arthritis DBQ, Ankle Conditions DBQ, and the Foot Conditions, Including Flatfoot (Pes Planus) DBQ all indicate that no records were reviewed in connection with the May 2015 examination of the Veteran for his gout, pes planus, and the left ankle collateral ligament sprain. VA has a duty to ensure any medical examination or opinion it provides is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007) (overruled on other grounds, Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013)). A medical examination is adequate "where it is based upon consideration of the veteran's prior medical history and examinations and also describes the disability... in sufficient detail so that the Board's 'evaluation of the claimed disability will be a fully informed one.'" Stefl v. Nicholson, 21 Vet. App. 120, 123 (2007) (quoting Ardison v. Brown, 6 Vet. App. 405, 407 (1994)). If an examination report does not contain sufficient detail, "it is incumbent upon the rating board to return the report as inadequate for evaluation purposes." 38 C.F.R. § 4.2 (2012); see Bowling v. Principi, 15 Vet. App. 1, 12 (2001) (emphasizing the Board's duty to return inadequate examination report). Here, the Board finds that pertinent medical records may contain information that that would significantly affect the responses provided on the aforementioned DBQ forms. Because the examiner did not review the claims file in connection with the May 2015 VA examinations, the Board finds that the Veteran should be afforded new VA examinations for his gout, pes planus, and the left ankle collateral ligament sprain, after the examiner's review of the pertinent evidence in the claims file. Additionally, the May 2015 Foot Conditions DBQ indicates that the Veteran did not report foot pain during that examination, however, the Veteran reported that he suffers from chronic foot pain in the August 2015 NOD. In the Non-Degenerative Arthritis DBQ, the examiner noted that one medication was used continuously, however, in the NOD, the Veteran noted additional medications were being used continuously. The examiner also noted "rare" flare-ups and that no assistive devices were used in connection with gout, but in the NOD, the Veteran also stated that he had flare-ups a couple of times a week and was issued a cane for his gout. Lastly, the Veteran also reported insomnia symptoms, such as memory loss, that were not noted on the May 2015 Mental Disorders (other than PTSD and Eating Disorders) DSM V Disability Benefits Questionnaire. This implies possible worsening of the Veteran's insomnia since the May 2015 VA examination. As noted above, the Veteran's most recent VA examinations for the increased rating issues on appeal were in May 2015. The Veteran's reported symptoms and the VA examination reports are conflicting. The Board notes that contemporaneous medical evidence is needed in order to assess the current severity of his service-connected insomnia, gout, pes planus, and left ankle disability. Thus, as the most recent VA examinations are more than 7 years ago, remand for VA examinations are warranted. See 38 C.F.R. §§ 3.326, 3.327; Snuffer v. Gober, 10 Vet. App. 400, 403 (1997). The matters are REMANDED for the following action: 1. Take appropriate action to identify and obtain any outstanding VA treatment records. 2. Ask the Veteran to complete a VA Form 21-4142 for any private healthcare facilities that have treated him for gout, pes planus, left ankle collateral ligament sprain, and insomnia. Make two requests for the authorized records from any such facilities, unless it is clear after the first request that a second request would be futile. 3. Schedule the Veteran for an examination by an appropriate clinician to determine the current severity of his service-connected insomnia disorder. 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. The examiner must attempt to elicit information regarding the severity, frequency, and duration of symptoms. To the extent possible, the examiner should identify any symptoms and social and occupational impairment due to his service-connected insomnia disorder alone. 4. Schedule the Veteran for an examination by an appropriate clinician to determine the current severity of his service-connected gout, pes planus, and left ankle collateral ligament sprain. The examiner should provide a full description of the disability and report all signs and symptoms necessary for evaluating the Veteran's disabilities under the rating criteria. In so doing, the examiner must 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, when prompted, based on direct observation, the examiner should provide an estimate, if at all possible, of the additional impairment due to flare-ups based on the other evidence of record and the Veteran's statements. 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). When conducting the examinations for the pes planus and left ankle collateral ligament sprain, 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). A. J. Spector 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.