Citation Nr: 22013647 Decision Date: 03/10/22 Archive Date: 03/10/22 DOCKET NO. 16-34 863 DATE: March 10, 2022 REMANDED Entitlement to an increased disability rating in excess of 20 percent for left shoulder degenerative joint disease (DJD) is remanded. Entitlement to an increased disability rating for right shoulder DJD, prior to March 7, 2017, is remanded. Entitlement to an increased disability rating in excess of 30 percent for a total right shoulder arthroplasty, from May 1, 2018, is remanded. REASONS FOR REMAND The Veteran had active duty in the United States Navy from December 1977 to June 2001. These matters come before the Board of Veterans' Appeals (Board) from a September 2015 rating decision of a Department of Veterans Affairs (VA) Veterans Benefits Administration (VBA) On his July 2016 VA Form 9, the Veteran requested a Board hearing. In statements received in April 2020, the Veteran withdrew his hearing request. Thus, the hearing is deemed withdrawn pursuant to 38 C.F.R. §20.704 (e). The appeal was last before the Board in June 2021, when it was remanded for additional development. The appeal has been returned for further appellate review. Unfortunately, the Board finds that a Remand is warranted as the September 2021 VA examination and November 2021 VA addendum report are inadequate. Barr v. Nicholson, 21 Vet. App. 303 (2007). Initial review of the aforementioned reports reveals that they are authored by different physicians. The November 2021 examination report did not comply with the Board's June 2021 remand instructions. Further, the November 2021 examination report contradicts the pertinent findings noted in the September 2021 VA examination report without supporting rationale. Additionally, the September 2021 examiner noted the Veteran had a left shoulder total arthroplasty in 2020. However, VA treatment records indicate the Veteran may have had a left shoulder total arthroplasty in 2019. As there are several inconsistent findings between the September 2021 VA examination report and the November 2021 addendum report and the reports are authored by different physicians, the Board finds a new VA examination is required that adequately considers the severity of the Veteran's bilateral shoulder disabilities. The matters are REMANDED for the following action: 1. Schedule the Veteran for an examination by an appropriate clinician to determine the current severity of his service-connected bilateral shoulder disabilities. 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, to include obtaining any necessary diagnostic tests. 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). 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 and with repeated use over time. If it is not possible to provide a specific measurement 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). Finally, the examiner should provide a retrospective opinion as to the range of motion prior to March 7, 2017, of the shoulders in (1) active motion, (2) passive motion, (3) in weight-bearing, and (4) in non-weight-bearing. A rationale for any opinions expressed should be set forth. If the examiner cannot provide an opinion without resorting to speculation, he/she should explain why an opinion cannot be provided (e.g., lack of sufficient information/evidence, the limits of medical knowledge, etc.). The clinician should keep in mind that the Veteran is competent to report his symptoms and history. Such reports, including those of continuity of symptomatology and functional limitations, must be acknowledged and considered in formulating any opinion. Should the clinician reject the Veteran's reports, she/he must provide an explanation for such rejection. The clinician must provide complete, clearly stated rationales for the conclusions reached. The clinician should include explanations that consider the record and pertinent medical principles, and the clinician's rationale should include citation to pertinent evidence and/or medical principles relied upon to form all opinions. 2. Then, after any other indicated development is completed, the Veteran's claims should be readjudicated. If the benefit sought on appeal remains denied, the Veteran and his representative should be furnished a supplemental statement of the case and provided an appropriate opportunity to respond before returning the case to the Board for further appellate action. K.A. KENNERLY Veterans Law Judge Board of Veterans' Appeals Attorney for the Board K. McDuffie, 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.