Citation Nr: 22014572 Decision Date: 03/14/22 Archive Date: 03/14/22 DOCKET NO. 17-23 759 DATE: March 14, 2022 REMANDED Entitlement to a rating in excess of 50 percent for posttraumatic stress disorder (PTSD) prior to March 1, 2021 is remanded. Entitlement to a rating in excess of 20 percent for right shoulder bursitis to include rotator cuff tendonitis and arthritis (right shoulder disability) prior to November 17, 2020 is remanded. Entitlement to a rating in excess of 20 percent for left shoulder bursitis to include rotator cuff tendonitis and arthritis (left shoulder disability) prior to November 17, 2020 is remanded. Entitlement to a rating in excess of 40 percent for a right shoulder disability from November 17, 2020 is remanded. Entitlement to a rating in excess of 30 percent for left shoulder disability from November 17, 2020 is remanded. REASONS FOR REMAND The Veteran had active service from October 1966 to March 1969. These matters are before the Board of Veterans' Appeals (Board) on appeal from a rating decision of a Department of Veterans Affairs (VA) Regional Office (RO). These matters were last before the Board in September 2021, when they were remanded for additional development. During the pendency of the remand, a December 2021 rating decision granted a 100 percent rating for the Veteran's PTSD, effective March 1, 2021. As that is the highest schedular rating available, that period is no longer on appeal. 1. Entitlement to a rating in excess of 50 percent for PTSD prior to March 1, 2021 is remanded. 2. Entitlement to a rating in excess of 20 percent for a right shoulder disability prior to November 17, 2020 is remanded. 3. Entitlement to a rating in excess of 20 percent for a left shoulder disability prior to November 17, 2020 is remanded. 4. Entitlement to a rating in excess of 40 percent for a right shoulder disability from November 17, 2020 is remanded. 5. Entitlement to a rating in excess of 30 percent for a left shoulder disability from November 17, 2020 is remanded. The evidence indicates there may be outstanding relevant VA treatment records. A December 9, 2021 VA treatment record indicates that the Veteran was to return for a follow up appointment in February 2022. VA treatment records subsequent to December 13, 2021 have not been associated with the claims file. Additionally, VA treatment records from October 26, 2018, January 22, 2019, and October 3, 2019 note that non-VA care records from October 10, 2018, December 3, 2018, and September 23, 2019 had been scanned into VistA Imaging. It does not appear that the referenced records have been associated with the claims file. A remand to obtain the outstanding records is required. See Jones v. Wilkie, 918 F.3d 922, 926 (Fed. Cir. 2019) (stating the duty to assist is not discharged "based on a mere belief that the likelihood of finding a record substantiating a veteran's claim is 'low' or 'extremely low'"). While the Veteran was provided a VA shoulder examination in August 2021, the examination report does not comply with the requirements set forth in Correia v. McDonald, 28 Vet. App. 158, 168 (2016). Specifically, while the examination reports indicate that the Veteran had pain with range of motion testing, the examiner did not indicate where the Veteran's pain started or ended. Accordingly, a remand for a Correia compliant examination is warranted. The matters are REMANDED for the following actions: 1. Ask the Veteran to provide the names and addresses of all medical care providers who have recently treated him for his claimed disabilities. After securing any necessary releases, request any relevant records identified. In addition, obtain updated VA treatment records as well as the VistA Imaging records referenced in the October 26, 2018, January 22, 2019, and October 3, 2019 VA record entries. If any such records are determined to be unavailable, issue a formal finding of unavailability and notify the Veteran of this fact. 2. After the above record development is completed to the extent possible, schedule the Veteran for a VA shoulder examination to determine the current nature and severity of his service-connected right and left shoulder disabilities. The claims file should be reviewed in conjunction with the examination. All indicated tests should be conducted and the results reported. Range of motion testing should be undertaken, and should be tested actively and passively, in weight bearing, and after repetitive use. (a.) For each range of motion testing conducted for the right or left shoulder, the examiner must state where in the range of motion the Veteran reports that he begins to experience pain. If the examiner is unable to conduct any of the required testing or concludes that the required testing is not necessary in this case, clearly explain why that is so. (b.) The examiner should also state whether there is likely to be additional range of motion loss due to flare-ups and due to pain, weakness, fatigability, or incoordination. If so, the examiner is asked to describe the additional loss, in degrees, if possible. In doing so, the examiner should elicit relevant information as to the Veteran's flares or ask him to describe the additional functional loss, if any, he suffered during flares and then estimate the Veteran's functional loss due to flares based on all the evidence of record, including the Veteran's lay information. (c.) If it is not possible to provide a specific measurement, or an opinion regarding flare-ups, symptoms, or functional impairment 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). K. A. BANFIELD Veterans Law Judge Board of Veterans' Appeals Attorney for the Board J. Anderson 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.