Citation Nr: 22014752
Decision Date: 03/14/22	Archive Date: 03/14/22

DOCKET NO. 19-29 672
DATE: March 14, 2022

REMANDED

Entitlement to service connection for a bilateral shoulder disability is remanded.

REASONS FOR REMAND

The Veteran served on active duty from September 1978 to September 1991.

This matter comes before the Board of Veterans' Appeals (Board) on appeal of an October 2017 rating decision by a Department of Veterans Affairs (VA) Regional Office (RO).

In September 2021, the Veteran testified at a hearing conducted by the undersigned Veterans Law Judge. A transcript of the hearing has been added to the Veteran's claims file.

1. Entitlement to service connection for a bilateral shoulder disability is remanded.

In August 2017, the Veteran underwent a shoulder and arm examination. There, the medical examiner confirmed bilateral degenerative arthritis from imaging studies but found it unrelated to service. In the opinion, the examiner stated that she was "unable to locate information regarding a previous right shoulder fracture in the service treatment records (supporting medical documentation not available for review), the described injury he sustained was treated and subsequently improved." 

As drafted, it is unclear whether the examiner was stating that the Veteran's service treatment records do not document a shoulder injury, or that she was not able to review any service treatment records. Because the service treatment records document treatment for a shoulder injury, and because it is unclear whether these records were available for review, a new opinion is necessary. 

Remand is further warranted to obtain outstanding private medical records. In October 2021, the Veteran submitted a VA Form 21-4142a ("General Release for Medical Provider Information to the Department of Veterans Affairs"). The Private Medical Records Retrieval Center (PMRRC) rejected his medical records request because it was "incomplete" and "missing [VA Form] 4142." The rejection notice stated that the Veteran's request "must be worked via the traditional process." To date, this has not been done. On remand, the RO should ask the Veteran for the missing form or, alternatively, follow up with the traditional process.

Finally, as the case is being remanded for additional development, any outstanding VA treatment records should be associated with the claims file. See Bell v. Derwinski, 2 Vet. App. 611, 613 (1992) (per curiam).

The matter is REMANDED for the following action:

1. Obtain all outstanding VA treatment records and associate them with the claims file.

2. Ask the Veteran to submit a VA Form 21-4142, Authorization and Consent to Release Information to the Department of Veteran Affairs (VA). If returned, make reasonable efforts to obtain the private medical records and associate them with the claims file.

3. Then, arrange for an appropriate healthcare provider to review the Veteran's claims file and provide an opinion on whether the Veteran's bilateral (right and/or left) shoulder disability had its clinical onset during service or is due to an event or incident of the Veteran's period of active service.

If the reviewing health care provider finds that physical examination or telehealth interview of the Veteran and/or diagnostic testing is necessary, such should be accomplished.

A clear rationale for all opinions would be helpful and a discussion of the facts and medical principles involved would be of considerable assistance to the Board.

 

 

M. Donohue

Veterans Law Judge

Board of Veterans' Appeals

Attorney for the Board	C. Canedy, 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.