Citation Nr: 22014965 Decision Date: 03/15/22 Archive Date: 03/15/22 DOCKET NO. 16-48 375 DATE: March 15, 2022 REMANDED The appeal for service connection for residuals of a gunshot wound residuals, as secondary to a service-connected lumbar spine disability is remanded. The appeal for service connection for a right shoulder disability is remanded. REASONS FOR REMAND The Veteran served on active duty in the United States Army from September 1996 to June 1999. This matter comes before the Board of Veterans' Appeals (Board) from a May 2013 rating decision from the Department of Veterans Affairs (VA) Regional Office in Baltimore, Maryland. In April 2020, the Veteran testified at a videoconference hearing before the undersigned Veterans Law Judge. A transcript of this hearing is of record. In August 2020 and November 2021, the Board remanded the case to the Regional Office for further evidentiary development. However, the Board regrets additional delay, as further developments are required before the Board may render a fully-informed decision on these issues on appeal. Specifically, in November 2021, the Board remanded both issues for an addendum opinion because the Regional Office obtained VA opinions on gunshot wound residuals and the right shoulder disability, as these opinions were based on insufficient rationales; and pertinently, they were not in substantial compliance with prior Board remand directives. Thus, subsequently, the Regional Office obtained supplemental opinions for gunshot wound residuals and the right shoulder disability in December 2021. Despite these VA opinions, however, further assessment is still needed. Thus, as the Board is precluded from exercising its own independent medical findings, a remand is required for new VA examinations and medical opinions on the etiology of the Veteran's gun shot wound residuals and right shoulder disability. On an additional note, in reviewing the claims file, the Board observes that the most recent rating Codesheet, from May 2013, does not reflect the Veteran's service-connected low back disability, and that this information has not been reflected in any Codesheet since this service connection claim was granted in May 1999. As the issuance of a rating codesheet is pertinent for purposes of documenting the Veteran's claim and payment history, a complete, accurate, updated rating codesheet, to include the pertinent details about the Veteran's service-connected chronic low back pain, should be issued. The matters are REMANDED for the following action: 1. Issue an updated rating codesheet for purposes of including pertinent details about the Veteran's service-connected low back disability. 2. Also, schedule the Veteran for a VA examination, with a physician (VA examiner) who has not yet evaluated the Veteran, for gunshot wound residuals. The VA examiner must review a complete claims file and must note that review in the report. A copy of this REMAND must also be provided to the VA examiner. The VA examiner must undertake the following: a. Perform a physical examination documenting the residuals of the gun shot wound and the low back disability. i. What are the manifestations and symptoms of the Veteran's current low back disability? ii. What are the Veteran's current gunshot wound residuals? iii. With a clear rationale, please explain whether or not the Veteran's service-connected low back disability aggravates or makes his gunshot wound residuals worse. Why do you say so? b. In rendering an opinion, please also consider and address all pertinent medical evidence, especially including the September 2020 private opinion. The Board calls particular attention to Dr. P.H.G.'s statement that " low back pain[,] therefore[,] made it more difficult to manage the complex pain syndrome and his wheelchair sitting status as a result of the GSW." With a clear rationale, please explain whether you agree or disagree with Dr. P.H.G.'s statements. c. A detailed explanation is requested for all opinions. If it is not possible to render an opinion without resorting to speculation, please provide an explanation as to why this is this case, and what additional evidence, if any, would make it feasible to render such an opinion. 3. Additionally, schedule the Veteran for a VA examination, with a physician (VA examiner) who has not yet evaluated the Veteran, for right shoulder conditions. The VA examiner must review a complete claims file and must note that review in the report. A copy of this REMAND must also be provided to the VA examiner. The VA examiner must undertake the following: a. Opine whether it is at least as likely as not (more than 50 percent probability) the Veteran s right shoulder disability is the result of an in-service injury, illness or event; was incurred in active service; and/or is otherwise related to his active service. b. Also, opine whether it is at least as likely as not the Veteran's right shoulder disability is aggravated by his service-connected low back disability. "Aggravation" means an increase in severity of the disorder beyond any medically established baseline. c. In rendering all opinions, please consider all lay statements from the Veteran, especially including lay statements from his April 2020 videoconference hearing about his related in-service accident and injury. d. The VA examiner is reminded that reliance on the lack of complaints, treatment, or a diagnosis of a condition in service treatment records or other medical treatment records is an insufficient rationale for finding a lack of a causal relationship between the Veteran's service and his current disability or a service-connected disability. e. A detailed explanation is requested for all opinions. If it is not possible to render an opinion without resorting to speculation, please provide an explanation as to why this is this case, and what additional evidence, if any, would make it feasible to render such an opinion. M. Tenner Veterans Law Judge Board of Veterans' Appeals Attorney for the Board V-N. Pratt, 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.