Citation Nr: 22017182 Decision Date: 03/24/22 Archive Date: 03/24/22 DOCKET NO. 16-14 464 DATE: March 24, 2022 REMANDED Entitlement to an initial rating in excess of 10 percent for degenerative arthritis of the spine is remanded. REASONS FOR REMAND The Veteran served on active duty from January 2000 to April 2000, from October 2001 to October 2002, from August 2003 to August 2004, and from April 2013 to March 2014. This matter comes to the Board of Veterans' Appeals (Board) on appeal from an April 2015 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO). In May 2019, the Veteran testified at a hearing before the undersigned Veterans Law Judge; a transcript has now been associated with the claims folder. The Board remanded the appeal in November 2020 and September 2021. REMAND In the September 2021 remand, the Board directed that the RO should obtain an authorization from the Veteran for private treatment records relating to Dr. Celestin or Reliant Orthopedics. In an October 2021 development letter, the RO requested that the Veteran submit an authorization for those records. In the December 2021 supplemental statement of the case, the RO noted that there was no response to this letter. In January 2022 correspondence the Veteran indicated that he submitted the requested authorization in an e-mail. The completed authorization form is not associated with the claims file; thus, a remand is necessary to allow the RO to locate the authorization or obtain a new authorization for these records. Furthermore, the January 2022 correspondence included a letter from Ready Med which indicated that they had recently treated the Veteran. A remand is required to allow VA to obtain authorization and request records from this facility. Finally, in the correspondence, the Veteran indicated that his disability has "changed/increased to a compression fracture with protruding disk above the fracture and a bulging disk below the fracture.' He also reported numbness and tingling in the upper extremities. This statement suggests that the Veteran's disability has worsened since his last VA examination in June 2019. As such, a VA examination to ascertain the current severity of the Veteran's degenerative arthritis of the spine is necessary. The Veteran reported that he is currently on active duty and is out of the country. If possible, the Veteran's current service treatment records should be obtained. The matter is REMANDED for the following action: 1. If available, obtain the Veteran's updated and/or recent service treatment records. Document all requests for information as well as all responses in the claims file. 2. If the RO is unable to locate a recently completed VA Form 21-4142 from for Dr. Celestin or Reliant Orthopedics, then ask the Veteran to complete a new VA Form 21-4142 for Dr. Celestin or Reliant Orthopedics, Ready Med, and any clinician or facility who has treated the Veteran's spine disability. Make two requests for the authorized records, unless it is clear 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 degenerative arthritis of the spine. a) If the Veteran is currently on active duty AND deployed, schedule the Veteran for VA examinations or examination by military physician, upon his return stateside. If the Veteran is currently on active duty stateside or currently a civilian, schedule to the Veteran for VA examinations, or alternatively by a military provider. b) 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. In so doing, the examiner must test the Veteran's active motion, passive motion, and pain with weight-bearing and without weight-bearing. The results should reflect ranges of motion in each state. The examiner must also attempt to elicit information regarding the severity, frequency, and duration of any flare-ups, and the degree of functional loss during flare-ups or with repeated use over time. The functional loss should be expressed in ranges of motion. 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). D. JOHNSON Veterans Law Judge Board of Veterans' Appeals Attorney for the Board K. Vuong, 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.