Citation Nr: 22017245
Decision Date: 03/24/22	Archive Date: 03/24/22

DOCKET NO. 17-55 172
DATE: March 24, 2022

REMANDED

Entitlement to a disability rating in excess of 30 percent from April 21, 2014, to September 10, 2014, and in excess of 40 percent from September 11, 2014, for recurrent dislocation of the right shoulder with arthritis is remanded.

REASONS FOR REMAND

In November 2020, the Board remanded the issues of entitlement to service connection for left shoulder dislocation, and entitlement to increased disability ratings for recurrent dislocation of the right shoulder with degenerative arthritis for further development.  In a March 2021 rating decision, entitlement to service connection for left shoulder degenerative arthritis was granted.

Evidence indicates there may be outstanding private treatment records associated with the Veteran's VA treatment records.  An August 2018 VA Community Care Consult Result note stated the Veteran was seen at Layton Physical Therapy regarding complaints of pain in the right shoulder, the plan of care was two visits per week for four weeks, and that attached medical records should be seen for full details.  However, medical records from Layton Physical Therapy are not associated with the evidentiary record.  A remand is required to allow VA to obtain them.

On remand, the Veteran should also clarify whether he has had further surgery on his right shoulder.  An April 2019 Dr. J.H.W. progress note included a recommendation for reverse shoulder replacement, and stated the Veteran was agreeable.  Upon the February 2021 VA examination, the examiner stated in the diagnosis section of the Disability Benefits Questionnaire the Veteran is status post right shoulder reverse arthroplasty.  However, the examiner later listed the Veteran's only surgical procedure on the right shoulder as the 1978 stabilization.  On remand, VA should obtain clarification from the Veteran, and obtain authorization and request any records related to any further right shoulder surgical procedures.

The matter is REMANDED for the following action:

1. Obtain any treatment records from Layton Physical Therapy associated with the Veteran's VA treatment records, and updated VA treatment records from November 2020 to the present.

2. Ask the Veteran to complete a VA Form 21-4142 for Layton Physical Therapy, and for any other private treatment and/or surgical procedure(s) for his right shoulder from April 2019 to the present.  Make two requests for authorized records from each identified provider, unless it is clear after the first request that a second request would be futile.

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3. After the above development, and any additionally indicated development, has been completed, readjudicate the issue on appeal.  If the benefit sought is not granted to the Veteran's satisfaction, send the Veteran a Supplemental Statement of the Case and provide an opportunity to respond.  If necessary, return the case to the Board for further appellate review.

 

 

David Gratz

Veterans Law Judge

Board of Veterans' Appeals

Attorney for the Board	S. M. Cooney, 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.