Citation Nr: 22017935 Decision Date: 03/27/22 Archive Date: 03/27/22 DOCKET NO. 17-56 536 DATE: March 27, 2022 REMANDED Entitlement to a disability rating in excess of 20 percent from November 29, 2011, and 40 percent from January 27, 2020, for spondylosis with intervertebral disc syndrome (IVDS), lumbar spine, is remanded. REASONS FOR REMAND The Veteran served on active duty from October 1983 to August 1993 and from September 1993 to August 2008. This matter comes to the Board of Veterans' Appeals (Board) on appeal from a May 2013 rating decision issued by the Department of Veterans' Affairs (VA) Regional Office (RO) in Houston, Texas. The Board previously remanded this claim in April 2019 for additional development. Unfortunately, as will be discussed in more detail below, remand is again necessary to ensure substantial compliance with the April 2019 remand directives and that the Veteran is afforded an adequate examination. See Stegall v. West, 11 Vet. App. 268, 271 (1998). Entitlement to a disability rating in excess of 20 percent from November 29, 2011, and 40 percent from January 27, 2020, for spondylosis with IVDS, lumbar spine, is remanded. The Veteran contends his lumbar spine disability symptoms warrant a higher disability rating. The Board finds remand is necessary to ensure substantial compliance with the April 2019 remand directives. Specifically, the RO was directed to obtain any identified outstanding private treatment records for which the Veteran provides authorization. Upon review, in response to the RO's inquiry, the Veteran identified treatment with CPM Consultants in Pain Medication (CPM), South Texas Arthritis Care Center, and Texas Neurosurgical Spine. Treatment records from CPM have since been added to the claims file. The record, however, lacks any treatment records or documented attempts to obtain said records from South Texas Arthritis Care Center or Texas Neurosurgical Spine. As such, remand is necessary to ensure substantial compliance with the April 2019 remand directives by attempting to obtain these identified private treatment records. Additionally, the Veteran was afforded a VA examination in January 2020 during which the examiner opined that he did not have left lower extremity radiculopathy. Upon review, however, 2015 and 2019 treatment records reference complaints of numbness and pain in both lower extremities that remain unaddressed. Thus, an addendum opinion is necessary for consideration of these treatment records. Based on the above, remand is necessary to complete the previously directed development and obtain an addendum opinion. The matters are REMANDED for the following action: 1. Obtain all outstanding treatment records from both South Texas Arthritis Care Center and Texas Neurosurgical Spine as authorized by the Veteran. At least two attempts to obtain these records should be documented in the claims file. If any such records are unavailable, the Veteran should be so informed and given the opportunity to submit said records. 2. After the above development, return the entire claims file and this remand to the January 2020 VA examiner, if available, or to another appropriate examiner for review. The examiner should provide an addendum opinion as to whether the Veteran has left lower extremity radiculopathy. The necessity of an in-person examination is left to the examiner's discretion. In so opining, the examiner is directed to address and consider treatment records in 2015 and 2019 noting complaints of left lower extremity numbness and pain. The examiner must provide a complete rationale for any opinion expressed, based on the examiner's clinical and medical expertise; established medical principles; and references to the evidence of record, as appropriate. If any opinion cannot be expressed without resorting to speculation, ensure that the examiner so indicates and discusses why an opinion is not possible, to include whether there is additional evidence that could enable an opinion to be provided, or whether the inability to provide the opinion is based on the limits of medical knowledge. 3. After the above development, and any other development deemed necessary, readjudicate the claim. SHEREEN M. MARCUS Veterans Law Judge Board of Veterans' Appeals Attorney for the Board A.C. Allen, 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.