Citation Nr: 22047167 Decision Date: 08/19/22 Archive Date: 08/19/22 DOCKET NO. 20-22 967 DATE: August 19, 2022 REMANDED Entitlement to a certificate of eligibility for specially adapted housing (SAH) is remanded. Entitlement to a certificate of eligibility for a special home adaptation (SHA) grant is remanded. REASONS FOR REMAND The Veteran served on active duty in the United States Army from July 1978 to August 1992. These matters come before the Board of Veterans' Appeals (Board) on appeal from a May 2018 rating decision issued by a Department of Veterans Affairs (VA) regional office. In April 2022, the Veteran testified via video conference before the undersigned Veterans Law Judge (VLJ). A copy of the hearing transcript has been associated with the claims file. 1. Entitlement to a certificate of eligibility for SAH is remanded. 2. Entitlement to a certificate of eligibility for an SHA grant is remanded. The Board regrets the delay associated with this remand. However, based on a review of the evidence of record, the Board finds that a remand is necessary to allow the Agency of Original Jurisdiction (AOJ) to conduct additional development. First, a remand is necessary as the evidence indicates that there may be pertinent private medical records, of which VA is aware, that are not associated with the claims file. The record indicates that the Veteran receives treatment at Penrose St. Francis Hospital. However, records relating to such treatment have not been associated with the claims file since April 2012. See Penrose St. Francis Hospital records, received September 2010, February 2012, and April 2012. The record also indicates that the Veteran receives treatment from Colorado Springs Neurological Associates through the Veterans CHOICE program; no records relating to such treatment have been associated with the claims file, nor is there any indication that such records have been requested. See Denver VA Medical Center (VAMC) records, received August 2019 and March 2020 in CAPRI; May 2022 CSNA Correspondence. As such, a remand is necessary to allow the AOJ to attempt to obtain pertinent private medical records. See 38 U.S.C. § 5103(a)(1), (b)(1); Ivey v. Derwinski, 2 Vet. App. 320, 323 (1992). Second, a remand is necessary to allow the AOJ to obtain an opinion regarding the extent to which the Veteran's service-connected disabilities result in loss of use of the upper or lower extremities, affect the functions or balance and propulsion, or preclude locomotion without the aids of braces, crutches canes, or a wheelchair. The Board acknowledges that, in VA examinations conducted in September 2019, the examiner noted that the Veteran's service-connected right knee condition necessitated the regular use of a brace, cane, walker, and wheelchair for ambulation and that his heart condition precluded walking more than an eighth of a mile at a time. See September 2019 VA Heart Conditions Disability Benefits Questionnaire (DBQ); September 2019 VA Knee and Lower Leg Conditions DBQ. However, the record indicates that the Veteran may experience loss of use of his lower extremities due to diabetes with associated peripheral neuropathy, arthritis of the feet, arthritis of the left knee, and cervical myelopathy. See Denver VAMC records; May 2022 CSNA Correspondence Further, as discussed above, the record indicates that pertinent private medical records have not been associated the claims file. As such, the September 2019 examinations are inadequate to the extent the extent the examiner was unable to consider the Veteran's prior medical history. See Stefl v. Nicholson, 21 Vet. App. 303, 312 (2007). Thus, the Board finds that the record is unclear the extent to which the Veteran's service-connected disabilities result in loss of use of the upper or lower extremities, affect the functions or balance and propulsion, or preclude locomotion without the aids of braces, crutches canes, or a wheelchair. Therefore, a remand is necessary to afford the Veteran with an examination to assess the severity of and functional limitations caused by his relevant service-connected conditions. Lastly, the Board notes that the record indicates that the Veteran may experience loss of use of his lower extremities due to diabetes with associated peripheral neuropathy, arthritis of the feet, arthritis of the left knee, and cervical myelopathy. See Denver VAMC records; May 2022 CSNA Correspondence. The Board also notes that entitlement to service connection for diabetes and a neck condition were denied in a February 2005 rating decision, service connection for a left foot condition was denied in a November 2007 rating decision, and service connection for a left knee condition and a right foot condition were denied in a May 2013 rating decision. If the Veteran believes that such conditions are related to his service, or are secondary to a service-connected condition, he is encouraged to submit a supplemental claim, along with new and relevant evidence, seeking readjudication of such claims. Accordingly, the matters are REMANDED for the following action: 1. With the Veteran's assistance as appropriate, obtain and associate with the claims file any outstanding pertinent medical records, whether VA or private, to include records relating to treatment at Penrose St. Francis Hospital, CSNA, and records relating to treatment through the Veterans CHOCIE program, as well as records relating to treatment at Denver VAMC from March 2020 to current. 2. After completing the development above, and any additional development warranted by the record, obtain an opinion from an appropriate clinician regarding the severity of the Veteran's service-connected conditions and the impact of such conditions upon his activities of daily living for the purpose of determining his eligibility for SAH or an SHA grant. The entire claims file must be provided to, and reviewed by, the examiner. If the examiner determines it to be necessary, an examination should be scheduled, and any indicated tests, studies, or evaluations should be performed. The examiner is asked to: (a.) If an examination is conducted, obtain the Veteran's detailed lay history. If the examiner described flare-ups, the examiner must elicit information regarding the severity, frequency, and duration thereof. (b.) Provide a full description of the Veteran's service-connected conditions and indicate the extent to which such conditions: result in loss of use of the upper or lower extremities; preclude locomotion without the aid of braces, crutches, canes, or a wheelchair; and/or affect the functions of balance and propulsion. (c.) In formulating the requested opinions, the examiner is instructed to consider and specifically address: i. The Veteran's lay history; ii. The Veteran's April 2022 testimony that his service-connected conditions, together, result in balance and propulsion issues, rendering it difficult to ambulate. iii. The Veteran's VA treatment records, indicating that he utilizes an electric scooter for ambulation due to peripheral neuropathy and arthritis of the knees and feet; and iv. The May 2022 correspondence from CSNA, indicating that the Veteran experiences loss of use of his upper and lower extremities due to cervical spine conditions. The term "preclude locomotion" means the necessity for regular and constant use of a wheelchair, braces, crutches, or canes as a normal mode of locomotion, though occasional locomotion by other methods may be possible. Any opinion expressed by the examiner should be accompanied by a complete rationale. If medical literature is relied upon in rendering a determination, the examiner should identify and specifically cite each reference material utilized. If the examiner is unable to offer an opinion without resort to speculation, a thorough explanation as to why an opinion cannot be rendered should be provided. The examiner is reminded that the Veteran is competent to report symptoms, treatment, and injuries, and that his reports must be taken into account in formulating the requested opinions. 3. The AOJ must review the claims file and ensure that the foregoing development action has been completed in full. If any development is incomplete, appropriate corrective action must be implemented. If any report does not include adequate responses to the specific opinions requested, it must be returned to the providing examiner for corrective action. T. MAINELLI Veterans Law Judge Board of Veterans' Appeals Attorney for the Board J. T. Martin III, 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.