Citation Nr: 23019746
Decision Date: 03/30/23	Archive Date: 03/30/23

DOCKET NO. 10-48 923
DATE: March 30, 2023

REMANDED

Entitlement to a rating in excess of 20 percent for chronic myofascial pain, right shoulder with arthritis is remanded.

Entitlement to a rating in excess of 20 percent for chronic myofascial pain, left shoulder with arthritis is remanded.

REASONS FOR REMAND

The Veteran served on active duty from March 1980 to December 1991.

These matters come before the Board of Veterans' Appeals (Board) on appeal from a May 2010 rating decision issued by a Regional Office (RO) of the United States Department of Veterans Affairs (VA).

The claims currently before the Board were most recently remanded in an August 2022 Board decision for new examinations. The claims now return to the Board after completed development. 

1. Entitlement to a rating in excess of 20 percent for chronic myofascial pain, right shoulder with arthritis is remanded.

2. Entitlement to a rating in excess of 20 percent for chronic myofascial pain, left shoulder with arthritis is remanded.

After review of the claims file, the Board finds that proper documentation of attempts to contact the Veteran are not in the file. As a result, the claims should be remanded in order to schedule a new examination.

In the Board's August 2022 remand, the Board requested new examinations be conducted for the Veteran. Review of the claims file indicates that examination orders were submitted in August 2022 and October 2022 for new examinations. In November 2022, the site cancelled the claim but did not provide a reason. In November 2022 and December 2022, VA contacted the Veteran to reschedule the examinations as the private contractor was unable to contact the Veteran.

The Board concludes that the documentation is inadequate. Here, VA did not submit contemporaneous documentation of their attempts to contact the Veteran. 

Further, the August 2022 and October 2022 examination orders indicate that the Veteran did not need to attend the examinations. If this is the case, the Board is confused as to why an opinion was not obtained.

As such, the Board finds good cause to reschedule the examinations. Any future attempts to contact the Veteran must be contemporaneously documented in the claims file.

The matters are REMANDED for the following action:

1. Schedule the Veteran for a new VA examination to determine the current severity of her chronic myofascial pain in the left and right shoulders.

Any attempts to schedule the Veteran for a VA examination must be documented in the claims file. If the Veteran does not need to report for the examination, the examiner must conduct the examination and file all necessary medical reports.

The VA examination must be conducted by a VA examiner of appropriate expertise. The examiner must review the claims file and must note that review in the report.  All necessary tests and studies should be accomplished, and all clinical findings reported in detail. The VA examiner must undertake the following:

(a.) Specifically indicate whether motion of either arm is limited to 25 degrees from the side, midway between the side and shoulder level, or at shoulder level.

(b.) Determine whether the Veteran's service-connected shoulder disabilities result in any additional loss of motion due to weakness, excess fatigability, pain, flare-ups, or incoordination.

A complete rationale for any opinion expressed should be provided in a report.

 

 

Melanie J. Mann

Veterans Law Judge

Board of Veterans' Appeals

Attorney for the Board	Jonah Nelson

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.