Citation Nr: A26007202 Decision Date: 01/27/26 Archive Date: 01/27/26 DOCKET NO. 230103-313131 DATE: January 27, 2026 REMANDED Entitlement to an initial disability rating in excess of 10 percent for service-connected cervical strain is remanded. Entitlement to an initial, compensable disability rating for service-connected posttraumatic headaches is remanded. Entitlement to service connection for left arm radiculopathy as secondary to service-connected cervical strain is remanded. Entitlement to service connection for right arm radiculopathy as secondary to service-connected cervical strain is remanded. REASONS FOR REMAND The Veteran served on active duty from November 2005 to February 2007. This matter comes before the Board of Veterans' Appeals (Board) on appeal from an October 2022 Appeals Modernization Act (AMA) rating decision by the Agency of Original Jurisdiction (AOJ) that considered the evidence of record on that date. In January 2023, the Veteran submitted a VA Form 10182 electing Evidence Submission Reviewed by a Veterans Law Judge as the review option. Based on the Veteran's election, the Board may only consider the evidence of record at the time of the October 2022 rating decision, as well as any evidence submitted by the Veteran, or his representative, with, or within 90 days from receipt of, the VA Form 10182. 38 C.F.R. § 20.303. Any additional evidence associated with the claims file during a period of time when additional evidence was not allowed has not been considered. If the Veteran would like VA to consider any evidence that was added to the claims file that the Board could not consider, the Veteran may file a Supplemental Claim (VA Form 20-0995) and submit or identify this evidence. 38 C.F.R. § 3.2501. If the evidence is new and relevant, VA will issue another decision on the claim, considering the new evidence in addition to the evidence previously considered. Id. Specific instructions for filing a Supplemental Claim are included with this decision. However, because the Board is remanding the claims, any evidence the Board could not consider will be considered by the AOJ in the adjudication of the claims. 38 C.F.R. § 3.103(c)(2)(ii). 1. Entitlement to an initial disability rating in excess of 10 percent for service-connected cervical strain is remanded. 2. Entitlement to an initial, compensable disability rating for service-connected posttraumatic headache is remanded. Under the AMA, if a duty to assist error occurred prior to the AOJ's decision on appeal, the appeal must be remanded to the AOJ for correction of the error. 38 C.F.R. § 20.802(a). When VA undertakes to provide a VA examination or obtain a VA opinion pursuant to the duty to assist, it must ensure that the examination or opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). The Veteran underwent VA examinations for his service-connected cervical strain and posttraumatic headaches in October 2022. The Board finds the October 2022 VA examinations inadequate to make an informed decision, requiring remand. In reporting the severity of the Veteran's claimed disabilities, the examiner did not address whether his symptoms would be more severe if the Veteran were not taking medication. In this regard, the Veteran reported that he takes Ibuprofen to treat both of his claimed conditions. See October 2022 VA Examination. VA may not deny a higher rating on the basis of relief provided by medication when the ameliorative effects of medication are not contemplated by the rating criteria. Jones v. Shinseki, 26 Vet. App. 56, 63 (2012); Ingram v. Collins, 38 Vet. App. 130 (2025) ("VA may not evaluate a disability by relying on factors outside the rating criteria, such as the beneficial effects of medication when medication is not mentioned or contemplated by the rating criteria."). Accordingly, because the examinations are not adequate to make an informed determination on that issue, remand is warranted to correct the AOJ's error in satisfying VA's duty to provide an adequate examination, as the error occurred prior to the decision on appeal. 3. Entitlement to service connection for left arm radiculopathy is remanded. 4. Entitlement to service connection for right arm radiculopathy is remanded. On VA Cervical Spine conditions examination in October 2022, in regard to the findings of decreased sensation to light touch on the medial aspect of the Veteran's bilateral upper extremities, the examiner stated that there was insufficient data in the file to provide definitive diagnosis or pathology. In addition, the examiner stated that "There are no further diagnostics (such as EMG/NCV, C-spine MRI, or labs) or documentation available to validate. Thus, there is no evidence or way to determine etiology without resorting to mere speculation. Veteran needs referral for further work-up and ongoing management." In short, the VA examiner indicated that diagnostic testing was required to determine the etiology of the Veteran's neurological symptoms in his upper extremities and that further work up was required; however, no diagnostic testing was completed. As such, a remand for an additional examination with appropriate diagnostic testing is required. The matters are REMANDED for the following action: 1. Schedule the Veteran for an examination by an appropriate clinician to determine the severity of his service-connected cervical strain. 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. The examiner should clarify whether the x-ray findings of mid lower cervical spondylosis and probable degenerative facet changes are part and parcel of, or related to, his service-connected cervical spine disability. See x-ray dated October 19, 2022. (a.) The examiner must test the Veteran's active motion, passive motion, and pain with weight-bearing and without weight-bearing. (b.) The examiner must attempt to elicit information regarding the severity, frequency, and duration of any flare-ups, and the degree of functional loss during flare-ups. If it is not possible to provide a specific measurement based on direct observation, the examiner should provide an estimate, if at all possible, of the additional impairment due to flare-ups and after repeated use over time based on the other evidence of record and the Veteran's statements. (c.) If the Veteran were not benefitting from the ameliorative effects of medication, would his range of motion be further reduced? If so, the examiner is asked to provide an estimate, to the extent possible, of what the range of motion would be if his symptoms were not alleviated by medication, to include whether the equivalent of unfavorable ankylosis would be present. In this regard, the Veteran takes Ibuprofen to treat his service-connected cervical strain. A complete rationale must be given for all opinions and conclusions expressed. 2. Schedule the Veteran for an examination by an appropriate clinician to determine the diagnosis and etiology of any neurological condition of the upper extremities. Appropriate diagnostic testing must be completed, in accordance with the VA examiner's statement in October 2022. After review of the claims file, the examiner must provide opinions on the following: (a.) Identify all neurological disorders of the Veteran's upper extremities. (b.) Whether it is at least as likely as not (likelihood is at least approximately balanced or nearly equal, if not higher) that any current neurological disorder of the Veteran's upper extremities was (i) caused (in whole or in part) by, or is/was (ii) aggravated by his service-connected cervical spine disorder. NOTE: The examiner is advised that a "permanent worsening" is not required to establish aggravation. Aggravation may include temporary worsening, or flare-ups, of a disability. A complete rationale must be given for all opinions and conclusions expressed. 3. Schedule the Veteran for an examination by an appropriate clinician to determine the severity of his service-connected posttraumatic headaches. 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. If the Veteran were not benefitting from the ameliorative effects of medication, would his posttraumatic headache symptoms be more severe? If so, the examiner is asked to provide an estimate, to the extent possible, of the frequency and severity of his posttraumatic headaches if his symptoms were not alleviated by medication. In this regard, the Veteran takes Ibuprofen to treat his service-connected posttraumatic headache disability. A complete rationale must be given for all opinions and conclusions expressed. P.M. DILORENZO Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Mohammad, Tahmina 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.