Entitlement to an initial rating for spondylosis and degenerative joint disease, lumbosacral spine, in excess of 10 percent, prior to March 15, 2022, and in excess of 20 percent thereafter, is remanded.

Citation Nr: 26001424 Decision Date: 01/30/26 Archive Date: 01/30/26 DOCKET NO. 17-20 549 DATE: January 30, 2026 REMANDED Entitlement to an initial rating for spondylosis and degenerative joint disease, lumbosacral spine, in excess of 10 percent, prior to March 15, 2022, and in excess of 20 percent thereafter, is remanded. Entitlement to an initial rating for cervical strain with degenerative disc disease with spinal stenosis in excess of 10 percent, prior to September 14, 2016, in excess of 20 percent from September 14, 2016, to March 2, 2022, and in excess of 30 percent from March 3, 2022, is remanded. Entitlement to an initial rating in excess of 10 percent disabling for left lower extremity femoral radiculopathy associated with spondylosis and degenerative joint disease, lumbosacral spine, is remanded. Entitlement to an initial rating in excess of 10 percent disabling for left lower extremity sciatic radiculopathy associated with spondylosis and degenerative joint disease, lumbosacral spine, is remanded. Entitlement to an initial rating in excess of 10 percent disabling for right lower extremity femoral radiculopathy associated with spondylosis and degenerative joint disease, lumbosacral spine, is remanded. Entitlement to an initial rating in excess of 10 percent disabling for right lower extremity sciatic radiculopathy associated with spondylosis and degenerative joint disease, lumbosacral spine, is remanded. REASONS FOR REMAND The Veteran served on active duty in the United States Navy from November 1988 to August 2004 and in the United States Air Force from April 2008 to May 2014, with service in Kuwait, Djibouti, and Afghanistan. See VA Memo received December 2022. His awards and decorations include the Sea Service Deployment Ribbon, Overseas Service Ribbon, Combat Action Ribbon, and Air Force Combat Action Medal. The Board of Veterans' Appeals (Board) sincerely thanks the Veteran for his service to our country. This matter comes before the Board from a September 2014 (with notification in October 2014) rating decision issued by a Department of Veterans Affairs (VA) Regional Office, known as the agency of original jurisdiction (AOJ). In August 2020, the Veteran testified at a virtual Hearing before the undersigned Veterans Law Judge (VLJ). A transcript of the hearing is associated with the record. This case was previously before the Board in March 2021, March 2023, and March 2024. Most recently, in the March 2024 Board decision, the Board remanded the remaining issues for additional development. The case has now returned to the Board for further appellate review. 1. Entitlement to an initial rating for spondylosis and degenerative joint disease, lumbosacral spine, in excess of 10 percent, prior to March 15, 2022, and in excess of 20 percent thereafter, is remanded. 2. Entitlement to an initial rating for cervical strain with degenerative disc disease with spinal stenosis in excess of 10 percent, prior to September 14, 2016, in excess of 20 percent from September 14, 2016, to March 2, 2022, and in excess of 30 percent from March 3, 2022, is remanded. 3. Entitlement to an initial rating in excess of 10 percent disabling for left lower extremity femoral radiculopathy associated with spondylosis and degenerative joint disease, lumbosacral spine, is remanded. 4. Entitlement to an initial rating in excess of 10 percent disabling for left lower extremity sciatic radiculopathy associated with spondylosis and degenerative joint disease, lumbosacral spine, is remanded. 5. Entitlement to an initial rating in excess of 10 percent disabling for right lower extremity femoral radiculopathy associated with spondylosis and degenerative joint disease, lumbosacral spine, is remanded. 6. Entitlement to an initial rating in excess of 10 percent disabling for right lower extremity sciatic radiculopathy associated with spondylosis and degenerative joint disease, lumbosacral spine, is remanded. The Board recognizes the time that the Veteran has devoted to this appeal process and appreciates his patience. The Board has sought to identify the specific and limited reasons that a new remand is necessary; this remand is the result of developments that occurred after the prior Board remand. Specifically, in the March 2024 Board decision, the Board remanded the Veteran's service-connected cervical strain with degenerative disc disease with spinal stenosis in part to obtain an examination to determine the current severity and manifestations of his cervical spine disability, as he underwent an anterior cervical discectomy and fusion (ACDF) in June 2022. The record indicates that an examination request was input by the AOJ in August 2024. However, the Veteran was unavailable for an examination at that time. See exam request received September 2024. Accordingly, a new examination request was input by the AOJ in November 2024. The Veterans Benefits Management System (VBMS) exams tab indicates the new examination was scheduled for November 22, 2024. However, an exam scheduling request contention cancellation, dated November 25, 2024, documents the Veteran did not attend the examination. See exam request received November 2024. The Board notes that the record includes VA treatment records, received the same day as the most recent Supplemental Statement of the Case (SSOC), which indicate the Veteran underwent a bilateral total hip arthroplasty at a non-VA facility on November 12, 2024. See VA treatment records received December 2024. While the record does not include the operative report or other information related to the downtime needed after the surgery, the Board notes the examination was scheduled only 10 days after his bilateral hip surgery. VA has a duty to assist a claimant in obtaining a medical examination and/or medical opinion when necessary to decide a claim. 38 C.F.R. § 3.159(c)(4). When entitlement or continued entitlement to a benefit cannot be established or confirmed without a current VA examination or reexamination, and a claimant, without good cause, fails to report for such examination, action shall be determined under 38 C.F.R. § 3.655. Examples of good cause include, but are not limited to, the illness or hospitalization of the claimant, death of an immediate family member, etc. 38 C.F.R. § 3.655(a). Based on the above-noted facts, it appears the Veteran had good cause for not attending the VA examination, as the record indicates the Veteran underwent bilateral hip surgery only 10 days prior to the examination date. Therefore, a remand is necessary to provide the Veteran with an opportunity to report for a new VA examination for his service-connected cervical strain with degenerative disc disease with spinal stenosis. Furthermore, in the March 2024 Board decision, the Board also remanded the Veteran's service-connected spondylosis and degenerative joint disease, lumbosacral spine; left lower extremity femoral radiculopathy; left lower extremity sciatic radiculopathy, right lower extremity femoral radiculopathy, and right lower extremity sciatic radiculopathy to obtain relevant medical records, including chiropractic treatment records. The Board notes that those records were obtained and indicate that the Veteran received treatment for his service-connected back disability and bilateral lumbar radiculopathy in conjunction with his bilateral hip pain. See treatment records received March 2024. However, despite the record indicating related treatment between the conditions, the record does not document that the AOJ contacted the Veteran to request a release to obtain the medical records from Renown South Meadows for his bilateral hip arthroscopy in November 2024 or Reno Orthopedic Clinic for treatment for his bilateral hips in October 2024 prior to the December 2024 SSOC. See 38 C.F.R. § 3.159(e)(2) (if VA becomes aware of the existence of relevant records before deciding a claim, VA will, among other things, request that the claimant provide a release for the records); see also VA treatment records received December 2024. As these records are not associated with the Veteran's claims file but may be relevant to this claim, a remand is required to allow VA to obtain authorization and request these records. Finally, VA treatment records, received December 2024, document community care orthopedic consult results were scanned into VistA on October 31, 2024; November 8, 2024, and November 14, 2024. However, the referenced records are not available for review in the claims file. As these records are also not associated with the Veteran's claims file but may be relevant to this claim, a remand is needed to print and upload these records into the Veteran's claims file. The matters are REMANDED for the following action: 1. As the Board does not have access to VistA or other systems where scanned records reside, please print out the community care orthopedic consult results, as documented in the October 31, 2024; November 8, 2024, and November 14, 2024, VA Medical Center treatment records, and upload these records into VBMS (so as to enable Board review and to include it in the claims file/VBMS). 2. Send the Veteran VA Forms 21-4142 and 21-4142a to obtain the authorization and information needed to request the private treatment records identified below. The Veteran should also be advised that he may associate the records with his VA claims file himself. (a.) October 2024 treatment records from Reno Orthopedic Clinic for his bilateral hips; and (b.) November 2024 records from Renown South Meadows related to his bilateral hip arthroscopy. Make two requests for the authorized records from any adequately identified medical provider, unless it is clear after the first request that a second request would be futile. The Veteran is advised that in completing the VA Form 21-4142a, he must adequately identify each medical provider (including providing a complete address) in order for VA to make a request for any records on his behalf. If any identified and requested records are not available, or if the search for any such records otherwise yields negative results, that fact should clearly be documented in the file, and the Veteran should be informed in writing. 3. Please schedule the Veteran for an examination by an appropriate clinician to determine the current severity of his service-connected cervical strain with degenerative disc disease with spinal stenosis, status post anterior cervical discectomy and fusion in June 2022. 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. In so doing, the examiner must test the Veteran's active motion, passive motion, and pain with weight-bearing and without weight-bearing. If it is not possible to provide a specific measurement without speculation, the examiner must state whether the need to speculate is due to a deficiency in the state of general medical knowledge (no one could respond given medical science and the known facts), a deficiency in the record (additional facts are required), or the examiner (does not have the knowledge or training). The examiner must also 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 based on the other evidence of record and the Veteran's statements. If it is not possible to provide a specific measurement without speculation, the examiner must state whether the need to speculate is due to a deficiency in the state of general medical knowledge (no one could respond given medical science and the known facts), a deficiency in the record (additional facts are required), or the examiner (does not have the knowledge or training). 4. Then, after the foregoing development has been conducted, please readjudicate the issues on appeal with consideration of all evidence received since the issuance of the December 2024 SSOC. If any benefit sought on appeal is not granted, the Veteran and his representative must be furnished a new SSOC that considers all of the evidence added to the record since the December 2024 SSOC and afforded the appropriate time period for response. M. C. GRAHAM Veterans Law Judge Board of Veterans' Appeals Attorney for the Board S. Black, 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.