Relying on an inadequate VA exam, Board erred when it denied an increased rating for a low back disability
Inadequate Medical Exams for Low Back Disability
The Court held that the Board clearly erred when it relied on two inadequate VA examinations to deny an increased rating for a low back disability. A May 2014 examination was inconsistent where it noted that flare-ups did not cause further loss of range of motion. However the exam also indicated that there was functional loss described as pain on movement and less movement than normal.
A December 2009 examination was inadequate because it did not adequately address the Appellant’s functional impairment due to flare-ups. The 2009 examination purported to address both the Appellant’s flare-ups and limitations of motion from repetitive use, but the examination did not detail limitation of motion during flare-ups as required by this Court’s holding in Mitchell v. Shinseki, 25 Vet.App. 32, 38 (2011). Instead, the examiner only opined that there was no additional limitation stemming from repetitive use.
The Court agreed that the 2009 exam was inadequate due to it not addressing functional impairment due to flareups. It also agreed that the 2014 exam was internally inconsistent, and thus inadequate. Thus, the Court vacated the Board’s decision and remanded the case for a new medical opinion to address these issues.
Click here to read the Court’s decision.