Citation Nr: 1800964 Decision Date: 01/08/18 Archive Date: 01/19/18 DOCKET NO. 12-32 440 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Boston, Massachusetts THE ISSUES 1. Entitlement to service connection for a low back disability, to include lumbar degenerative disc disease and lumbar arthritis. 2. Entitlement to a rating in excess of 20 percent for cervical degenerative disc disease with spondylosis. 3. Entitlement to a rating in excess of 20 percent for peripheral neuropathy of the left upper extremity, associated with cervical degenerative disc disease with spondylosis. 4. Entitlement to a separate rating for peripheral neuropathy of the right upper extremity, associated with cervical degenerative disc disease with spondylosis. REPRESENTATION Veteran represented by: Disabled American Veterans ATTORNEY FOR THE BOARD G. A. Ong, Associate Counsel INTRODUCTION The Veteran served on active duty from July 1974 to July 1977. This matter is before the Board of Veterans' Appeals (Board) on appeal from February 2006 and August 2013 rating decisions by the Department of Veterans Affairs (VA) Regional Office (RO) in Boston, Massachusetts. In May 2015, the Board remanded this matter for further evidentiary development. The VA examinations and Statement of the Case (SOC) having been provided, the directives have been substantially complied with and the matter again is before the Board. D'Aries v. Peake, 22 Vet. App. 97, 105 (2008); Stegall v. West, 11 Vet. App. 268, 271 (1998). When a Veteran files a claim for an increased rating, he is presumed to be seeking the maximum benefit under any applicable theory, including Total Disability Based Upon Individual Unemployability (TDIU). See generally Roberson v. Principi, 251 F.3d 1378 (Fed. Cir. 2001); Rice v. Shinseki, 22 Vet. App. 447 (2009). As noted in the prior Board remand, the Veteran is currently employed, and the Veteran has not argued, nor does the record reflect, that the service-connected disabilities render him unable to secure or follow a substantially gainful occupation. Accordingly, the Board concludes that a claim for a TDIU has not been raised. The issue of entitlement to additional compensation based upon dependent parent(s) was raised in a VA Form 21-509, Statement of Dependency of Parent(s), received in September 2013. The RO issued a decision in December 2016, granting additional dependency compensation benefits. The Board declines to take jurisdiction of this issue at this time because the electronic record reveals that development is ongoing at the AOJ. This matter is not currently developed for appellate review. This appeal is limited to the issues on the title page. This appeal was processed using the Veterans Benefits Management System (VBMS) and Virtual VA paperless claims processing systems. FINDINGS OF FACT 1. A low back disability, to include lumbar degenerative disc disease and lumbar arthritis, was not manifest during service or within one year of separation, and is not shown to be causally or etiologically related to an in-service event, injury or disease, or to have been caused or aggravated by another service-connected disability. 2. For the entire period on appeal, the Veteran's cervical degenerative disc disease with spondylosis has been manifested by forward flexion of the cervical spine greater than 15 degrees but not greater than 30 degrees; but not by forward flexion of the cervical spine to 15 degrees or less or favorable ankylosis of the entire cervical spine. 4. From October 4, 2005 forward, the Veteran's peripheral neuropathy of the left upper extremity has been manifested by no more than mild incomplete paralysis of the upper radicular nerve group. 4. From October 4, 2005 forward, the Veteran's peripheral neuropathy of the right upper extremity has been manifested by no more than mild incomplete paralysis of the upper radicular nerve group. CONCLUSIONS OF LAW 1. A low back disability, to include lumbar degenerative disc disease and lumbar arthritis, was not incurred in or aggravated by service. 38 U.S.C. §§ 1101, 1110, 1131, 1137, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.310 (2017). 2. The criteria for a rating in excess of 20 percent for cervical degenerative disc disease with spondylosis have not been met or approximated. 38 U.S.C. §§ 1155 (2012); 38 C.F.R. §§ 3.321, 4.1-4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5242 (2017). 3. From October 4, 2005 forward, peripheral neuropathy of the left upper extremity is no more than 20 percent disabling. 38 U.S.C. § 1155 (2012); 38 C.F.R. §§ 3.321, 4.1-4.7, 4.10, 4.124a, Diagnostic Code 8610 (2017). 4. From October 4, 2005 forward, peripheral neuropathy of the right upper extremity is no more than 20 percent disabling. 38 U.S.C. § 1155 (2012); 38 C.F.R. §§ 3.321, 4.1-4.7, 4.10, 4.124a, Diagnostic Code 8610 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Duty to Notify and Assist VA has a duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.326(a) (2017). The RO provided timely notice in its letter dated September 2013 that met the requirements. The notice included all criteria for service connection on both direct and secondary bases and an explanation of the Veteran's and VA's respective responsibilities to obtain relevant evidence. Dingess v. Nicholson, 19 Vet. App. 473, 490 (2006). Concerning the cervical degenerative disc disease with spondylosis and peripheral neuropathy of the left upper extremity, the appeal arises from the Veteran's disagreement with the evaluations following the grants of service connection. Once service connection is granted the claim is substantiated, additional notice is not required, and any defect in the notice is not prejudicial. Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007); Dunlap v. Nicholson, 21 Vet. App. 112 (2007). No additional discussion of the duty to notify is therefore required. In addition, the duty to assist the Veteran has also been satisfied in this case. The RO associated the Veteran's service and VA treatment records with the claims file. All released or submitted private treatment records have been associated with the claims file, including Workers' Compensation and United States Postal Service records. No other relevant records have been identified and are outstanding. As such, VA has satisfied its duty to assist with the procurement of relevant records. 38 U.S.C. § 5103A; 38 C.F.R. § 3.159(c). The duty to assist also includes providing a medical examination or obtaining a medical opinion when necessary to make a decision on a claim, as defined by law. See 38 C.F.R. § 3.159(c)(4). In this case, the Veteran was provided with VA examinations in March 1978, March 1982, May 2001, December 2005, January 2007, December 2009, March 2013, August 2013, and September 2015. In correspondence in September 2015, the Veteran contended that the most recent examination was not adequate because there was insufficient recognition of the effects of pain on movements and because the clinical tests did not include imaging studies. The Board finds that examinations were adequate because the examiners considered and addressed the Veteran's contentions including his reports of pain and dysfunction, conducted thorough examinations, reviewed the claims file, and provided sufficient supporting rationales for their opinions where necessary. The Veteran is not competent to determine whether imaging studies are necessary to evaluate the claimed disabilities, as this requires medical training. The examiners provided sufficient clinical observations for application to the rating criteria. Based on the foregoing, the Board finds the examination reports to be thorough, complete, and a sufficient basis upon which to reach a decision on the Veteran's service connection claim decided herein. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 302-05 (2008); Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). Since VA has obtained all relevant identified records and provided adequate medical examinations, its duty to assist in this case is satisfied. Hence, there is no error or issue that precludes the Board from addressing the merits of this appeal. II. Service Connection Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C. § 1101; 38 C.F.R. § 3.303(a). Generally, to establish service connection a Veteran must show: "(1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service." Davidson v. Shinseki, 581 F.3d 1313, 1315-16 (Fed. Cir. 2009); Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Service connection may also be granted for any injury or disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease or injury was incurred in service. 38 C.F.R. § 3.303(d). Service connection may also be warranted for disability proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310(a). This permits service connection not only for a disability caused by a service-connected disability, but for the degree of disability resulting from aggravation of a disability by a service-connected disability. See Allen v. Brown, 7 Vet. App. 439, 448 (1995). In the case of aggravation by a service-connected disability, a Veteran may be compensated for the degree of disability over and above the degree of disability existing prior to the aggravation. Id.; see also 38 C.F.R. § 3.310(b). Service connection may also be established for a current disability on the basis of a presumption that certain chronic diseases, to include arthritis, manifesting themselves to a certain degree within a certain time after service must have had their onset in service. 38 U.S.C. §§ 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.303, 3.307, 3.309(a). Generally, the disease must have manifested to a degree of 10 percent or more within one year of service. 38 C.F.R. § 3.307(a)(3). For the showing of chronic disease in service there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time, as distinguished from merely isolated findings or a diagnosis including the word "chronic." When the disease identity is established (leprosy, tuberculosis, multiple sclerosis, etc.), there is no requirement of evidentiary showing of continuity. Continuity of symptomatology is required only where the condition noted during service (or in the presumptive period) is not, in fact, shown to be chronic or where the diagnosis of chronicity may be legitimately questioned. When the fact of chronicity in service is not adequately supported, then a showing of continuity after discharge is required to support the claim. 38 CFR 3.303(b). Walker v. Shinseki, 708 F.3d 1331 (2013). VA is required to give due consideration to all pertinent medical and lay evidence in evaluating a claim for disability benefits. 38 U.S.C. § 1154(a). Lay evidence can be competent and sufficient to establish a diagnosis of a condition when (1) a layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). Lay evidence cannot be determined to be not credible merely because it is unaccompanied by contemporaneous medical evidence. Buchanan v. Nicholson, 451 F.3d 1331, 1336-37 (Fed. Cir. 2006). However, the lack of contemporaneous medical evidence can be considered and weighed against a Veteran's lay statements. Id. Further, a negative inference may be drawn from the absence of complaints or treatment for an extended period. Maxson v. West, 12 Vet. App. 453, 459 (1999), aff'd sub nom. Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000). The Veteran contends he is entitled to service connection for a low back disability. The record reflects the Veteran has current diagnoses of lumbar degenerative disc disease and lumbar arthritis. Concerning the in-service event, injury or disease, however, the medical evidence does not show that his lumbar degenerative disc disease and lumbar arthritis had their onset or manifested in service. Service treatment records do not reflect treatment for or a diagnosis of arthritis while in service. No in-service complaints of symptoms associated with the lower back are of record. Indeed, the medical evidence indicates that lumbar degenerative disc disease and arthritis did not manifest until well after his separation from service. The Board finds the preponderance of the evidence is against a finding of an in-service event, injury or disease, or of a medical nexus between active service and the Veteran's lumbar degenerative disc disease and lumbar arthritis. In August 2013, the VA examiner indicated that there were no back pain issues identified in service treatment records upon review of the file. The VA examiner further stated that the first finding of back pain was in 1990 and was reportedly due to lifting a heavy mail bag. Thereafter, the VA examiner noted the record contained references to muscle spasms at work in May 2001, while the Veteran endorsed injuries to his neck, back, and thoracic spine in 2005 due to a motor vehicle accident. The examination report further referenced a 2009 radiology treatment note that reported the Veteran had experienced low back pain for four years and "works as letter carrier and this causes aggravation." Based upon the review of the record, the VA examiner opined that the Veteran's back pain is at least as likely as not established as either work related or traumatic due to the motor vehicle accident and an occupation consistent with axial load bearing. The VA examiner further opined that it is less likely than not that any service-connected neck condition is associated with the current thoracic or lumbar back issues. The August 2013 VA examiner appropriately considered and addressed the Veteran's contentions, reviewed the claims file in conjunction with the examination, conducted a thorough medical examination of the Veteran, and provided a sufficient supporting rationale for the opinion. Therefore, the report of the VA examiner is consistent with the evidence of record, is credible, and entitled to significant probative weight. Turning to the presumption in favor of chronic diseases and continuity of symptomatology, the Veteran has been diagnosed with arthritis and is therefore considered a chronic disease for VA purposes. 38 C.F.R. § 3.309(a). As such, both theories are potentially applicable in this case. Walker, 708 F.3d 1331; 38 C.F.R. §§ 3.303(b), 3.307, 3.309. However as discussed above, the medical evidence does not show that the Veteran's lumbar arthritis manifested to a sufficient degree in-service to identify the disease entity or within the first post-service year. Alternatively, the Veteran contends that his low back disability is caused by his service-connected cervical degenerative disc disease with spondylosis. The Board, however, further finds that there are no competent and credible opinions of record regarding the causes or aggravating factors of lumbar degenerative disc disease and lumbar arthritis by the service-connected cervical degenerative disc disease with spondylosis. In a June 2015 letter, the Veteran's treating clinician reported that the pain symptoms are likely arthritic or muscular in nature. She further opined that the lumbar spine and cervical spine are at opposite ends of the back, and is unlikely that they are connected. The Veteran's treating clinician noted, however, that it is possible the Veteran "could somehow" be compensating from his cervical spine injury thereby causing problems with the lower spine. The use of the words "possible," "may," or "can be" make a doctor's opinion speculative in nature. See Bostain v. West, 11 Vet. App. 124, 127-28 (1998) (quoting Obert v. Brown, 5 Vet. App. 30, 33 (1993)) (medical opinion expressed in terms of "may" also implies "may or may not" and is too speculative to establish medical nexus). See also Warren v. Brown, 6 Vet. App. 4, 6 (1993) (doctor's statement framed in terms such as "could have been" is not probative); Tirpak v. Derwinski, 2 Vet. App. 609, 611 (1992) ("may or may not" language by physician is too speculative). This opinion is speculative in nature and as such is not probative. It is well established that medical opinions that are speculative, general, or inconclusive in nature do not provide a sufficient basis upon which to support a claim. McLendon v. Nicholson, 20 Vet. App. 79, 85 (2006). Pursuant to the May 2015 Board remand, the Veteran underwent a subsequent VA thoracolumbar spine examination in September 2015. The VA examiner indicated the record reflects diagnoses of lumbar intervertebral disc disease and lumbar arthritis. The VA examiner opined that the claimed low back disability is less likely than not proximately due to or a result of the Veteran's service-connected condition. The VA examiner stated the neck and lower back do not share a functional relationship as the neck supports the head and allows the head and neck range of motion activities. The lower back, noted the VA examiner, supports body weight and allows trunk range of motion. Therefore, the VA examiner opined that a condition of the cervical spine would not have an adverse functional effect on the lower back or cause the development of a lower back condition. The VA examiner further opined that due to these anatomical differences, it is difficult to find a relationship between the service-connected cervical condition and the diagnosed lumbar condition. The Board accords significant weight to the opinions of the September 2015 VA examiner. The examiner provided a sufficient supporting rationale for the opinion. In an April 2010 letter by the Veteran's treating physician, it was reported that the Veteran had posttraumatic arthritis that developed over time from the service-connected cervical spine disability. The treating physician referenced the degenerative arthritic changes present in the cervical spine and differentiated the condition from general "wear and tear." Of note, the treating physician reported the Veteran's lumbar spine appeared radiologically normal and free of symptoms. Therefore, the reports of the VA examiners are consistent with the evidence of record, are credible, and entitled to significant probative weight. In sum, the competent and credible evidence of record does not demonstrate that the Veteran's lumbar degenerative disc disease and lumbar arthritis arose in service or is otherwise related to service. The record further does not reflect that the Veteran's low back disability had been caused or aggravated by another service-connected disability. As there is no competent nexus opinion underlying the claim, service connection for the disability is not warranted on a direct or secondary basis. 38 C.F.R. §§ 3.303, 3.310. Since the preponderance of the evidence is against the claim, the benefit of the doubt rule is not applicable. See 38 U.S.C. § 5107(b); Ortiz v. Principi, 274 F.3d 1361, 1364 (Fed. Cir. 2001); Gilbert v. Derwinski, 1 Vet. App. 49, 55-57 (1990); 38 C.F.R. § 3.102. For these reasons, the claim is denied. III. Increased Schedular Ratings The record reflects the Veteran submitted a claim for an increased rating for his service-connected cervical degenerative disc disease with spondylosis in October 2005. In a February 2006 rating decision, the RO continued the 20 percent disability rating for the condition. That same month, the Veteran submitted a letter where he stated his cervical spine disability had increased in severity such that he should be entitled to a higher evaluation rating, and submitted additional records in support of his claim. The RO, in a March 2007 rating decision, treated the February 2006 letter as a new claim for an increased evaluation. The record reflects the Veteran did not receive an SOC. Manlicon v. West, 12 Vet. App. 238 (1999). Thereafter, the Veteran submitted a new claim for an increased evaluation in November 2009. Although the Board in its May 2015 remand considered the July 2010 and February 2014 rating decisions as on appeal, upon further review, the Veteran's statements in his February 2006 letter are sufficient to constitute a Notice of Disagreement (NOD). Subsequent to the February 2006 through to the February 2014 rating decisions, the Veteran had submitted new and material records pertinent to the rating criteria for his service-connected disability. In sum, the February 2006 rating decision was not final and the period on appeal begins from his October 2005 application. Disability evaluations are determined by the application of the facts presented to VA's Schedule for Rating Disabilities (Rating Schedule) at 38 C.F.R. Part 4. The percentage ratings contained in the Rating Schedule represent, as far as can be practicably determined, the average impairment in earning capacity resulting from diseases and injuries incurred or aggravated during military service and the residual conditions in civilian occupations. 38 U.S.C. § 1155; 38 C.F.R. §§ 3.321(a), 4.1. In evaluating the severity of a particular disability, it is essential to consider its history. 38 C.F.R. § 4.1 (2013); Peyton v. Derwinski, 1 Vet. App. 282 (1991). Where entitlement to compensation has already been established and an increase in the disability rating is at issue, the present level of disability is of primary importance. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). Separate evaluations may be assigned for separate periods of time based on the facts found. In other words, the evaluations may be staged. Staged ratings are appropriate for any rating claim when the factual findings show distinct time periods during the appeal period where the service-connected disability exhibits symptoms that would warrant different ratings. Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). In this case, the Board finds that based on the evidence, further staged increased ratings are not warranted. If the evidence for and against a claim is in equipoise, the claim will be granted. 38 C.F.R. § 4.3. A claim will be denied only if the preponderance of the evidence is against the claim. See 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 56 (1990). Any reasonable doubt regarding the degree of disability should be resolved in favor of the claimant. 38 C.F.R. § 4.3. Where there is a question as to which of two evaluations shall be applied, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that evaluation. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. When evaluating disabilities of the musculoskeletal system, functional loss due to pain and weakness causing additional disability beyond that reflected on range of motion measurements must be considered. See 38 C.F.R. § 4.40; DeLuca v. Brown, 8 Vet. App. 202 (1995). Consideration must also be given to weakened movement, excess fatigability and incoordination. 38 C.F.R. § 4.45. The evaluation of the same disability under several diagnostic codes, known as pyramiding, must be avoided; however, separate ratings may be assigned for distinct disabilities resulting from the same injury so long as the symptomatology for one condition is not duplicative of the symptomatology of the other condition. 38 C.F.R. § 4.14; Esteban v. Brown, 6 Vet. App. 259, 262 (1994). VA is required to give due consideration to all pertinent medical and lay evidence in evaluating a claim for disability benefits. 38 U.S.C. § 1154(a). Lay evidence can be competent and sufficient to establish a diagnosis of a condition when (1) a layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Jandreau, 492 F.3d at 1377. Lay evidence cannot be determined to be not credible merely because it is unaccompanied by contemporaneous medical evidence. Buchanan, 451 F.3d at 1336-37. However, the lack of contemporaneous medical evidence can be considered and weighed against a Veteran's lay statements. Id. Further, a negative inference may be drawn from the absence of complaints or treatment for an extended period. Maxson v. West, 12 Vet. App. 453, 459 (1999), aff'd sub nom. Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000). A. Cervical Degenerative Disc Disease with Spondylosis The Veteran's service-connected cervical degenerative disc disease with spondylosis is rated under the criteria contained in 38 C.F.R. § 4.124a, Diagnostic Code 5242, for degenerative arthritis of the spine. The Veteran contends that his symptoms are worse than the current 20 percent disability rating, assigned under Diagnostic Code 5242. Disabilities of the spine are rated under the General Rating Formula for Diseases and Injuries of the Spine (for Diagnostic Codes 5235 to 5243, unless 5243 is evaluated under the Formula for Rating Intervertebral Disc Syndrome (IVDS) Based on Incapacitating Episodes). The General Rating Formula for Diseases and Injuries of the Spine provides that a 10 percent evaluation is to be assigned for forward flexion of the cervical spine greater than 30 degrees, but not greater than 40 degrees, or combined range of motion of the cervical spine greater than 170 degrees, but not greater than 335 degrees, or muscle spasm, guarding, or localized tenderness not resulting in abnormal gait or spinal contour, or vertebral facture with loss of 50 percent or more of the height. A 20 percent rating is warranted for forward flexion of the cervical spine greater than 15 degrees but not greater than 30 degrees; or, the combined range of motion of the cervical spine not greater than 170 degrees; or, muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. A 30 percent evaluation is warranted for forward flexion of the cervical spine to 15 degrees or less or favorable ankylosis of the entire cervical spine. A 40 percent evaluation is warranted for unfavorable ankylosis of the entire cervical spine. The Notes following the General Rating Formula provide further guidance in rating diseases or injuries of the spine. Note 1 specifies that any associated objective neurologic abnormalities, including, but not limited to, bowel or bladder impairment, should be separately evaluated under an appropriate diagnostic code. Note 2 states that, for VA compensation purposes, normal forward flexion of the cervical spine is zero to 45 degrees, extension is zero to 45 degrees, left and right lateral flexion are zero to 45 degrees, and left and right lateral rotation are zero to 80 degrees. The combined range of motion refers to the sum of the range of forward flexion, extension, left and right lateral flexion, and left and right rotation. The normal combined range of motion of the cervical spine is 340 degrees. The normal ranges of motion for each component of spinal motion provided in this note are the maximum that can be used for calculation of the combined range of motion. Note 3 provides that in exceptional cases, an examiner may state that because of age, body habitus, neurological disease, or other factors not the result of disease or injury of the spine, the range of motion of spine in a particular individual should be considered normal for that individual, even though it does not conform to the normal range of motion stated in Note 2. Provided that the examiner provides an explanation, the examiner's assessment that the range of motion is normal for that individual will be accepted. Note 4 provides that range of motion measurements are to be rounded to the nearest five degrees. Note 5 defines unfavorable ankylosis as a condition in which the entire cervical spine, the entire the thoracolumbar spine, or the entire spine is fixed in flexion or extension, and the ankylosis results in one or more of the following: difficulty walking because of a limited line of vision; restricted opening of the mouth and chewing; breathing limited to diaphragmatic respiration; gastrointestinal symptoms due to pressure of the costal margin on the abdomen; dyspnea or dysphagia; atlantoaxial or cervical subluxation or dislocation; or neurologic symptoms due to nerve root stretching. Fixation of a spinal segment in neutral position (zero degrees) always represents favorable ankylosis. Under the Formula for Rating IVDS Based on Incapacitating Episodes (in pertinent part) a 20 percent disability rating is warranted with incapacitating episodes having a total duration of at least 2 weeks but less than 4 weeks during the past 12 months. A 40 percent disability rating is warranted with incapacitating episodes having a total duration of at least 4 weeks but less than 6 weeks during the past 12 months. A 60 percent disability rating is warranted with incapacitating episodes having a total duration of at least 6 weeks during the past 12 months. Note (1) for purposes of evaluations under the Formula for Rating IVDS Based on Incapacitating Episodes, defines an incapacitating episode as a period of acute signs and symptoms due to IVDS that requires bed rest prescribed by a physician and treatment by a physician. Private outpatient treatment records, including emergency department discharge notes, reflect the Veteran was involved in a motor vehicle accident in June 2005. The Veteran stated the accident exacerbated the pain symptoms associated with his service-connected cervical degenerative disc disease with spondylosis. In a VA spine examination in December 2005, the Veteran stated he experienced cervical spine stiffness flares once a month. He further endorsed mild stiffness, weakness, and spasm. The VA examiner observed mild weakness of the cervical sacrospinal muscles bilaterally, and recorded 0 to 30 degrees of flexion and 0 to 20 degrees of extension of the cervical spine. The VA examiner further reported right lateral flexion of 0 to 25 degrees, left lateral rotation of 0 to 35 degrees, and right lateral rotation of 0 to 30 degrees on cervical spine range of motion testing. The VA examiner noted the Veteran's limitation of motion was due to stiffness and not pain. An x-ray of the cervical spine performed during the examination yielded evidence of degenerative changes at C5-C6 and C6-C7 with no reference to ankylosis. The Veteran stated in February 2006 that his cervical spine disability has increased in severity over the years, such that he experiences radiating neck pain, discomfort when lying down and turning his head, and interrupted sleep. The Veteran indicated he also has difficulty concentrating, irritability, dizziness, and fatigue due to the pain symptoms. The record reflects the Veteran underwent a subsequent VA spine examination in January 2007. The VA examiner reported the Veteran displayed 50 degrees of forward flexion and 40 degrees of extension of the cervical spine. The Veteran further demonstrated 50 degrees of rotation, 20 degrees of lateral flexion bilaterally, and tenderness to palpation in the midline at C5-C6 of the cervical spine. Private outpatient treatment records in October 2009 indicate the Veteran described his neck pain as aching and stiff and mild to moderate in degree. On physical examination, the Veteran exhibited tenderness over the cervical spine. Statements by the Veteran dated November and December 2009 reflect he continued to endorse pain and discomfort in his neck and associated headaches. In a December 2009 VA spine examination, the Veteran displayed 0 to 45 degrees of flexion and 0 to 30 degrees of extension of the cervical spine. The VA examiner further reported 0 to 15 degrees of left lateral flexion, 0 to 45 degrees of left lateral rotation, 0 to 25 degrees of right lateral flexion, and 0 to 45 degrees of right lateral rotation. The VA examiner identified no objective evidence of pain on active or repetitive range of motion. A subsequent VA spine examination afforded to the Veteran in March 2013. Upon physical examination, cervical spine range of motion was recorded at 35 degrees of forward flexion, 45 degrees of extension, 45 degrees of right lateral flexion, 45 degrees of left lateral flexion, 80 degrees of right lateral rotation, and 80 degrees of left lateral rotation. The Veteran did not have additional limitation in range of motion of the cervical spine following repetitive-use testing but the VA examiner noted the Veteran displayed less movement than normal, excess fatigability, pain on movement, and tenderness. The record reflects the Veteran underwent an x-ray of the cervical spine in June 2015. Compared to the prior December 2005 x-ray, mild to moderate degenerative disease at the facet joint at the C5-C6 level on the left was identified. Pursuant to the May 2015 Board remand, a subsequent VA spine examination was performed in September 2015. The VA examiner recorded cervical range of motion measurements of 0 to 35 degrees of forward flexion, 0 to 35 degrees of extension, 0 to 40 degrees of lateral flexion bilaterally, and 0 to 60 degrees of lateral rotation bilaterally. The VA examiner reported the Veteran exhibited pain in the cervical spine but indicated no additional loss of function or range of motion after repetitive-use testing. Localized tenderness was noted but it did not result in abnormal gait or spinal contour. X-rays were obtained and flare ups were not reported. All of the spine examinations affirmatively reflect findings of no ankylosis, and no other medical evidence of record reflects any such limitation of favorable ankylosis of the spine. Accordingly, the 20 percent rating adequately represents any functional impairment attributable to the disability. See 38 C.F.R. §§ 4.10, 4.41 (2017). A 30 percent rating is not warranted under Diagnostic Code 5242 for any period on appeal. There is no lay or medical evidence conclusively demonstrating 15 degrees or less of forward flexion of the cervical spine or favorable ankylosis of the entire cervical spine. In light of the foregoing, the Board concludes that the Veteran's symptoms affecting the cervical spine more closely approximate that of the criteria for a 20 percent rating for the entire period on appeal. The March 2013 VA examiner reported the Veteran has IVDS. Nevertheless, the examiner further found the Veteran had no incapacitating episodes over the past 12 months. The VA examiners in December 2005, January 2007, December 2009, and September 2015, however, did not find the Veteran has IVDS. The Veteran's outpatient VA treatment records are silent for any notations of IVDS or incapacitating episodes, and the Veteran has not indicated that he suffers from incapacitating episodes as contemplated by the Incapacitating Episodes Formula during this period. 38 C.F.R. § 4.71a, Diagnostic Code 5243, Incapacitating Episodes Formula, Note 1. As such, the Veteran's cervical degenerative disc disease with spondylosis does not meet the criteria for IVDS as defined in the rating schedule. When evaluating disabilities of the spine, any associated objective neurologic abnormalities are to be rated separately under an applicable Diagnostic Code. 38 C.F.R. § 4.71a, General Formula, Note 1. Here, service connection for the Veteran's peripheral neuropathy of the left upper extremity, associated with cervical degenerative disc disease with spondylosis, has already been granted and rated as 20 percent disabling. The issue of whether the Veteran is entitled to a separate rating for peripheral neuropathy of the right upper extremity is also decided herein. Therefore any associated objective neurologic abnormalities are already contemplated by the assigned rating and decision herein. There is no evidence of any other nerve involvement during this period. As such, additional separate compensable ratings are not warranted at this time. 38 C.F.R. § 4.71a, General Formula, Note 1. The Veteran has not contended, and the evidence does not reflect, that he has experienced symptoms outside of those listed in the criteria. See Doucette v. Shulkin, 28 Vet. App. 366, 369-70 (2017) (confirming that the Board is not required to address issues unless they are specifically raised by the claimant or reasonably raised by the evidence of record). All potentially applicable Diagnostic Codes have been considered. See Schafrath v. Derwinski, 1 Vet. App. 589, 593 (1991). For all the foregoing reasons, the preponderance of the evidence is against a rating in excess of 20 percent at any time during the pendency of the claim for cervical degenerative disc disease. Hart v. Mansfield, 21 Vet. App. 505 (2007). As such, the benefit-of-the-doubt doctrine is inapplicable. 38 C.F.R. § 4.3. For these reasons, the claim is denied. B. Peripheral Neuropathy of the Upper Extremities The Veteran's service-connected peripheral neuropathy of the left upper extremity is rated under the criteria contained in 38 C.F.R. § 4.124a, Diagnostic Code 8610, for neuritis of the upper radicular group. The Veteran contends that his symptoms are worse than the current 20 percent disability rating, assigned under Diagnostic Code 8610. The record further reflects peripheral neuropathy of the right upper extremity, associated with the service-connected cervical degenerative disc disease with spondylosis. Based on the medical evidence of record, the Board finds that a separate rating for the Veteran's peripheral neuropathy of the right upper extremity under Diagnostic Code 8610 is also warranted. Diagnostic Code 8610 provides a rating for neuritis of the upper radicular group. The disability rating for diseases of the peripheral nerves under Diagnostic Code 8510 is based on relative loss of function of the involved extremity with attention to the site and character of the injury, the relative impairment of motor function, trophic changes, or sensory disturbances. See 38 C.F.R. § 4.120 (2017). Diagnostic Code 8510 provides ratings for paralysis of the upper radicular group of nerves (fifth and sixth cervicals); mild incomplete paralysis is rated 20 percent disabling on the major side and 20 percent on the minor side; moderate incomplete paralysis is rated 40 percent disabling on the major side and 30 percent on the minor side; and severe incomplete paralysis is rated 50 percent disabling on the major side and 40 percent on the minor side. Complete paralysis of the upper radicular group, with all shoulder and elbow movements lost or severely affected, hand and wrist movements not affected, is rated 70 percent disabling on the major side and 60 percent on the minor side. 38 C.F.R. § 4.124a, Diagnostic Code 8510. The term "incomplete paralysis" with this and other peripheral nerve injuries indicates a degree of lost or impaired function substantially less than the type pictured for complete paralysis given with each nerve, whether due to varied level of the nerve lesion or to partial regeneration. When the involvement is wholly sensory, the rating should be for the mild, or at most, the moderate degree. The ratings for the peripheral nerves are for unilateral involvement; when there is bilateral involvement, the VA adjudicator is to combine the ratings for the peripheral nerves, with application of the bilateral factor. 38 C.F.R. § 4.124a. The Board also observes that the words "mild," "moderate," and "severe," as used in Diagnostic Code 8510, are not defined in the VA Schedule for Rating Disabilities. Rather than applying a mechanical formula, the Board must evaluate all of the evidence, to the end that its decisions are "equitable and just." 38 C.F.R. § 4.6 (2017). After a review of all the evidence, the Board finds that the weight of the evidence demonstrates that the Veteran has no more than mild incomplete paralysis due to peripheral neuropathy of the bilateral upper extremities. The evidence of record does not show that he experiences moderate or severe incomplete paralysis. The medical evidence of record reflects the Veteran endorsed radiating pain in his neck and shoulders in October and November 2009, and was diagnosed with cervical radiculopathy of the left upper extremity in 2011. In a VA examination in March 2013, the VA examiner indicated the Veteran had mild paresthesias of the right upper extremity, which was attributable to a peripheral nerve condition. Subsequent private outpatient treatment records dated October 2013 reflect the Veteran reported numbness and tingling in his extremities. The Veteran underwent subsequent VA spine and neurological examinations in September 2015 pursuant to the May 2015 Board remand. The VA examiner reported the Veteran had paresthesias in the right upper extremity involving the nerve roots of the cervical spine. The VA examiner indicated the Veteran had mild incomplete paralysis of the upper radicular nerve group on the right side. Therefore, the Veteran's symptomatology most closely approximates the criteria for the currently assigned 20 percent disability evaluation for peripheral neuropathy of the left upper extremity. The Board finds that a rating of 20 percent, but no higher, from October 4, 2005 for the Veteran's peripheral neuropathy of the right upper extremity is warranted. The Board further finds that the preponderance of the evidence is against the assignment of a disability rating in excess of 20 percent for peripheral neuropathy of the left and right upper extremities from October 4, 2005 forward, and the appeal for a rating in excess of 20 percent is denied. 38 C.F.R. §§ 4.3, 4.7. The Veteran has not contended, and the evidence does not reflect, that he has experienced symptoms outside of those listed in the criteria. See Doucette, 28 Vet. App. at 369-70. All potentially applicable Diagnostic Codes have been considered. See Schafrath, 1 Vet. App. at 593. For all the foregoing reasons, the preponderance of the evidence is against a rating in excess of 20 percent at any time during the pendency of the claim for peripheral neuropathy of the upper extremities. Hart, 21 Vet. App. at 505. As such, the benefit-of-the-doubt doctrine is inapplicable. 38 C.F.R. § 4.3. ORDER Entitlement to service connection for a low back disability, to include lumbar degenerative disc disease and lumbar arthritis, is denied. Entitlement to a rating in excess of 20 percent for cervical degenerative disc disease with spondylosis, is denied. From October 4, 2005 forward, entitlement to a rating in excess of 20 percent for peripheral neuropathy of the left upper extremity, associated with cervical degenerative disc disease with spondylosis, is denied. From October 4, 2005 forward, entitlement to a separate rating for peripheral neuropathy of the right upper extremity, associated with cervical degenerative disc disease with spondylosis, is granted. ____________________________________________ J. W. FRANCIS Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs