Citation Nr: 18140779 Decision Date: 10/05/18 Archive Date: 10/05/18 DOCKET NO. 15-20 410 DATE: October 5, 2018 ORDER The appeal seeking a compensable rating for erectile dysfunction is dismissed. The appeal seeking a higher level of special monthly compensation (SMC) is dismissed. Entitlement to service connection for a right elbow disability is denied. Entitlement to service connection for a left elbow disability is denied. For the entire period on appeal, beginning on December 10, 2011, a 50 percent rating, but not higher, for sleep apnea is granted, subject to the law and regulations governing the award of monetary benefits. For the entire period on appeal, beginning on December 10, 2011, a total (100 percent) disability rating for PTSD is granted, subject to the law and regulations governing the award of monetary benefits. For the entire period on appeal, beginning on December 10, 2011, a 30 percent rating, but not higher, for right carpal tunnel syndrome (CTS) is granted, subject to the law and regulations governing the award of monetary benefits. For the entire period on appeal, beginning on December 10, 2011, a 20 percent rating, but not higher, for left CTS is granted, subject to the law and regulations governing the award of monetary benefits. An effective date of December 10, 2011, but no earlier, for the award of a TDIU is granted. REMANDED Entitlement to service connection for a right shoulder disability is remanded. Entitlement to service connection for a left shoulder disability is remanded. Entitlement to increased rating in excess of 20 percent for cervical strain is remanded. Entitlement to increased rating in excess of 20 percent for lumbar strain is remanded. Entitlement to increased rating in excess of 10 percent for right lower extremity radiculopathy is remanded. Entitlement to increased rating in excess of 10 percent for left lower extremity radiculopathy is remanded. Entitlement to increased rating in excess of 10 percent for gastroesophageal reflux disease (GERD) is remanded. FINDINGS OF FACT 1. By correspondence received on July 18, 2016, prior to the promulgation of a decision in the appeal, the Veteran withdrew his appeal for entitlement to a compensable rating for erectile dysfunction and for a higher-level of SMC. 2. The Veteran does not have a current diagnosis of a right elbow disability. 3. The Veteran’s left elbow disability was not incurred in service and is not otherwise etiologically related to it. 4. For the entire period on appeal, the Veteran’s obstructive sleep apnea is manifested by persistent daytime hypersomnolence and requires the use of a CPAP machine. 5. Resolving all doubt in the Veteran’s favor, for the entire period on appeal, his psychiatric disability more nearly approximates total occupational and social impairment. 6. Resolving all doubt in the Veteran’s favor, for the entire period on appeal, his right upper extremity CTS symptoms more nearly approximate moderate incomplete paralysis; severe incomplete paralysis or complete paralysis is not shown. 7. Resolving all doubt in the Veteran’s favor, for the entire period on appeal, his left upper extremity CTS symptoms more nearly approximate moderate incomplete paralysis; severe incomplete paralysis or complete paralysis is not shown. 8. The Veteran filed a claim for an increased rating for his service-connected disabilities on December 10, 2011, at which time, he met the schedular criteria for TDIU. 9. The record shows that the Veteran was not working for the entire period on appeal, and his service-connected disabilities rendered him unable to obtain or maintain employment CONCLUSIONS OF LAW 1. The criteria for withdrawal of an appeal by the Veteran seeking entitlement to a compensable rating for erectile dysfunction have been met. 38 U.S.C. § 7105(b)(2), (d)(5) (2012); 38 C.F.R. § 20.204 (2017). 2. The criteria for withdrawal of an appeal by the Veteran seeking entitlement to “higher-level” SMC have been met. 38 U.S.C. § 7105(b)(2), (d)(5) (2012); 38 C.F.R. § 20.204 (2017). 3. The criteria to establish service connection for a right elbow disability are not met. 38 U.S.C. §§ 1110, 1131, 5107 (2012); 38 C.F.R. § 3.303 (2017). 4. The criteria to establish service connection for a left elbow disability are not met. 38 U.S.C. §§ 1110, 1131, 5107 (2012); 38 C.F.R. § 3.303 (2017). 5. For the entire period on appeal, the criteria for a 50 percent disability rating, but not higher, for obstructive sleep apnea are met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.102, 4.7, 4.14, 4.97, Diagnostic Code 6847 (2017). 6. For the entire period on appeal, the criteria for a total (100 percent) disability rating for major depressive disorder are approximated. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.102, 4.130, Diagnostic Code (DC) 9434 (2017). 7. For the entire period on appeal, the criteria for a 30 percent disability rating, but no higher, right upper extremity CTS have been approximated. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.1, 4.6, 4.7, 4.20, 4.27, 4.123, 4.124a, Diagnostic Code 8515 (2017). 8. For the entire period on appeal, the criteria for a 20 percent disability rating, but no higher, left upper extremity CTS are approximated. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.1, 4.6, 4.7, 4.20, 4.27, 4.123, 4.124a, Diagnostic Code 8515 (2017). 9. The criteria for an effective date of December 10, 2011, for the award of a TDIU are met. 38 U.S.C. §§ 1155, 5107, 5110 (2012); 38 C.F.R. §§ 3.156(b), 3.157, 3.340, 3.400, 4.15, 4.16, 20.200, 20.201, 20.302, 20.1100 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from January 1978 to January 1982 and from September 1982 to April 1999. The Board has limited the discussion below to the relevant evidence required to support its findings of fact and conclusions of law, as well as to the specific contentions regarding the case as raised directly by the Veteran and those reasonably raised by the record. See Doucette v. Shulkin, 28 Vet. App. 366, 69-70 (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); Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015). Dismissal of Increased Rating Claim for Erectile Dysfunction and a Higher-Level of SMC The Board may dismiss any appeal which fails to allege specific error of fact or law in the determination being appealed. 38 U.S.C. § 7105 (2012). An appeal may be withdrawn as to any or all issues involved in the appeal at any time before the Board promulgates a decision. 38 C.F.R. § 20.204 (2017). Withdrawal may be made by the appellant or by his or her authorized representative. 38 C.F.R. § 20.204. In the present case, the Veteran’s representative, by a correspondence dated in July 2016, indicated that, regarding his appeal for SMC and erectile dysfunction, the Veteran would like to completely and totally withdraw only these two appeals. Hence, with regard to these issues, there remains no allegations of errors of fact or law for appellate consideration. Accordingly, the Board does not have jurisdiction to review these issues and the appeal with regard to these issues is dismissed. Service Connection Claims Service connection will be granted if the evidence demonstrates that a current disability resulted from an injury or disease incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a). 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). Establishing service connection generally requires competent evidence of three things: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship, i.e., a nexus, between the claimed in-service disease or injury and the current disability. Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2009). The Board must analyze the credibility and probative value of the evidence, account for the evidence that it finds persuasive or unpersuasive, and provide the reasons for its rejection of any material evidence favorable to the claimant. Kahana v. Shinseki, 24 Vet. App. 428, 433 (2011). This includes weighing the credibility and probative value of lay evidence against the remaining evidence of record. See King v. Shinseki, 700 F.3d 1339 (Fed. Cir. 2012); Kahana, 24 Vet. App. at 433-34. A Veteran bears the evidentiary burden to establish all elements of a service connection claim, including the nexus requirement. Fagan v. Shinseki, 573 F.3d 1282, 1287 (Fed. Cir. 2009). In making its ultimate determination, the Board must give a veteran the benefit of the doubt on any issue material to the claim when there is an approximate balance of positive and negative evidence. Id. at 1287 (quoting 38 U.S.C. § 5107 (b)). Right Elbow In his claim for compensation, the Veteran noted an “elbow injury,” but did not specify which elbow. At any rate, the Veteran has not met the threshold element of any service connection claim, namely: a current disability. A careful review of the Veteran’s post-service medical treatment records dated from the date of claim forward are completely silent to any complaints, treatment, or diagnosis of a right elbow disability. In fact, during a May 2015 VA examination of the elbows, a right elbow diagnosis was not rendered. The laws authorizing Veterans’ benefits provide benefits only where there is current disability, as identified by a medical diagnosis. In the absence of proof of a current disability, there is no valid claim of service connection. Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). The Board concludes that the Veteran has not presented competent evidence showing that he has a current right elbow. See 38 U.S.C. § 5107 (a) (“[A] claimant has the responsibility to present and support a claim for benefits.”); Fagan v. Shinseki, 573 F.3d 1282, 1287 (Fed. Cir. 2009) (holding that it is the claimant’s general evidentiary burden to establish all elements of the claim). In analyzing this claim, the Board recognizes that the Veteran is competent to report his observable elbow symptoms but the evidence does not show that he has a right elbow disability. Again, he never specified which elbow he seeks compensation for, but to the extent that it is his right elbow, the post-service medical treatment notes are silent to any complaints, treatment, or diagnosis of a right elbow condition. For the reasons and bases discussed above, the preponderance of the evidence is against the Veteran’s claim, and it therefore must be denied. See 38 U.S.C. § 5107(b) (2012); Gilbert v. Derwinski, 1 Vet. App. 49, 55-56 (1990). Left Elbow Initially, the Board finds that the Veteran has a current diagnosis of tennis elbow of the left elbow. See May 2015 VA examination report. However, after a careful review of the lay and medical evidence, the Board concludes that the current left elbow disability is not related to service. Turning to the evidence, service treatment records are silent to any complaints, treatment, or diagnosis of a left elbow condition. Post-service private treatment records furnished by the Social Security Administration (SSA) dated in February 2012 indicate that the Veteran reported that he had “some left elbow pain which has been bothering him for some time.” No diagnosis was rendered at the time. Private treatment notes dated in September 2012 reveal that the Veteran reported various orthopedic problems, but made no complaints about his left elbow. The physical examination of the elbows revealed normal elbows with no evidence of swelling or tenderness, normal range of motion, and normal motor strength (5/5). The Veteran was provided with a May 2015 VA examination to determine the nature and etiology of claimed elbow disability during which the examiner diagnosed left tennis elbow. The Veteran reported that he had elbow pain due to the repetitive motion he experienced as a cook in the military. He further stated that he had had that pain for 30 years. At the examination, the Veteran reported pain with lifting and weakness, and the examiner indicated that he had carpal tunnel release, and he used hot pads and a brace for treatment. The examiner opined in an April 2016 addendum opinion that the Veteran’s currently diagnosed left tennis elbow was less likely than not related to service. The examiner acknowledged that the Veteran received treatment for left lateral epicondylitis during service, but also noted that he was not treated thereafter and no interval changes were shown on an April 1999 Report of Medical History. There were also no reports of painful or trick elbow or shoulder. The examiner further noted that September 2012 private treatment records showed no elbow problems. The examiner further explained: Lateral epicondylitis is essentially pain on the outside of the elbow. It is an overuse injury that affects the tendons on the outside of the elbow. It is an overuse injury caused by repeating simple activities over and over again. Ultimately, the muscles and tendons become injured and small tears develop. As the injury progresses, more of the tendon is injured and subsequently the pain increases. Seemingly simple activities such as using a screwdriver, reaching, holding, pulling, or cutting activities can cause tennis elbow. Anyone using their hands can develop lateral epicondylitis. The examiner additionally noted that there was no tear present during service but rather only tenderness. Based on this, the examiner concluded that it was less likely that “left elbow problems would be expected to surface later on in his life,” and as such, “other more current explanations would have occurred so as to result in the recent claimed issue.” The examiner then noted, that alternative explanation does exist for the development of the Veteran’s later left tennis elbow, namely, activities commonly encountered in everyday life. Based on the foregoing, the Board finds that service connection for a left elbow disability is not warranted. While the Veteran asserts that his left elbow is directly related to service, the Board finds that, under the specific facts of this case, including no chronic symptoms in service and no continuous symptoms after service, his lay statements are outweighed by the objective lay and medical evidence of record. While the Veteran is competent to describe symptoms related to his currently diagnosed left elbow disability and report that such symptoms were present since service, the Board finds that, based on the record as a whole, the Veteran is not credible with regard to his statements, which were provided for purposes of compensation. As discussed in detail above, to include by the examiner who provided the April 2016 addendum opinion, the medical record establishes that his in-service complaints of left elbow pain are not related to the currently diagnosed tennis elbow, but rather were noted many years after separation from service. The Board is charged with the duty to assess the credibility and weight given to evidence. Wensch v. Principi, 15 Vet. App. 362, 367 (2001). In weighing credibility, VA may consider interest, bias, inconsistent statements, bad character, internal inconsistency, facial plausibility, self-interest, consistency with other evidence of record, malingering, desire for monetary gain, and demeanor of the witness. Caluza v. Brown, 7 Vet. App. 498 (1995); Macarubbo v. Gober, 10 Vet. App. 388 (1997); Coburn v. Nicholson, 19 Vet. App. 427, 432 (2006) (Board may reject such statements of the veteran if rebutted by the overall weight of the evidence). A claimant’s inaccurate or less than truthful account of one incident does not automatically invalidate all his statements. However, in the present case, the Veteran’s statements do not reflect merely slight inconsistencies on peripheral matters, but go to the heart of the matter. Given that they are inconsistent, the Board cannot rely on them to establish the onset of the disability. The mere absence of medical records does not contradict a Veteran’s statements about his symptom history. Buchanan v. Nicholson, 451 F.3d 1331, 1336 (Fed. Cir. 2006). However, if it is determined based upon reliable evidence that there was an extended period of time after service without any manifestations of the claimed condition, then that tends to weigh against a finding of a connection between the disability and service. Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000). In this case, the Veteran’s recent statements reporting a long history of symptoms of the claimed disability are contradicted by past records in which he appears to have reported all his existing medical conditions without mentioning any problems related to his left elbow. See AZ v. Shinseki, 731 F.3d 1303, 1318 (Fed. Cir. 2013) (recognizing the widely held view that the absence of an entry in a record may be considered evidence that the fact did not occur if it appears that the fact would have been recorded if present); Buczynski v. Shinseki, 24 Vet. App. 221, 224 (2011); Kahana, 24 Vet. App. at 440 (Lance, J., concurring) (citing Fed. R. Evid. 803(7) for the proposition that “the absence of an entry in a record may be evidence against the existence of a fact if such a fact would ordinarily be recorded”). In this case, despite receiving treatment for various orthopedic problems post-service, as well as for his bilateral carpal tunnel syndrome, it was not until approximately 13 years after service that the Veteran complained of left elbow pain. This long period without problems is one factor that weighs against the claim. Based upon the language and context of the medical records, the Board finds that the Veteran was reporting all the disabilities/medical conditions/symptoms that he was experiencing at that time. Therefore, his failure to report any complaints of left elbow pain prior to 2012 is persuasive evidence that he was not then experiencing any relevant problems and outweighs his present recollection to the contrary. The Board emphasizes that it is not only relying on the absence of evidence, but also on the contemporaneous, affirmative lay reports of symptoms and history by the Veteran, as well as contemporaneous medical records that specifically show that his left elbow was normal years after service, to include in September 2012. Thus, to the extent that the Veteran now asserts that his left elbow disability developed during active service, the Board finds that the current assertions made for VA compensation purposes are contradicted and outweighed by the more contemporaneous lay and medical evidence, including the Veteran’s own statements at service separation. See Harvey v. Brown, 6 Vet. App. 390, 394 (1994). Moreover, there is simply no medical evidence suggesting that the left elbow disability shown years after service is related to the documented in-service treatment for left elbow pain or any other reported in-service injury. As fully discussed above, despite years of treatment, no medical professional has concluded the left elbow disability is related to service. In this regard, the April 2016 VA examiner’s opinion is of high probative value. The VA examiner’s opinion was demonstrably fully informed of the pertinent factual premises of the case and provided a fully articulated opinion with supporting reasoned analysis explaining why the Veteran’s left elbow disability did not have its onset during active duty. See Nieves-Rodriguez, 22 Vet. App. 295, 303-304 (holding that it is the factually accurate, fully articulated, sound reasoning for the conclusion that contributes to the probative value of a medical opinion). There is no benefit of the doubt that could be resolved in the Veteran’s favor, since there is no medical evidence to the contrary. For the reasons and bases discussed above, the preponderance of the evidence is against the Veteran’s claim, and it therefore must be denied. See 38 U.S.C. § 5107(b) (2012); Gilbert v. Derwinski, 1 Vet. App. 49, 55-56 (1990). Increased Rating Claims Disability evaluations are determined by comparing a veteran’s present symptoms with the criteria set forth in the VA Schedule for Rating Disabilities, which is based upon average impairment in earning capacity. 38 U.S.C. § 1155; 38 C.F.R. Part 4. When a question arises as to which of two ratings applies under a particular diagnostic code, the higher evaluation is assigned if the disability more closely approximates the criteria for the higher rating; otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. After careful consideration of the evidence, any reasonable doubt is resolved in favor of the Veteran. 38 C.F.R. § 4.3. A disability rating may require re-evaluation in accordance with changes in a veteran’s condition. Thus, it is essential that the disability be considered in the context of the entire recorded history when determining the level of current impairment. See 38 C.F.R. § 4.1. See also Schafrath v. Derwinski, 1 Vet. App. 589 (1991). When a claimant is awarded service connection and assigned an initial disability rating, separate disability ratings may be assigned for separate periods of time in accordance with the facts found. Where the veteran is appealing the rating for an already established service-connected condition, his present level of disability is of primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). Staged ratings are appropriate for an increased rating claim when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. Hart v. Mansfield, 21 Vet. App. 505 (2007). When evaluating musculoskeletal disabilities based on limitation of motion, 38 C.F.R. § 4.40 requires consideration of functional loss caused by pain or other factors listed in that section that could occur during flare-ups or after repeated use and, therefore, not be reflected on range-of-motion testing. 38 C.F.R. § 4.45 requires consideration also be given to less movement than normal, more movement than normal, weakened movement, excess fatigability, incoordination, and pain on movement. See DeLuca v. Brown, 8 Vet. App. 202 (1995); see also Mitchell v. Shinseki, 25 Vet. App. 32, 44 (2011). Nonetheless, even when the background factors listed in § 4.40 or 4.45 are relevant when evaluating a disability, the rating is assigned based on the extent to which motion is limited, pursuant to 38 C.F.R. § 4.71a (musculoskeletal system) or § 4.73 (muscle injury); a separate or higher rating under § 4.40 or 4.45 itself is not appropriate. See Thompson v. McDonald, 815 F.3d 781, 785 (Fed. Cir. 2016) (“[I]t is clear that the guidance of § 4.40 is intended to be used in understanding the nature of the veteran’s disability, after which a rating is determined based on the § 4.71a [or 4.73] criteria.”). The evaluation of the same disability under various diagnoses, known as pyramiding, is generally to be avoided. 38 C.F.R. § 4.14. The critical element in permitting the assignment of several ratings under various diagnostic codes is that none of the symptomatology for any one of the disabilities is duplicative or overlapping with the symptomatology of the other disability. See Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994). Sleep Apnea The Veteran asserts that his service-connected sleep apnea warrants a higher rating. A. Rating Criteria Sleep apnea is rated pursuant to Diagnostic Code 6847, which provides a 30 percent rating for persistent day-time hypersomnolence. A 50 percent rating is warranted for sleep apnea requiring use of a breathing assistance device such as a continuous airway pressure (CPAP) machine. A 100 rating is warranted for chronic respiratory failure with carbon dioxide retention or cor pulmonale or for sleep apnea requiring a tracheostomy. 38 C.F.R. § 4.97, Diagnostic Code 6847 (2017). B. Discussion For the reasons expressed below, the Board finds that for the entire period on appeal, the Veteran’s sleep apnea warrants a 50 percent disability rating. In December 2011, VA received the Veteran’s claim for an increased rating for his service-connected sleep apnea, which is currently rated as 30 percent disabling. Turning to the evidence, during his April 2005 VA examination for sleep apnea, it was noted that the Veteran was instructed to use a CPAP device; however, he was unable to tolerate it. It further noted that in 2000, he again was evaluated for a CPAP device after the Veteran reported worsening of his symptoms, but had a hard time using it. At the time, he reported that he was unable to sleep more than one hour without waking himself up. VA treatment records beginning in 2011 indicate that the Veteran’s sleep apnea worsened. The Veteran underwent an additional VA examination in March 2012 to assess the severity of his sleep apnea. The examiner confirmed a diagnosis of sleep apnea and indicated that the use of a CPAP device was not required. The only symptom identified was persistent daytime hypersomnolence. In the remark section, the examiner noted that the Veteran has not received his CPAP equipment and was still having problems associated with sleep apnea. The examiner then opined that the Veteran’s sleep apnea was not related to service, because his separation examination “did not mention sleep apnea to be a problem.” Private treatment notes dated in September 2012 indicate that the Veteran had sleep apnea since 2000, which required the use of a CPAP machine, but he had difficulty with compliance with using it. The Veteran submitted VA treatment records dated in March 2013 that specifically show he was provided a CPAP device. The medical professional stated that the Veteran was service-connected for sleep apnea, but never received the machine, after he initially refused to use it. Based on the foregoing, the Board finds that the evidence clearly shows that the Veteran’s sleep apnea required the use of a CPAP device. Regarding the March 2012 examiner’s statement that a CPAP device was not necessary, the Board finds that this statement is internally contradicted by subsequent statements indicating that the Veteran has not received it yet. Furthermore, given the examiner’s indication that sleep apnea was not related to service, when this disability was already service-connected at the time, is indicative that this examiner’s review of the claims file was cursory at best. Accordingly, the Board assigns no probative value to the March 2012 examination report. Furthermore, the fact that the Veteran was not using or had difficulty using a CPAP machine has no bearing on his entitlement to a higher rating. Notably, a 50 percent rating is warranted for sleep apnea requiring use of a CPAP device, as such, whether the Veteran was able to use the device or not, is irrelevant. Here, the evidence clearly shows that he was required to use a CPAP device for his sleep apnea. The Veteran’s obstructive sleep apnea has been shown to be manifested by persistent daytime hypersomnolence and requires the use of a CPAP machine. Given these facts, the Board finds a 50 percent disability rating is warranted. The evidence does not show and the Veteran does not assert that he has a chronic respiratory failure with carbon dioxide retention or cor pulmonale or that his disorder requires a tracheostomy. Therefore, a 100 rating is not warranted. Psychiatric Disorder The Veteran asserts that his service-connected psychiatric disorder warrants a higher rating. A. Rating Criteria The criteria for rating psychiatric disabilities, other than eating disorders, are set forth in the General Rating Formula (General Rating Formula) for Mental Disorders. See 38 C.F.R. § 4.130. The RO has rated the Veteran’s depression and anxiety as 70 percent disabling pursuant to DC 9434 of the Rating Formula. See 38 C.F.R. § 4.130, DC 9434 (2017). VA received the Veteran’s increased rating claim on December 10, 2011. Under the General Rating Formula, a 70 percent rating is warranted if the evidence establishes there is occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately, and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work like setting); and/or inability to establish and maintain effective relationships. Id. A 100 percent rating (total occupational and social impairment) is warranted due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. Id. In applying the above criteria, the Board notes that, when it is not possible to separate the effects of the service-connected disability from a nonservice-connected disability, such signs and symptoms shall be attributed to the service-connected disability. See 38 C.F.R. § 3.102 (2017); Mittleider v. West, 11 Vet. App. 181 (1998) citing Mitchem v. Brown, 9 Vet. App. 136, 140 (1996) (the Board is precluded from differentiating between symptomatology attributed to a nonservice-connected disability and a service-connected disability in the absence of medical evidence which does so). When determining the appropriate disability evaluation to assign, the Board’s primary consideration is the Veteran’s symptoms, but it must also make findings as to how those symptoms impact a Veteran’s occupational and social impairment. Vazquez-Claudio v. Shinseki, 713 F.3d 112 (Fed. Cir. 2013). The use of the term “such as” in the rating criteria demonstrates that the symptoms after that phrase are not intended to constitute an exhaustive list, but rather are to serve as examples of the type and degree of the symptoms, or their effects, that would justify a particular rating. Mauerhan v. Principi, 16 Vet. App. 436 (2002). Thus, the Board need not find the presence of all, most, or even some, of the enumerated symptoms to award a specific rating. Id. at 442. Nevertheless, all ratings in the general rating formula are also associated with objectively observable symptomatology and the plain language of the regulation makes it clear that the Veteran’s impairment must be “due to” those symptoms; a Veteran may only qualify for a given disability rating by demonstrating the particular symptoms associated with that percentage, or others of similar severity, frequency, and duration. Vazquez-Claudio, 713 F.3d at 118. The Board recognizes that the Court in Mauerhan, 16 Vet. App. 436, stated that the symptoms listed in VA’s general Rating Formula for mental disorders is not intended to constitute an exhaustive list, but rather are to serve as examples of the type and degree of the symptoms, or their effects, that would justify a particular rating; however, the Court further indicated that, without those examples, differentiating between rating evaluations would be extremely ambiguous. In determining the level of impairment under 38 C.F.R. § 4.130, a rating specialist is not restricted to the symptoms provided under the diagnostic code, and should consider all symptoms which affect occupational and social impairment, including those identified in the DIAGNOSTIC AND STATISTICAL MANUAL OF MENTAL DISORDERS (DSM-IV or DSM 5). See Mauerhan v. Principi, 16 Vet. App. 436 (2002). If the evidence demonstrates that a claimant suffers symptoms or effects that cause an occupational or social impairment equivalent to those listed in that diagnostic code, the appropriate, equivalent rating is assigned. See Mauerhan, 16 Vet. App. 436. B. Discussion For the reasons expressed below, the Board finds that for the entire period on appeal, the Veteran’s psychiatric symptoms more nearly approximate total occupational and social impairment. In December 2011, VA received the Veteran’s claim for an increased rating for his service-connected psychiatric disorder, which is currently rated as 70 percent disabling. Turning to the evidence, VA psychiatry notes dated in April 2012 note that the Veteran called to cancel his appointment indicating “I cancelled my app[ointment] today because I am having depression.” The mental health professional noted that positive responses included constant depressed mood that was worsening. Thereafter, the Veteran was provided with a VA examination for mental disorders in April 2012, where the examiner confirmed a diagnosis of major depressive disorder, recurrent, severe without psychotic features and anxiety disorder, NOS. The examiner indicated that it was not possible to differentiate the symptoms attributing to each diagnosis. The examiner explained that due to the fact that the Veteran’s anxiety and depression have an overlap in symptoms and exist concurrently, the portion of each symptoms that is attributable to a particular condition at any given time cannot be delineated. In terms of social impairment, the Veteran married his fifth wife almost three years earlier. He described the marital relationship as strained, which he attributed, in part, to his tendency to isolate himself. He also stated that secondary to his numerous medications, he had difficulty with sexual relations that resulted in added pressure, because his wife wanted a baby. He also had a strained relationship with his son, indicating that he struggled with his son’s homosexuality. He further noted that he did not interact well with others and denied any hobbies other than watching some TV and climbing on trees “to get away from things.” In terms of occupational impairment, the Veteran last worked around 2007 and 2008 as a food and beverage director of a psychiatric facility. He reported a mutual parting-of the-ways after only three months, due to conflict with the facility director, and indicated that he did not look for new employment. The examiner identified psychiatric symptoms of depressed mood; anxiety; panic attacks that occur weekly or less often; chronic sleep impairment; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships; difficulty in adapting to stressful circumstances, including work or a worklike setting; suicidal ideation; impaired impulse control, such as unprovoked irritability with periods of violence; and, neglect of personal appearance and hygiene. Additional symptoms included anhedonia; social withdrawal; irritability; decreased libido (also struggling with erectile dysfunction secondary to medications); increased appetite; avoidance of crowds; hypervigilance (patrols property during the night and checks locks); exaggerated startle response; physical anxiety, restlessness, and fidgetiness; and, nervous habits. Based on the foregoing, the examiner concluded that the Veteran’s depression and anxiety resulted in occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking and/or mood. Private mental health treatment notes furnished by the Social Security Administration dated in August 2012 show that the Veteran’s behavior was uncooperative and inappropriate, and his speech was loud. Additional private mental health treatment notes dated in September 2012 indicate that the Veteran reported compliance with his psychiatric medications, which he found minimally helpful. He complained of frequent periods of increased agitation and anger, but denied suicidal ideation, hallucinations, or phobias. The Veteran underwent an additional VA mental health examination in November 2015, at which time the examiner confirmed diagnoses of major depressive disorder, moderate to severe, recurrent, and unspecified anxiety disorder. The examiner noted that it was not possible to differentiate the symptoms, because they overlapped between these diagnoses. In terms of social impairment, it was noted that the Veteran was married since 2008 and had a two years old son from this marriage. He reported that he did not speak to his other son who was 26-years-old at the time for three years. He further stated that his prescribed psychiatric medications “is taking a toll” on his sexual functioning. He reported that he had regular contact with his adopted brother and limited contact with his adopted sister. His biological sister resided with him. It was noted that he spent most of his time “sitting in my living room, in my family room.” He also did some yardwork and spent time with his son. He had two close friends, one who is retired and stayed with him three to four days a week to hang out and help him around. He had contact with his other friend once or twice a week. His hobbies included curing the grass, talking to his close friend, and playing with his little boy. In terms of occupational impairment, the Veteran worked for two to three months at the University Behavioral Center, a psychiatric facility for children, as a food and beverage director. He did not report any additional employment since his last job. He reported that he was not employed because “everything shrinks up” and “I’m moody.” He further stated that he becomes anxious outside of his house and when interacting with groups of people. The examiner identified psychiatric symptoms of depressed mood; anxiety; chronic sleep impairment; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships; difficulty in adapting to stressful circumstances, including work or a worklike setting; and, suicidal ideation. It was noted that the Veteran’s appearance and grooming was appropriate. He demonstrated restless motor activity and was cooperative during the interview. Speech was normal and attention and concentration were intact. His affect was broad and mood was anxious and tearful. He did not report any current thoughts of suicide or homicide. It was noted that he was not capable of managing his financial affairs based on his reports that his sister assisted him with this, and his statement that “she reminds me” to pay bills. The examiner stated that his ability to understand and follow instructions was considered not impaired; ability to retain instructions as well as sustain concentration to perform simple tasks was considered mild to moderately impaired; ability to sustain concentration to task persistence and pace was considered moderate to markedly impaired; bility to respond appropriately to coworkers, supervisors, or the general public was considered moderate to markedly impaired; and, ability to respond appropriately to changes in work setting was considered moderately impaired. The examiner concluded that the Veteran’s psychiatric disorder resulted in total occupational and social impairment. On review, the Board finds that for the entire period on appeal, the Veteran’s psychiatric symptoms more nearly approximate total occupational and social impairment. Notably, the November 2015 VA examiner concluded that the Veteran’s psychiatric disorder resulted in total occupational and social impairment. Furthermore, the lay reports and medical observations made during the November 2015 examination appear to be milder than those reported during the April 2012 VA examination, at which time the examiner concluded that the Veteran’s symptoms resulted in occupational and social impairment with deficiencies in most areas. Significantly, throughout the pendency of the appeal, the Veteran endorsed isolative behavior that included intermittent inability to perform activities of daily living such as maintenance of minimal personal hygiene; inappropriate behavior such as climbing on trees to isolate himself; at least one incident of grossly inappropriate behavior described as uncooperative and inappropriate; and, impairment in communication described as inappropriately loud voice. While the November 2015 VA examiner noted that the Veteran reported having two good friends, and an overall good relationship with his wife and son, it was still concluded that his overall disability picture more nearly approximated total occupational and social impairment. Furthermore, it appears that throughout the pendency of the appeal, the Veteran relied on his wife to remember to take his psychiatric medications, which he reported were only minimally helpful. Accordingly, with resolution of any reasonable doubt in his favor, the Board finds that the Veteran’s psychiatric symptoms more nearly approximate total occupational and social impairment for the entire period on appeal. Right and Left Upper Extremity Carpal Tunnel Syndrome The Veteran asserts that his bilateral CTS warrants a higher rating. A. Rating Criteria The Veteran’s carpal tunnel syndrome is rated pursuant to Diagnostic Code 8515, which assigns for the major extremity, a 10 percent rating for mild incomplete paralysis, a 30 percent rating for moderate incomplete paralysis, and a 50 percent rating for severe incomplete paralysis. A 70 percent rating is assigned where there is complete paralysis of the major extremity. For the minor extremity, Diagnostic Code 8515 provides a 10 percent rating for mild incomplete paralysis, a 20 percent rating for moderate incomplete paralysis, and a 40 percent rating for severe incomplete paralysis. A 60 percent rating is assigned where there is complete paralysis of the minor extremity. 38 C.F.R. § 4.124a. 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. Id. Neuritis, cranial or peripheral, characterized by loss of reflexes, muscle atrophy, sensory disturbances, and constant pain, at times excruciating, is to be rated on the scale provided for injury of the nerve involved, with a maximum equal to severe, incomplete, paralysis. 38 C.F.R. § 4.123 (2017). Similarly, neuralgia, cranial or peripheral, characterized usually by a dull and intermittent pain, of typical distribution so as to identify the nerve, is to be rated on the same scale, with a maximum equal to moderate incomplete paralysis. 38 C.F.R. § 4.124 (2017). Words such as “mild,” “moderate,” and “severe” 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). B. Discussion For the reasons expressed below, the Board finds that for the entire period on appeal, symptoms of the Veteran’s bilateral upper extremity CTS more nearly approximate moderate incomplete paralysis of the median nerves. In December 2011, VA received the Veteran’s claim for an increased rating for his service-connected right and left CTS, which are each currently rated as 10 percent disabling. Turning to the evidence, the Veteran was provided with a VA examination in March 2012 to determine the severity of his right and left CTS. It was noted that Veteran is a right-hand dominant. The Veteran reported bilateral hand numbness and difficulty holding objects. Upon physical examination, the examiner noted no constant pain, bilaterally; moderate intermittent pain, bilaterally; moderate paresthesias/dysesthesias, bilaterally; moderate numbness in the left upper extremity; and, severe numbness in the right upper extremity. Muscle strength testing was normal (5/5) throughout with no evidence of muscle atrophy. Reflexes and sensory examination were normal throughout, but the examiner noted decreased vibration sense in the fingers, bilaterally. There was no evidence of trophic changes. Phalen’s sign test was positive, bilaterally, and Tinel’s sign test was negative, bilaterally. The examiner concluded that the Veteran’s radial and ulnar nerves were normal, bilaterally, but noted mild incomplete paralysis of the median nerve, bilaterally. All additional nerve tests in the upper extremities were normal. It was noted that the Veteran did not use any assistive devices, and the examiner stated functioning was not so diminished that amputation with prosthesis would equally serve the Veteran. The examiner further noted that the Veteran previously had a surgery on his right wrist, which provided no relief, but resulted in a scar that was not panful, unstable, or total area greater than 6 square inches. In this regard, the examiner noted that EMG study was only abnormal on the left. The examiner concluded that the Veteran’s hand grip was 4/5, bilaterally, with decreased sensations of vibrations, but other sensations were intact. Though, the examiner further noted that the Veteran had subjective pain and tingling in hands mostly on the right hand. Subsequent medical records do not show complaints and or treatment for the Veteran’s service-connected CTS. Upon review of the medical and lay evidence of record, the Board finds that symptoms the Veteran’s bilateral upper extremity CTS more nearly approximate moderate incomplete paralysis of the median nerve. Although the examiner concluded that the level of severity was mild, bilaterally, the findings noted in the examination report specifically indicate moderate intermittent pain, bilaterally; moderate paresthesias/dysesthesias, bilaterally; moderate numbness in the left upper extremity; and, severe numbness in the right upper extremity. Furthermore, while the examiner noted normal muscle strength testing, it was later indicated that the Veteran had decreased hand grip. The same is true for the sensory findings, which were noted as normal, but later the examiner confirmed decreased sensation to vibrations in all fingers. Accordingly, the Board resolves all doubt in the Veteran’s favor in finding that his symptoms more nearly approximate moderate incomplete paralysis of the median nerves, which is consistent with a 30 percent disability rating for his dominant upper extremity CTS, and a 20 percent disability rating for his minor left upper extremity CTS. The Veteran does not allege and the record does not support an assignment of even higher ratings. Specifically, aside from severe numbness on the right side, no other severe symptoms were identified. In addition, the decrease in sensation and hand grip was minimal (4/5) and does not more nearly approximate severe symptoms. Earlier Effective Date Analysis for TDIU VA will grant a total rating for compensation purposes based on unemployability when the evidence shows that a veteran is precluded, due to service-connected disability, from obtaining or maintaining any form of gainful employment consistent with his or her education and occupational experience. See 38 C.F.R. §§ 3.340, 3.341, 4.16. Under the applicable regulations, benefits based on individual unemployability are granted only when it is established that the service-connected disability or disabilities are so severe, standing alone, as to prevent the retaining of gainful employment. Under 38 C.F.R. § 4.16, if there is only one such disability, it must be rated at least 60 percent disabling to qualify for benefits based on individual unemployability. If there are two or more such disabilities, there shall be at least one disability ratable at 40 percent or more and sufficient additional disability to bring the combined rating to 70 percent or more. Id. The Veteran in this case met the schedular criteria requirements under 38 C.F.R. § 4.16(a) for the entire rating period beginning December 10, 2011. Specifically, the Veteran was service connected for depression, rated as 70 percent disabling; sleep apnea rated as 50 percent disabling; lumbar strain, rated as 20 percent disabling; cervical strain, rated as 20 percent disabling; GERD, rated as 10 percent disabling; carpal tunnel, right and left upper extremity rated as 10 percent disabling, each; tinnitus, rated as 10 percent disabling, right and left lower extremity radiculopathy, rated as 10 percent disabling, each; bilateral hearing loss, rated as noncompensable; and, erectile dysfunction, rated as noncompensable. The Veteran had a combined rating of 90 percent beginning December 10, 2011. As such, the Board finds that the minimum schedular criteria for TDIU are met for the period beginning December 10, 2011. For the reasons expressed below, the Board finds that an effective date of December 10, 2011 is warranted. In a December 2015 rating decision, the RO granted entitlement to a TDIU, finding that the Veteran’s psychological and physical disabilities prevented him from securing and obtaining gainful employment, and assigned an effective date of November 7, 2013, the date the RO indicated VA received the Veteran’s claim for a TDIU. However, the Veteran’s asserts that he is entitled to a TDIU beginning on December 10, 2011. Initially, the Board notes that the Veteran filed his original claim for a TDIU on August 13, 2007 along with his claim for increased rating for depression. The RO denied both claims in a March 2008 rating decision, finding that the Veteran was working as a food coordinator in a children psychiatric facility. Thereafter, on December 10, 2011, the Veteran filed an increased rating claim for depression, and by an August 2012 rating decision the RO increased the Veteran’s rating for depression to 70 percent. Thereafter, throughout the pendency of the appeal, to include during various VA examinations, the Veteran’s inability to work due to his service-connected disabilities was noted. Here, the Board next finds that the Veteran’s TDIU claim does not arise from his November 2013 application for a TDIU, but rather was part and parcel of previously pending increased rating claims filed on December 10, 2011. Upon further review, and in consideration of the holding in Rice v. Shinseki, 22 Vet. App. 447 (2009), the Board finds that the issue of entitlement to a TDIU for the period prior to November 7, 2013, should have been considered as “part and parcel” of the increased rating claims on appeal. In other words, when evidence of unemployability is submitted in the course of a claim for a higher rating for one or more service-connected disabilities, and there is evidence of unemployability pertaining to the service-connected disability or disabilities at issue, a claim for TDIU will be considered part and parcel of the increased rating claim. See Rice v. Shinseki, 22 Vet. App. 447 (2009). Thus, as the issue of entitlement to TDIU in the context of an increased rating claim may be co-extensive with that claim in terms of the time period under review, the effective date of TDIU may be as early as the effective date applicable to the increased rating claim under 38 C.F.R. § 3.400(o). See Rice, 22 Vet. App. at 454 It is undisputed that the Veteran was not working during the period on appeal. Accordingly, the dispositive issue is whether he was unable to work as a result of his service-connected disabilities prior to November 7, 2013. Upon careful review of the lay and medical evidence, the Board finds that, for the entire period on appeal beginning December 10, 2011, the Veteran was precluded, due to his service-connected disabilities, from obtaining or maintaining any form of gainful employment. Turning to the evidence, a July 2011 VA psychiatry note authored by the Veteran’s treating psychiatry at the VA indicates that the Veteran’s TDIU claim should be considered based on his current depression and anxiety. Thereafter, during his March 2012 VA examination for sleep apnea, the examiner indicated that the Veteran’s sleep apnea impacted his ability to work, because he got very tired during the day and dozed off frequently. Notably, during his mental health examination, it was noted that he last worked as a food coordinator in a children psychiatric facility, in 2007 or 2008, for only three months, but left this job due to conflict with the facility director. The examiner further noted that the Veteran’s depression resulted in difficulty in establishing and maintaining effective work and social relationships and difficulty in adapting to stressful circumstances, including work or a worklike setting. Based on the foregoing, the evidence establishes that the Veteran was too disabled to work as of December 10, 2011. On this date, the Veteran had already met the schedular criteria for a TDIU, and the RO found that the Veteran’s service-connected disabilities were of such severity as to render him unemployable. For these reasons, and resolving reasonable doubt in the Veteran’s favor, the Board finds that an effective date of December 10, 2011, is warranted. It is noted that this date was specifically indicated by the Veteran’s attorney and as such, should represent a complete grant of the benefit sought here. See Correspondence dated on July 5, 2017. Neither the Veteran nor his attorney has raised any other issues, nor have any other issues been reasonably raised by the record. See Doucette v. Shulkin, 28 Vet. App. 366, 69-70 (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). REASONS FOR REMAND A remand is necessary in order to obtain an addendum medical opinion for the Veteran’s service connection claim for bilateral shoulder disability, to provide the Veteran with adequate VA examinations for his increased rating claims for lumbar spine, cervical spine, and GERD disabilities. Regarding the bilateral shoulder claim, the Board notes that the May 2015 VA examiner diagnosed bicipital tendonitis and degenerative arthritis in the left shoulder, and rotator cuff tear in the right shoulder. The examiner opined that the condition was less likely than not related to service, because during service, the condition was acute only, there was no evidence of chronicity of care, and therefore a nexus could not have been established. However, a review of the Veteran’s service treatment records shows that at least with regard to the right shoulder, in 1997, he complained of pain, which was noted to be chronic for over ten years, but progressively worse. Furthermore, private treatment notes dated in 2012 show that the Veteran complained of left shoulder injury twenty years earlier (while still in-service). Moreover, during the May 2015 VA examination, the Veteran reported that his bilateral shoulder problems began in service and have been continuous since separation. Given that the examiner’s rationale does not address the Veteran’s competent lay reports and the noted chronicity in service, the Board finds it inadequate. See Buchanan v. Nicholson, 451 F.3d 1331, 1337 (Fed. Cir. 2006) (lack of contemporaneous medical records does not serve as an “absolute bar” to the service connection claim). Regarding the lumbar and cervical spine claims, the Veteran underwent VA examinations for both disabilities in May 2015. At this time, he was unable to perform repetitive use testing because of his back and neck being “too painful.” Additionally, the Veteran reported flare-ups associated with both disabilities. Nevertheless, the examiner stated, “It is not possible to determine without resorting to mere speculation if additional limitation of motion is present due to pain during flare-ups or when joint is used repeatedly over a period of time, because there is no conceptual or empirical basis for making such a determination without directly observing function under these conditions.” The Court of Appeals for Veterans Claims, in a recent decision, held that “before the Board can accept an examiner’s statement that an opinion cannot be provided without resorting to speculation, it must be clear that this is predicated on a lack of knowledge among the “medical community at large” and not the insufficient knowledge of the specific examiner.” See Sharp v. Shulkin, 29 Vet. App. 26, 36 (2017) (quoting Jones v. Shinseki, 23 Vet. App. 382, 390 (2010)). Therefore, a new examination must be obtained before the spine claims can be decided on the merits. Regarding bilateral lower extremity radiculopathy, as indicated above, prior to certifying these issues to the Board, the RO, in a May 2016 rating decision, increased the Veteran’s disability rating for his lumbar and cervical strains to 20 percent, and granted 10 percent disability rating each, for lower right and left extremity radiculopathy. On the same date of the rating decision, the RO also issued a statement of the case for these issues; however, at least for the bilateral lower extremity radiculopathy, the Veteran has not submitted a notice of disagreement until July 2016, at which time he appealed both the assigned ratings for the lumbar and cervical strains as well as the bilateral lower extremity radiculopathy. While these symptoms as directly associated with the Veteran’s lumbar spine disability would generally be considered in the discussion for the increased rating lumbar spine claim, given the Board’s decision to remand this issue, herein, the increased ratings for bilateral lower extremity radiculopathy should also be remanded. Lastly, regarding the Veteran’s claim for increased rating for GERD, the only examination he was provided with in connection with his claim for increased rating was a March 2012 VA examination for stomach and duodenal conditions not including GERD or esophageal disorders. Although the examiner noted the diagnosis of GERD, the disability benefit questionnaire did not include relevant questions regarding the Veteran’s GERD symptoms apparently due to the use of the wrong examination report. Therefore, an adequate VA examination is necessary. The matters are REMANDED for the following action: 1. Ensure that all outstanding relevant VA treatment records are associated with the claims file. 2. Then, obtain an addendum opinion regarding the nature and etiology of the Veteran’s bilateral shoulder disability. The claims file and a copy of this Remand must be made available to the reviewing examiner, and the examiner shall indicate in the addendum report that the claims file was reviewed. The need for another examination is left to the discretion of the medical professional offering the addendum opinion. After a thorough review of the record and examination of the Veteran, the examiner is asked to respond to the following: Provide an opinion as to whether it is at least as likely as not (50 percent or greater probability) that the Veteran’s bilateral shoulder disability is a result of military service. In doing so, please address the Veteran’s competent lay reports of chronic bilateral shoulder pain, especially in light of the aforementioned STRs dated in 1997 showing treatment for chronic pain during the previous 10-years while still in service as well as his military occupational specialty of a galley specialist working in food, which required repetitive motion of the shoulders. A complete rationale should be provided. 3. Then, provide the Veteran with VA examinations to identify the current severity of his lumbar spine disability with associated bilateral lower extremity radiculopathy AND his cervical spine disability. The claims file must be made available to and be reviewed by the examiner. All indicated studies, tests, and evaluations must be conducted, and all findings reported in detail. After a thorough review of the record and examination of the Veteran, the examiner is asked to respond to the following: (a) Elicit from the Veteran all signs and symptoms of his lumbar spine and cervical spine disabilities. In doing so, also obtain information from the Veteran (and the treatment records) as to the frequency, duration, characteristics, severity, or functional loss with any repetitive use or during any flare-ups. (b) Full range of motion testing must be performed where possible. The lumbar and cervical spine should be tested in (1) active motion, (2) passive motion, (3) in weight-bearing, and (4) in nonweight-bearing. If the examiner is unable to conduct the required testing or concludes that the required testing is not necessary in this case, he or she should clearly explain why that is so. If pain is found during the examination, the examiner should note when the pain begins. (c) In assessing functional loss, flare-ups and increased functional loss on repetitive use must be considered. The examiner must consider all procurable and ascertainable data and describe the extent of any pain, incoordination, weakened movement, and excess fatigability on use, and, to the extent possible, report functional impairment due to such factors in terms of additional degrees of limitation of motion. **If the examiner is unable to provide such an opinion without resort to speculation, the examiner must provide a rationale for this conclusion, with specific consideration of the instructions in the VA Clinician’s Guide to estimate, “per [the] veteran,” what extent, if any, flare-ups affect functional impairment. The examiner must include a discussion of any specific facts that cannot be determined if unable to opine without speculation. Sharp v. Shulkin, 29 Vet. App. 26, 36 (2017). (d) Determine the current severity of the Veteran’s bilateral lower extremity radiculopathy. A complete rationale should be provided. 4. Provide the Veteran with an appropriate VA examination to determine the nature and severity of his GERD. After a thorough review of the record and examination of the Veteran, the examiner is asked to respond to the following: Elicit from the Veteran and the treatment records all signs and symptoms of his GERD since December 2011, and determine the current level of severity of the disorder. 5. Then, readjudicate the claims on appeal. If the benefits on appeal remain denied, furnish the Veteran and his attorney with a copy of a supplemental statement of the case and allow an appropriate time for response. S. B. MAYS Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD Yaffe, Achiya