Citation Nr: 18155007 Decision Date: 12/04/18 Archive Date: 12/03/18 DOCKET NO. 17-51 771 DATE: December 4, 2018 ORDER The Veteran’s application to reopen his claim of service connection for left arm and hand numbness is denied. An effective date of January 2, 2017, for an increased rating in the Veteran’s lumbar spine degenerative arthritis with disc bulging is granted. An effective date of January 2, 2017, for a separate compensable rating for left lower extremity radiculopathy is granted. An effective date prior to March 13, 2017, for an increased rating in the Veteran’s cervical spine degenerative arthritis with disc protrusion, stenosis, and bulging is denied. An effective date prior to March 13, 2017, for a separate compensable rating for right arm nerve impingement is denied. A 20 percent rating since January 2, 2017, for lumbar spine degenerative arthritis with disc bulging is granted. A 40 percent rating since January 2, 2017, for left lower extremity radiculopathy is granted. A rating of more than 10 percent since March 13, 2017, for cervical spine degenerative arthritis with disc protrusion, stenosis, and bulging is denied. A 40 percent rating since March 13, 2017, for right arm nerve impingement is granted. A 30 percent rating since March 13, 2017, for gastroesophageal reflux disease (GERD) is granted. A 50 percent rating since March 13, 2017, for posttraumatic stress disorder (PTSD) is granted. REMANDED The issue of service connection for erectile dysfunction (ED) is remanded. The issue of service connection for headaches, to include as a residual of a traumatic brain injury (TBI) is remanded. FINDINGS OF FACT 1. In July 2010, the Veteran was notified that VA denied service connection for left arm and hand numbness. The Veteran was informed in writing of the adverse determination and his appellate rights and did not submit a notice of disagreement (NOD) with the decision. 2. The July 2010 rating decision is final. 3. The additional documentation submitted since the July 2010 rating decision is not new and material and does not raise a reasonable possibility of substantiating the Veteran’s claim of service connection for left arm and hand numbness. 4. The Veteran had an increase in the disability of his lumbar spine disorder, including the onset of left lower extremity radiculopathy, effective January 2, 2017. 5. There is no evidence that the Veteran had an increase in his cervical spine disorder, including right upper extremity disability, prior to the date VA received his claim for an increased rating on March 17, 2017. 6. Since January 2, 2017, the Veteran’s lumbar spine disorder caused difficulty performing household chores; difficulty walking, standing, or sitting for prolonged periods; difficulty performing physical activities; back spasms; fatigue; sleep impairment; flare-ups every 2 weeks lasting up to 2 days each; increased pain with bending, twisting, or squatting; an antalgic gait; pain on passive range of motion; decreased sensation in the left foot and toes; mild constant pain, severe intermittent pain, severe paresthesias and/or dysesthesias, and moderate numbness in his left lower extremity; two incapacitating episodes of several days each; and normal range of motion with pain on forward flexion and extension. 7. Since March 13, 2017, the Veteran’s cervical spine disorder caused neck pain, fatigue, flare-ups, and stiffness; weakness, numbness, and tingling in the right arm; decreased sensation in the right hand and fingers; decreased grip strength; moderate paresthesias and/or dysesthesias and moderate numbness in the right upper extremity; and forward flexion from 0 to 40 degrees with pain, extension from 0 to 40 degrees with pain, right lateral flexion from 0 to 40 degrees, left lateral flexion from 0 to 40 degrees, right lateral rotation from 0 to 60 degrees, and left lateral rotation from 0 to 50 degrees. 8. Since March 13, 2017, the Veteran’s GERD with a hiatal hernia caused difficulty swallowing; pyrosis; regurgitation; and severe esophageal stricture which caused him to choke one time per day and which permitted the passage of liquids only and caused marked impairment of his general health. 9. Since March 13, 2017, the Veteran’s PTSD caused recurrent distressing dreams about in-service trauma; intense or prolonged psychological distress at exposure to cues that symbolized or resembled an aspect of the traumatic events; marked physiological reactions to cues that symbolized or resembled an aspect of the traumatic events; avoidance of memories, thoughts, or feelings about or closely associated with the traumatic events; avoidance of external reminders that aroused distressing memories, thoughts, or feelings about or closely associated with the traumatic events; persistent and exaggerated negative beliefs or expectations about himself, others, or the world; persistent negative emotional state; markedly diminished interest or participation in significant activities; feelings of detachment or estrangement from others; irritable behavior and angry outbursts; hypervigilance; exaggerated startle response; chronic sleep impairment; depressed mood; anxiety; suspiciousness; panic attacks occurring weekly or less often; disturbances of motivation and mood; restricted affect; denial; memory loss; difficulty getting along with other people; and agitation. CONCLUSIONS OF LAW 1. The July 2010 rating decision denying service connection for left arm and hand numbness is final. 38 U.S.C. § 7105 (2012); 38 C.F.R. § 20.1103 (2017). 2. New and material evidence sufficient to reopen the Veteran’s claim of entitlement to service connection for left arm and hand numbness has not been presented. 38 U.S.C. §§ 5103, 5103A, 5107, 5108 (2012); 38 C.F.R. §§ 3.102, 3.156, 3.159, 3.326(a) (2017). 3. The criteria for an effective date of January 2, 2017, for an increased rating in the Veteran’s lumbar spine disability have been met. 38 U.S.C. § 5107; 38 C.F.R. §§ 3.102, 3.400(o)(2) (2017). 4. The criteria for an effective date of January 2, 2017, for a separate compensable rating for left lower extremity radiculopathy have been met. 38 U.S.C. § 5107; 38 C.F.R. §§ 3.102, 3.400(o)(2) (2017). 5. The criteria for an effective date prior to March 13, 2017, for an increased rating in the Veteran’s cervical spine disability have not been met. 38 U.S.C. § 5107; 38 C.F.R. §§ 3.102, 3.400(o)(2) (2017). 6. The criteria for an effective date prior to March 13, 2017, for a separate compensable rating for right arm nerve impingement have not been met. 38 U.S.C. § 5107; 38 C.F.R. §§ 3.102, 3.400(o)(2) (2017). 7. The criteria for a rating of 20 percent, since January 2, 2017, for lumbar spine degenerative arthritis with disc bulging have been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.321, 3.326(a), 4.7, 4.10, 4.14, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5242 (2017). 8. The criteria for a rating of 40 percent, since January 2, 2017, for left lower extremity radiculopathy have been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.321, 3.326(a), 4.7, 4.10, 4.14, 4.40, 4.45, 4.59, 4.124a, Diagnostic Code 8520 (2017). 9. The criteria for a rating of more than 10 percent, since March 13, 2017, for cervical spine degenerative arthritis with disc protrusion, stenosis, and bulging have not been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.321, 3.326(a), 4.7, 4.10, 4.14, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5242 (2017). 10. The criteria for a rating of 40 percent, since March 13, 2017, for right arm nerve impingement have been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.321, 3.326(a), 4.7, 4.10, 4.14, 4.40, 4.45, 4.59, 4.124a, Diagnostic Code 8512 (2017). 11. The criteria for a rating of 30 percent, since March 13, 2017, for GERD have been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.321, 3.326(a), 4.7, 4.14, 4.114, Diagnostic Code 7346 (2017). 12. The criteria for a rating of 50 percent, since March 13, 2017, for PTSD have been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.321, 3.326(a), 4.7, 4.14, 4.130, Diagnostic Code 9411 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served in the U.S. Army from July 1989 to April 2010. He served in Southwest Asia and his military decorations include the Combat Action Badge and the Master Parachutist Badge. 1. Whether new and material has been received to reopen the Veteran’s claim of entitlement to left hand and arm numbness and, if so, whether service connection is warranted. Generally, absent the filing of an NOD within one year of the date of mailing of the notification of the initial review and determination of a veteran’s claim and the subsequent filing of a timely substantive appeal, a rating determination is final and is not subject to revision upon the same factual basis except upon a finding of clear and unmistakable error (CUE). 38 U.S.C. §§ 5108, 7105; 38 C.F.R. §§ 20.200, 20.300, 20.1103. A claimant may reopen a finally adjudicated claim by submitting new and material evidence. New evidence means existing evidence not previously submitted to agency decisionmakers. Material evidence means existing evidence that, by itself or when considered with previous evidence of record, relates to an unestablished fact necessary to substantiate the claim. New and material evidence can be neither cumulative nor redundant of the evidence of record at the time of the last prior final denial of the claim sought to be reopened, and must raise a reasonable possibility of substantiating the claim. 38 C.F.R. § 3.156(a). The provisions of 38 C.F.R. § 3.156(a) create a low threshold, with the phrase “raises a reasonable possibility of substantiating the claim” enabling rather than precluding reopening and not constituting a third requirement that must be met before the claim is reopened. Shade v. Shinseki, 24 Vet. App. 110 (2010); Evans v. Brown, 9 Vet. App 273, 283 (1996). See Hodge v. West, 155 F.3d 1356 (Fed. Cir. 1998). New and material evidence received prior to the expiration of the appeal period will be considered as having been filed in connection with the claim which was pending at the beginning of the appeal period. 38 C.F.R. § 3.156(b). Where documents are within VA’s control and could reasonably be expected to be a part of the record, such documents are, in contemplation of law, before VA and should be included in the record. Bell v. Derwinski, 2 Vet. App. 611, 613 (1992). The Board is required to consider the question of whether new and material evidence has been received to reopen the Veteran’s claim without regard to the RO’s determination in order to establish the Board’s jurisdiction to address the underlying claims and to adjudicate the claims on a de novo basis. Jackson v. Principi, 265 F.3d 1366, 1369 (Fed. Cir. 2001); Barnett v. Brown, 83 F.3d 1380 (Fed. Cir. 1996). In July 2010, VA denied service connection for left arm and hand numbness because there was no “current clinical evidence of a sensory or motor disturbance or dysfunction of the left arm or hand.” The Veteran was informed in writing of the adverse decision and did not submit an NOD. New and material evidence pertaining to the issue of service connection for left arm and hand numbness was not received by VA or constructively in its possession within one year of written notice to the Veteran of the July 2010 rating decision. Therefore, that decision became final. 38 C.F.R. § 3.156(b). The additional documentation received since the July 2010 rating decision does not include a current diagnosis of left arm or hand disorder, including numbness. When determining whether a claim should be reopened, the credibility of the newly submitted evidence is presumed. Justus v. Principi, 3 Vet. App. 510 (1992). Here, without examination of any other evidence of record, the newly-submitted evidence is of such significance that, when considered for the limited purpose of reopening the Veteran’s claim, it raises a reasonable possibility of substantiating his claim for service connection when considered with the previous evidence of record. As new and material evidence has not been received, the Veteran’s claim is not reopened. Effective Dates The effective date of an increased rating will be the earliest date as of which it is factually ascertainable based on all evidence of record that an increase in disability had occurred if a complete claim or intent to file a claim is received within 1 year from such date. Otherwise, the effective date will be the date of receipt of claim. When medical records indicate an increase in a disability, receipt of such medical records may be used to establish effective date(s) for retroactive benefits based on facts found of an increase in a disability only if a complete claim or intent to file a claim for an increase is received within 1 year of the date of the report of examination, hospitalization, or medical treatment. The provisions of this paragraph apply only when such reports relate to examination or treatment of a disability for which service-connection has previously been established. 38 C.F.R. § 3.400(o)(2). 2. Entitlement to an effective date prior to March 13, 2017, for a rating of 10 percent for lumbar spine degenerative arthritis with disc bulging and an effective date prior to March 13, 2017, for a separate compensable rating for left lower extremity radiculopathy. On March 13, 2017, VA received a VA Form 21-526b, Veteran Supplemental Claim form as to an increased rating for a back disorder. In a June 2017 rating decision, the Veteran was granted an increased rating for his lumbar spine disorder effective March 13, 2017. He was also granted a separate compensable rating for associated left lower extremity radiculopathy effective on that date. A private treatment record dated February 2, 2017, indicates that the Veteran had complaints of increased low back pain with left lower extremity sciatica for the prior month. The evidence indicates that the Veteran had increased low back disability, including low back pain and left lower extremity radicular symptoms, beginning a month prior to his February 2, 2017, medical appointment. Affording the Veteran, the benefit of the doubt, the Board finds that the effective date of his increased lumbar spine rating and the date of the separate compensable rating for his left lower extremity radiculopathy should be January 2, 2017. 3. Entitlement to an effective date prior to March 13, 2017, for a rating of 10 percent for cervical spine degenerative arthritis with disc protrusion, stenosis, and bulging, and an effective date prior to March 13, 2017, for a separate compensable rating for right arm nerve impingement. On March 17, 2017, VA received a VA Form 21-526b, Veteran Supplemental Claim form stating that the Veteran wished to file a claim for an increased rating for his cervical spine disorder. In a June 2017 rating decision, the Veteran was granted an increased rating effective March 13, 2017. He was also granted a separate compensable rating for associated right arm nerve impingement effective on that date. The Veteran has provided no argument, and the file contains no evidence, that the Veteran is entitled to an effective date prior to March 13, 2017, for the increase in his cervical spine rating or for the separate compensable rating for his right arm nerve impingement. There are no records indicating treatment for or complaints of the cervical spine or right arm. The right arm disorder is a symptom of the service connected cervical spine disorder and the increased rating claim for the cervical spine encompassed all associated neurological symptoms, including the right arm symptoms. As there is no indication in the 1 year prior to the claim being received by VA that the Veteran had increased cervical spine disability, the proper effective date is the date that VA received the claim for an increased rating on March 17, 2017. The Veteran has been granted an effective date of March 13, 2017. An earlier effective date is not warranted and the appeal is denied. Increased Ratings Disability evaluations are determined by comparing the Veteran’s current symptomatology with the criteria set forth in the Schedule for Rating Disabilities. 38 U.S.C. § 1155 (2012); 38 C.F.R. Part 4 (2017). Where there is a question as to which of two disability evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that evaluation. Otherwise, the lower evaluation will be assigned. 38 C.F.R. § 4.7. The evaluation of the same disability under several diagnostic codes, known as pyramiding, must be avoided. 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 or overlapping with the symptomatology of the other condition. 38 C.F.R. § 4.14; Esteban v. Brown, 6 Vet. App. 259, 262 (1994). 4. Entitlement to a rating of more than 10 percent for lumbar spine degenerative arthritis with disc bulging, and a rating of more than 10 percent for associated left lower extremity radiculopathy, since January 2, 2017. Diagnostic Code 5242 provides ratings for lumbar spine disorders. A 10 percent rating is warranted for forward flexion of the thoracolumbar spine greater than 60 degrees but not greater than 85 degrees; or, combined range of motion of the thoracolumbar spine greater than 120 degrees but not greater than 235 degrees; or, muscle spasm, guarding, or localized tenderness not resulting in abnormal gait or abnormal spinal contour; or, vertebral body fracture with loss of 50 percent or more of the height. A 20 percent rating is warranted for forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees; or, for the combined range of motion of the thoracolumbar spine not greater than 120 degrees; or, for 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 40 percent rating is warranted for forward flexion of the thoracolumbar spine 30 degrees or less or for favorable ankylosis of the entire thoracolumbar spine. A 50 percent rating is warranted for unfavorable ankylosis of the entire thoracolumbar spine. 38 C.F.R. § 4.71a, Diagnostic Code 5242 (2017). There are also several relevant note provisions associated with Diagnostic Code 5242. Note (1): Evaluate any associated objective neurologic abnormalities, including, but not limited to, bowel or bladder impairment, separately, under an appropriate diagnostic code. Note (2): (See also Plate V.) For VA compensation purposes, normal forward flexion of the thoracolumbar spine is zero to 90 degrees, extension is zero to 30 degrees, left and right lateral flexion are zero to 30 degrees, and left and right lateral rotation are zero to 30 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 thoracolumbar spine is 240 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): In exceptional cases, an examiner may state that because of age, body habitus, neurologic disease, or other factors not the result of disease or injury of the spine, the range of motion of the 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 supplies an explanation, the examiner’s assessment that the range of motion is normal for that individual will be accepted. Note (4): Round each range of motion measurement to the nearest five degrees. Note (5): For VA compensation purposes, unfavorable ankylosis is a condition in which the entire cervical spine, the entire 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. Note (6): Separately evaluate disability of the thoracolumbar and cervical spine segments, except when there is unfavorable ankylosis of both segments, which will be rated as a single disability. 38 C.F.R. § 4.71a, Diagnostic Code 5242 (2017). Diagnostic Code 8520 provides ratings for paralysis of the sciatic nerve. A 10 percent rating is warranted for mild incomplete paralysis, a 20 percent rating is warranted for moderate incomplete paralysis, a 40 percent rating is warranted for moderately severe incomplete paralysis, and a 60 percent rating is warranted for severe incomplete paralysis with marked muscular atrophy. 38 C.F.R. § 4.124a, Diagnostic Code 8520. A May 2017 statement from the Veteran’s spouse indicates that the Veteran was unable to perform yard work or household chores, such as sweeping or mopping, due to back pain. He could use a riding lawnmower for approximately 20 to 30 minutes before pain became too severe. His spouse stated that he was unable to walk for more than 30 minutes or sit in one position for more than 30 minutes without back pain. She also reported that he had several hobbies, including golf, mountain biking, cycling, running, and kayak fishing that his back pain prevented him from doing. She stated that his sleep was restless and that he had difficulty straightening up after bending. In May 2017, the Veteran was afforded a VA examination. The Veteran reported pain, fatigue, difficulty sitting for more than 20 to 30 minutes, and pain, tingling, and numbness radiating into his left leg. The Veteran reported flare-ups approximately every 2 weeks and lasting up to 2 days each; the pain intensity during flare-ups was a level 10 out of 10. He reported increased pain when sitting for more than 30 minutes, standing longer than 30 minutes, bending, twisting, or squatting. The examiner noted functional impairment resulting in severe pain which extended down the left leg, difficulty sleeping, difficulty sitting for more than 20 minutes, and difficulty walking. On examination, he had a normal range of motion with pain on forward flexion and extension. Pain did not cause any functional loss. There was no pain with weight-bearing, no pain with non weight bearing, no pain on palpation, no loss of range of motion following repeated use, no localized tenderness, no guarding, no muscle spasm, and no muscle atrophy. The examiner indicated that the Veteran had a slightly antalgic gait and there was objective evidence of pain on passive range of motion testing. Muscle strength and reflexes were normal. He had decreased sensation in his left foot and toes and mild constant pain, severe intermittent pain, severe paresthesias and/or dysesthesias, and moderate numbness in his left lower extremity. He used no assistive devices and had no difficulty getting up from a chair, getting on and off the examination table, lying in a supine position and raising his legs, or doing heel, toe, and tandem walking. The examiner indicated that the Veteran did not have Intervertebral Disc Syndrome (IVDS) and had no neurological abnormalities associated with his lumbar spine other than the left lower extremity radiculopathy. The examiner diagnosed the Veteran with lumbar spine degenerative arthritis with disc bulging and left lower extremity radiculopathy of the sciatic nerve. On his July 2017 notice of disagreement (NOD), the Veteran reported occasional back spasms, incapacitating episodes on two occasions in the prior year that lasted for several days each and for which he sought treatment, severe pain and cramping in the left lower extremity, difficulty sitting for an extended period, and difficulty standing and walking. Since January 2, 2017, the Veteran’s lumbar spine disorder caused difficulty performing household chores; difficulty walking, standing, or sitting for prolonged periods; difficulty performing physical activities; back spasms; fatigue; sleep impairment; flare-ups every 2 weeks lasting up to 2 days each; increased pain with bending, twisting, or squatting; an antalgic gait; pain on passive range of motion; decreased sensation in the left foot and toes; mild constant pain, severe intermittent pain, severe paresthesias and/or dysesthesias, and moderate numbness in his left lower extremity; two incapacitating episodes of several days each; and normal range of motion with pain on forward flexion and extension. Given these facts, the Board finds that a 20 percent rating for the Veteran’s lumbar spine disorder most closely approximates the Veteran’s limitation of motion and functional impairment during the relevant period. The Board also finds that a separate 40 percent rating is warranted for the Veteran’s left lower extremity radiculopathy. 38 C.F.R. § 4.7. See Hart v. Mansfield, 21 Vet. App. 505 (2007). In making these determinations, the Board has considered, along with the schedular criteria, the Veteran’s functional loss due to pain. 38 C.F.R. §§ 4.40, 4.45 (2017); DeLuca v. Brown, 8 Vet. App. 202, 206-207 (1995). A 40 percent rating is not warranted for the Veteran’s lumbar spine disorder because the Veteran did not have forward flexion limited to 30 degrees or less, did not have any ankylosis, and did not have IVDS. A 60 percent rating is not warranted for left lower extremity radiculopathy because the Veteran did not have any muscle atrophy. 5. Entitlement to a rating of more than 10 percent for cervical spine degenerative arthritis with disc protrusion, stenosis, and bulging, and a rating of more than 20 percent for associated right arm nerve impingement, since March 13, 2017. Diagnostic Code 5242 provides ratings for cervical spine disorders. A 10 percent rating is warranted 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 abnormal spinal contour; or, vertebral body fracture 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 for the combined range of motion of the cervical spine not greater than 170 degrees; or, for 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 rating is warranted for forward flexion of the cervical spine 15 degrees or less; or favorable ankylosis of the entire cervical spine. A 40 percent rating is warranted for unfavorable ankylosis of the entire cervical spine. A 100 percent rating is warranted for unfavorable ankylosis of the entire spine. 38 C.F.R. § 4.71a, Diagnostic Code 5240 (2017). Notes 1, 3, 4, 5, and 6 listed above for lumbar spine disorders also apply to cervical spine disorders. Note (2) states that: (See also Plate V.) 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. 38 C.F.R. § 4.71a, Diagnostic Code 5242 (2017). Paralysis of the upper extremity lower radicular group is rated according to diagnostic code 8512. A 20 percent rating is warranted for mild incomplete paralysis of the lower radicular group of the major upper extremity. A 40 percent rating is warranted for moderate incomplete paralysis of the lower radicular group of the major upper extremity. A 50 percent rating is warranted for severe incomplete paralysis of the lower radicular group of the major upper extremity. A 70 percent rating is warranted for complete paralysis of the lower radicular group of the major upper extremity. 38 C.F.R. § 4.124a, Diagnostic Code 8512 (2017). Paralysis of the radial nerve is rated according to diagnostic code 8514. A 20 percent rating is warranted for mild incomplete paralysis of the radial nerve of the major upper extremity. A 30 percent rating is warranted for moderate incomplete paralysis of the radial nerve of the major upper extremity. A 50 percent rating is warranted for severe incomplete paralysis of the radial nerve of the major upper extremity. A 70 percent rating is warranted for complete paralysis of the radial nerve of the major upper extremity. 38 C.F.R. § 4.124a, Diagnostic Code 8514 (2017). In his March 2017 claim, the Veteran reported decreased range of motion in the cervical spine, soreness, and fatigue. In her May 2017 statement, the Veteran’s spouse wrote that the Veteran had weakness and numbness in his arms. In May 2017, the Veteran was afforded a VA examination. The examiner indicated that the Veteran was ambidextrous. The Veteran reported neck pain, decreased mobility, radiating pain and numbness down his right arm, and tingling in the right arm when using a mouse at his desk at work. The Veteran reported flare-ups in his neck approximately once every 2 weeks and lasting 1 day each. During flare-ups, he had pain at a level 6 out of 10, stiffness, and soreness. The Veteran reported functional impairment resulting in stiffness, weakness, and decreased range of motion in the neck when sitting. On examination, he had forward flexion from 0 to 40 degrees, extension from 0 to 40 degrees, right lateral flexion from 0 to 40 degrees, left lateral flexion from 0 to 40 degrees, right lateral rotation from 0 to 60 degrees, and left lateral rotation from 0 to 50 degrees. He had pain with forward flexion and extension but pain did not cause functional loss and there was objective evidence of pain on passive range of motion testing. He had no pain with weight bearing or non-weight-bearing, no tenderness on palpation, and no additional loss of range of motion on repeated use testing. Pain, weakness, fatigability, or incoordination did not limit functional ability with repeated use over time. He had no localized tenderness, guarding, or muscle spasms and no muscle atrophy. Muscle strength testing and reflexes were normal. He had decreased sensation in his right hand and fingers and moderate paresthesias and/or dysesthesias and moderate numbness in the right upper extremity. The examiner indicated that the Veteran had right upper extremity radiculopathy involving the lower radicular group. The Veteran did not have IVDS. The examiner diagnosed cervical spine degenerative arthritis with disc protrusion, stenosis, and bulging with right upper extremity radiculopathy. In his July 2017 NOD, the Veteran reported daily numbness and tingling in his right arm which interfered with activities and his sleeping. He also reported decreased grip strength. Since March 13, 2017, the Veteran’s cervical spine disorder caused neck pain, fatigue, flare-ups, and stiffness; weakness, numbness, and tingling in the right arm; decreased sensation in the right hand and fingers; decreased grip strength; moderate paresthesias and/or dysesthesias and moderate numbness in the right upper extremity; and forward flexion from 0 to 40 degrees with pain, extension from 0 to 40 degrees with pain, right lateral flexion from 0 to 40 degrees, left lateral flexion from 0 to 40 degrees, right lateral rotation from 0 to 60 degrees, and left lateral rotation from 0 to 50 degrees. Given these facts, the Board finds that the current 10 percent rating adequately reflects the Veteran’s cervical spine limitation of motion and functional impairment during the relevant period. 38 C.F.R. § 4.7. See Hart, 21 Vet. App. at 505. In making this determination, the Board has considered, along with the schedular criteria, the Veteran’s functional loss due to pain. 38 C.F.R. §§ 4.40, 4.45 (2017); DeLuca, 8 Vet. App. at 206-207. A 20 percent rating is not warranted for the cervical spine symptoms as the Veteran did not have forward flexion between 15 and 30 degrees, had combined cervical range of motion greater than 170 degrees, had no muscle spasm or guarding, had no abnormal spinal contour, and had no IVDS. As the May 2017 examiner indicated that the Veteran was ambidextrous, the Board will rate the Veteran’s right upper extremity as a major limb. The Board finds that the Veteran is entitled to a 40 percent rating for moderate right upper extremity radiculopathy involving the lower radicular group under diagnostic code 8512. The Veteran’s right arm symptoms were previously rated according to diagnostic code 8514 but the May 2017 examiner indicated that the lower radicular group, not just the radial nerve, were involved in the Veteran’s radiculopathy. Diagnostic code 8512 affords him a higher rating and is, therefore, more beneficial to the Veteran. The Veteran is not entitled to a 50 percent rating as the May 2017 examiner indicated that the Veteran’s symptoms were moderate. 6. Entitlement to a rating of more than 10 percent for GERD since March 13, 2017. A 10 percent rating for GERD is warranted for two or more of the symptoms for the 30 percent rating of less severity. A 30 percent rating is warranted for persistently recurrent epigastric distress with dysphagia, pyrosis, and regurgitation, accompanied by substernal or arm or shoulder pain, productive of considerable impairment of health. A 60 percent rating is warranted for symptoms of pain, vomiting, material weight loss and hematemesis or melena with moderate anemia; or other symptom combinations productive of severe impairment of health. 38 C.F.R. § 4.114, Diagnostic Code 7346. In May 2017, the Veteran was afforded a VA examination. The examiner indicated that the Veteran had GERD and a hiatal hernia. The Veteran reported heartburn and difficulty swallowing. He took Omeprazole twice daily for his symptoms. The examiner indicated that the Veteran had pyrosis and severe esophageal stricture which caused him to choke one time per day and which permitted the passage of liquids only and caused marked impairment of his general health. In a July 2017 statement, the Veteran reported dysphagia nearly every day, pyrosis daily, and regurgitation weekly. He wrote that “Regurgitation causes a burning in my throat and a bad taste that lingers. Pyrosis causes mild to major discomfort daily. The dysphagia makes it difficult [to swallow], which causes choking by food or beverage going down ‘the wrong pipe.’” Since March 13, 2017, the Veteran’s GERD with a hiatal hernia caused difficulty swallowing; pyrosis; regurgitation; and severe esophageal stricture which caused him to choke one time per day and which permitted the passage of liquids only and caused marked impairment of his general health. Given these facts, the Board finds that the Veteran’s symptoms most closely approximate a 30 percent rating. 38 C.F.R. § 4.7. A 60 percent rating is not warranted as the Veteran did not have pain, vomiting, weight loss, hematemesis, melena, or anemia, and the May 2017 examiner indicated that his symptoms caused marked impairment, not severe impairment, in his health. 7. Entitlement to a rating of more than 30 percent for PTSD since March 13, 2017. A 30 percent evaluation is warranted for PTSD where there is occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, mild memory loss (such as forgetting names, directions, recent events). A 50 percent evaluation requires occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships. A 70 percent evaluation requires occupational and social impairment with deficiencies in most areas such as work, school, family relations, judgment, thinking, or mood due to symptoms such as suicidal ideation, obsessional rituals which interfere with routine activities, intermittently illogical, obscure, or irrelevant speech, 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 an inability to establish and maintain effective relationships. A 100 percent evaluation requires total occupational and social impairment due to symptoms such as gross impairment in thought processes or communication, persistent delusions or hallucinations, grossly inappropriate behavior, a persistent danger of hurting himself or others, an intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene), disorientation to time or place, and memory loss for names of close relatives, own occupation, or own name. 38 C.F.R. § 4.130, Diagnostic Code 9411 (2017). The use of the phrase “such symptoms as,” followed by a list of examples, provides guidance as to the severity of symptomatology contemplated for each rating. In particular, use of such terminology permits consideration of items listed as well as other symptoms and contemplates the effect of those symptoms on the claimant's social and work situation. See Mauerhan v. Principi, 16 Vet. App. 436 (2002). In her May 2017 statement, the Veteran’s spouse reported that the Veteran seemed depressed. In May 2017, the Veteran was afforded a VA examination. He reported that he had been married to his second spouse for approximately 1 year and that they had a good relationship. Her two children lived with them and he had a good relationship with his adult daughter. He was working as an intelligence analyst and reported no work related difficulties. He reported nightmares and an anxious mood but no violent behavior, panic attacks, or suicidal or homicidal ideation. The examiner indicated that he had symptoms of recurrent distressing dreams related to in service traumatic events; marked physiological reactions to internal or external cues that symbolized or resembled an aspect of the traumatic events; avoidance of distressing memories, thoughts, or feelings about or closely associated with the traumatic events; persistent and exaggerated negative beliefs or expectations about himself, others, or the world; markedly diminished interest or participation in significant activities; irritable behavior and angry outbursts; hypervigilance; exaggerated startle response; chronic sleep impairment; depressed mood; anxiety; disturbances of motivation and mood; and a slightly restricted affect. In a July 2017 statement, the Veteran indicated that he had symptoms of anger, anxiety, chronic sleep impairment, denial, depression, flashbacks, memory loss, panic attacks, and difficulty getting along with other people. In August 2017, the Veteran was afforded another VA examination. He reported that his back pain worsened his depressive symptoms and sleep disturbances. The Veteran continued to work full-time as an intelligence analyst and indicated that his symptoms impacted him socially more than professionally. He reported that he drank socially, consuming at most 1 beer per week. The examiner indicated that the Veteran had symptoms of recurrent distressing dreams about in-service trauma; intense or prolonged psychological distress at exposure to cues that symbolized or resembled an aspect of the traumatic events; marked physiological reactions to cues that symbolized or resembled an aspect of the traumatic events; avoidance of memories, thoughts, or feelings about or closely associated with the traumatic events; avoidance of external reminders that aroused distressing memories, thoughts, or feelings about or closely associated with the traumatic events; persistent and exaggerated negative beliefs or expectations about himself, others, or the world; persistent negative emotional state; markedly diminished interest or participation in significant activities; feelings of detachment or estrangement from others; irritable behavior and angry outbursts; hypervigilance; exaggerated startle response; chronic sleep impairment; depressed mood; anxiety; suspiciousness; panic attacks occurring weekly or less often; and disturbances of motivation and mood. The examiner noted that the Veteran “appeared to be experiencing some pain and agitation.” He had a restricted affect, reported that he sometimes experienced anger while driving, and had no suicidal or homicidal ideation and no hallucinations. Since March 13, 2017, the Veteran’s PTSD caused recurrent distressing dreams about in-service trauma; intense or prolonged psychological distress at exposure to cues that symbolized or resembled an aspect of the traumatic events; marked physiological reactions to cues that symbolized or resembled an aspect of the traumatic events; avoidance of memories, thoughts, or feelings about or closely associated with the traumatic events; avoidance of external reminders that aroused distressing memories, thoughts, or feelings about or closely associated with the traumatic events; persistent and exaggerated negative beliefs or expectations about himself, others, or the world; persistent negative emotional state; markedly diminished interest or participation in significant activities; feelings of detachment or estrangement from others; irritable behavior and angry outbursts; hypervigilance; exaggerated startle response; chronic sleep impairment; depressed mood; anxiety; suspiciousness; panic attacks occurring weekly or less often; disturbances of motivation and mood; restricted affect; denial; memory loss; difficulty getting along with other people; and agitation. Given these facts, the Board finds that the Veteran’s symptoms most closely approximate a 50 percent rating for the period on appeal. 38 C.F.R. § 4.7. The Veteran is not entitled to a 70 percent rating has he had no suicidal or homicidal ideation, no hallucinations or delusions, maintained full-time employment with no work-related impairment, and had a good relationship with his family. REASONS FOR REMAND 1. The issue of service connection for ED is remanded. 2. The issue of service connection for headaches, to include as a residual of a TBI, is remanded. The matters are REMANDED for the following action: 1. Reasons for the remand: In February 2018, the Veteran submitted an NOD with the denial of service connection for ED. A statement of the case (SOC) addressing the NOD has not been issued to him. Therefore, remand is necessary. See Manlincon v. West, 12 Vet. App. 238, 240 241 (1999). Remand of the issue of service connection for headaches is necessary to obtain a new VA medical opinion. The May 2017 examination report states that the Veteran had no diagnosis despite the examiner stating several times that the Veteran had headaches. The examiner also stated that the Veteran has had no treatment for headaches, but private treatment records indicate that the Veteran was taking prescription medication for headaches. Additionally, the examiner was asked to provide an opinion as to whether the Veteran’s headache disorder was caused or aggravated by his lumbar spine disorder, despite his repeated assertions that his cervical spine disorder was causing or aggravating his headaches. The Veteran served in Southwest Asia and an opinion as to whether his headaches are a result of an undiagnosed illness or a medically unexplained chronic multi symptom illness is necessary. The Veteran had also indicated that he experienced head trauma several times in service. Therefore, a TBI examination is also necessary. 2. Issue an SOC to the Veteran and his accredited representative which addresses the issue of service connection for ED. The Veteran should be given the appropriate opportunity to respond to the SOC. 3. Schedule the Veteran for (1) a VA headaches examination and (2) a TBI examination with a psychiatrist, physiatrist, neurosurgeon, or neurologist to obtain an opinion as to the nature and etiology of a headache disorder. All indicated tests and studies should be accomplished and the findings reported in detail. All relevant medical records must be made available to the examiner for review of pertinent documents. The examination report should specifically state that such a review was conducted. The examiner must provide a comprehensive explanation for all opinions provided. The examiner should address the following: (a.) Whether the Veteran has a headache disorder diagnosis. (b.) Whether the Veteran’s headaches were caused by any in-service event, injury, disease, or disorder, or in any way originated during service. (c.) Whether the Veteran’s headaches are a residual of an in-service TBI. (d.) Whether any diagnosed headache disorder has no conclusive pathophysiology or etiology. (e.) Whether any undiagnosed headache complaints are the result of an undiagnosed illness or medically unexplained chronic multi symptom illness. (f.) Whether the Veteran’s headaches were caused by any service-connected disorder. (g.) Whether the Veteran’s headaches were aggravated by any service-connected disorder. Service connection is currently in effect for PTSD; right arm nerve impingement; tinnitus; GERD; cervical spine degenerative arthritis with disc protrusion, stenosis, and bulging; lumbar spine degenerative arthritis with disc bulging; left lower extremity radiculopathy; and syncope. The examiner’s attention is drawn to the following: *May 2016 private treatment record stating that the Veteran had had a CT scan of the head which was unremarkable and stating that he was prescribed medication for headaches. VBMS Entry 3/27/2017, p. 15-16. *May 2017 VA examination report stating that the Veteran had headaches which occurred 2 to 3 times per week. *July 2017 statement from the Veteran where he reported several occurrences of in-service head trauma and in-service exposure to improvised explosive devices (IEDs) and mortar fire. (Continued on the next page)   4. Readjudicate the issue on appeal. If the benefit sought on appeal remains denied, the Veteran should be provided a supplemental statement of the case (SSOC). An appropriate period should be allowed for response before the case is returned to the Board. Vito A. Clementi Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD J. E. Miller, Associate Counsel