Citation Nr: 18157220 Decision Date: 12/12/18 Archive Date: 12/11/18 DOCKET NO. 13-01 786 DATE: December 12, 2018 ORDER Entitlement to a disability rating greater than 20 percent for residuals of status post L4-5 hemilaminectomy and discectomy for herniated nucleus pulposus (lumbar spine disability) is denied. Entitlement to a disability rating greater than 40 percent for right lower extremity lumbar radiculopathy is denied. Entitlement to a disability rating greater than 40 percent for left lower extremity lumbar radiculopathy is denied. Entitlement to a total disability rating based on individual unemployability due to service-connected disabilities (TDIU) is granted. REMANDED Entitlement to service connection for chronic inflammatory demyelinating polyneuropathy (CIDP), to include as secondary to a service-connected lumbar spine disability and bilateral lower extremity lumbar radiculopathy, is remanded. Entitlement to a separate compensable rating for neurogenic bladder with voiding dysfunction secondary to a service-connected lumbar spine disability and lumbar radiculopathy of the bilateral lower extremities is remanded. FINDINGS OF FACT 1. The Veteran’s service-connected lumbar spine disability has manifested as no worse than forward flexion limited to 50 degrees (accounting for painful motion on examination found to cause functional loss) and functional impairments such as interference with sitting, standing, weight-bearing, prolonged walking, lifting, and climbing; however, at no point during the appeal period was there competent evidence of unfavorable ankylosis of the entire thoracolumbar spine or the entire spine; nor was there evidence of incapacitating episodes of intervertebral disc syndrome (IVDS) with a total duration of at least four weeks but less than six weeks during any past twelve-month period. 2. The Veteran's service-connected right lower extremity radiculopathy manifested as symptoms approximating no worse than moderately severe, incomplete paralysis, with symptoms such as complaints of pain, some sensory loss, diminished reflexes, and motor deficits. 3. The Veteran’s service-connected left lower extremity radiculopathy manifested as symptoms approximating no worse than moderately severe, incomplete paralysis, with symptoms such as complaints of pain, some sensory loss, diminished reflexes, and motor deficits. 4. The evidence is at least in equipoise that the combined effects of the Veteran’s service-connected lumbar spine disability and bilateral lower extremity lumbar radiculopathy have rendered him unemployable. CONCLUSIONS OF LAW 1. The criteria for a disability rating greater than 20 percent for a lumbar spine disability have not been met. 38 U.S.C. §§ 1155, 5102, 5103, 5103A, 5107; 38 C.F.R. §§ 3.159, 3.321, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code (DC) 5242. 2. The criteria for a disability rating greater than 40 percent for right lower extremity lumbar radiculopathy have not been met. 38 U.S.C. §§ 1155, 5103A, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.40, 4.45, 4.59, 4.124a, DC 8520. 3. The criteria for a disability rating greater than 40 percent for left lower extremity lumbar radiculopathy have not been met. 38 U.S.C. §§ 1155, 5103A, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.40, 4.45, 4.59, 4.124a, DC 8520. 4. The criteria for entitlement to a schedular TDIU based on the combined effects of the Veteran’s service-connected disabilities have been met. 38 U.S.C. §§ 1155, 5110; 38 C.F.R. §§ 3.155, 4.15, 4.16, 4.19. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from July 1977 to October 1986. He testified before the undersigned Veterans Law Judge during an October 2016 video conference hearing and a transcript of that proceeding is of record. The record contains evidence that the Agency of Original Jurisdiction (AOJ) has not considered. In an October 2018 brief, the Veteran’s representative stated that the Veteran wished to waive initial AOJ review of this evidence. In July 2017, the Board remanded this appeal for development. As the Regional Office (RO) substantially complied with the remand, an additional remand to comply with the Board’s directives is not required. See Stegall v. West, 11 Vet. App. 268 (1998). Increased rating claims for spine disabilities necessarily include consideration of the availability of separate ratings for associated neurological abnormalities. As discussed further in the remand below, medical evidence of record raises the issue of whether a separate compensable disability rating is warranted for a voiding dysfunction associated with the Veteran’s service-connected lumbar spine disability and/or lumbar radiculopathy. Accordingly, the Board has split the increased rating claim for a lumbar spine disability presently on appeal (decided herein) from the issue of entitlement to a separate compensable rating for a voiding dysfunction associated with the service-connected lumbar spine disability (remanded herein). Various lay statements of record suggest the Veteran’s interest in filing a service connection claim for an acquired psychiatric disability secondary to chronic pain from his service-connected lumbar spine disability and bilateral lower extremity lumbar radiculopathy. Effective March 24, 2015, VA adopted a standardized claims system. The AOJ should provide the Veteran with a claim form and invite him to submit a formal claim. The Board has thoroughly reviewed all the evidence in the Veteran’s VA files. In every decision, the Board must provide a statement of the reasons or bases for its determination, adequate to enable an appellant to understand the precise basis for the Board’s decision, as well as to facilitate review by the Court. 38 U.S.C. § 7104(d)(1); see Allday v. Brown, 7 Vet. App. 517, 527 (1995). Although the entire record must be reviewed by the Board, the Court has repeatedly found that the Board is not required to discuss, in detail, every piece of evidence. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000); Dela Cruz v. Principi, 15 Vet. App. 143, 149 (2001) (rejecting the notion that the Veterans Claims Assistance Act mandates that the Board discuss all evidence). Rather, the law requires only that the Board address its reasons for rejecting evidence favorable to the appellant. See Timberlake v. Gober, 14 Vet. App. 122 (2000). The analysis below focuses on the most salient and relevant evidence and on what this evidence shows, or fails to show, on the claim. The appellant must not assume that the Board has overlooked pieces of evidence that are not explicitly discussed herein. See id. Pertinent regulations for consideration were provided to the Veteran in the October 2012 and December 2013 and Statements of the Case (SOCs) and will not be repeated here in full. Increased Rating Claims For the reasons below, the increased rating claims for a lumbar spine disability and lumbar radiculopathy of the right and left lower extremities are denied. 1. Entitlement to a disability rating greater than 20 percent for a lumbar spine disability is denied. The Veteran currently has a 20 percent disability rating under DC 5242 for his service-connected lumbar spine disability. He seeks a higher rating. After a full review of the record, the Board finds that a higher rating is unwarranted at any point during the appeal period for the following reasons. First, his lumbar spine disability has manifested as no worse than forward flexion limited to 50 degrees, accounting for painful motion noted on examination and found to cause functional loss. See January 2010, August 2011, May 2013, and September 2017 VA examinations. This degree of limitation of motion falls squarely within the criteria for the current, 20 percent rating assigned under 38 C.F.R. § 4.71a, DC 5242 (General Rating Formula for Diseases and Injuries of the Spine) (General Rating Formula). The Board recognizes that some VA and private outpatient treatment records noted limited or decreased motion of the lumbar spine during the appeal period. However, they were inadequate for rating purposes because they did not express such limitations in terms of degrees. VA and private providers generally noted limited or decreased motion of the lumbar spine, but failed to specify such limitations in terms of degrees. Thus, the Board would have to engage in mere speculation to surmise the specific degrees of limited lumbar spine flexion during these encounters. Second, at no point during the appeal period was there competent evidence of unfavorable ankylosis of the entire thoracolumbar spine or the entire spine. See January 2010, August 2011, May 2013, and September 2017 VA examinations. 38 C.F.R. § 4.71a, DC 5242 (General Rating Formula). Third, a higher rating is unwarranted under 38 C.F.R. § 4.71a, DC 5243, Formula for Rating IVDS Based on Incapacitating Episodes (Formula for Rating IVDS). At no point during the appeal period was there competent evidence of incapacitating episodes of IVDS with a total duration of at least four weeks but less than six weeks during any past twelve-month period. While the Veteran may voluntary restrict his activities and rest during episodes of IVDS flare-ups, that is not how VA regulations define “incapacitating episodes” in this context. See 38 C.F.R. § 4.71a, DC 5243, Note (1) (defining “incapacitating episode” as a period of acute signs and symptoms due to IVDS that requires bed rest prescribed by a physician and treatment by a physician). The Board considered evidence of functional loss due to flare-ups of pain, fatigability, incoordination, pain on movement, and weakness and find that these principles do not support a higher rating. 38 C.F.R. §§ 4.40, 4.45, 4.59; DeLuca v. Brown, 8 Vet. App. 202, 206-7 (1995). Even accounting for such symptoms and functional loss, the Veteran’s lumbar spine symptoms and impairments fall squarely within the criteria for the currently assigned, 20 percent rating. Regarding neurological abnormalities related to the service-connected lumbar spine disability, the Veteran already has been assigned separate compensable ratings of 40 percent each for right and left lower extremity radiculopathy. The Board will address those issues, which also are on appeal, in the discussion below. Also, as discussed in the remand below, further development is needed regarding whether voiding dysfunction symptoms shown during the appeal period are at least as likely as not secondary to / symptoms of his service-connected lumbar spine disability or lumbar radiculopathy. The evidence does not show any other neurological abnormalities related to the service-connected lumbar spine disability. See 38 C.F.R. § 4.71a, General Rating Formula, Note (1). The Board acknowledges the Veteran’s assertions that his lumbar disability is of great severity such that a higher disability rating is warranted. However, the most probative and competent medical evidence summarized above does not justify a higher rating under the criteria. The Board does not doubt that he has had lumbar spine symptoms such as limitation of motion with pain and other functional impairments such as interference with sitting, standing, weight-bearing, lifting, climbing, and prolonged walking. However, there is no specific, competent medical evidence that would warrant a higher rating under the relevant rating criteria. Additionally, the Veteran suggested that in the 2017 remand, the Board conceded that his service-connected lumbar spine disability had worsened such that a higher rating was warranted. Specifically, he cites the 2017 remand’s reference to evidence of possible worsening of his service-connected disabilities. However, he took this finding out of context. This preliminary finding justified remanding the increased rating claims on appeal for current VA examinations and other development, as opposed to a finding of fact in a merits decision adjudicating whether his service-connected lumbar spine disability had worsened such that a higher rating was warranted. A remand’s preliminary finding of evidence suggesting possible worsening since a prior VA examination (warranting a current VA examination) does not equate to a merits decision or concession that a higher disability rating is warranted. In conclusion, entitlement to a disability rating greater than 20 percent for the service-connected lumbar spine disability is denied. The benefit of the doubt rule under 38 U.S.C. § 5107(b) does not apply because there is not an approximate balance of evidence. See Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Finally, neither the Veteran nor his representative has raised any other issues; nor have any other issues been reasonably raised by the record. See Doucette v. Shulkin, No. 15-2818, 2017 U.S. App. Vet. Claims LEXIS 319, *8-9 (Vet. App. Mar. 17, 2017) (confirming Board not required to address issues unless specifically raised by claimant or reasonably raised by evidence of record). 2. Entitlement to disability ratings greater than 40 percent for both right and left lower extremity lumbar radiculopathy are denied. The AOJ assigned separate, 40 percent disability ratings for lumbar radiculopathy of both the right and left lower extremities under 38 C.F.R. § 4.124a, DC 8520. He seeks higher ratings for both disabilities. Diseases of the peripheral nerves are evaluated under the Schedule of Ratings for Diseases of the Peripheral Nerves. See 38 C.F.R. § 4.124a. Disabilities associated with the sciatic nerves are evaluated under DC 8520. A higher, 60 percent disability rating is warranted under DC 5250 for incomplete paralysis of the sciatic nerve that is severe, with marked muscular atrophy. 38 C.F.R. § 4.124a. When rating peripheral nerve injuries and their residuals, attention should be given to the site and character of the injury, the relative impairment and motor function, trophic changes, or sensory disturbances. 38 C.F.R. § 4.120. Disability from neurological disorders is rated from 10 percent to 100 percent in proportion to the impairment of motor, sensory, or mental function, and that with partial loss of use of one or more extremities from neurological lesions, rating is to be by comparison with mild, moderate, severe, or complete paralysis of the peripheral nerves. See 38 C.F.R. § 4.124a (note). The VA Schedule for Rating Disabilities does not define the terms mild, moderate, moderately severe, and severe. Rather than applying a mechanical formula, the Board must evaluate all the evidence such that its decisions are “equitable and just.” 38 C.F.R. § 4.6. The term “incomplete paralysis” indicates a degree of loss or impaired function substantially less than the type of picture for complete paralysis given with each nerve, whether due to varied level of the nerve lesion or to partial. 38 C.F.R. § 4.124a (note). After a full review of the record, the Board finds that disability ratings greater than 40 percent each are unwarranted for the Veteran’s service-connected lumbar radiculopathy of the right and left lower extremities. At no time during the appeal period did either disability manifest as or approximate severe, incomplete paralysis with marked muscular atrophy. Initially, the Board observes that the September 2017 VA spine examiner thoroughly discussed the Veteran’s separate diagnoses of his non-service-connected CIDP (manifested as symptoms such as bilateral lower and upper extremity feelings of “burning” in a “stocking and glove” pattern), and his service-connected right and left lower extremity lumbar radiculopathy (manifested as symptoms such as bilateral lower extremity pain as well as sensory, motor, and reflex impairments). When clarifying the sensory examination findings regarding the Veteran’s bilateral lower extremity radiculopathy, the 2017 VA examiner competently and persuasively found that the sensory impairment was in the territory of the S1 nerve roots bilaterally (of both lower legs and feet). The examiner also competently found that the sensory impairment attributable to the bilateral lower extremity radiculopathy was “superimposed” on decreased to light touch in a stocking and glove sensory impairment involving both feet and both lower legs up to the knees. Thus, the 2017 VA examiner implied that the Veteran’s service-connected bilateral lower extremity radiculopathy symptoms overlapped to some degree with his non-service connected CIDP lower extremity symptoms. This finding is consistent with the weight of the competent medical evidence of record, including VA treatment records and findings in other VA examinations. Thus, to the extent that these separate nerve conditions have some overlapping symptoms such as lower extremity pain, affording the Veteran the benefit of the doubt, the Board will consider such symptoms when rating the service-connected right and left lower extremity radiculopathy at issue here. During the appeal period, the Veteran’s right and lower extremity radiculopathy primarily manifested as symptoms such as: generally moderate to severe pain; generally diminished or decreased sensation of the lower extremities, though with some evidence of absent sensation of the lower leg and foot at times; generally mild paresthesias and feelings of numbness; and generally decreased or hypoactive lower extremity reflexes, though with periods of some absent lower extremity reflexes at times. See, e.g., January 2010, August 2011, May 2013, and September 2017 VA examinations; see also generally VA and private treatment records. The Board affords great probative value to the 2013 and 2017 VA examiners’ competent, persuasive descriptions of the severity of the Veteran’s service-connected bilateral lower extremity radiculopathy. See May 2013 VA examination (finding moderate left lower extremity radiculopathy; concluding lumbar radiculopathy was at most a “moderate” problem); see also September 2017 VA examination (finding “mild” and incomplete bilateral radiculopathy with sciatic nerve involvement). Their respective findings were based on thorough considerations of the Veteran’s medical history, reported symptoms, and clinical examination findings. The May 2013 VA examiner competently and persuasively explained that the most disabling issue was the non-service-connected CIDP, as opposed to the service-connected lumbar radiculopathy, which was at most a “moderate” problem. This finding is corroborated by the January 2010 VA examiner’s conclusion that most of the Veteran’s symptoms likely were due to his non-service-connected polyneuropathy, as opposed to his lumbar radiculopathy. Also, the 2013 and 2017 VA examiners’ respective characterizations of the Veteran’s bilateral lower extremity radiculopathy were consistent with the weight of the medical evidence of record, including objective neurological findings during these and other VA examinations, as well as neurological findings in VA and private treatment records showing symptoms that, on balance, approximated no worse than moderately severe, incomplete paralysis. The Board recognizes that the August 2011 VA examiner characterized the Veteran’s bilateral lower extremity radiculopathy as “severe.” However, this finding is an outlier considering the weight of the competent medical evidence summarized above. The Board does not doubt that at times during the appeal period the Veteran had flare-ups of his radiculopathy symptoms. However, such flare-ups of arguably severe symptoms were not representative of the overall nature and degree of his radiculopathy symptoms and impairments as shown by the weight of the medical evidence summarized above. The Board also acknowledges that at least one VA provider described the Veteran’s lower extremity radicular pain as “severe.” See April 2014 VA neurology note. The degree of pain is relevant to the overall severity of the peripheral nerve disability and the Board has considered this well-documented symptom. However, the severity of pain alone is not dispositive of whether a higher rating is warranted for symptoms approximating severe, incomplete paralysis. Indeed, other pertinent symptoms and impairments include the degree of sensory, motor, and reflex functioning. Considering the totality of the Veteran’s bilateral lower extremity radiculopathy symptoms, these disabilities have not manifested as or approximated severe, incomplete paralysis based on the weight of the medical evidence. Also, even assuming for the sake of argument that the evidence showed severe, incomplete paralysis of either sciatic nerve, there is still no competent medical evidence showing marked muscular atrophy of either lower extremity at any point during the appeal period. To the contrary, VA examiners consistently and affirmatively found no muscle atrophy. See August 2011, May 2013, September 2017 VA examinations. Thus, even if the Board were to concede the presence of severe, incomplete paralysis, a higher rating still would be unwarranted for radiculopathy of either lower extremity under 38 C.F.R. § 4.124a, DC 8520. The Board acknowledges the Veteran’s assertions that his right and left lower extremity radiculopathy disabilities were of great severity such that higher disability ratings are warranted. The Board does not doubt that he has had significant lower extremity sciatic nerve symptoms such as pain and difficulty with prolonged walking, standing, and climbing. However, the weight of the most probative and competent medical evidence summarized above does not justify a higher disability rating under the schedular criteria. There is no specific, competent medical evidence showing symptoms approximating severe, incomplete paralysis with marked muscle atrophy of either lower extremity. In conclusion, disability ratings greater than 40 percent are unwarranted for the Veteran’s service-connected right and left lower extremity lumbar radiculopathy. As the preponderance of the evidence is against these claims, the benefit of the doubt doctrine does not apply. 38 U.S.C. § 5107(b); 38 C.F.R. §§ 3.102, 4.3; Gilbert, 1 Vet. App. at 53-56. Finally, neither the Veteran nor his representative has raised any other issues; nor have any other issues been reasonably raised by the record. See Doucette, supra. TDIU The Veteran seeks entitlement to a TDIU. He contends that he became too disabled to work in June 2011, when he last worked full-time for a cigar manufacturing company as a master mechanic, a position that he had held since early 1997. He primarily contends that he is unemployable due to the functional impact of his service-connected lumbar spine disability and bilateral lower extremity lumbar radiculopathy. The Board agrees and finds that entitlement to a TDIU is warranted based on the combined effects of his service-connected lumbar spine disability and bilateral lower extremity radiculopathy. Throughout the appeal period, the Veteran has had a combined, schedular disability rating of 80 percent. He also has had at least one service-connected disability rated at 40 percent or more (right and left lower extremity radiculopathy, each rated as 40 percent disabling). Thus, he meets the schedular TDIU criteria under 38 C.F.R. § 4.16(a). Accordingly, entitlement to TDIU is warranted if the evidence shows that he was unable to secure or follow a substantially gainful occupation due to his service-connected disabilities, without regard to age, non-service connected disabilities, or previous unemployability status. 38 C.F.R. §§ 4.16(a), 4.19. The Board finds that this is the case here. Therefore, entitlement to a TDIU is granted. A. Employment and Education Background The Veteran’s education is through two years of college. He reported that he earned an Associate’s Degree in technology. After service, he primarily worked as a mechanic and a master mechanic. He last worked in June 2011 for a cigar manufacturing company as a full-time master mechanic, as position that he had held since early 1997. He asserts that he became too disabled to work in June 2011 because he could no longer manage the physical demands of the position. He competently and credibly testified that his master mechanic duties required maintaining machines at a factory. He explained that since the factory was very large, his duties required walking long distances from machine-to-machine. His position also required extensive and frequent standing, bending, lifting heavy parts, climbing stairs, and other physically demanding tasks. See generally 2016 Board hearing testimony of Veteran and his spouse; Social Security Administration (SSA) disability claim records; November 2012 VA Form 21-8940. Throughout the appeal period, the Veteran consistently reported his employment history to VA adjudicators, medical providers, VA examiners, and SSA evaluators. His wife also competently and credibly testified that she worked at the same factory as the Veteran, and she corroborated his testimony regarding his occupational background and functional impairments. B. Unemployability Due to Service-Connected Disabilities The evidence is at least in equipoise that the combined effects of the Veteran’s service-connected lumbar spine disability and bilateral lower extremity radiculopathy have rendered him unemployable. The Board affords great probative value to the competent, credible, and persuasive medical and lay evidence summarized below showing the significant functional impact of these disabilities on his ability to work: • September 2011 SSA Disability Determination Explanation and cited medical, vocational, and lay evidence (discussing in detail exertional and postural limitations on physical activities due to lumbar spine disability and radicular pain, e.g., limitations on standing and walking, climbing, kneeling, and crouching; citing 2011 VA spine examination functional impact findings as evidence of postural limitations; competently and persuasively finding Veteran did not have residual functional capacity [RFC] to perform past relevant work [PRW] as a mechanic because his PRW involved “medium to heavy” work, and he had been reduced to a “light” RFC; SSA found him disabled beginning in June 2011 based on exertional limitations alone). • February 2016 SSA Disability Determination Explanation and cited medical, vocational, and lay evidence (finding primary impairment was degenerative disc disease and describing impairments as “severe;” discussing in detail exertional and postural limitations on physical activities due to lumbar spine disability and radicular pain, e.g., limitations on lifting, standing, walking, sitting, climbing, kneeling, and crouching; finding Veteran did not have the RFC to perform his PRW as a mechanic because his maximum sustained work capability was “light;” SSA evaluator based the favorable RFC findings in part on evidence of impairments due to opiate pain medications, persistent low back pain, and persistent, chronic radiculopathy; SSA evaluator found Veteran’s allegations appeared fully credible and were consistent with the medical evidence); • August 2011 VA spine examination (competently and persuasively finding Veteran’s back pain prevents him from working as mechanic; noting he could not perform labor activities such as bending and stooping); • May 2013 VA spine examination (competently and persuasively finding service-connected lumbar spine disability functionally impacted Veteran’s ability to work in terms of difficulty lifting more than twenty pounds and difficulty bending; concluding strenuous physical employment would be limited given the service-connected spine disability due to limitation of range of motion and pain down the left leg); • September 2017 VA spine examination (competently and persuasively finding Veteran’s service-connected lumbar spine disability functionally impacted his ability to work in terms of limitations on bending, twisting, lifting more than ten pounds, walking for more than twenty minutes, and standing for more than fifteen minutes); • VA and private outpatient treatment records from throughout the appeal period (documenting long-term use of narcotic pain medications prescribed to manage chronic lumbar spine and associated radicular pain; noting functional impairments due to service-connected lumbar spine and bilateral lower extremity radiculopathy that generally mirrored the favorable functional impairment findings in the VA examinations and SSA records summarized above); • Lay statements and 2016 Board hearing testimony by the Veteran and his spouse (competently and credibly describing functional impact of service-connected lumbar spine disability and bilateral lower extremity radiculopathy, in a manner that was consistent with such impairments noted in VA examinations, SSA disability records, and VA and private treatment records summarized above); • August 2010 private treatment record (Veteran credibly reported to provider, less than one year before the end of his last position, that he had to limit his work due to lumbar spine impairments, e.g., difficulty walking); • November 2009 statement by M.E.J. (competently and credibly describing contemporaneous, daily observations of the Veteran’s pain behaviors at work, e.g., placing his hand on his back when in pain and irritability due to pain; credibly explaining he was Veteran’s subordinate and he did not have friendship with Veteran outside of work; statement was written less than two years before Veteran stopped working). In sum, the evidence summarized above is at least in equipoise that the Veteran’s functional impairments due to his service-connected lumbar spine disability and bilateral lower extremity radiculopathy have rendered him unemployable, considering his specific education and employment background. Most of his post-service career experience was as a mechanic or master mechanic until he stopped working in June 2011. Mechanic positions for which he would be qualified require extensive, physically demanding tasks such as prolonged standing, walking long distances, bending, lifting heavy objects, and climbing stairs. The Board recognizes that the 2013 VA examiner found that the service-connected lumbar spine disability would not preclude “light duty” employment. However, it strains credulity to imagine a hypothetical job for which the Veteran would be qualified to obtain or maintain employment, given his specific, narrow employment background as a mechanic, the physical demands of this field, and his significant physical impairments due to his service-connected disabilities detailed above. His unemployability based on his service-connected physical impairments is compounded by his long-term use of narcotic medications to manage chronic pain from his service-connected disabilities. Mechanic positions for which he would be qualified require working extensively with heavy, presumably dangerous machinery. Thus, it is implausible to imagine a hypothetical mechanic position in which an employer would not consider him a liability. In conclusion, affording the Veteran the benefit of the doubt, entitlement to a TDIU is granted. Gilbert, supra. Special Monthly Compensation (SMC) The Board considered VA’s duty to maximize a veteran’s benefits, including possible entitlement to SMC in addition to a total disability rating. See Akles v. Derwinski, 1 Vet. App. 118 (1991) (observing that entitlement to SMC is an “inferred issue” in the context of an increased rating claim that must be considered when the record indicates that it may be available, even if the claimant does not place eligibility for this ancillary benefit at issue). SMC at the housebound rate is payable where a veteran has a single service-connected disability rated at 100 percent, and has an additional, service-connected disability or disabilities independently ratable at 60 percent, that are separate and distinct from the 100 percent service-connected disability and involve different anatomical segments or bodily systems. 38 C.F.R. § 3.350(i). Under Bradley v. Peake, 22 Vet. App. 280 (2008), 38 U.S.C. § 1114(s) does not limit “a service-connected disability rated as total” to only a schedular rating of 100 percent, and 38 C.F.R. § 3.350(i) permits a TDIU that is based on a single disability to satisfy the statutory requirement of a total rating. In the decision above, the Board granted entitlement to a TDIU based on the combined effects of the Veteran’s service-connected lumbar spine disability and bilateral lower extremity radiculopathy. As the grant of a TDIU here was not exclusively based on a single disability, it does not satisfy the requirement of a single, 100 percent rating for SMC purposes under 38 U.S.C. § 1114(s) and Bradley, supra. Therefore, the Board will not infer the issue of entitlement to SMC at the housebound rate based on the grant a TDIU herein. Duties to Notify and Assist The Veteran suggested that the September 2017 VA examinations were inadequate because they were neither thorough nor conducted by a specialist. See August 2018 correspondence. The Board rejects these contentions and affirmatively finds that the VA examinations relied on in the denials above were adequate for rating purposes. The VA examiners reviewed the Veteran’s pertinent medical history, conducted thorough clinical evaluations, and adequately discussed relevant symptomatology and impairments. See Stefl v. Nicholson, 21 Vet. App. 120, 123-124 (2007). To be adequate, VA examinations need not be conducted by a preferred specialist. The medical professionals who conducted the cited VA examinations were competent to make their respective findings. Contrary to the Veteran’s contentions otherwise, the VA examinations cited above contained thorough, clear, and supported findings necessary for rating his service-connected lumbar spine disability and bilateral lower extremity radiculopathy. Thus, there is no duty to provide another VA examination regarding the claims denied above. Neither the Veteran nor his representative has raised any other duty to notify or duty to assist issues regarding the claims denied above since the Board’s 2017 remand. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015) (holding that “the Board’s obligation to read filings in a liberal manner does not require the Board... to search the record and address procedural arguments when the veteran fails to raise them before the Board.”); Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016) (applying Scott to a duty to assist argument). Moreover, neither the Veteran nor his representative asserted that VA failed to comply with 38 C.F.R.§ 3.103(c)(2), and neither identified any prejudice in the conduct of the Board hearing. As the issue has not been raised, there is no need for the Board to discuss compliance with Bryant v. Shinseki, 23 Vet. App. 488 (2010). See Dickens, supra. REASONS FOR REMAND 1. Entitlement to service connection for CIDP, to include as secondary to a service-connected lumbar spine disability and bilateral lower extremity lumbar radiculopathy, is remanded. The Veteran contends in part that his current CIDP is secondary to his service-connected lumbar spine disability. The May 2013 negative VA medical opinion addressed whether his current CIDP symptoms were related to / caused by his service-connected lumbar spine disability. However, it did not address whether his current CIDP was aggravated by his service-connected lumbar spine condition. Thus, an addendum medical opinion addressing this issue is required. The Veteran alternatively contends that his current CIDP is directly related to service, and the March 2018 negative VA medical opinion addressed this issue. However, the 2018 opinion insufficiently explained the finding that there were no signs or symptoms consistent with CIDP during service. Specifically, the examiner did not expressly consider service treatment records showing lower extremity neurological complaints, abnormal clinical findings, and treatment during service. Military medical providers clearly attributed some of those neurological complaints and findings to his well-documented, service-connected lumbar spine issues. However, further explanation is needed to address a February 1986 service treatment record showing lower extremity nerve symptoms during service that appear to closely mirror his current CIDP symptoms. See February 1986 orthopedic consult (noting complaints of increased paresthesias of both legs; Veteran reported that for the past three days, he had noticed increased low back pain, bilateral foot numbness, and pain radiating down the right leg; various abnormal examination findings included 4-5/5 motor examination that was diffuse and not localized to a specific nerve root; sensory examination was in “stocking-glove” pattern with decreased sensation below the ankle); compare with current medical evidence showing similar symptoms, which medical professionals consistently have attributed to the Veteran’s current CIDP diagnosis, e.g.: January 2010 VA examination (noting on examination sensation diminished in stocking-like distribution of the feet and ankles); March 2011 private neurological treatment record (noting on examination diminished sensation in glove / stocking distribution); May 2013 VA examination (finding on examination decreased light touch and pain sensation at the bilateral feet and hands in a “stocking-glove distribution;” expressly distinguishing between service-connected lumbar spine and radiculopathy symptoms versus non-service connected CIDP symptoms involving all four extremities); October 2012 VA neurology note (noting on examination decreased sensation of the bilateral feet and hands in a stocking-glove distribution, in the context of ongoing treatment for CIDP); May 2017 VA primary care note (regarding medical history, noting that around 2007, the Veteran had severe burning neuropathy of the bilateral feet that was still present, which was diagnosed as CIDP); September 2017 VA examination (finding that sensory impairments due to the service-connected lumbar radiculopathy of the lower extremities were “superimposed on decreased to light touch in a stocking and glove sensory impairment involving both feet, both lower legs [up to both knees], both hands and both forearms [up to the elbows] bilaterally”). Therefore, an addendum nexus opinion is needed to consider whether the bilateral “stocking / glove” pattern of the lower extremities shown during service were manifestations of his current CIDP. In addition, the Veteran was afforded prior VA medical opinions regarding his CIDP in May 2013 and March 2018. However, the examiners did not expressly consider his conceded exposure to jet fuels based on his verified military occupational specialty (MOS) as an aircraft mechanic. Nor did they consider the favorable January 2011 nexus opinion by the Veteran’s private physician or an article submitted by the Veteran that suggests a possible link between exposure to certain jet fuels and neuropathies. The addendum must address this evidence. 2. Entitlement to a separate compensable rating for neurogenic bladder with voiding dysfunction secondary to a service-connected lumbar spine disability and bilateral lower extremity radiculopathy is remanded. As explained above, increased rating claims for spinal disabilities require consideration of possible separate, compensable ratings for associated neurological abnormalities. See 38 C.F.R. § 4.71a, General Rating Formula, Note (1). The Board finds that a VA medical opinion is needed to assess whether urinary incontinence issues noted in various VA outpatient treatment records during the appeal period were neurological residuals or symptoms of his service-connected lumbar spine disability and/or bilateral lower extremity lumbar radiculopathy. See, e.g., October 2013 VA primary care note (regarding assessment of urinary incontinence, provider noted, “Consider neurogenic bladder?”); May 2014 VA urology note (Veteran reported that both back and urinary trouble seemed to worsen several months ago); June 2014 VA urology note (noting ongoing treatment for complaints of enuresis; stating clinical findings suggested enuresis may be due to sphincter dyssynergia, which “could be [due] to his back problems or…chronic pain”). As prior VA examinations did not address this issue raised by the evidence of record, a medical opinion is needed. The matters are REMANDED for the following action: 1. Schedule a VA medical opinion regarding the Veteran’s documented voiding dysfunction with a VA examiner who is a physician, given the medical complexity of this case. The examiner must note his or her review of the complete claims file, including this remand. Then, the examiner must address the following, with full supporting rationale: (a.) Is it at least as likely as not that the Veteran’s urinary incontinence (noted in 2013 and 2014 VA treatment records summarized above) was caused by his service-connected lumbar spine disability and/or bilateral lower extremity lumbar radiculopathy? (b.) Is it at least as likely as not that the Veteran’s urinary incontinence (noted in 2013 to 2014 VA treatment records summarized above) was aggravated by (i.e., worsened beyond its natural progression by) his service-connected lumbar spine disability or bilateral lower extremity lumbar radiculopathy? In both opinions requested above, the examiner must expressly consider the 2013 and 2014 VA outpatient treatment records summarized above suggesting a possible relationship between the Veteran’s urinary incontinence and his service-connected lumbar spine disability. See, e.g.: October 2013 VA primary care note (regarding assessment of urinary incontinence, provider noted, “Consider neurogenic bladder?”); June 2014 VA urology note (noting ongoing treatment for complaints of enuresis; stating clinical findings suggested urinary symptoms may be due to sphincter dyssynergia, which “could be [due] to his back problems or chronic pain”); October 2015 VA primary care note (suggesting urinary incontinence may have been morphine side effect). If any opinion requested above is not possible without resort to mere speculation, then the examiner must explain why. If the examiner finds that he or she cannot provide any requested opinion without another VA examination, then the RO must schedule one. 2. Schedule addendum VA medical opinions regarding the Veteran’s CIDP with a VA examiner who is a physician, given the medical complexity of this case. The examiner must note his or her review of the complete claims file, including this remand. Then, the examiner must address the following, with full supporting rationales: (a.) Is it at least as likely as not that the Veteran’s current CIDP has been aggravated by (i.e., worsened beyond its natural progression by) his service-connected lumbar spine disability or bilateral lower extremity lumbar radiculopathy? Please expressly consider the November 2014 VA physical therapy note (finding he presented with signs and symptoms consistent with CIDP “with associated lower extremity radiculopathy”). (b.) Is it at least as likely as not that the Veteran’s current CIDP either began during active service or is otherwise etiologically related active service? Please expressly consider: i. February 1986 service treatment record (orthopedic consult) showing lower extremity signs and symptoms such as bilateral foot numbness and “stocking and glove” distribution of sensory impairments, which appear to closely mirror his current CIDP symptoms – e.g.: May 2013 VA examination (finding on examination decreased light touch and pain sensation at the bilateral feet and hands in a “stocking-glove distribution;” expressly distinguishing between service-connected lumbar spine and radiculopathy symptoms versus non-service connected CIDP symptoms involving all four extremities); October 2012 VA neurology note (finding on examination decreased sensation of the bilateral feet and hands in a stocking-glove distribution in the context of ongoing treatment for CIDP); September 2017 VA examination (finding sensory impairment involving both feet manifested as decreased sensation to light touch in a “stocking and glove” pattern of both upper extremities and both lower extremities). ii. Veteran’s contention that current CIDP may be related to his conceded in-service exposure to aircraft jet fuels based on his verified MOS as a jet engine mechanic (see article received in September 2009 regarding toxicology of various jet fuels stating that repeated or prolonged exposure to JP-4 may result in peripheral neuropathy); January 2011 note by private physician Dr. P. (finding contact with jet fuel JP-4 during service “may be” the cause of Veteran’s current neuropathy, per literature review); iii. medical evidence from well before the January 2011 service connection claim on appeal showing signs and symptoms that appear to mirror his current CIDP symptoms, e.g., July 1999 VA spine examination (noting complaints of bilateral lower extremity paresthesias); November 2001 VA spine examination (Veteran reported bilateral leg pain and intermittent numbness and tingling in both feet; he also reported at times he tends to drop things with his right hand; upon neurological examination, the sensory examination revealed a diminished perception to pinprick and light touch “in the stocking distribution of both feet”). If any opinion requested above is not possible without resort to mere speculation, then the examiner must explain why. If the VA examiner finds that he or she cannot provide any requested opinion without another VA examination, then the RO must schedule one. MICHELLE L. KANE Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD R. Janofsky, Associate Counsel