Citation Nr: 18160172 Decision Date: 12/27/18 Archive Date: 12/26/18 DOCKET NO. 11-07 463 DATE: December 27, 2018 ORDER The reduction in the rating for intervertebral disc syndrome (IVDS) from 20 percent to 10 percent was not proper, and the 20 percent rating is restored from April 1, 2013. (The condition was previously rated as myofascitis and disc space narrowing and sclerosis between T11 and T12.) The claim of entitlement to an initial increased disability rating for IVDS, in excess of 20 percent, is denied. The claim of entitlement to an initial increased disability rating for status-post surgery of C6/C7 posterolateral foraminotomy, rated as 10 percent from April 1, 2009, to July 14, 2016, 20 percent from July 15, 2016, to April 23, 2018, and 30 percent from April 24, 2018, is denied. REMANDED The claim of entitlement to service connection for erectile dysfunction (ED) is remanded. FINDINGS OF FACT 1. The July 2013 rating decision, which reduced the Veteran’s disability rating for thoracic spine IVDS from 20 percent to 10 percent, effective April 1, 2013, was improper as the clinical evidence of record fails to show actual improvement in the Veteran’s IVDS. 2. For the period from April 1, 2009, the Veteran’s thoracic spine IVDS manifested at worst by forward flexion to 45 degrees with stiffness and pain and mild/moderate bilateral radiculopathy (for which service connection is already in effect and separately rated). 3. For the period from April 1, 2009, to July 14, 2016, the Veteran’s status-post surgery, C6/C7 posterolateral foraminotomy manifested in forward flexion no worse than 40 degrees. (The Veteran’s associated radiculopathy of the upper extremities is separately service-connected.) 4. For the period from July 15, 2016, to April 23, 2018, the cervical spine disorder manifested in forward flexion to 30 degrees. 5. For the period from April 24, 2018, the cervical spine disorder manifested in forward flexion to 10 degrees. CONCLUSIONS OF LAW 1. The July 2013 rating decision which reduced the Veteran’s 20 percent rating for service-connected thoracic spine IVDS from 20 percent to 10 percent, effective April 1, 2013, was improper and restoration is warranted. 38 U.S.C. § 1155 (2012); 38 C.F.R. §§ 3.105, 3.44, 4.1, 4.6, 4.7, 4.85, 4.86 Diagnostic Codes (DCs) 5237, 5242, 5243 (2018). 2. For the period from April 1, 2009, the criteria for an initial rating in excess of 20 percent for thoracic spine IVDS have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.102, 3.105, 3.344, 4.1, 4.7, 4.40, 4.45, 4.59, 4.71a, DCs 5237, 5242, 5243 (2018). 3. For the period from April 1, 2009, to July 14, 2016, the criteria for an initial rating in excess of 10 percent for a cervical spine disorder have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.102, 3.105, 3.344, 4.1, 4.7, 4.40, 4.45, 4.59, 4.71a, DC 5237 (2018). 4. For the period from July 15, 2016, to April 23, 2018, the criteria for an initial rating in excess of 20 percent for a cervical spine disorder have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.102, 3.105, 3.344, 4.1, 4.7, 4.40, 4.45, 4.59, 4.71a, DC 5237 (2018). 5. For the period from April 24, 2018, the criteria for an initial rating in excess of 30 percent for a cervical spine disorder have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.102, 3.105, 3.344, 4.1, 4.7, 4.40, 4.45, 4.59, 4.71a, DC 5237 (2018). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from March 1989 to March 2009. This case is before the Board of Veterans’ Appeals (Board) on appeal from rating decisions of a Department of Veterans Affairs (VA) regional office (RO). In March 2016, a videoconference hearing was held before the undersigned veterans law judge; a transcript of the hearing is associated with the claims file. The procedural history as to the claims on appeal was provided in the Board’s January 2018 remand and will not be repeated here. The Board remanded the case for additional evidentiary development, to include contemporaneous examinations as to the thoracic and cervical spine. The case has now been returned to the Board for further appellate consideration. Whether the Reduction in Disability Rating for IVDS from 20 Percent to 10 Percent, Effective April 1, 2013, was Proper. The Veteran contests the reduction in his IVDS/thoracic spine disorder from 20 to 10 percent, April 1, 2013, as determined in a July 2013 rating decision. The July 2013 rating decision reduction however, did not result in a reduction of the Veteran’s compensation. Specifically, it is noted that his service-connected disabilities remained at a combined rating of 40 percent. See the July 2013 rating decision and the August 2013 notice letter. Where the evaluation of a disability is reduced but the amount of compensation is not reduced, the notice procedures for a reduction in evaluation pursuant to 38 C.F.R. § 3.105(e) (2018) do not apply. See Stelzel v. Mansfield, 508 F.3d 1345, 1349 (Fed. Cir. 2007). As the reduction in the September 2013 rating decision did not impact the Veteran’s overall disability compensation as his combined disability evaluation remained at 40 percent, the notice requirements under 38 C.F.R. § 3.105(e) (2018) are inapplicable in the present case. The remaining inquiry is whether the reduction as to the spine disability rating was proper based on the evidence then of record. At the time of the July 2013 rating reduction for the IVDS/thoracic spine disability, service connection had been in effect from April 1, 2009, at 20 percent. Thus, the disability rating of 20 percent had been in effect for less than five years. Where, as here, a disability rating has been in effect for less than five years, a rating reduction is warranted where reexamination of the disability discloses improvement of that disability. See 38 C.F.R. § 3.344(c) (2018). The Board also notes that, notwithstanding the required procedural steps, a rating reduction is not proper without evidence of actual improvement in the Veteran’s ability to function under the ordinary conditions of life and work. See Faust v. West, 13 Vet. App. 342, 349 (2000) (noting that VA must review the entire history of the veteran’s disability, ascertain whether the evidence reflects an actual change in the disability, and ascertain whether the examination reports reflecting such change are based upon thorough examinations) (citing Brown v. Brown, 5 Vet. App. 413, 421 (1993)). The Board finds that the reduction of the Veteran’s rating for his IVDS (previously evaluated as myofascitis and disc space narrowing and sclerosis between T11 and T12), from 20 percent to 10 percent, was improper. In July 2013, the RO reduced the Veteran’s spine disability rating from 20 to 10 percent based on findings from an April 2013 VA examination report. That examination showed that the Veteran’s range of motion (ROM) of the thoracolumbar spine in forward flexion was to 75 degrees without evidence of painful motion. Also, there was no painful motion upon extension to 20 degrees. Right lateral flexion was to 25 degrees and left lateral flexion was to 20 degrees. Again, there was no painful motion. Bilateral rotation ended at 25 degrees without painful motion. The combined ROM was to 190 degrees. ROM studies upon previous examination in November 2008 showed a combined ROM of 200 degrees as evidenced by forward flexion to 60 degrees, extension to 20 degrees, and bilateral lateral flexion and rotation to 30 degrees. Thus, the 2013 combined ROM was less than when examined in 2008, thereby suggesting that the Veteran’s spine disability did not actually improve at the time of the reduction. In a rating reduction case, VA must not only demonstrate “that an improvement in a disability has actually occurred, but also that improvement actually reflects an improvement in the veteran’s ability to function under the ordinary conditions of life and work.” See Brown, 5 Vet. App. at 421. VA has not carried this burden with respect to the reduction in the Veteran’s disability ratings for his thoracic spine disability. Therefore, the Board finds that the reduction of the 20 percent disability rating for the Veteran’s IVDS in the July 2013 rating decision was improper. Consequently, restoration of the 20 percent ratings for the thoracic spine disability is warranted, effective April 1, 2013. Increased Ratings – In General Disability evaluations are determined by the application of the Schedule for Rating Disabilities, which assigns ratings based on the average impairment of earning capacity resulting from a service-connected disability. 38 U.S.C. § 1155 (2012); 38 C.F.R. Part 4 (2018). Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7 (2018). It is not expected that all cases will show all the findings specified; however, findings sufficiently characteristic to identify the disease and the disability therefrom and coordination of rating with impairment of function will be expected in all instances. 38 C.F.R. § 4.21 (2018). When an unlisted condition is encountered it will be permissible to rate under a closely related disease or injury in which not only the functions affected, but the anatomical localization and symptomatology are closely analogous. 38 C.F.R. § 4.20 (2018). In order to evaluate the level of disability and any changes in condition, it is necessary to consider the complete medical history of the veteran’s condition. Schafrath v. Derwinski, 1 Vet. App. 589, 594 (1991). However, where an increase in the level of a service-connected disability is at issue, the primary concern is the present level of disability. Francisco v. Brown, 7 Vet. App. 55 (1994). Staged ratings may be appropriate when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. See e.g. Hart v. Mansfield, 21 Vet. App. 505 (2007). A claimant is entitled to the benefit of the doubt when there is an approximate balance of positive and negative evidence on any issue material to the claim. See 38 U.S.C. § 5107 (2012); 38 C.F.R. § 3.102 (2018) (providing, in pertinent part, that reasonable doubt will be resolved in favor of the claimant). When the evidence supports the claim or is in relative equipoise, the claim will be granted. See Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990); see also Wise v. Shinseki, 26 Vet. App. 517, 532 (2014). If the preponderance of the evidence weighs against the claim, it must be denied. See id; Alemany v. Brown, 9 Vet. App. 518, 519 (1996). Disability of the musculoskeletal system is primarily the inability, due to damage or infection in the parts of the system, to perform the normal working movements of the body with normal excursion, strength, speed, coordination, and endurance. It is essential that the examination on which ratings are based adequately portray the anatomical damage, and the functional loss, with respect to all these elements. The functional loss may be due to absence of part, or all, of the necessary bones, joints and muscles, or associated structures, or to deformity, adhesions, defective innervation, or other pathology, or it may be due to pain, supported by adequate pathology and evidenced by visible behavior of the claimant undertaking the motion. Weakness is as important as limitation of motion, and a part which becomes painful on use must be regarded as seriously disabled. 38 C.F.R. § 4.40 (2003). The RO must analyze the evidence of pain, weakened movement, excess fatigability, or incoordination and determine the level of associated functional loss in light of 38 C.F.R. § 4.40, which requires the VA to regard as "seriously disabled" any part of the musculoskeletal system that becomes painful on use. DeLuca v. Brown, 8 Vet. App. 202 (1995). Pertinent DCs Disabilities of the spine may be rated under the General Rating Formula for Diseases and Injuries of the Spine. See 38 C.F.R. § 4.71a, DCs 5235-5243 (2018). With or without symptoms such as pain (whether or not it radiates), stiffness, or aching in the area of the spine affected by residuals of injury or disease, the Formula provides for ratings as follows. A 10 percent rating is warranted for forward flexion of the thoracolumbar spine greater than 60 degrees but not greater than 85 degrees; or forward flexion of the cervical spine greater than 30 degrees, but not greater than 40 degrees, or combined range of motion of the thoracolumbar spine greater than 120 degrees but not greater than 235 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 thoracolumbar spine greater than 30 degrees but not greater than 60 degrees; or, forward flexion of the cervical spine greater than 15 degrees but not greater than 30 degrees; or, the combined range of motion of the cervical spine not greater than 170 degrees; or muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis. Reversed lordosis, or abnormal kyphosis. A 30 percent 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 when there is unfavorable ankylosis of the entire cervical spine; or, forward flexion of the thoracolumbar spine to 30 degrees or less, or with favorable ankylosis of the entire thoracolumbar spine. A 50 percent rating is warranted when there is unfavorable ankylosis of the entire thoracolumbar spine. 4.71a. The Notes following the General Rating Formula for Diseases and Injuries of the Spine provide further guidance in rating diseases or injuries of the spine. Note (1) provides that any associated objective neurologic abnormalities, including, but not limited to, bowel or bladder impairment, should be rated separately under an appropriate DC. Note (2) provides that, for VA compensation purposes, normal forward flexion of the cervical spine is zero to 45 degrees, extension is zero to 45 degrees, left and right lateral flexion are zero to 45 degrees and left and right lateral flexion are zero to 80 degrees. 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 cervical 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. See also Plate V, 38 C.F.R. § 4.71a. Note (3) provides that, 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) provides that the rater is to round each range of motion measurement to the nearest five degrees. Note (5) provides that, for VA compensation purposes, unfavorable ankylosis is a condition in which 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) provides that disability of the thoracolumbar spine segments are to be rated separately, except when there is unfavorable ankylosis of both segments, which will be rated as a single disability. 38 C.F.R. § 4.71a. Spine conditions can also be rated under the criteria for intervertebral disc syndrome (IVDS), DC 5243. DC 5243 provides a 10 percent disability rating for intervertebral disc syndrome with incapacitating episodes having a total duration of at least one week but less than 2 weeks during the past 12 months; a 20 percent disability rating for intervertebral disc syndrome where incapacitating episodes have a total duration of at least 2 weeks but less than 4 weeks during the past 12 months. A 40 percent rating is warranted where incapacitating episodes have a total duration of at least 4 weeks but less than 6 weeks during the past 12 months. A 60 percent rating is warranted where incapacitating episodes have a total duration of at least 6 weeks during the past 12 months. “Incapacitating episodes” is defined in Note (1) as a period of acute signs and symptoms due to intervertebral disc syndrome that requires bed rest prescribed by a physician and treatment by a physician. When evaluating musculoskeletal disabilities based on limitation of motion, 38 C.F.R. § 4.40 (2018) requires consideration of functional loss caused by pain or other factors listed in that section that could occur during flare-ups or after repeated use and, therefore, not be reflected on range of motion testing. 38 C.F.R. § 4.45 (2018) requires consideration also be given to less movement than normal, more movement than normal, weakened movement, excess fatigability, incoordination, and pain on movement. See DeLuca v. Brown, 8 Vet. App. 202 (1995); see also Mitchell v. Shinseki, 25 Vet. App. 32, 44 (2011). Nonetheless, even when the background factors listed in § 4.40 or 4.45 are relevant when evaluating a disability, the rating is assigned based on the extent to which motion is limited, pursuant to 38 C.F.R. § 4.71a (musculoskeletal system) or § 4.73 (muscle injury); a separate or higher rating under § 4.40 or 4.45 itself is not appropriate. See Thompson v. McDonald, 815 F3d 781, 785 (Fed. Cir. 2016) (“[I]t is clear that the guidance of § 4.40 is intended to be used in understanding the nature of the veteran’s disability, after which a rating is determined based on the § 4.71a [or 4.73] criteria.”). Entitlement to an initial increased disability rating in excess of 20 percent for IVDS. As a result of the decision that the reduction was improper, the 20 percent rating has been restored from April 1, 2013. In effect, with the restoration of the 20 percent rating, the 20 percent rating has been in effect since service connection was established, effective April 1, 2009. The question that remains before the Board is whether an initial disability rating in excess of 20 percent is warranted for IVDS at any time. As already discussed, a 20 percent rating was initially assigned upon rating decision in October 2009. This grant was primarily based on ROM limitation of flexion to 60 degrees as evidenced on November 2008 exam. In addition to the November 2008 examination results already summarized in detail, private records dated from 2010 through 2012 showed muscle spasms in the back. Additional VA examination in April 2013 showed improvement in forward flexion to 75 degrees without painful motion. Extension ended at 20 degrees with no painful motion. Right lateral flexion was to 25 degrees without painful motion. Left lateral flexion was to 20 degrees without painful motion. Bilateral rotation was to 25 degrees without painful motion. The Veteran was able to perform repetitive use testing after 3 repetitions without change in ROM results. Sensory and radiculopathy examinations were negative. Subsequently dated private records reflect that the Veteran continued to report chronic low back pain. VA X-ray of the lumbar spine in September 2013 showed mild compression deformities T11 and T12 and to lesser extent T10. There were significant degenerative changes at L3/L4 disc space and advanced facet arthropathy at L3-L4-L51-S1. Additionally, there was evidence of pars defect at L4. At the March 2016 hearing, the Veteran testified that his low back condition had worsened since examination in 2013. He reported that it was painful to bend over, and he had trouble picking up heavy objects. He fixed trucks and found it was difficult to get up from working underneath the carriages. He wore patches and was on medication to help with his complaints. (Tr. at pgs. 6-12.) When examined by VA in July 2016, the Veteran reported intermittent shooting pains down his lower extremities. ROM testing showed forward flexion to 50 degrees. Extension was to 30 degrees. Bilateral lateral flexion and bilateral rotation were also to 30 degrees. The combined ROM was 200 degrees. There was no evidence of pain upon weight bearing. There was no objective evidence of localized tenderness or pain on palpation of the joints or associated soft tissue of the thoracolumbar spine. The Veteran was able to perform repetitive use testing with at least 3 repetitions. There was no guarding of muscle spasm. There was mild radiculopathy in both lower extremities. Magnetic resonance imaging (MRI) of the lumbar spine in August 2016 showed multilevel IVDS. VA examination in April 2018 showed complaints of increased back pain and decreased ROM. ROM testing showed forward flexion to 45 degrees. Extension, bilateral lateral flexion, and rotation were to 5 degrees. Combined ROM was to 70 degrees. There was pain on examination. As to radiculopathy, there was mild pain and numbness. There was moderate paresthesias and dysesthesias. The Board finds that the preponderance of the evidence of record is against an initial disability rating in excess of 20 percent for the service-connected low back disability under the General Formula, even with consideration of the DeLuca precepts. Under the General Formula, a 40 percent rating is warranted where there is forward flexion of the thoracolumbar spine of 30 degrees or less. Here, the Veteran demonstrated forward flexion, at worst, to 45 degrees. While pain was noted upon several ROM tests over the years, there was no additional loss of function or ROM indicated at those times. Overall, in the absence of forward flexion of the thoracolumbar spine to 30 degrees or less or favorable ankylosis, the preponderance of the evidence of record is against an initial rating in excess of 20 percent for the service-connected IVDS under the General Formula. The preponderance of the evidence of record is also against an initial disability rating in excess of 20 percent for the service-connected low back disability under the criteria for evaluating IVDS. Here, there is no evidence of IVDS where there are incapacitating episodes (as defined by regulation) having a total duration of at least four weeks but less than six weeks during the past 12 months--the criteria necessary for a 40 percent rating under IVDS. During the above-cited VA examinations, the evidence reflects IVDS. Mild to moderate radiculopathy is indicated in the lower extremities, but the clinical records do not reflect incapacitating episodes at any time. Moreover, the Veteran is separately rated for lower extremity radiculopathy. The Board further finds that a staged schedular rating for the service-connected back disability is not warranted as the symptomatology associated with this disability has remained stable throughout the appeal. Fenderson, supra. With regard to giving proper consideration to the effects of pain in assigning a disability rating, as well as the provisions of 38 C.F.R. § 4.45 (2018) and the holdings in DeLuca and Mitchell, the reports from the examinations addressing the service-connected lumbar spine disability document consideration of these principles, to include repetitive motion. There is no indication that increased compensation would be warranted for the service-connected thoracic spine disability under these principles. Entitlement to an initial increased disability rating for status-post surgery of C6/C7 posterolateral foraminotomy, rated as 10 percent from April 1, 2009, to July 14, 2016; 20 percent from July 15, 2016, to April 23, 2018; and 30 percent from April 24, 2018. Review of the Veteran’s service treatment records (STRs) reflects disc bulge in 2000. The Veteran underwent surgery in December 2000 for herniated nucleus pulposus of C6-C7. When the cervical spine was examined just before discharge in November 2008, range of motion testing showed forward flexion to 45 degrees. Extension was to 25 degrees. Right lateral flexion was to 20 degrees, and left lateral flexion was to 30 degrees. Right rotation was to 50 degrees, and left rotation was to 40 degrees. Pain, weakness, lack of endurance, fatigue, or incoordination did not impact further on the range of motion after repetitive use. When examined by VA in April 2013, the cervical spine complaints included occasional pain and aching. Range of motion testing showed forward flexion to 40 degrees. Extension was to 40 degrees. Right lateral flexion was to 30 degrees. Left lateral flexion was to 25 degrees. Right lateral rotation was to 65 degrees. Left lateral rotation was to 55 degrees. There was no objective evidence of painful motion on this test. The Veteran was able to perform repetitive use testing after 3 repetitions without change in range of motion degrees. There was no localized tenderness or pain in the cervical spine. There was no guarding or muscle spasm. Sensory examination was normal. VA cervical spine X-ray in September 2013 showed small posterior central disc bulge at C4-5 with a larger right paracentral disc bulge at C6-7 resulting in right-sided foraminal impingement. At the March 2016 hearing, the Veteran testified as to tingling and numbness in the fingers and shoulder blades which he related as due to his neck condition. (Service connection is in effect for these neurological findings as noted upon rating decision in December 2016.) He sat in a recliner at home where he could rest his neck to relieve the pain. He had decreased range of motion due to his neck pain. Tr. at pgs. 12-18. Upon VA X-ray of the cervical spine in July 2016, there was prevertebral soft tissue swelling. There was disc space narrowing with marginal osteophytosis which was predominantly mild at C5-C6 and to lesser extent at C6-C7. There was a left bony foraminal narrowing at C5-C6 and to less extent suggested at C6-C7 and possible C7-T1. There was right bony foraminal narrowing at C5 C6. Range of motion testing showed forward flexion to 35 degrees. Extension was to 25 degrees. Right lateral flexion was to 30 degrees. Left lateral flexion was to 20 degrees. Right lateral rotation was to 20 degrees, and left lateral rotation was to 30 degrees. Following repetitive use testing, forward flexion was to 30 degrees. Extension was to 20 degrees. Bilateral lateral flexion and rotation remained as prior to repetitive use. MRI of the cervical spine in August 2016 showed multilevel lower cervical spine degenerative disc disease, most severe at C5-C6. VA examination of the cervical spine in April 2018 included range of motion testing. Forward flexion was to 10 degrees. Extension was to 10 degrees. Right and left lateral flexion were to 5 degrees. Right lateral rotation was to 10 degrees. Left lateral rotation was to 0 degrees. Pain was exhibited on all ranges of motion. There was no additional loss of function or range of motion after three repetitions. The Veteran had had no incapacitating episodes due to his cervical spine disability. On review of the lay and medical evidence of record, the criteria for an initial rating in excess of 10 percent for the Veteran’s cervical spine disability are not met prior to July 15, 2016. Prior to that date, forward flexion of the cervical spine was consistently greater than 30 degrees and the combined range of motion for the cervical spine was greater than 170 degrees. From July 15, 2016 to April 23, 2018, the lay and medical evidence of record establishes that the criteria for a rating in excess of 20 percent for a cervical spine disability are not met. The next-higher rating of 30 percent requires evidence of forward flexion of the cervical spine 15 degrees or less; or, favorable ankylosis of the entire cervical spine. Forward flexion of the cervical spine testing during the July 2016 VA examination was to 30 degrees. Even considering the Veteran’s pain he experienced, the resulting functional impairment was not equivalent to the criteria required for rating in excess of 20 percent under DC 5243. In addition, there was no evidence that the Veteran had any ankylosis of the cervical spine, whether favorable or unfavorable, or any functional impairment analogous to ankylosis of the cervical spine. For these reasons, the Board finds that the criteria for a rating in excess of 20 percent are not met from July 15, 2016, to April 23, 2018. From April 24, 2018, the lay and medical evidence of record establishes that the criteria for a rating in excess of 30 percent are not met proper. At that time, forward flexion was limited to 10 degrees. This warrants a 30 percent rating under the applicable DCs. To warrant an increased rating of 40 percent, there must be unfavorable ankylosis of the entire cervical spine (which is not demonstrated). The Board also considered the Veteran’s reported impairment of function, such as pain, fatigue, weakness, and stiffness, and has considered additional limitations of motion due to pain and flare-ups. Even considering additional limitation of motion or function of the cervical spine due to pain or other symptoms such as weakness, fatigability, stiffness, or spasm (see 38 C.F.R. §§ 4.40, 4.45, 4.59), the evidence does not show that the cervical spine disability more nearly approximates the criteria for a higher rating for any period on appeal. To the extent that the Veteran has reported experiencing pain, spasms, flare-ups, and functional impairment, including limited ability to turn her head, such symptoms and impairment are contemplated by the ratings assigned herein and are not of such severity that it could be characterized as meeting the requirements for the next-higher rating. As such, higher ratings based on additional limitation of function of the cervical spine are not warranted for any period on appeal. The Board further finds that a higher disability rating or ratings are not warranted under the IVDS Formula. 38 C.F.R. § 4.71a, DC 5243. No incapacitating episodes as a result of the cervical spine condition were reported. Thus, the Board finds that, for the entire period on appeal, higher ratings based on incapacitating episodes are not warranted. 38 C.F.R. §§ 4.3, 4.7 (2018). In addition to consideration of the orthopedic manifestations of the cervical spine disability, VA regulations require that consideration be given to any associated objective neurologic abnormalities, which are to be evaluated separately under an appropriate diagnostic code. As previously noted, the Veteran is currently in receipt of separate compensable ratings for each upper extremity. In summary, the Board denies entitlement to an initial rating in excess of 10 percent for a cervical spine disability prior to July 15, 2016, a rating in excess of 20 percent from July 15, 2016, to April 23, 2018, and in excess of 30 percent from April 24, 2018. REASONS FOR REMAND The claim of entitlement to service connection for ED is remanded. Of record are two VA examinations reports (November 2016 and March 2018) which address the etiology of the Veteran’s ED. These reports are not favorable to the Veteran’s claim; however, neither report discusses whether any of the Veteran’s medications caused his ED. Thus, a supplemental opinion is needed. The matter is REMANDED for the following action: Return the claims file to the March 2018 VA examiner who addressed the etiology of the Veteran’s ED (or a suitable substitute if that examiner is unavailable) for an addendum opinion. The claims file must be reviewed by the examiner and such should be noted in the report. The examiner should also specifically identify the Veteran’s medications taken for any of his service-connected disorders. The examiner should opine as to whether the Veteran’s ED is at least as likely as not (50 percent or greater probability) (a) caused or (b) aggravated by the Veteran’s medications prescribed for his service-connected disabilities. (CONTINUED ON NEXT PAGE) Please explain why or why not. A complete rationale that supports each opinion is needed. BARBARA B. COPELAND Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD T. Hal Smith