Citation Nr: 1806560 Decision Date: 02/01/18 Archive Date: 02/14/18 DOCKET NO. 14-06 360 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Muskogee, Oklahoma THE ISSUES 1. Entitlement to service connection for peripheral neuropathy of the left lower extremity, to include as secondary to service-connected degenerative changes of the cervical spine. 2. Entitlement to service connection for peripheral neuropathy of the right lower extremity, to include as secondary to service-connected degenerative changes of the cervical spine. 3. Entitlement to a rating in excess of 20 percent prior to August 14, 2013, in excess of 10 percent from August 14, 2013 to April 20, 2015, and in excess of 20 percent beginning April 21, 2015, for degenerative changes of the cervical spine with intervertebral disc syndrome (IVDS). 4. Entitlement to an initial rating in excess of 30 percent prior to August 14, 2013, in excess of 10 percent from August 14, 2013 to April 20, 2015, and in excess of 20 percent beginning April 21, 2015, for radiculopathy of the left upper extremity, as secondary to service-connected degenerative changes of the cervical spine. 5. Entitlement to an initial rating in excess of 20 percent prior to August 14, 2013, and in excess of 10 percent beginning August 14, 2013, for radiculopathy of the right upper extremity, as secondary to service-connected degenerative changes of the cervical spine. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD N. Breitbach, Associate Counsel INTRODUCTION The Veteran served on active duty with the United States Marine Corps from January 1988 to January 1992. These matters are before the Board of Veterans' Appeals (Board) on appeal from an October 2013 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO). This decision awarded an increased 20 percent rating for the cervical spine disability from April 25, 2012 to August 13, 2013 and provided a 10 percent rating from August 14, 2013 to April 21, 2015. The decision also awarded service connection for right upper extremity radiculopathy, rated 20 percent prior to August 14, 2013 and 10 percent from that date, and awarded service connection for left upper extremity radiculopathy, rated 30 percent prior to August 14, 2013, and 10 percent from that date. A January 2016 rating decision increased the Veteran's cervical spine disability and left upper extremity radiculopathy disability ratings to 20 percent, each, effective April 21, 2015. As the Veteran has not expressed satisfaction with these increased ratings and they are less than the maximum under the applicable criteria, the claims remain on appeal. See AB v. Brown, 6 Vet. App. 35, 38 (1993). The issues seeking service connection for peripheral neuropathy of the left lower extremity and peripheral neuropathy of the right lower extremity are addressed in the REMAND portion of the decision below and are REMANDED to the AOJ. VA will notify the Veteran if further action is required. FINDINGS OF FACT 1. Throughout the appeal period, the Veteran's degenerative changes of the cervical spine have been manifested by forward flexion greater than 15 degrees but not greater than 30 degrees and combined range of motion of the cervical spine not greater than 170 degrees, even with consideration of pain and associated functional loss; and with no incapacitating episodes. 2. Prior to August 14, 2013, the Veteran's radiculopathy of the left upper extremity was manifested by moderate incomplete paralysis (all radicular groups). 3. Beginning August 14, 2013, the Veteran's radiculopathy of the left upper extremity has been manifested by mild incomplete paralysis (all radicular groups). 4. Throughout the appeal period, the Veteran's radiculopathy of the right upper extremity has been manifested by mild incomplete paralysis of the lower radicular group. CONCLUSIONS OF LAW 1. Prior to August 14, 2013, the criteria for a rating in excess of 20 percent for the Veteran's service-connected degenerative changes of the cervical spine are not met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. § 4.71a, Diagnostic Code 5242 (2017). 2. From August 14, 2013 to April 20, 2015, the criteria for a 20 percent rating, but no higher, for the Veteran's service-connected degenerative changes of the cervical spine are met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. § 4.71a, Diagnostic Code 5242 (2017). 3. From April 21, 2015, the criteria for a rating in excess of 20 percent for the Veteran's service-connected degenerative changes of the cervical spine are not met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. § 4.71a, Diagnostic Code 5242 (2017). 4. Prior to August 14, 2013, the criteria for an initial rating in excess of 30 percent for the Veteran's service-connected radiculopathy of the left upper extremity are not met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. § 4.71a, Diagnostic Code 8511 (2017). 5. From August 14, 2013 to April 20, 2015, the criteria for an initial 20 percent, but no higher, rating for the Veteran's service-connected radiculopathy of the left upper extremity are met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. § 4.71a, Diagnostic Code 8513 (2017). 6. From April 21, 2015, the criteria for a rating in excess of 20 percent for the Veteran's service-connected radiculopathy of the left upper extremity are not met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. § 4.71a, Diagnostic Code 8512 (2017). 7. Prior to August 14, 2013, the criteria for an initial rating in excess of 20 percent for the Veteran's service-connected radiculopathy of the right upper extremity are not met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. § 4.71a, Diagnostic Code 8512 (2017). 8. From August 14, 2013, the criteria for an initial 20 percent, but no higher, rating for the Veteran's service-connected radiculopathy of the right upper extremity are met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. § 4.71a, Diagnostic Code 8512 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS VA has duties to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C. §§ 5103, 5103A (2012); 38 C.F.R. § 3.159 (2017). Neither the Veteran nor his representative has raised any issues with the duty to notify or duty to assist. 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). Accordingly, appellate review may proceed without prejudice to the Veteran with respect to his claims. See Bernard v. Brown, 4 Vet. App. 384 (1993). Increased Rating: General Legal Criteria Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (Rating Schedule). 38 C.F.R. Part 4. The Rating Schedule is primarily a guide in the evaluation of disability resulting from all types of diseases and injuries encountered as a result of or incident to military service. The ratings are intended to compensate, as far as can practicably be determined, the average impairment of earning capacity resulting from such diseases and injuries and their residual conditions in civilian occupations. See 38 U.S.C. § 1155; 38 C.F.R. § 4.1. The evaluation of a service-connected disability involving a joint rated on limitation of motion requires adequate consideration of functional loss due to pain under 38 C.F.R. § 4.40 and functional loss due to weakness, fatigability, incoordination or pain on movement of a joint under 38 C.F.R. § 4.45. See DeLuca v. Brown, 8 Vet. App. 202 (1995). The basis of disability evaluations is the ability of the body as a whole to function under the ordinary conditions of daily life, including employment. See 38 C.F.R. § 4.10. Disability of the musculoskeletal system is primarily the inability to perform the normal working movements of the body with normal excursion, strength, speed, coordination and endurance. See 38 C.F.R. § 4.40. Consideration is to be given to whether there is less movement than normal, more movement than normal, weakened movement, excess fatigability, incoordination, pain on movement, swelling, deformity, atrophy of disuse, instability of station, or interference with standing, sitting, or weight bearing. See 38 C.F.R. § 4.45. Cervical Spine The RO rated the Veteran's service-connected degenerative disc disease of the cervical spine as 20 percent disabling from April 25, 2012 to August 13, 2013 under Diagnostic Code 5242, as 10 percent disabling from August 14, 2013 to April 20, 2015 under Diagnostic Code 5242, and as 20 percent disabling beginning April 21, 2015 under Diagnostic Code 5243, for IVDS. 38 C.F.R. § 4.71a. The Veteran's IVDS can be evaluated either under the General Rating Formula for Diseases and Injuries of the Spine or under the Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes, whichever method results in the higher evaluation when all disabilities are combined under § 4.25. Under the General Rating Formula for Diseases and Injuries of the Spine, a 10 percent rating is assigned for forward flexion of the cervical spine greater than 30 degrees but not greater than 40 degrees; or, combined range of motion of the cervical spine greater than 170 degrees but not greater than 335 degrees; or, muscle spasm, guarding, or localized tenderness not resulting in abnormal gait or abnormal spinal contour; or, vertebral body fracture with loss of 50 percent or more of the height under the General Rating Formula for Diseases and Injuries of the Spine. A 20 percent rating is assigned for forward flexion of the cervical spine greater than 15 degrees but not greater than 30 degrees; or, the combined range of motion of the cervical spine not greater than 170 degrees; or, muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. A 30 percent rating is assigned for forward flexion of the cervical spine 15 degrees or less; or, favorable ankylosis of the entire cervical spine. A 40 percent rating is assigned for unfavorable ankylosis of the entire cervical spine. A 100 percent rating is assigned for unfavorable ankylosis of the entire spine. 38 C.F.R. § 4.71a, General Rating Formula for Diseases and Injuries of the Spine (for DCs 5235 to 5243). For VA compensation purposes, normal forward flexion of the cervical spine is 0 to 45 degrees; extension is 0 to 45 degrees; left and right lateral flexion are 0 to 45 degrees; and left and right lateral rotation are 0 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, General Rating Formula for Diseases and Injuries of the Spine, Note 2. Under the Formula for Rating IVDS, a 10 percent rating is warranted with incapacitating episodes having a total duration of at least 1 week but less than 2 weeks during the past 12 months. A 20 percent rating is warranted with incapacitating episodes having a total duration of at least 2 weeks but less than 4 weeks during the past 12 months. A 40 percent rating is warranted with incapacitating episodes having a total duration of at least 4 weeks but less than 6 weeks during the past 12 months. A 60 percent rating is warranted with incapacitating episodes having a total duration of at least 6 months. An incapacitating episode is a period of acute signs and symptoms due to IVDS that requires bed rest prescribed by a physician and treatment by a physician. The Veteran filed a claim for an increased rating for his service-connected degenerative changes of the cervical spine in April 2012. For the reasons that follow, the Board finds that the evidence more nearly approximates an assignment of a 20 percent rating under Diagnostic Code 5242, but no higher, for the entire period on appeal. An October 2012 VA examination indicates that in the cervical spine the Veteran had flexion of 30 degrees with pain at 20 degrees, extension of 30 degrees with pain at 20 degrees, right lateral flexion of 20 degrees with pain at 15 degrees, left lateral flexion of 20 degrees with pain at 15 degrees, right lateral rotation of 30 degrees with pain at 25 degrees, and left lateral rotation of 30 degrees with pain at 25 degrees. Repetitive use testing produced the same or better range of motion for flexion, extension, right lateral flexion, left lateral flexion, right lateral rotation, and left lateral rotation. The Veteran reported he has flare-ups that restrict his movement from side to side and up and down. The Veteran reported his flare-ups are accompanied by headaches. The examiner noted the Veteran has functional loss with contributing factors of less movement than normal, excess fatigability, and pain on movement. The Veteran had tenderness in the lower cervical spine, a normal gait, normal muscle strength in the upper extremities, no muscle atrophy, no guarding or muscle spasm, and no IVDS. The examiner indicated there was no bowel or bladder impairment due to cervical myelopathy. The examiner stated that the Veteran's cervical spine disability impacts his ability to work in that it limits computer work, prolonged driving, and prolonged sitting. The Veteran attended a VA examination in August 2013 where range of motion testing of the cervical spine revealed flexion of 45 degrees, extension of 45 degrees, right lateral flexion of 45 degrees, left lateral flexion of 45 degrees, right lateral rotation of 80 degrees, and left lateral rotation of 80 degrees with evidence of pain at each endpoint. Repetitive use testing produced the same range of motion for flexion, extension, right lateral flexion, left lateral flexion, right lateral rotation, and left lateral rotation. The Veteran reported he has flare-ups that occur two times per day lasting 30 to 60 minutes and are precipitated by weather changes and alleviated by rest and massage. The Veteran reported he retains 50 percent of function during flare-ups, and he reported he loses approximately 45 degrees in range of motion. The examiner reported the Veteran had functional loss after repetitive use in the form of pain on movement. The Veteran had no localized tenderness in the cervical spine, normal motor strength, no muscle spasm, and no IVDS. There was no bowel or bladder impairment due to cervical myelopathy. The examiner stated the Veteran's cervical spine disability did not impact the Veteran's ability to work. At an April 2015 VA examination, a cervical spine examination revealed the Veteran had flexion of 25 degrees with pain, extension of 20 degrees with pain at 15 degrees, right lateral flexion of 15 degrees with pain, left lateral flexion of 15 degrees with pain, right lateral rotation of 30 degrees with pain at 25 degrees, and left lateral rotation of 35 degrees with pain at 30 degrees. Repetitive use testing produced the same range of motion for flexion, extension, right lateral flexion, left lateral flexion, right lateral rotation, and left lateral rotation. The Veteran reported he has flare-ups that limit his range of motion in his neck, but the Veteran did not describe the frequency of the flare-ups. The examiner noted the Veteran has functional loss with contributing factors of less movement than normal, excess fatigability, and pain on movement. The examiner noted how the Veteran had tenderness in the lower cervical spine, no guarding or muscle spasm, and normal muscle strength. The examiner found the Veteran to have IVDS, but also noted that the Veteran had not had any incapacitating episodes in the previous 12 months due to IVDS. In terms of the functional impact of the Veteran's cervical spine disability, the examiner stated repetitive neck activity should be limited. The examiner noted that there were contributing factors of pain, weakness, fatigability, and/or incoordination and there was additional limitation of functional ability of the cervical spine during flare-ups or repeated use over time. In evaluating the Veteran's increased rating claim, the Board must also address the provisions of 38 C.F.R. §§ 4.40 and 4.45. The Board recognizes the Veteran's complaints of pain, stiffness, and functional loss as a result of his cervical spine disability, notably his difficulty with prolonged sitting. In particular, the Board notes the Veteran's April 2012 statement where he contended that he has stiffness that goes up his neck and down his lower back, radiating outwards on both sides. In addition, the Veteran stated that it is difficult to stand after sitting for any length of time. The Board has considered the October 2012 statement from the Veteran's coworker in which the coworker stated that they have to leave early on business trips that involve driving to allow for frequent stops so the Veteran can stretch. Further, the coworker stated it takes "quite a few minutes" for the Veteran to "straighten up" after sitting for almost any length of time. In addition, the Board has considered the November 2012 statement from the Veteran's spouse in which she stated the Veteran can hardly walk and struggles to straighten up after sitting for any length of time. When considering the reports functional loss as shown by the VA examinations, the Veteran's reports of pain and stiffness, and the lay statements from the Veteran's spouse and coworker, the evidence shows the Veteran's cervical spine forward flexion was greater than 15 degrees, but not greater than 30 degrees throughout the appeal period. However, even when considering the reported functional loss, the Veteran's disability picture did not more nearly approximate forward flexion limited to 15 degrees or less or with favorable ankylosis of the entire spine. Thus, a 20 percent rating, but no higher, is warranted throughout the period on appeal. The Board has considered whether the Veteran is entitled to a higher rating under the rating criteria for IVDS. However, the evidence does not show that the Veteran had any episode of acute signs and symptoms due to IVDS that required bed rest prescribed by a physician and treatment by a physician in any 12 month period beginning 12 months prior to the Veteran's increased rating claim and through the appeal period. The October 2012 VA examiner initially provided a diagnosis of degenerative joint disease of the cervical spine with IVDS involving the bilateral ulnar and median nerves, but the examiner found the Veteran did not have IVDS of the cervical spine following the examination. Similarly, the April 2015 VA examiner diagnosed the Veteran with degenerative joint disease of the cervical spine with IVDS of the bilateral ulnar nerve, and following the examination, the examiner found that the Veteran had IVDS. However, the VA examiner noted that the Veteran had not had any incapacitating episodes in the 12 months preceding the April 2015 examination. Therefore, a rating in excess of 20 percent for the cervical spine is not warranted under the rating criteria for IVDS. The Board has also considered whether any separate ratings are warranted for any neurological impairment. 38 C.F.R. § 4.71a, Diagnostic Code 5242, Note (1). The Veteran is separately rated for radiculopathy of the upper extremities and the evaluations of those disabilities are discussed below. Additionally, the Veteran's pending claims of service connection for peripheral neuropathy of the bilateral lower extremities are being remanded for further development. There is no indication of any other neurological impairment from the Veteran's cervical spine disability, including bowel or bladder impairment. In sum, the Board finds that the evidence most nearly approximates an assignment of a 20 percent rating, but no higher, for the entire period. Consequently, the benefit-of-the-doubt rule is not applicable. 38 U.S.C. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). Radiculopathy of the Left Upper Extremity The Veteran filed a claim for an increased rating for his service-connected radiculopathy of the left upper extremity in April 2012. The RO rated the Veteran's service-connected radiculopathy of the left upper extremity at 30 percent from April 25, 2012 to August 13, 2013 under Diagnostic Code 8511, at 10 percent from August 14, 2013 to April 20, 2015 under Diagnostic Code 8511, and at 20 percent beginning April 21, 2015 under Diagnostic Code 8513. 38 C.F.R. § 4.71a. The Veteran is right handed, so his left upper extremity is considered the minor upper extremity. 38 C.F.R. § 4.69. For the minor extremity, Diagnostic Code 8511 provides a 20 percent rating for mild incomplete paralysis, a 30 percent rating for moderate incomplete paralysis, and a 40 percent rating for severe incomplete paralysis of the middle radicular group. Where there is complete paralysis, as manifested by adduction, abduction and rotation of the arm, flexion of elbow, and extension of the wrist lost or severely affected, a 60 percent rating is assigned for the minor extremity. 38 C.F.R. § 4.124a. Under Diagnostic Code 8513, for the minor extremity, the rating schedule provides a 20 percent rating for mild incomplete paralysis, a 30 percent rating for moderate incomplete paralysis, and a 40 percent rating for severe incomplete paralysis of all radicular groups. Where there is complete paralysis of the minor extremity, an 80 percent rating is assigned. 38 C.F.R. § 4.124a. The rating code provides that the term "incomplete paralysis," with this and other peripheral nerve injuries, indicates a degree of lost or impaired function substantially less than the type picture for complete paralysis given with each nerve, whether due to varied level of the nerve lesion or to partial regeneration. When the involvement is wholly sensory, the rating should be for the mild, or at most, the moderate degree. See Miller v. Shulkin, 28 Vet. App. 376 (2017) (finding that the plain language of the note to § 4.124a contains no mention of non-sensory manifestations and declining to read into the regulation a corresponding minimum disability rating for non-sensory manifestations). For the reasons that follow, the Board has concluded that the Veteran's left upper extremity radiculopathy is most appropriately evaluated under Diagnostic Code 8513 for the entire appeal period. VA can change the Diagnostic Code that a particular disability is rated under so long as the rating under that Diagnostic Code has not been in effect for 20 years. See 38 C.F.R. 3.951(b); see Murray v. Shinskeki, 24 Vet. App. 420, 425 (2011). VA must explain the change in the Diagnostic Code. See Pernorio v. Derwinski, 2 Vet. App. 625, 629 (1992). The October 2012 and April 2015 VA examinations and the Veteran's consistent symptoms throughout the appeal period illustrate the Veteran's left upper extremity disability affects both the median and ulnar nerves, so the Board concludes that Diagnostic Code 8513 best reflects the location of the Veteran's radiculopathy of the left upper extremity. See Butts v. Brown, 5 Vet. App. 532, 538 (1993). In addition, changing the Diagnostic Code from 8511 to 8513 does not reduce the Veteran's rating at any time during the appeal period. Accordingly, the Board has changed the Diagnostic Code to 8513 for the left upper extremity for the entire appeal period. Prior to August 14, 2013 The Veteran's radiculopathy of the left upper extremity is rated as 30 percent disabling under Diagnostic Code 8511 from April 25, 2012 to August 13, 2013. The Board finds that a rating in excess of 30 percent is not warranted under Diagnostic Code 8513. An October 2012 VA examination of the left upper extremity revealed moderate constant pain, moderate intermittent pain, moderate paresthesias, and moderate numbness. The examiner noted the severity of the Veteran's radiculopathy as moderate. The Veteran also had 1+ (hypoactive) reflexes for his biceps, triceps, and brachioradialis in the reflex examination. In addition, the sensory examination revealed decreased sensation in the shoulder area, inner and outer forearm, and hand and fingers. The Veteran had normal strength throughout the left upper extremity. The Veteran reported no flare-ups directly related to his left upper extremity, but the examiner stated the functional impact of the Veteran's cervical disability is that the disability limits the Veteran's computer work. The Board recognizes the Veteran's April 2012 and November 2012 statements in which he contended he has neuropathy in his left upper extremity from his hand through his shoulder. Further the Veteran stated that it feels like he has pins and needles sticking in three fingers of his left hand all of the time, he has difficulty carrying and holding objects, and difficulty opening jars. The Board has considered the October 2012 statement from the Veteran's coworker in which the coworker stated that he has recognized the Veteran has numbness in his extremities and that the coworker sees the Veteran shaking his hands to get the numbness out on a daily basis. In addition, the Board has considered the November 2012 statement from the Veteran's spouse in which she stated the Veteran is constantly rubbing his hands and arms as if he is trying to wake them up. Further, the Veteran's spouse reported that the Veteran tells her that there are pins and needles throughout both hands and wrists. Even with consideration of the Veteran's reports of numbness and tingling in the left upper extremity, and the lay statements from the Veteran's spouse and coworker, the evidence does not show the Veteran's left upper extremity radiculopathy has been manifested by more than moderate incomplete paralysis. The symptoms shown have been mostly sensory and have not more nearly approximated severe incomplete paralysis. Therefore, the Board finds that a rating in excess of 30 percent is not warranted for the period prior to August 14, 2013. 38 U.S.C. § 5107(b); Gilbert, 1 Vet. App. at 55. Beginning August 14, 2013 The Veteran's radiculopathy of the left upper extremity is rated as 10 percent disabling under Diagnostic Code 8511 from August 14, 2013 to April 20, 2015 and as 20 percent disabling under Diagnostic Code 8513 beginning April 21, 2015. For the reasons that follow, the Board finds that the evidence more nearly approximates an assignment of a 20 percent rating under Diagnostic Code 8513, but no higher, beginning August 14, 2013. An August 2013 VA examination showed no evidence of any peripheral nerve disorder according to the VA examiner. All tests of the left upper extremity were normal, and the examiner reported the Veteran had no physical examination evidence of any peripheral nerve condition. However, the Veteran reported that he had been told in the past that he has bilateral carpal tunnel syndrome, and the Veteran reported he has ulnar hand abnormal sensation up the left extremity to the shoulder region. The Veteran attended a private examination in October 2014 in which he reported he has moderate paresthesias and moderate numbness in the left upper extremity. The physician noted the Veteran had 4/5 grip and pinch strength in the left hand; decreased sensation in the left hand and fingers, left inner and outer forearm, and left shoulder area; and mild incomplete paralysis of the ulnar nerve in the left upper extremity. The physician stated the functional impact of the Veteran's peripheral nerve condition is that there is a minimal change of bilateral dexterity, which worsens with use in his occupation as an architect. The examination showed the Veteran had no muscle atrophy, normal reflexes, a negative Phalen's sign, and a negative Tinel's sign. The Veteran attended a VA examination in April 2015 for his peripheral nerve disability. For his left upper extremity, the Veteran reported no constant pain, moderate intermittent pain, moderate paresthesias, and moderate numbness. In testing the nerves and radicular groups in the left upper extremity, the examiner noted mild incomplete paralysis of the median nerve and mild incomplete paralysis of the ulnar nerve. The examiner also noted that the Veteran had a positive Phalen's sign and Tinel's sign. The sensory examination was normal for the forearm and shoulder but the Veteran had decreased sensation in his hand and fingers. Strength testing and the reflex examination produced normal results. The examiner stated that the functional impact of the Veteran's peripheral nerve condition is that repetitive neck activity should be limited. The Board has considered the Veteran's reports of pain and tingling in the left upper extremity throughout this period and the lay statements from the Veteran's spouse and coworker that are applicable although made prior to this period, but the evidence does not show the Veteran's left upper extremity has been limited by more than mild incomplete paralysis beginning August 14, 2013. Therefore, the Board finds that the evidence more nearly approximates an assignment of a 20 percent rating for mild incomplete paralysis under Diagnostic Code 8513, but no higher, for the period beginning August 14, 2013. 38 U.S.C. § 5107(b); Gilbert, 1 Vet. App. at 55. Radiculopathy of the Right Upper Extremity The Veteran filed a claim for an increased rating for his service-connected right upper extremity radiculopathy in April 2012. The RO rated the Veteran's service-connected radiculopathy of the right upper extremity at 20 percent from April 25, 2012 to August 13, 2013 under Diagnostic Code 8511 and at 10 percent beginning August 14, 2013 under Diagnostic Codes 8511 and 8516. 38 C.F.R. § 4.71a. The RO changed the Diagnostic Code from 8511 to 8516 for the Veteran's right upper extremity radiculopathy in the January 2016 rating decision without explanation. The Veteran is right handed, so his right upper extremity is considered the major upper extremity. 38 C.F.R. § 4.69. For the major extremity, Diagnostic Code 8511 provides a 20 percent rating for mild incomplete paralysis, a 40 percent rating for moderate incomplete paralysis, and a 50 percent rating for severe incomplete paralysis of the middle radicular group. Where there is complete paralysis, as manifested by adduction, abduction and rotation of the arm, flexion of elbow, and extension of the wrist lost or severely affected, a 70 percent rating is assigned for the major extremity. 38 C.F.R. § 4.124a. Under Diagnostic Code 8512, for the major extremity, the rating schedule provides a 20 percent rating for mild incomplete paralysis, a 40 percent rating for moderate incomplete paralysis, and a 50 percent rating for severe incomplete paralysis of the lower radicular group. Where there is complete paralysis, as manifested by all the intrinsic muscles of the hand, and some or all of the flexors of the wrist and fingers, paralyzed (substantial loss of use of the hand), a 70 percent rating is assigned. 38 C.F.R. § 4.124a. Under Diagnostic Code 8516, for the major extremity, the rating schedule provides a 10 percent rating for mild incomplete paralysis, a 30 percent rating for moderate incomplete paralysis, and a 40 percent rating for severe incomplete paralysis of the ulnar nerve. Where there is complete paralysis, as manifested by the "griffin claw" deformity, due to flexor contraction of ring and little fingers, atrophy very marked in dorsal interspace and thenar and hypothenar eminences; loss of extension of ring and little fingers cannot spread the fingers (or reverse), cannot adduct the thumb; flexion of wrist weakened, a 60 percent rating is assigned. 38 C.F.R. § 4.124a. The rating code provides that the term "incomplete paralysis," with this and other peripheral nerve injuries, indicates a degree of lost or impaired function substantially less than the type picture for complete paralysis given with each nerve, whether due to varied level of the nerve lesion or to partial regeneration. When the involvement is wholly sensory, the rating should be for the mild, or at most, the moderate degree. See Miller, 28 Vet. App. 376 (2017) (finding that the plain language of the note to § 4.124a contains no mention of non-sensory manifestations and declining to read into the regulation a corresponding minimum disability rating for non-sensory manifestations). The Board concludes that the Veteran's right upper extremity radiculopathy is most appropriately evaluated under Diagnostic Code 8512 for the entire appeal period. VA can change the Diagnostic Code a particular disability is rated under so long as the rating under that Diagnostic Code has not been in effect for 20 years. See 38 C.F.R. 3.951(b); see Murray, 24 Vet. App. at 425. VA must explain the change of the Diagnostic Code. See Pernorio, 2 Vet. App. at 629. In particular, although the April 2015 VA examiner found mild incomplete paralysis in the ulnar nerve only, the Veteran's symptoms throughout the appeal period have consistently involved sensory manifestations that have extended beyond the ulnar nerve through the lower radicular group. In addition, changing the Diagnostic Code from 8511 and 8516 to 8512 does not reduce the Veteran's rating at any time during the appeal period. Therefore, the Board deems that Diagnostic Code 8512 best reflects the Veteran's radiculopathy of the right upper extremity for the entire appeal period. For the reasons that follow, the Board finds that the evidence more nearly approximates an assignment of a 20 percent rating under Diagnostic Code 8512, but no higher, for the entire period of the appeal. An October 2012 VA examination of the right upper extremity revealed mild constant pain, mild intermittent pain, moderate paresthesias, and moderate numbness. The examiner noted the severity of the Veteran's radiculopathy as mild. The Veteran also had 1+ for his biceps, triceps, and brachioradialis in the reflex examination. In addition, the sensory examination revealed decreased sensation in the shoulder area, inner and outer forearm, and hand and fingers. The Veteran had normal strength throughout the left upper extremity. The Veteran reported no flare-ups directly related to his left upper extremity, but the examiner stated the functional impact of the Veteran's cervical disability is that the disability limits the Veteran's computer work. An August 2013 VA examination showed no evidence of any peripheral nerve disorder according to the VA examiner. All tests of the right upper extremity were normal, and the examiner reported the Veteran had no peripheral nerve condition that impacted the Veteran's ability to work. However, the Veteran reported that he had been told in the past that he has bilateral carpal tunnel syndrome, and the Veteran reported he has ulnar hand abnormal sensation up the right extremity to the shoulder region. The Veteran attended a private examination in October 2014 in which he reported he has moderate paresthesias and moderate numbness in the right upper extremity. The physician noted the Veteran had 4/5 grip and pinch strength in the right hand; decreased sensation in the right hand and fingers, right inner and outer forearm, and right shoulder area; and mild incomplete paralysis of the ulnar nerve in the right upper extremity. The physician stated the functional impact of the Veteran's peripheral nerve condition is that there is a minimal change of bilateral dexterity, which worsens with use in his occupation as an architect. The examination showed the Veteran had no muscle atrophy, normal reflexes, a negative Phalen's sign, and a negative Tinel's sign. The Veteran attended a VA examination in April 2015 for his peripheral nerve disability. For his right upper extremity, the Veteran reported no constant pain, moderate intermittent pain, moderate paresthesias, and moderate numbness. In testing the nerves and radicular groups in the right upper extremity, the examiner noted mild incomplete paralysis of the ulnar nerve and no paralysis of the median nerve. The examiner also noted that the Veteran had a negative Phalen's sign and Tinel's sign. The sensory examination was normal for the forearm and shoulder but the Veteran had decreased sensation in his hand and fingers. Strength testing and the reflex examination produced normal results. The examiner stated that the functional impact of the Veteran's peripheral nerve condition is that repetitive neck activity should be limited. The Board has considered the Veteran's April 2012 and November 2012 statements, his statements to the VA examiners, and his statements at the October 2014 private examination, wherein he contends he has neuropathy and pain in his right upper extremity from his hand through his shoulder. Further, the Board has considered the Veteran's statements that he has difficulty carrying and holding objects and difficulty opening jars. The Board has considered the October 2012 statement from the Veteran's coworker in which the coworker stated that he has recognized the Veteran has numbness in his extremities and that the coworker sees the Veteran shaking his hands to get the numbness out on a daily basis. In addition, the Board has considered the November 2012 statement from the Veteran's spouse in which she stated the Veteran is constantly rubbing his hands and arms as if he is trying to wake them up. Further, the Veteran's spouse reported that the Veteran tells her that there are pins and needles throughout both hands and wrists. Even with consideration of the Veteran's reports of pain and tingling in the right upper extremity, and the lay statements from the Veteran's spouse and coworker, the evidence does not show the Veteran's right upper extremity has been limited by more than mild incomplete paralysis throughout the appeal period. Therefore, the Board finds that the evidence more nearly approximates an assignment of a 20 percent rating, but no higher, for the entire period. 38 U.S.C. § 5107(b); Gilbert, 1 Vet. App. at 55. Extraschedular Per the representative's December 2017 contention that the Veteran's service-connected impairments currently before the Board impose a greater degree of limitation than regular schedular standards, the Board also has considered whether the Veteran is entitled to a greater level of compensation on an extraschedular basis. Ordinarily, the VA Schedule will apply unless there are exceptional or unusual factors which would render application of the schedule impractical. See Fisher v. Principi, 4 Vet. App. 57, 60 (1993). According to the regulation, an extraschedular disability rating is warranted based upon a finding that the case presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization that would render impractical the application of the regular schedular standards. See 38 C.F.R. § 3.321(b)(1). An exceptional case is said to include such factors as marked interference with employment or frequent periods of hospitalization as to render impracticable the application of the regular schedular standards. See Fanning v. Brown, 4 Vet. App. 225, 229 (1993). Under Thun v. Peake, 22 Vet. App. 111 (2008), there is a three-step inquiry for determining whether a veteran is entitled to an extraschedular rating. First, the Board must determine whether the evidence presents such an exceptional disability picture that the available schedular evaluation for the service-connected disability is inadequate. Second, if the schedular evaluation does not contemplate the Veteran's level of disability and symptomatology and is found inadequate, the Board must determine whether the Veteran's disability picture exhibits other related factors such as those provided by the regulation as 'governing norms.' Third, if the rating schedule is inadequate to evaluate a veteran's disability picture and that picture has attendant thereto related factors such as marked interference with employment or frequent periods of hospitalization, then the case must be referred to the Under Secretary for Benefits or the Director of the Compensation Service to determine whether, to accord justice, the Veteran's disability picture requires the assignment of an extraschedular rating. See 82 Fed. Reg. 57,830 (Dec. 8, 2017) (revising 38 C.F.R. § 3.321(b)(1) to clarify that extraschedular evaluations are only warranted for a single service-connected disability, and not for the combined effect of two or more service-connected disabilities). In the case at hand, the record reflects that the manifestations of the Veteran's cervical spine disability and radiculopathy of the left and right upper extremities are not outside of those contemplated by the schedular criteria. The Veteran's cervical spine disability is manifested by pain and reduced range of motion, symptoms described precisely by the schedular rating criteria. The Veteran's radiculopathy of the left and right upper extremities is manifested by sensory manifestations resulting in mild and moderate incomplete paralysis, symptoms described precisely by the schedular rating criteria. As the Board finds that the Veteran's disability picture is contemplated by the rating schedule, the inquiry ends and the Board need not consider whether the disability picture exhibits other related factors such as marked interference with employment and frequent periods of hospitalization. Doucette v. Shulkin, 28 Vet. App. 366 (2017). The Board, therefore, has determined that referral of this case for extraschedular consideration pursuant to 38 C.F.R. § 3.321(b)(1) is not warranted. ORDER Entitlement to a rating in excess of 20 percent for degenerative changes of the cervical spine with IVDS, prior to August 14, 2013, and from April 21, 2015, is denied. Entitlement to a 20 percent, but no higher, rating from August 14, 2013 to April 20, 2015 for degenerative changes of the cervical spine with IVDS, is granted, subject to the regulations governing the payment of monetary awards. Entitlement to an initial rating in excess of 30 percent for radiculopathy of the left upper extremity, prior to August 14, 2013, is denied. Entitlement to a 20 percent, but no higher, initial rating from August 14, 2013 to April 20, 2015, for radiculopathy of the left upper extremity, is granted, subject to the regulations governing the payment of monetary awards. Entitlement to an initial rating in excess of 20 percent from April 21, 2015 for radiculopathy of the left upper extremity is denied. Entitlement to an initial rating in excess of 20 percent for radiculopathy of the right upper extremity, prior to August 14, 2013, is denied. Entitlement to a 20 percent, but no higher, initial rating beginning August 14, 2013 for radiculopathy of the right upper extremity, is granted, subject to the regulations governing the payment of monetary awards. REMAND The Board finds that additional development is needed prior to adjudication for the Veteran's claims for entitlement to service connection for peripheral neuropathy of the left lower extremity and peripheral neuropathy of the right lower extremity. The Veteran was afforded VA examinations for the bilateral lower extremity peripheral neuropathy in August 2013 and April 2015. The August 2013 VA examination showed no evidence of any peripheral nerve disorder according to the VA examiner. All tests of the lower extremities were normal, and the examiner reported the Veteran had no peripheral nerve condition. In response to the question of whether the Veteran's left and right lower extremity peripheral neuropathy is related to the Veteran's neck condition, the examiner opined that the Veteran's left and right lower extremity peripheral neuropathy is less likely than not a result of the Veteran's neck condition as no lower extremity peripheral neuropathy is found. The examiner reasoned that neurological examinations of the lower extremities were normal. In addition, the Board finds the August 2013 opinion, the only opinion in the record, to be inadequate because in the precedential decision of Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008), the Court held that the probative value of a medical opinion comes from it being factually accurate, fully articulated, and having a sound reasoning for the conclusion. The April 2015 VA examination illustrates the Veteran had decreased sensation bilaterally in the thighs and knees and in the feet and toes. In addition, the April 2015 VA examiner noted how the Veteran had mild incomplete paralysis in the sciatic nerve bilaterally. The April 2015 examiner did not test any other lower extremity nerves. In addition, an October 2014 private examination reveals the Veteran had decreased sensation in the feet and toes bilaterally. The October 2014 private examination and April 2015 VA examination were not in the record at the time of the August 2013 VA opinion, but based on the current record, the August 2013 opinion is no longer factually accurate, as it appears the Veteran has a neurological condition of the bilateral lower extremities. Therefore, further development in the form of an additional examination and opinion is necessary. See Barr v. Nicholson, 21 Vet. App. 303 (2007). Accordingly, the case is REMANDED for the following actions: 1. With any needed assistance from the Veteran, obtain any identified outstanding private treatment records. 2. Obtain and associate with the Veteran's electronic record any outstanding VA treatment records from November 2014 onward. 3. After completing the development requested in items 1 and 2, schedule the Veteran for an appropriate VA examination with a clinician with appropriate expertise in order to properly assess the Veteran's left and right lower extremity neuropathy. The entire claims file should be made available to the examiner in conjunction with this request. After completing all indicated tests and studies, the examiner is to answer the following questions: A) Provide a diagnosis for any left or right lower extremity neurological disability that has existed during the pendency of the claim (since April 2012). B) Please identify the likely etiology of each diagnosed left and right lower extremity neurological disability. Specifically, respond to the following questions: i) Is it at least as likely as not (a 50% or greater probability) that any diagnosed right and left lower extremity peripheral neuropathy is caused by the Veteran's service-connected cervical spine disability? ii) Is it at least as likely as not (a 50% or greater probability) that any diagnosed right and left lower extremity peripheral neuropathy is aggravated (that is, any increase in severity beyond the natural progress of the condition as shown by comparing the current disability to medical evidence created prior to any aggravation) by the Veteran's service-connected cervical spine disability? If the Veteran's current right and left lower extremity disability has been aggravated by his service-connected cervical spine disability, the examiner should also indicate the extent of such aggravation by identifying the baseline level of disability. This may be ascertained by the medical evidence of record and also by the Veteran's statements as to the nature, severity, and frequency of his observable symptoms over time. The examiner must fully explain the rationale for all opinions, with citation to supporting clinical data/lay statements, as deemed appropriate. If the examiner cannot provide the requested opinion without resorting to speculation, he or she should expressly indicate this and provide a supporting rationale as to why an opinion cannot be made without resorting to speculation. 4. Finally, after completing the above actions, as well as any other development that may be warranted, readjudicate the Veteran's claims in light of all the evidence of record. If any benefit on appeal remains denied, a supplemental statement of the case must be provided to the Veteran and his representative. After the Veteran and his representative have had an adequate opportunity to respond, the appeal must be returned to the Board for appellate review. The Veteran has the right to submit additional evidence and argument on the matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). These claims must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C. §§ 5109B, 7112 (2012). ______________________________________________ M. Sorisio Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs