Citation Nr: 19166237 Decision Date: 08/27/19 Archive Date: 08/27/19 DOCKET NO. 13-21 039A DATE: August 27, 2019 ORDER Entitlement to a rating in excess of 20 percent for lumbar degenerative disc disease, lumbar strain and myositis (low back disability), prior to April 25, 2013 and higher than 40 percent from that date onwards is denied. A higher 20 percent rating is granted for associated right lower extremity radiculopathy throughout the period under consideration; a rating in excess of 20 percent, however, is denied. A rating higher than 10 percent for a left ankle disability prior to June 15, 2016, is denied, but a higher 20 percent rating since is granted. Entitlement to a rating in excess of 20 percent for Type II Diabetes Mellitus is denied. REMANDED Entitlement to service connection for a cervical degenerative disc disease (DDD) (neck disability) is remanded. FINDINGS OF FACT 1. Prior to April 25, 2013, the Veteran’s low back disability is not shown to have been manifested by forward flexion limited to 30 degrees or less or favorable ankylosis of the entire thoracolumbar spine; also, any associated lower extremity radiculopathy was at most mild in the left lower extremity, though moderate in the right lower extremity (irrespective of whether the result of his low back disability or also service-connected Type II Diabetes Mellitus). 2. Since April 25, 2013 the Veteran’s low back disability is not shown to have been manifested by unfavorable ankylosis of the thoracolumbar spine or by incapacitating episodes of intervertebral disc syndrome (IVDS) with a total duration of at least 6 weeks during a 12-month period; the associated lower extremity radiculopathy has been at most mild in the left lower extremity and moderate in the right lower extremity. 3. Prior to June 15, 2016, the Veteran’s left ankle disability was manifested by subjective pain and swelling, but without evidence of moderate or marked consequent limited motion. 4. As of June 15, 2016, however, the Veteran’s left ankle disability is reasonably shown to have been manifested by limitation of motion approximating “marked”; but the ankle is not ankylosed. 5. The treatment of the Veteran’s Type II Diabetes Mellitus does not require that he regulate his activities.   CONCLUSIONS OF LAW 1. Ratings for the Veteran’s low back disability in excess of 20 percent prior to April 25, 2013, and in excess of 40 percent since, are not warranted. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.7, 4.21, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes (Codes) 5237, 5243. 2. Throughout the period of this appeal, a 20 percent rating, though no higher, is warranted for the associated right lower extremity radiculopathy. 38 U.S.C. § 1155; 38 C.F.R. §§ 4.1-4.7, 4.10, 4.14, 4.21, 4.120, 4.124a, Code 8520. 3. Prior to June 15, 2016, at most a 10 percent rating was warranted for the Veteran’s left ankle disability; but from that date onwards, a higher 20 percent rating is warranted. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.3, 4.7, 4.71a, Code 5271. 4. The criteria for a rating in excess of 20 percent for Type II Diabetes Mellitus have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.3, 4.7, 4.118, Code 7913. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The appellant is a Veteran who served on active duty (AD) from February 1983 to May 1983, from September 1994 to December 1994, and from January 2002 to October 2002, with subsequent periods of active duty for training (ACDUTRA) and inactive duty training (INACDUTRA). These matters are before the Board on appeal from November 2010 and February 2014 rating decisions of a Department of Veterans Affairs (VA) Regional Office (RO). In October 2017, these claims were remanded for additional development. Increased Ratings Disability ratings are determined by applying the criteria set forth in VA’s Schedule for Rating Disabilities (Rating Schedule), which is based on the average impairment of earning capacity. Individual disabilities are assigned separate diagnostic codes. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. The basis of disability evaluations is the ability of the body as a whole, or of the psyche, or of a system or organ of the body to function under the ordinary conditions of daily life including employment. 38 C.F.R. § 4.10. When evaluating the severity of a disability, it is essential that the disability is considered in the context of the entire recorded history. 38 C.F.R. § 4.1; Peyton v. Derwinski, 1 Vet. App. 282 (1991). Where entitlement to compensation already has been established and an increase in the disability rating is at issue, the present level of disability is of primary importance. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). But if the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings, then separate ratings may be assigned for separate periods of time based on the facts found. This practice is known as “staged” ratings and is employed for initial or established ratings. Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). If the disability picture more closely approximates the criteria for the higher of two ratings, the higher rating will be assigned; otherwise, the lower rating is assigned. 38 C.F.R. § 4.7. In general, 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. When, after careful consideration of all procurable and assembled data, a reasonable doubt arises regarding the degree of disability, such doubt will be resolved in favor of the Veteran. 38 C.F.R. § 4.3. 1. Entitlement to a rating higher than 20 percent for lumbar degenerative disc disease, lumbar strain and myositis (low back disability) prior to April 25, 2013, and a rating higher than 40 percent since 2. Entitlement to a rating higher than 10 percent for associated right lower extremity radiculopathy prior to April 25, 2013, and a rating higher than 20 percent since The criteria for rating spine disabilities are found at 38 C.F.R. § 4.71a, Codes 5235 to 5243. Under the General Formula the following ratings apply: a 20 percent rating is warranted when there is forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees; or combined range of motion of the thoracolumbar spine not greater than 120 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 40 percent rating is warranted for forward flexion of the thoracolumbar spine limited to 30 degrees or less, or favorable ankylosis of the entire thoracolumbar spine. A 50 percent rating is warranted for unfavorable ankylosis of the entire thoracolumbar spine. A 100 percent rating is warranted for unfavorable ankylosis of the entire spine. Any associated objective neurologic abnormalities are to be evaluated separately, under an appropriate diagnostic code. 38 C.F.R. § 4.71a, Codes 5235-42, Note (1). Because of this, right L5 radiculopathy is separately rated. For VA compensation purposes, normal forward flexion of the thoracolumbar spine is from zero to 90 degrees, normal extension is from zero to 30 degrees, normal left and right lateral flexion is from zero to 30 degrees, and normal left and right lateral rotation is from zero to 30 degrees. 38 C.F.R. § 4.71a, Codes 5235-42, Note (2). So normal combined range of motion is 270 degrees. All measured ranges of motion are to be rounded to the nearest five degrees. 38 C.F.R. § 4.71a, Codes 5235-42, Note (4). For VA compensation purposes, unfavorable ankylosis is a condition in which the entire thoracolumbar 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. 38 C.F.R. § 4.71a, Codes 5235-42, Note (5). Under the Formula for Rating IVDS Based on Incapacitating Episodes, the following ratings apply: a 20 percent rating is warranted for incapacitating episodes having a total duration of at least two weeks but less than four weeks per year. A 40 percent rating is warranted for incapacitating episodes having a total duration of at least four weeks but less than six weeks per year. A 60 percent rating is warranted for incapacitating episodes having a total duration of at least six weeks but less than twelve weeks per year. An “incapacitating episode” is defined as “a period of acute signs and symptoms due to [IVDS] that requires bed rest prescribed by a physician and treatment by a physician.” 38 C.F.R. § 4.71a, Code 5243, Formula for Rating IVDS Based on Incapacitating Episodes, Note (1). Under 38 C.F.R. § 4.124a, Diagnostic Code 8520, which governs paralysis of the sciatic nerve, the minimum 10 percent evaluation is assigned for mild incomplete paralysis of the sciatic nerve. A 20 percent evaluation is assigned for moderate incomplete paralysis of the sciatic nerve. A 40 percent evaluation is assigned for moderately-severe incomplete paralysis of the sciatic nerve. A 60 percent evaluation is assigned for severe incomplete paralysis of the sciatic nerve with marked muscular atrophy. The maximum 80 percent evaluation is assigned for complete paralysis of the sciatic nerve; the foot dangles and drops, no active movement possible of muscles below the knee, flexion of knee weakened or (very rarely) lost. The term “incomplete paralysis” indicates a degree of lost or impaired function substantially less than the type pictured for complete paralysis given with each nerve, whether due to varied level of the nerve lesion or to partial regeneration. When the involvement is wholly sensory, the rating should be for the mild, or at most, the moderate degree. The ratings for the peripheral nerves are for unilateral involvement; when bilateral, combine with application of the bilateral factor. Id. The terms “mild,” “moderate,” “moderately severe” and “severe” are not defined in the Schedule. Rather than applying a mechanical formula, the Board must evaluate all of the evidence to the end that its decisions are “equitable and just.” 38 C.F.R. § 4.6 (2016). As there is considerable overlap in the relevant evidence concerning the Veteran’s claims for increases in the disability ratings assigned for his low back disability and associated right L5 radiculopathy, the Board will discuss the two claims concurrently. In June 2009, the Veteran underwent a VA examination for his low back disability. He reported constant low back pain which he described as a pressure like sensation radiating to the lower extremities. Range-of-motion (ROM) testing showed forward flexion to 40 degrees, extension to 14 degrees, right and left lateral bending to 20 degrees, each, and right and left rotation to 22 degrees, each. After repetitive use, ROM showed forward flexion to 36 degrees, extension to 10 degrees, right and left lateral bending to 20 degrees, each, and right and left rotation to 22 degrees, each. Muscle strength, reflex and sensory were all normal. There was no ankylosis of the spine. An electromyograph (EMG) showed right L5 radiculopathy. The diagnoses were lumbar myositis, lumbar degenerative disc disease, right L5 radiculopathy and lumbar strain. A November 2009 VA treatment record notes the Veteran’s report of low back pain which weakens his legs. An April 2010 VA treatment record notes that Veteran’s complaints of low back pain worsened with flexion, change in position and prolonged sitting. On September 2010 VA examination, the Veteran reported weekly fare-ups caused by prolonged sitting or standing. He reported functional impairment due decreased ambulation and decreased ROM secondary to low back pain. He reported radiating pain, described as numbness, weakness and pressure. ROM testing showed, forward flexion was to 39 degrees, extension was to 7 degrees, right lateral flexion was to 14 degrees and left lateral flexion was to 12 degrees, and right and left lateral rotation were to 12 degrees. Pain was noted on all ROM. There was lumbar spine tenderness on palpation. There was no additional loss of function or range of motion after three repetitions. The examiner noted muscle spasms, guarding and antalgic gait. There was no muscle atrophy. He had hypoactive (1+) reflexes of the lower extremities, bilaterally. The spine was not ankylosed. On April 2013 VA examination, the Veteran reported worsening back pain and thoracolumbar spine flare ups with stooping, heavying lifting, and prolonged standing. ROM testing showed forward flexion to 35 degrees without pain and 5 degrees with pain, extension to 20 degrees without pain and 5 degrees with pain, left lateral flexion to 20 degrees without pain and 5 degrees with pain, right lateral flexion to 20 degrees without pain and to 5 degrees with pain, left and right rotation to 15 degrees each without pain and 5 degrees each with pain. Repetitive use testing showed additional loss of ROM; flexion was to 25 degrees, extension was to 20 degrees, right and left lateral flexion were to 15 degrees, each, right and left rotation was to 15 degrees each. Functional loss included pain on movement. There was localized pain to palpation of the thoracolumbar spine. There was guarding and/or muscle spasm of the thoracolumbar spine; the guarding or muscle spasm did not result in abnormal gait or spinal contour. Muscle strength and reflexes were normal. Sensory exam showed decreased sensation to light tough for the right anterior thigh, right knee, right lower leg/ankle, and right foot/toes. The severity of the Veteran’s right lower radiculopathy was noted to be moderate. It was noted that the Veteran did not have IVDS and did not use assistive devices. On June 2015 VA examination, the diagnoses included lumbosacral strain degenerative arthritis of the spine and right lumbar radiculopathy. The Veteran reported weekly thoracolumbar spine flare ups lasting hours and functional impairment due to inability to stand and ambulation tolerance. On physical examination, forward flexion was to 20 degrees, extension was to 10 degrees, right and left lateral flexion were from 0 to 25 degrees, right lateral flexion to 10 degrees, left lateral flexion to 15 degrees, right and left lateral rotation were to 10 degrees. Pain was noted and caused functional loss. There was pain with weight bearing and tenderness on palpation of the thoracolumbar spine. There was no additional loss of function or range of motion after three repetitions. There was guarding and/or muscle spasm of the thoracolumbar spine; the guarding or muscle spasm did not result in abnormal gait or spinal contour. Straight-leg-raising was positive to the right and negative to the left. Reflex examination was normal. Sensory exam showed decreased sensation to light tough for the right lower leg/ankle, and right foot/toes. The severity of the Veteran’s right lower radiculopathy was noted to be moderate. Involvement of the right sciatic nerves were indicated. The spine was not ankylosed. There were no neurological manifestations of the thoracolumbar spine other than the already separately rated right lower extremity radiculopathy. IVDS was not diagnosed. He did not use assistive devices. He reported constant use of a brace. For the following reasons and bases, a rating higher than 20 percent is not warranted for the initial period at issue prior to April 25, 2013. The reports of the June 2009 and September 2010 VA examinations, treatment records, and lay statements, overall, provide evidence against any higher rating during this initial phase, as they do not show forward flexion limited to 30 degrees or less or favorable ankylosis of the entire thoracolumbar spine (the criteria for a higher 40 percent rating). As such, the Veteran’s documented symptoms of his low back disability for the initial period at issue prior to April 25, 2013 were correctly rated as 20-percent disabling. A rating higher than 40 percent under the General Formula since April 25, 2013, requires unfavorable ankylosis of the entire thoracolumbar spine or unfavorable ankylosis of the entire spine (that is, when additionally considering the adjacent cervical segment), and neither is shown. As already alluded to, all evaluations and examinations have shown the Veteran retains some motion of his thoracolumbar spine (even with factors such as pain and repetitive use considered). No examiner has indicated this segment of the Veteran’s spine is ankylosed, much less ankylosed in an unfavorable position. See Note (5) in Codes 5235-42. The Board additionally has considered whether a higher rating under the Formula for Rating IVDS is warranted. But VA examiners have indicated the Veteran does not have IVDS, and in any event review of the record does not show physician-prescribed bedrest in accordance with Note (1) to Code 5243. Therefore, a rating (for sure, a higher rating) based on incapacitating episodes is not warranted because, by definition, he has not had any. The preponderance of the evidence is against this claim for higher “staged” ratings for these two periods at issue. Therefore, the benefit-of-the-doubt rule does not apply, and this portion of the appeal must be denied. 38 U.S.C. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Associated Right L5 Radiculopathy At present the Veteran has a 10 percent rating for his right lower extremity radiculopathy prior to April 25, 2013, and a higher 20 percent rating since. But the Board finds that, even for the initial period at issue prior to April 25, 2013, the associated right L5 radiculopathy more nearly approximates “moderate” incomplete paralysis of the affected nerve. Therefore, he is entitled to a 20 percent rating even during this initial period at issue. In pertinent part, the record documents the Veteran’s complaints of pain, numbness, and weakness in his right lower extremity owing to his low back disability. Further, prior to April 25, 2013, he was observed to have an antalgic gait, including during his September 2010 VA examination. That examination also reflects hypoactive (1+) reflexes. Moreover, the law mandates resolving all reasonable doubt regarding the degree of disability in his favor, 38 C.F.R. § 4.3, and where there is a question as to which of two evaluations applies, assigning the higher of the two where the disability picture more nearly approximates the criteria for the next higher rating, 38 C.F.R. § 4.7. Therefore, the Board finds that the Veteran is entitled to a higher 20 percent (but no greater) rating for his right lower radiculopathy for this initial period at issue prior to April 25, 2013. The evidence does not show, however, that at any time he has had moderately-severe incomplete paralysis of his sciatic nerve to warrant an even higher evaluation under DC 8520. Thus, the criteria for an even greater 40 percent rating are not met, either prior to or since April 25, 2013.   3. Entitlement to a rating in excess of 0 percent (i.e., a compensable rating) for a left ankle disability prior to July 19, 2010 and higher than 10 percent since The Veteran’s left ankle disability is rated under hyphenated Code 5299-5271. Hyphenated diagnostic codes are used when a rating under one diagnostic code requires use of an additional diagnostic code to identify the basis for the evaluation assigned; the additional code is shown after the hyphen. Code 5271 provides for a 10 percent rating for limitation of ankle motion, when moderate, and for a 20 percent [maximum] rating when marked. The words “moderate” and “marked” are not defined in the Rating Schedule; however, the Rating Schedule provides some guidance by defining full range of motion of the ankle as 0 to 20 degrees of dorsiflexion and 0 to 45 degrees of plantar flexion. See 38 C.F.R. § 4.71a, Plate II. On March 2009 VA examination, the Veteran reported flare-ups lasting several hours, aggravated by prolonged standing and ambulation and alleviated by medication and leg elevation. He reported pain rated a 6/10 and locking. On ROM studies, dorsiflexion of the left ankle was to 20 degree with pain beginning at 10 degrees and plantar flexion was to 45 degree with pain beginning at 25 degrees. There was tenderness at the lateral malleolus. X-rays of the left ankle showed enthesopathic changes at the left ankle joint. On September 2010 VA examination, the Veteran reported that his left ankle disability had progressively worsened. He reported symptoms of pain, instability, weakness, stiffness and swelling. On examination there was tenderness on palpation of the joint. ROM studies of the left ankle revealed dorsiflexion to 15 degrees and plantar flexion to 27 degrees. There was no additional limitation of motion following repetitive testing, but objective evidence of pain was noted. The examiner opined that the Veteran’s left ankle disability impacts his ability perform usual daily activities. On April 25, 2013 VA examination, ROM of the left ankle was dorsiflexion to 15 degrees, with pain beginning at 5 degrees and plantar flexion to 30 degrees, with pain beginning at 5 degrees. Repetitive use testing showed additional loss of ROM, dorsiflexion to 15 degrees, and plantar flexion to 25 degrees, with pain beginning at 5 degrees. Functional loss included less movement than normal, excessive fatigability and pain on movement. Muscle strength testing of the left ankle was a 4/5. There was not ankylosis of the left ankle. X-rays revealed degenerative arthritis. On June 2015 VA examination, the Veteran reported weekly flare-ups, lasting hours. He also reported that his left ankle limited his ability stand and walk. On ROM studies, dorsiflexion of the left ankle was to 5 degree and plantar flexion was to 25 degree. Pain noted on examination and caused functional loss. There was objective evidence of pain on weight bearing and localized tenderness on palpation. There was no additional limitation of motion following repetitive testing. Left ankle instability was suspected. The Veteran reported constant use of a brace. As already mentioned, the Veteran’s left ankle disability has been assigned “staged” ratings of 0 percent prior to July 19, 2010, and 10 percent from that date onwards under hyphenated Code 5299-5271. The Board finds that, prior to June 16, 2015 (the date of VA examination), the disability picture for the left ankle disability more nearly approximated the criteria for a 10 percent rating when consideration is given to the functional loss of the left ankle due to pain, locking, and noncompensable limited motion. 38 C.F.R. §§ 4.40, 4.45, 4.59; see also Mitchell v. Shinseki, 24 Vet. App. 32 (2011); DeLuca v. Brown, 8 Vet. App. 202 (1995). The Veteran is competent to report symptoms of pain and swelling, and the Board finds him generally credible in this regard because he has consistently reported pain throughout the period of appeal. Thus, the competent and credible evidence shows that the left ankle disability is productive of functional loss and impairment due to pain. VA’s policy is to treat actually painful, unstable, or malaligned joints as warranting at least the minimum compensable rating for the joint. 38 C.F.R. § 4.59. This regulation applies to any service-connected joint disability, not just arthritis. See Burton v. Shinseki, 25 Vet. App. 1 (2011). The 10 percent rating contemplates the Veteran’s functional impairment in the left ankle during flare-ups or due to pain with activity or use. However, the Board further finds that, from June 16, 2015, onwards, the overall record reasonably supports concluding the Veteran’s left ankle disability is reasonably shown to exceed the moderate level reflected by a 10 percent rating and to instead approximate the greater “marked” level commensurate with a higher 20 percent rating. Thus, he is entitled to this higher 20 percent rating from the June 16, 2015 examination date, onwards. See 38 C.F.R. §§ 4.3, 4.7. The Board realizes that the ranges of motion found on examination do not appear to reflect fully a marked limitation of motion. But those findings must be viewed in light of the overall findings. Notably, the examination also found that there was pain causing functional loss and localized tenderness on palpation. Considering the VA examination findings along with the Veteran’s own descriptions of his limitations due to the disability, the Board finds that the level of impairment due to his left ankle disability is shown as of June 16, 2015, though no earlier, to have exceeded moderate limitation of motion and to have approximated “marked”, warranting a staged (to 20 percent) rating from the June 16, 2015 examination date. Id. The Board has considered whether a further (above 20 percent) increase in the rating may be warranted. As a further increase would require ankylosis in plantar flexion or dorsiflexion, and ankylosis of the ankle has not been found, a rating higher than 20 percent is not warranted The Board also has considered whether a separate or higher evaluation is available under other codes. However, the Veteran as mentioned is not shown to have ankylosis of the ankle to warrant an evaluation under Diagnostic Code 5270. There equally is no evidence of ankylosis of the subastragalar or tarsal joint, malunion of the os calcis or astragalus, or astragalectomy to warrant ratings under Diagnostic Codes 5272-5274. The Board, therefore, finds that a separate or higher evaluation is not warranted for this left ankle disability under any other code. 4. Entitlement to a rating in excess of 20 percent for Diabetes Mellitus, Type II Under Code 7913, diabetes mellitus which is manageable by restricted diet only is rated at 10 percent. Diabetes mellitus requiring insulin and restricted diet, or oral hypoglycemic agent and restricted diet, is rated at 20 percent. Diabetes mellitus requiring insulin, restricted diet, and regulation of activities (avoidance of strenuous occupational and recreational activities) is rated at 40 percent. The Veteran’s VA treatment records document his diabetes mellitus treatment. An April 2003 VA treatment records notes that he was prescribed glyburide and diet and exercise was reinforced. A September 2013 treatment record notes that the glyburide dose was increased, and metformin was added to his medications as his diabetes was still uncontrolled. On April 2014 and June 2015 VA examinations, it was noted that the Veteran’s diabetes mellitus was managed by restricted diet and required daily injections of insulin for treatment. However, he did not require regulation of activities as part of medical management for his diabetes mellitus, and his condition did not cause any physical complications nor impact his ability to work Regulation of activities is defined as “avoidance of strenuous occupational and recreational activities”. 38 C.F.R. § 4.119, Code 7913; see also Camacho v. Nicholson, 21 Vet. App. 360, 363 (2007). The objective medical evidence does not show that the Veteran’s diabetes mellitus results in any regulation of activities. In fact, to the contrary, he has been instructed to have more physical activity (exercise), not instead less. The Board finds that the weight of the evidence is against finding that management of the Veteran’s diabetes mellitus, type II, requires a regulation of his activities as required for a higher 40 percent rating under Code 7913. Throughout the rating period on appeal, his treatment regimen has required the use of insulin or an oral hypoglycemic agent, and a restricted diet, which is consistent with the 20 percent rating criteria under Code 7913.   Regulation of activities is the additional criterion necessary for the next higher 40 percent schedular rating. See Camacho v. Nicholson, 21 Vet. App. 360 (2007) (holding that the criteria for rating diabetes mellitus are conjunctive, and that each element of the criteria is needed to meet the requirements for the specified evaluation). For these reasons and bases, the preponderance of the evidence is against this claim. Therefore, in this circumstance the benefit-of-the-doubt doctrine does not apply, and the claim for a higher rating for the diabetes must be denied. 38 U.S.C. § 5107(b); 38 C.F.R. § 4.3. See also Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). REASONS FOR REMAND Entitlement to service connection for cervical degenerative changes with cervical radiculopathy (neck disability). The Veteran contends that his neck disability is related to an injury he sustained while on active duty. A March 2007 Line of Duty Determination Statement notes he was involved in a motor vehicle accident and sustained a back injury while on ACDUTRA. A November 2009 VA treatment record notes his report of neck pain since that injury in service. Notably, he since has established his entitlement to service connection for low back disability resulting for that motor vehicle accident in service. Pursuant to the prior October 2017 Board remand, the Veteran was afforded a VA examination to ascertain the etiology of his current neck disability; the diagnosis was cervical degenerative disc disease (DDD). The examiner explained that cervical DDD is a chronic condition that gets progressively worse over time with the natural aging process. He opined that the Veteran’s disability was less likely than not related to his service and more likely related to aging. The Board finds the opinion is inadequate for rating purposes, however, because it lacks sufficient rationale and the examiner failed to consider the Veteran’s reports of continuity of symptoms since service. Specifically, in attributing the Veteran’s cervical DDD to simple aging, the VA examiner’s opinion does not account for the motor vehicle accident in service and provides no basis for disassociating the Veteran’s neck disability from his service-connected low back disability. Consequently, more medical comment is needed concerning this claim. This matter is REMANDED for the following action: Forward the Veteran’s file to an appropriate clinician for review and to provide a supplemental (addendum) opinion regarding the nature and etiology of the Veteran’s neck disability. After reviewing the relevant evidence in the file, including this decision and remand (and prior opinion provided after and as a result of the Board’s prior remand), the examiner should: (a) Identify the likely etiology of the Veteran’s neck disability, i.e., cervical DDD. Specifically, is it at least as likely as not (a 50% or greater probability) this disability is etiologically related to the Veteran’s service/events therein, to specifically include the injury he sustained in the motor vehicle accident while in service? (b) When responding, the examiner also is asked to indicate whether it is at least as likely as not (50 percent or greater probability) that the Veteran’s neck disability was caused OR aggravated by his service-connected low back disability? *So opinions are needed concerning direct and secondary service connection.   If a neck disability is found not to be related to service (to include the motor vehicle accident mentioned), please identify the etiology considered more likely and explain the basis for dissociating the etiology of the Veteran’s neck disability from the etiology of his service-connected low back disability. In other words, if, as the prior examiner concluded, the neck disability is more likely the result of cervical DDD progressively worsening over time, including owing to simple aging, there still needs to be discussion of why the Veteran’s service and especially his service-connected low back disability are not additional factors. The examiner must include rationale with all opinions, citing to supporting evidence in the file and/or accepted medical authority. KEITH W. ALLEN Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board P. Poindexter The Board’s decision in this case is binding only with respect to the instant matter decided. This decision is not precedential, and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.