Citation Nr: 20008169 Decision Date: 01/31/20 Archive Date: 02/20/20 DOCKET NO. 17-03 077 DATE: January 31, 2020 ORDER Entitlement to an initial evaluation for posttraumatic stress disorder (PTSD) in excess of 10 percent prior to August 31, 2015, and in excess of 70 percent thereafter is denied. Entitlement to an initial evaluation in excess of 20 percent for degenerative disc disease of the lumbar spine (hereinafter lumbar spine disability) is denied. Entitlement to an initial evaluation in excess of 20 percent for neuropathy of the left lower extremity is denied. Entitlement to an initial evaluation in excess of 20 percent for neuropathy of the right lower extremity is denied. REMANDED Entitlement to special monthly compensation based on the regular need for aid and attendance of another is remanded. FINDINGS OF FACT 1. For the period prior to August 31, 2015 the Veteran’s PTSD has resulted in no more than occupational and social impairment due to mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress, or symptoms controlled by continuous medication. 2. For the period beginning August 31, 2015 the Veteran’s PTSD has resulted in occupational and social impairment, with deficiencies in most areas, but has not resulted in total occupational and social impairment. 3. The Veteran’s lumbar spine disability has not resulted in forward flexion for the thoracolumbar spine of 30 degrees or less, and has not been characterized by unfavorable ankylosis of the entire thoracolumbar spine, or any incapacitating episodes. 4. The Veteran’s left lower extremity neuropathy has been characterized by moderate, but not severe, incomplete paralysis of the left sciatic nerve. 5. The Veteran’s right lower extremity neuropathy has been characterized by moderate, but not severe, incomplete paralysis of the right sciatic nerve. CONCLUSIONS OF LAW 1. The criteria for an initial disability rating in excess of 10 percent prior to August 31, 2015, and 70 percent thereafter have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.321, 4.1, 4.2, 4.3, 4.7, 4.10, 4.21, 4.126, 4.130, DC 9411. 2. The criteria for an initial rating in excess of 20 percent for a lumbar spine disability have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.1, 4.2, 4.3, 4.7, 4.10, 4.21, 4.40, 4.45, 4.71a, DC 5242. 3. The criteria for an initial rating in excess of 20 percent for left lower extremity neuropathy have not all been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.1, 4.2, 4.3, 4.7, 4.10, 4.21, 4.40, 4.45, 4.71a, DC 8520. 4. The criteria for an initial rating in excess of 20 percent for right lower extremity neuropathy have not all been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.1, 4.2, 4.3, 4.7, 4.10, 4.21, 4.40, 4.45, 4.71a, DC 8520. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active duty service from July 1960 to February 1981. This matter is before the Board of Veterans’ Appeals (Board) on appeal from a November 2015 rating decision by a Department of Veterans Affairs (VA) Regional Office (RO). This case was previously before the Board in January 2018. The Board remanded the claim for new VA examinations and to attempt to obtain the Veteran’s private treatment records. The Veteran attended VA examinations in April 2019 and May 2019, and reasonable attempts were made to obtain said records. Accordingly, the Board finds that the remand directives were substantially complied with. See Stegall v. West, 11 Vet. App. 268 (1998). Increased Rating Disability ratings are determined by applying the criteria set forth in the VA’s Schedule for Rating Disabilities, 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. In determining the severity of a disability, the Board is required to consider the potential application of various other provisions of the regulations governing VA benefits, whether or not they were raised by the Veteran, as well as the entire history of the Veteran’s disability. 38 C.F.R. §§ 4.1, 4.2; Schafrath v. Derwinski, 1 Vet. App. 589, 595 (1991). If the disability 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. 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. In deciding this appeal, the Board has considered whether separate ratings for different periods of time, based on the facts found, are warranted, a practice of assigning ratings referred to as “staging the ratings.” See Fenderson v. West, 12 Vet. App. 119 (1999). 1. PTSD The Veteran’s PTSD is rated as 10 percent disabling prior to August 31, 2015, and 70 percent thereafter. The Veteran contends that his PTSD should be afforded a higher rating. Under the applicable rating criteria, a 10 percent disability rating is warranted when there is occupational and social impairment due to mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress, or symptoms controlled by continuous medication. 38 C.F.R. § 4.130, DC 9411. A 30 percent disability rating is warranted when there is occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, mild memory loss (such as forgetting names, directions, recent events). Id. A 50 percent disability rating is warranted when there is occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped, speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short and long term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships. Id. A 70 percent disability rating is warranted for occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work-like setting); inability to establish and maintain effective relationships. Id. Finally, a 100 percent disability rating is warranted when there is total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. Id. Symptoms listed in the VA’s general rating formula for mental disorders serve as examples of the type and degree of the symptoms, or their effects, that would justify a particular rating, and are not intended to constitute an exhaustive list. See Mauerhan v. Principi, 16 Vet. App. 436, 442-44 (2002). The U.S. Court of Appeals for the Federal Circuit (Federal Circuit) has emphasized that the list of symptoms under a given rating is a nonexhaustive list, as indicated by the words “such as” that precede each list of symptoms. Vazquez-Claudio v. Shinseki, 713 F.3d 112, 115 (Fed. Cir. 2013). In Vazquez-Claudio, the Federal Circuit held “that a veteran may only qualify for a given disability rating under § 4.130 by demonstrating the particular symptoms associated with that percentage or others of similar severity, frequency, and duration.” Id. at 117. Other language in the decision indicates that the phrase “others of similar severity, frequency, and duration,” can be thought of as symptoms of like kind to those listed in the regulation for a given disability rating. Id. at 116. The nomenclature employed in the rating formula is based upon the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, of the American Psychiatric Association (DSM-5). See 38 C.F.R. § 4.130. Period prior to August 31, 2015 The Veteran attended a VA examination in September 2013. The examiner opined that the Veteran’s PTSD resulted in occupational and social impairment due to mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress, or; symptoms controlled by medication. The examiner stated that the Veteran’s PTSD symptoms included difficulty falling or staying asleep, exaggerated startle response, and anxiety. There are no other VA medical records or private medical records regarding the Veteran’s PTSD for the period prior to August 31, 2015. In a June 2012 Statement in Support of Claim, the Veteran stated that he experienced trouble with sleep, nightmares, night sweats, aversion to loud noises, and confinement issues around crowds which he attributes to his PTSD. In a May 2014 Notice of Disagreement, the Veteran stated that he had attended extensive counseling, experienced anxiety, had taken mood altering medications, and sought intervention by professionals as related to his PTSD. These reports appear to be consistent with the findings of the September 2013 VA examiner. For the period prior to August 31, 2015, the Veteran does not have symptoms that lead to a 30 percent disability rating. The most probative medical evidence of record is the September 2013 VA examination in which the examiner stated that the Veteran’s PTSD is manifested by mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress. There is no evidence that the Veteran’s PTSD caused occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, mild memory loss (such as forgetting names, directions, recent events). The Veteran reported being married to his wife for 52 years, a good relationship with his sons, a few friends and many acquaintances, and that he and his wife travel. Thus, a 30 percent rating is not warranted for this period. Based on the foregoing evidence, the Veteran’s PTSD most closely resembles the criteria for a 10 percent rating for the period prior to August 31, 2015. The preponderance of the evidence is against the assignment of a rating in excess of 10 percent for this period. There is no reasonable doubt to be resolved as to this issue. 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102 Period beginning August 31, 2015 The Veteran attended a VA examination in August 2015. The examiner opined that the Veteran’s PTSD caused occupational and social deficiencies in most areas, such as work, school, family relations, judgment, thinking and/or mood. The Veteran reported unremitting thoughts of suicide (passive in nature) with at least one incident involving hospitalization, he described severe depression, and no interest interacting with anyone other than his dogs. His wife described their relationship to be platonic; she finds him to be angry, irritable and demanding, and that he is often lost in tasks, cannot drive, and wanders off. The examiner stated that the Veteran exhibited symptoms of depressed mood, anxiety, suspiciousness, chronic sleep impairment, memory impairment, circumstantial speech, difficulty in understanding complex commands, impaired judgment, impaired abstract thinking, disturbances of motivation and mood, difficulty in establishing and maintaining effective work and social relationships difficulty in adapting to stressful circumstances, inability to establish and maintain effective relationships, and suicidal ideation. The VA examiner stated that the Veteran said his symptoms have worsened, and that both the Veteran and his wife reported he has been significantly impacted in the last year during which time his two service dogs and the Veteran’s father passed away. The Veteran submitted a March 2017 statement that indicated his PTSD symptoms had worsened; he reported an inability to maintain basic hygiene on a daily basis without the assistance of his wife, forgetting to brush his teeth, feeling too much anxiety to shower alone, and that he is forgetting the names of people he has known for years. The Veteran attended a VA examination in May 2019. The examiner opined that the Veteran’s PTSD resulted in occupational and social impairment with reduced reliability and productivity. The examiner noted that the Veteran has since been diagnosed with Alzheimer’s, and that his neurocognitive disorder accounts for modest cognitive decline from a previous level of functioning with some degree of demonstrated impairment in focus/attention/concentration and short-term/delayed memory. He found that the Veteran exhibited the following symptoms regarding his PTSD: depressed mood, anxiety, suspiciousness chronic sleep impairment, mild memory loss, impairment of short and long-term memory, disturbances of motivation and mood, difficulty in establishing and maintaining effective wok and social relationships, and difficulty in adapting to stressful circumstances. Within his rationale for his opinion, he further stated that the Veteran experienced distressing dreams of the events; flashbacks related to the events: physiological reactivity to exposure to cues of the events; intense or prolonged psychological distress at exposure to internal or external cues of the events; avoidance of thoughts and feelings about the events; avoidance of activities, places, or people that arouse recollections of the events; inability to remember important aspects of the events; persistent negative emotional state; decreased interest in activities that previously brought pleasure; feelings of detachment/estrangement; problems with sleep; irritability/outburst of anger; hypervigilance and exaggerated startle response; and decreased concentration. He stated that the severity of the Veteran’s current PTSD remains consistent/unchanged from the level previously evaluated. The Veteran continues to present with significant depression, anxiety, and anger within the context of his PTSD. The examiner stated that the Veteran did not demonstrate ideas of reference, delusions, and/or hallucinations. The Veteran’s thinking appeared logical, linear, and goal directed, his grooming and hygiene was adequate, and his insight and judgment appeared within normal limits. The Veteran submitted an October 2018 private medical opinion from his psychologist Dr. P.C. He stated that the Veteran’s is becoming increasingly forgetful, he becomes loose in thought process, has a weakened ability to sustain attention, his mood is despondent, and he lacks motivation. The Veteran has started to become disoriented, demonstrating cognitive slippage, has recently become more withdrawn and reserved, and has difficulty finishing up projects due to forgetfulness. He stated the Veteran becomes easily despondent and has episodes of crying. Dr. P.C. acknowledged the Veteran’s diagnosis of dementia. After a thorough review of the evidence, it appears that although the symptoms associated with the Veteran’s service-connected PTSD have fluctuated in severity to some degree, his symptoms of PTSD most closely parallel the type of symptoms described in the criteria for the 70 percent disability rating for the period beginning August 31, 2015. The medical and lay evidence of record is consistent with the findings in the August 2015 and May 2019 VA examinations, and as such, the Board finds these examinations to be the most probative medical evidence of record. A higher rating of 100 percent is not warranted as the Veteran does not have the type of symptoms that warrant this rating, nor the level of impairment required. The Veteran reported that he remains married to his wife of 57 years. He described the relationship as loving and supportive. He also reported having loving and supportive relationships with his children, he is noted to have linear thought, and intact insight and judgment. As such, the record does not show total occupational and social impairment due to PTSD, as required for the 100 percent schedular rating. The Board has considered the Veteran’s reported memory and difficulty in maintaining hygiene problems. However, the VA examiner attributed his neurocognitive symptoms to a non-service connected disorder and the Board finds the examiner’s statements sufficient to differentiate the symptoms due to his PTSD from those due to his non-service connected disorder. The preponderance of the evidence is against assigning a rating in excess of 70 percent. There is no reasonable doubt to be resolved as to this issue. 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102. 2. Lumbar Spine Disability The Veteran’s lumbar disability is rated as 20 percent disabling. 38 C.F.R. § 4.71a, DC 5242. Disabilities of the spine are rated under the under the General Rating Formula for Diseases and Injuries of the Spine (General Formula) found at 38 C.F.R. § 4.71a. Intervertebral disc syndrome can, alternately, be rated under the Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes” also found at § 4.71a. The General Formula specifies that the criteria and ratings apply with or without symptoms such as pain (whether or not it radiates) stiffness, or aching in the area affected by residuals of injury or disease. The General Formula provides that an evaluation of 10 percent rating is warranted for: Forward flexion of the thoracolumbar spine greater than 60 degrees but not greater than 85 degrees; or the combined range of motion of the thoracolumbar spine greater than 120 degrees but not greater than 235 degrees; or, muscle spasm, guarding, or localized tenderness not resulting in an abnormal gait or abnormal spinal contour, or, vertebral body fracture with loss of 50 percent or more of the height. 38 C.F.R. § 4.71a. A 20 percent rating is warranted for: Forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees; a 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. Id. A 40 percent rating is warranted for forward flexion of the thoracolumbar spine 30 degrees or less; or, favorable ankylosis of the entire thoracolumbar spine. Id. A 50 percent rating is warranted for unfavorable ankylosis of the entire thoracolumbar spine. Id. Ankylosis is defined, for VA compensation purposes, as a condition in which all or part of the spine is fixed in flexion or extension. Id. at Note (5). The General Formula directs raters that any associated objective neurologic abnormalities, including, but not limited to, bowel or bladder impairment, are to be evaluated separately, under an appropriate diagnostic code. Id. at Note (1). For VA compensation purposes, normal forward flexion of the thoracolumbar spine is zero to 90 degrees, extension is 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 for the cervical spine is 340 degrees, and the normal combined range of motion for the thoracolumbar spine is 240 degrees. Id. at Note (2). In determining the appropriate evaluation for musculoskeletal disabilities, particular attention is focused on functional loss of use of the affected part. Under 38 C.F.R. § 4.40, functional loss may be due to pain, supported by adequate pathology and evidenced by visible behavior on motion. Weakness is as important as limitation of motion, and a part that becomes painful on use must be regarded as seriously disabled. Under 38 C.F.R. § 4.45, factors of joint disability include increased or limited motion, weakness, fatigability, or painful movement, swelling, deformity or disuse atrophy. Under 38 C.F.R. § 4.59, painful motion is an important factor of joint disability and actually painful joints are entitled to at least the minimum compensable rating for the joint. This regulation also requires that, whenever possible, the joints involved are tested for pain on both active and passive motion, in weight-bearing and nonweight-bearing and, if possible, with the range of the opposite undamaged joint. See Correia v. McDonald, 28 Vet. App. 158, 168 (2016). Where functional loss is alleged due to pain upon motion, the provisions of 38 C.F.R. § 4.40 and § 4.45 must be considered. DeLuca v. Brown, 8 Vet. App. 202, 207-08 (1995). Within this context, a finding of functional loss due to pain must be supported by adequate pathology, and evidenced by the visible behavior of the claimant. Johnston v. Brown, 10 Vet. App. 80, 85 (1997). Pain itself does not rise to the level of functional loss as contemplated by § 4.40 and § 4.45, but may result in functional loss only if it limits the ability to perform the normal working movements of the body with normal excursion, strength, coordination or endurance. Mitchell v. Shinseki, 25 Vet. App. 32, 43 (2011). The Veteran attended a VA examination in September 2013. The VA examiner diagnosed the Veteran with lumbar degenerative disc disease and bilateral peripheral neuropathy. Range of motion testing showed forward flexion to 90 degrees, extension to 30 degrees, right and left lateral flexion to 10 degrees, right and left lateral rotation to 30 degrees, and no change after repetitive use testing. The Veteran denied flare-ups. The examiner found that the Veteran had functional loss and/or functional impairment of the back as caused by less movement than normal, weakened movement, and pain on movement. He had no localized tenderness or pain to palpitation of joints and/or soft tissue of the back. No IVDS. He had guarding or muscle spasm of the back that resulted in abnormal spinal contour, such as scoliosis, reversed lordosis, or abnormal kyphosis. He had no muscle atrophy, and he reported using a cane occasionally. The Veteran attended a VA examination in August 2015. Range of motion testing showed forward flexion to 80 degrees, extension to 10 degrees, right lateral flexion to 20 degrees, left lateral flexion to 25 degrees, right lateral rotation to 30 degrees or greater, and left lateral rotation to 30 degrees or greater. The examiner noted that the Veteran’s abnormal range of motion due to pain limited his ability to bend, twist, stoop, and life and carry heavy loads. Pain was noted on examination on forward flexion and extension. The Veteran reported flare-ups and described them as his back locking up with bending which lasts for about 30 minutes and he takes aspirin. When he experiences a flare-up, he stated that he has increased tenderness and limited movement, and that he cannot really bend, and he must walk slowly and usually sits in a chair. There was no evidence of localized tenderness or pain to palpitation for joints and/or soft tissue of the back. No change to range of motion after repetitive use testing. The examiner stated that pain significantly limited the Veteran’s functional ability with repeated use over time; specifically, that forward flexion ended at 75 degrees, extension to 5 degrees, right lateral flexion to 15 degrees, left lateral flexion to 20 degrees, and right and left lateral rotation to 25 degrees. The examination was not conducted during a flare-up, but the examiner provided the following findings regarding estimated limitation during a flare-up described by the Veteran: forward flexion to 75 degrees, extension to 5 degrees, right lateral flexion to 15 degrees, left lateral flexion to 20 degrees, right and left lateral rotation to 25 degrees. The examiner stated that the Veteran has no guarding or muscle spasms of the back, no ankylosis, and no IVDS. The Veteran did not report the use of any assistive devices. The Veteran attended a VA examination in April 2019. Range of motion testing showed forward flexion to 80 degrees, extension to 25 degrees, right and left lateral flexion to 30 degrees, and right and left lateral rotation to 30 degrees. The Veteran did not report flare-ups. No evidence of pain with weight bearing. No additional loss of function or range of motion after repetitive use testing. Pain, fatigue, and weakness were found to limit functional ability with repeated use over time, specifically limiting forward flexion to 65 degrees, extension to 25 degrees, right and left lateral flexion to 30 degrees, and right and left lateral rotation to 30 degrees. No guarding or muscle spasm, no ankylosis, and no IVDS. The Veteran reported using a cane occasionally. The examiner found that the Veteran’s lumbar disability is stable to somewhat improved. A rating in excess of 20 percent is not warranted because the evidence of record does not indicate that the Veteran had forward flexion of the thoracolumbar spine 30 degrees or less or favorable ankylosis of the entire thoracolumbar spine. The Board notes that although the Veteran did describe flare-ups at the September 2015 VA examination, and he stated that they caused him to be unable to bend, that this report was only made once during the entirety of the time on appeal, and that overall, the Veteran’s disability picture as a whole more closely approximates the rating criteria for a 20 percent disability rating. Further, consistent with the most recent examination in April 2019, the Veteran’s back disability appears to have improved. The Veteran’s VA and private treatment records do not indicate that the Veteran had a greater restriction of range of motion than found on the VA examinations. The Board acknowledges the Veteran’s contention that his service-connected lumbar disability warrants a higher evaluation. In determining the actual degree of disability, however, contemporaneous medical records and an objective examination by a health professional are more probative of the degree of the Veteran’s impairment. This is particularly so where the rating criteria require analysis of the clinically significant symptoms and objectively measurable criteria, like range of motion. See Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). The Board finds that the medical opinion of this Veteran, who lacks medical training, is not competent evidence of the clinical significance of his symptoms. Id. The Board finds that the Veteran’s level of disability most closely approximates the criteria for the 20 percent disability rating. As the preponderance of the evidence is again assigning a rating in excess of 20 percent, there is no reasonable doubt to be resolved. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. 3. Bilateral Lower Extremity Neuropathy The Veteran’s right and left lower extremity neuropathy are rated as 20 percent disabling. 38 C.F.R. § 4.124a, DC 8520. Under this DC, a 10 percent rating is warranted for mild incomplete paralysis. A 20 percent rating is warranted for moderate incomplete paralysis. A 40 percent rating is warranted for moderately severe incomplete paralysis. A 60 percent rating is warranted for severe incomplete paralysis with marked muscular atrophy. An 80 percent rating is warranted for complete paralysis. Words such as “mild,” “moderate,” “moderately severe,” and “severe” are not defined in the Rating 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. Use of terminology such as “severe” by VA examiners and others, although evidence to be considered by the Board, is not dispositive of an issue. All evidence must be evaluated in arriving at a decision regarding an increased rating. 38 C.F.R. §§ 4.2, 4.6. The Veteran attended a VA examination in September 2013. The examiner found that the Veteran had normal (5/5) muscle strength on all tests performed, no muscle atrophy, and bilateral knee and ankles exhibited hypoactive reflexes. The Veteran had decreased sensation in the right and left lower leg/ankle, and absent sensation in the right and left foot/toes. He had a negative right straight leg raising test, and positive left straight leg raising test. The Veteran was found to have severe numbness of both the right and left lower extremity. The examiner characterized the Veteran’s bilateral lower extremity radiculopathy to be moderate in severity. He stated that although the Veteran is unaware of the numbness in his legs and feet, it is present and is likely due to his lumbar disability. The Veteran attended a VA examination in September 2015. At this examination, the Veteran was noted to have no radicular pain or signs and symptoms of radiculopathy. The Veteran attended a VA examination in April 2019. The examiner found that the Veteran had severe numbness in his right and left lower extremity. He had normal (5/5) muscle strength on all tests performed, no muscle atrophy, and bilateral knee and ankles exhibited hypoactive reflexes. The Veteran had decreased sensation in the right and left foot/toes. He had no trophic changes, and a normal gait. He had negative right and left straight leg raising tests. The examiner characterized the Veteran’s bilateral paralysis of the sciatic nerve to be moderate incomplete paralysis. The examiner referenced a January 2016 lower extremity motor nerve conduction study was performed and it showed evidence of bilateral lower extremity axonal sensory peripheral neuropathy. The examiner stated that the Veteran’s current level of severity is overall stable and unchanged. Considering the Veteran’s reports and treatment records are consistent with the findings of the most recent VA examination detailed above, the Board finds that his right and left lower extremities are characterized by moderate incomplete paralysis of the sciatic nerve. A rating in excess of 20 percent is not warranted as the Veteran does not exhibit symptoms required for a higher rating. The Veteran’s bilateral lower extremity neuropathy most closely approximates the 20 percent criteria. There is no reasonable doubt to be resolved as to this issue. 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102. REASONS FOR REMAND 1. Entitlement to SMC based on the need for regular aid and attendance is remanded. SMC is payable if, as the result of service-connected disabilities, a veteran is so helpless as to be in need of regular aid and attendance of another person. 38 U.S.C. § 1114 (l); 38 C.F.R. § 3.350 (b). Under 38 C.F.R. § 3.352 (a), the following factors will be accorded consideration in determining whether a veteran is in need of regular aid and attendance of another person: (1) the inability of the veteran to dress or undress himself, or to keep himself ordinarily clean and presentable; (2) frequent need of adjustment of any special prosthetic or orthopedic appliances which by reason of the particular disability cannot be done without such aid; (3) inability of the veteran to feed himself because of the loss of coordination of upper extremities or because of extreme weakness; and (4) inability to attend to the wants of nature; or incapacity, physical or mental, which requires care or assistance on a regular basis to protect the veteran from the hazards or dangers incident to his daily environment. It is not required that all of the disabling conditions enumerated in 38 C.F.R. § 3.352 (a) be found to exist before a favorable rating may be made. The particular personal functions which a veteran is unable to perform should be considered in connection with his or her condition as a whole. It is only necessary that the evidence establish that a veteran is so helpless as to need regular aid and attendance, not that there is a constant need. Id. The claims file contains evidence that the Veteran may necessitate regular aid and attendance of another person. Particularly, the October 2018 treatment opinion of the Veteran’s private psychologist opining that he would benefit from aid and attendance, as well as the March 2017 affidavit wherein the Veteran states the he requires his wife’s help in order to maintain basic hygiene. Of importance, the Veteran has been diagnosed with Alzheimer’s and/or dementia, which is not service-connected. Upon examination, the opinion provided should pay attention to the effects of the Veteran’s service-connected disabilities as they pertain to his ability to care for himself, excluding the symptoms attributable to his newly diagnosed neurocognitive disorder, should the examiner be able to differentiate. Remand is necessary for the Veteran’s claim of entitlement to special monthly compensation for aid and attendance to obtain a medical opinion as to the Veteran’s ability to care for himself. The matters are REMANDED for the following action: 1. Ensure that the Veteran is scheduled for a VA examination to determine whether the Veteran requires aid and attendance as a result of his service-connected disabilities. The claims folder must be made available to and be reviewed by the examiner in conjunction with the examination. All tests deemed necessary should be conducted and the results reported in detail. Specifically, the examiner shall address the following factors: (a.) The inability of the veteran to dress or undress himself, or to keep himself ordinarily clean and presentable; (b.) Frequent need of adjustment of any special prosthetic or orthopedic appliances which by reason of the particular disability cannot be done without such aid; (c.) Inability of the veteran to feed himself because of the loss of coordination of upper extremities or because of extreme weakness; and (d.) Inability to attend to the wants of nature; or incapacity, physical or mental, which requires care or assistance on a regular basis to protect the veteran from the hazards or dangers incident to his daily environment. A thorough explanation must be provided for the opinions rendered. Of importance, the Veteran has been diagnosed with Alzheimer’s and/or dementia, which is not service-connected. Upon examination, the opinion provided should pay attention to the effects of the Veteran’s service-connected disabilities as they pertain to his ability to care for himself, excluding the symptoms attributable to his newly diagnosed neurocognitive disorder, should the examiner be able to differentiate. If the examiner cannot provide the requested opinions without resorting to speculation, s/he should expressly indicate this and provide supporting rationale as to why the opinions cannot be made without resorting to speculation. (Continued on the next page)   The examiner is advised that by law, the mere statement that the claims folder was reviewed and/or the examiner has expertise is not sufficient to find the examination/opinion sufficient. JAMES G. REINHART Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Katie Poe, Associate Counsel 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.