Citation Nr: 20021419 Decision Date: 03/25/20 Archive Date: 03/25/20 DOCKET NO. 11-00 295A DATE: March 25, 2020 ORDER Entitlement to a 20 percent rating for lumbar spine disability prior to December 13, 2019 is granted, subject to the laws and regulations governing the payment of monetary awards. Entitlement to a rating in excess of 20 percent from December 13, 2019 for a lumbar spine disability is denied. Entitlement to a compensable rating prior to December 13, 2019 for radiculopathy right lower extremity, and in excess of 20 percent from that date is denied. Entitlement to a compensable rating prior to December 13, 2019 for radiculopathy left lower extremity and in excess of 20 percent from that date is denied. REMANDED Entitlement to a rating in excess of 20 percent for peripheral neuropathy lower left extremity is remanded. Entitlement to a rating in excess of 10 percent prior to December 13, 2019 for peripheral neuropathy upper left extremity, and in excess of 20 percent from that date is remanded. Entitlement to a rating in excess of 10 percent prior to December 13, 2019 for peripheral neuropathy upper right extremity, and in excess of 30 percent from that date is remanded. Entitlement to a rating in excess of 20 percent for peripheral neuropathy right lower extremity is remanded. Entitlement to a total disability rating based on individual unemployability due to service-connected disabilities (TDIU) prior to December 13, 2019 is remanded. FINDINGS OF FACT 1. Prior to December 13, 2019, the Veteran’s lumbar spine disability was reasonably shown to be manifested by muscle spasms severe enough to result in an abnormal gait. 2. From December 13, 2019, the Veteran’s lumbar spine disability was not shown to have been manifested by forward flexion of the thoracolumbar spine limited to 30 degrees or less; ankylosis; or incapacitating episodes of intervertebral disc syndrome having a total duration of at least four weeks during a 12 month period. 3. Prior to December 13, 2019, the Veteran did not demonstrate subjective or objective symptoms of neurological impairment in the right lower extremity related to his service-connected low back strain. 4. From December 13, 2019, the Veteran’s right lower extremity radiculopathy was manifested by moderate incomplete paralysis. 5. Prior to December 13, 2019, the Veteran did not demonstrate subjective or objective symptoms of neurological impairment in the left lower extremity related to his service-connected low back strain. 6. From December 13, 2019, the Veteran’s left lower extremity radiculopathy was manifested by moderate incomplete paralysis. CONCLUSIONS OF LAW 1. The criteria for a 20 percent rating, but no higher for the Veteran’s lumbar spine disability prior to December 13, 2019 have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. § §§ 3.159, 3.321, 4.40, 4.71a Diagnostic Code (Code) 5243, 5237, 5242. 2. The criteria for a rating in excess of 20 percent rating, for the Veteran’s lumbar spine disability from December 13, 2019 have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. § §§ 3.159, 3.321, 4.40, 4.71a Diagnostic Code (Code) 5243. 3. Prior to December 13, 2019, the criteria for a compensable rating for a neurological disability of the right lower extremity have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. § §§ 3.159, 3.321, 4.124a Diagnostic Code 8515. 4. The criteria for a rating in excess of 20 percent for the Veteran’s service-connected right lower extremity radiculopathy from December 13, 2019 have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. § §§ 3.159, 3.321, 4.124a Diagnostic Code (Code) 8515. 5. Prior to December 13, 2019, the criteria for a compensable rating for a neurological disability of the left lower extremity have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. § §§ 3.159, 3.321, 4.124a Diagnostic Code 8515. 6. The criteria for a rating in excess of 20 percent for the Veteran’s service-connected left lower extremity radiculopathy from December 13, 2019 have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. § §§ 3.159, 3.321, 4.124a Diagnostic Code (Code) 8515. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from February 1962 to February 1982. In August 2017, the Veteran testified at a videoconference hearing before the undersigned Veterans Law Judge. A transcript of that hearing is of record. The appeal was most recently before the Board in May 2019 when it was remanded for further development. The Board finds there has been substantial compliance with the remand directives for the claims decided herein. Stegall v. West, 11 Vet. App. 268 (1998). An interim January 2020 rating decision increased the ratings for the following disabilities, each effective December 13, 2019 (the date of a VA examination): lumbar spine disability from 10 to 20 percent; peripheral neuropathy of the right upper extremity from 10 to 30 percent, and; peripheral neuropathy of the left upper extremity from 10 to 20 percent. The ratings are less than the maximum schedular ratings; the appeals are continued. AB v Brown, 6 Vet. App. 35 (1993). Additionally, the January 2020 rating decision granted service connection and assigned a separate 20 percent rating for right lower extremity radiculopathy and a separate 20 percent rating for left lower extremity radiculopathy, all effective December 13, 2019, the date of a VA examination. The ratings for those disabilities are part of the increased rating claim for the back and are before the Board. As a result of the January 2020 rating decision, the Veteran’s combined disability rating is 100 percent from December 13, 2019. Accordingly, the issue of TDIU is moot for the period from December 13, 2019. See Herlehy v. Principi, 15 Vet. App. 33 (2001). However, the TDIU claim remains pending prior to December 13, 2019. Increased Rating The Veteran seeks entitlement to higher ratings for his service-connected lumbar spine disability and related right and left lower extremity radiculopathies. Disability ratings are determined by comparing the Veteran’s symptoms with criteria listed in VA’s Schedule for Rating Disabilities, which is based, as far as practically can be determined, on average impairment in earning capacity. Separate Codes identify the various disabilities. 38 C.F.R. § Part 4. When rating a service-connected disability, the entire history must be borne in mind. Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Where there is a question as to which of two ratings shall be applied, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § § 4.7. Where entitlement to compensation has already been established and an increase in the disability rating is at issue, the present level of disability is of primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). Staged ratings are appropriate in any increased-rating claim in which distinct time periods with different ratable symptoms can be identified. Hart v. Mansfield, 21 Vet. App. 505 (2007). Lumbar Spine Disability The Veteran filed his claim for a higher rating in March 2008. His back disability is evaluated as 10 percent to December 13, 2019 and 20 percent from that date. The Board concludes that a 20 percent rating, but no higher, is warranted for the Veteran’s lumbar spine disability strain prior to December 13, 2019, and a rating in excess of 20 percent is not warranted from that date. Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). Disability of the musculoskeletal system is primarily the inability, due to damage or infection in the parts of the system, to perform the normal working movements of the body with normal excursion, strength, speed, coordination, and endurance. In evaluating disabilities of the musculoskeletal system, it is necessary to consider, along with the schedular criteria, functional loss due to flare-ups of pain, fatigability, incoordination, pain on movement, and weakness. DeLuca v. Brown, 8 Vet. App. 202 (1995). Weakness is as important as limitation of motion, and a part which becomes painful on use must be regarded as seriously disabled. 38 C.F.R. § 4.40. Pain on movement, swelling, deformity or atrophy of disuse as well as instability of station, disturbance of locomotion, interference with sitting, standing and weight bearing are relevant considerations for determination of joint disabilities. See 38 C.F.R. § 4.45. These determinations are, if feasible, be expressed in terms of the degree of additional loss-of-motion due to any weakened movement, excess fatigability, incoordination, flare-ups, or pain. Mitchell v. Shinseki, 25 Vet. App. 32 (2011). Disabilities of the spine are to be evaluated under the General Rating Formula for Diseases and Injuries of the Spine (outlined below). 38 C.F.R. § 4.71a, Diagnostic Codes 5235-5242. Intervertebral disc syndrome will be evaluated under the general formula for rating diseases and injuries of the spine or under the formula for rating intervertebral disc syndrome based on incapacitating episodes (outlined below), whichever method results in the higher evaluation when all disabilities are combined under 38 C.F.R. § 4.25. 38 C.F.R. § 4.71a, Codes 5235-5242. Any associated objective neurologic abnormalities, including, but not limited to, bowel or bladder impairment are to be evaluated separately under the appropriate diagnostic code(s). Id. at Note (1). Under the General Rating Formula for Diseases and Injuries of the Spine, with or without symptoms such as pain (whether or not it radiates), stiffness, or aching in the area of the spine affected by residuals of injury or disease, a 20 percent rating is warranted for forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees; or, the 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, for 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. 38 C.F.R. § 4.71a, Code 5235-5242. For VA compensation purposes, normal forward flexion of the thoracolumbar spine is zero to 90 degrees, normal extension is zero to 30 degrees, normal left and right lateral flexion is zero to 30 degrees, and normal left and right lateral rotation is zero to 30 degrees. 38 C.F.R. § 4.71a, Codes 5235-5242, Note (2). All measured ranges of motion are to be rounded to the nearest five degrees. 38 C.F.R. § 4.71a, Codes 5235-5242, Note (4). Under the Formula for Rating Intervertebral Disc Syndrome (IVDS) Based on Incapacitating Episodes. An “incapacitating episode” is defined as “a period of acute signs and symptoms due to intervertebral disc syndrome that requires bed rest prescribed by a physician and treatment by a physician.” 38 C.F.R. § 4.71a, Code 5243, Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes, Note (1). In a February 2008 private chiropractic treatment note, the Veteran reported low back pain beginning two weeks earlier “after flexing over and twisting while installing a television bracket in his R.V.” He reported having a localized sharp and stabbing pain to the lumbosacral joint with an increasing degree of severity over his right sacroiliac joint. He rated the pain as 7 out of 10. He denied any radiation down into his lower extremities. On range of motion flexion was to 30 degrees on active motion and 35 degrees on passive motion, with pain; extension was to 25 degrees on both active and passive motion, with no pain; left lateral flexion was to 20 degrees on active motion and 25 degrees on passive motion, with pain; right lateral flexion was to 20 degrees on active motion and 25 degrees on passive motion, with pain; left rotation was to 10 degrees on both active and passive motion, with pain; and right rotation was to 10 degrees on both active and passive motion, with pain. Manual muscle strength testing was normal bilaterally for hip flexors, hip extensors, knee extensors, knee flexors, extensor hallucis, ankle flexors, and ankle extensor. The provider noted had hypoesthesia bilaterally of the L4, L5, and S1 vertebrae, but it was associated with the Veteran’s diabetic neuropathy. The provider noted the Veteran reported a significant decrease in subjective symptoms and pain-free active range of motion after treatment. On June 2008 VA examination, the examiner noted he did not review the Veteran’s claims file, but reviewed his medical records. The Veteran reported that his lower back pain had continually worsened since service, more exponentially over the past three to four years. He reported his pain was in the midline as well as in the left buttocks, but no radiating pains. He also reported stiffness and flare-ups. His flare-ups occur once a week, last for one to three hours, and consist of severe pain. Flare-ups are precipitated by activity and are spontaneous, alleviating factors are rest. He reported intermittent numbness and weakness in the distal aspects of his legs that usually accompanies flare-ups. He also reported difficulty sleeping secondary to his back pain and that prolonged sitting hurts his lower back. He denied any weight loss, falls, unsteady gait, fevers, chills, dizziness, visual disturbances, erectile dysfunction, bowel or bladder complaints secondary to his spine condition. The Veteran reported he could stand for approximately 15 minutes and could walk for a few blocks before he had to rest. On physical examination, the Veteran had tenderness and spasm in his lower back paraspinal muscles; there was no evidence of weakness, but he had a left sided limp while he walked. The examiner noted he did not have ankylosis. The examiner noted the Veteran used a cane. On range of motion testing, forward flexion was 0 to 75 degrees; extension was 0 to 10 degrees; right and left lateral flexion and right and left rotation were 0 to 20 degrees. The Veteran reported pain on all movement. He was able to perform repetitive testing with no change in range of motion or location, intensity, or nature of the pain on movement. He had no limitation due to fatigue, weakness, or incoordination. The examiner noted that the Veteran was not having a flare-up during the examination and opined that it would only be speculation to report limitation during the flare. The examiner noted he did not have any incapacitating episodes that required bedrest in the previous 12 months. Muscle strength and reflexes were normal. The examiner noted his numbness was consistent with his history of diabetic neuropathy. The examiner opined that while his occupational duties were not significantly limited as he was more in the administrative aspect of his business, his activities of daily living were limited by his back disability as it was more difficult for him to perform outdoor activities, chores, yard work, lifting or shopping. In his October 2008 notice of disagreement, the Veteran requested a 20 percent rating for his low back strain because the June 2008 VA examiner noted he had a left sided limp, which corresponded to an abnormal gait under the rating criteria. In an April 2009 VA treatment note, the Veteran reported back pain that had been getting worse. He reported that he could not do yard work anymore and could not stand on his back for too long because he had to rest his elbows to break the pressure on his back. He also reported that his feet were still numb and burn and his private endocrinologist changed his medication. On review of systems, the provider noted the Veteran had back pain, an unstable gait or balance with a cane, and no numbness or tingling. In a May 2010 VA treatment note, the provider noted that the Veteran’s low back pain was poorly controlled by the Veteran and it was aggravated by bending and increased stiffness, with difficulty standing and holding his arms out without propping himself up. In a December 2010 statement, the Veteran reported his low back strain was so severe that he could not stand for long periods of time and he could not stand with his hands out in front of him. He described the pain as so severed he had to rest his elbows on his counter or sit down. He also reported he was taking medication for pain. In a May 2011 VA treatment note, the Veteran reported chronic low back pain, mild to severe and his mediation was not helping. He was provided a trial of new medication and encouraged to use a back brace. At the August 2017 videoconference hearing, the Veteran testified that his range of motion in his back was very limited. He testified that he believed he could bend down to his knees, but it would be painful. He testified that when cooking and washing dishes he could only hold his hands out in front of him for a couple of minutes before he needed to be down on the counter bracing his back. He also testified that he had to stop the car on the way to his hearing three times to get out and walk around. He testified that sometimes his back spasmed, but he took daily medication for spasms and pain. He also testified that he did not have any pain radiating to his legs, but he had cramps which woke him up at night. On June 2018 VA examination, the Veteran reported back pain, which he described as a constant aching sensation, rated as 2 out of 10. He reported that he was limited to walking less than 300 feet, standing no more than 3 to 5 minutes, sitting still for less than t5 minutes, bending the back, twisting his back, pushing, pulling, climbing up and down stairs, and lifting less than 8 to 10 pounds only when he squats to lift. He also reported having pain while sitting, but he had to get up to move around the relieve the pain. He used a cane constantly, due to his neuropathy symptoms. The examiner noted that they were unable to test range of motion because the Veteran declined testing due to the severity of pain. The Veteran reported pain on all range of motion. The examiner noted the Veteran did not have guarding or muscle spasm of the spine, but had disturbance of locomotion. Muscle strength testing was normal bilaterally. Reflex testing was normal bilaterally for his knees and hypoactive for his ankles bilaterally. He also had decreased sensation for his right and left foot/toes. Straight leg testing was negative and the examiner noted he did not have radiculopathy. The examiner also noted he did not have ankylosis or IVDS. The Veteran constantly used a cane for the symptoms of neuropathy to help him keep stable during walking or standing. On December 2019 VA examination, lumbosacral strain and IVDS were diagnosed. The Veteran reported functional impairment as he was unable to bend over to pick up things, unable to lift 10-15 pounds, unable to sit, stand for more than 15 minutes at a time. The Veteran reported having flare-ups which occur often, are severe, lasts for an unknown amount of time, precipitated by unknown events, and alleviated by time and medication. On range of motion, forward flexion was to 75 degrees, extension was to 10 degrees, right lateral flexion was to 15 degrees, left lateral flexion was to 15 degrees, right lateral rotation was to 25 degrees, and left lateral rotation was to 25 degrees. The Veteran had pain on all range of motion, but it did not result in functional loss. There was evidence of localized pain, localised to muscular paravertebral tenderness to palpitation, moderate in severity. The Veteran was able to perform repetitive use testing with at least three repetition, but pain and weakness resulted in functional loss. On repeated use testing forward flexion was to 65 degrees, extension was to 0 degrees, right lateral flexion was to 5 degrees, left lateral flexion was to 5 degrees, right lateral rotation was to 15 degrees, and left lateral rotation was to 15 degrees. The examiner noted the examination was not being conducted during a flare-up but the examination was medically consistent with his statement describing functional loss during a flare-up. The examiner also found the Veteran had muscle spasms which resulted in an abnormal gait. The Veteran did not have muscle atrophy or ankylosis. Muscle strength, reflexes, and sensory testing were normal bilaterally. The Veteran had IVDS, but he did not have any episodes that required bed rest by a physician. The examiner noted the Veteran regularly used a cane to help him walk. The examiner opined that the back disability impacted his ability to work as he could not sit or stand for greater than 10 to 15 minutes and he has to get up for repeated breaks due to unbearable pain, and his numbness and pain made his gait slow and unsteady and made him a fall risk. In a January 2020 rating decision, the rating of the Veteran’s lumbar spine disability from 10 percent to 20 percent, effective December 13, 2019, the date of the VA examination. The Veteran’s VA treatment records throughout the period on appeal note that he had an abnormal gait. The Board concludes that a 20 percent rating, but no higher, is warranted prior to December 13, 2019, but a rating in excess of 20 percent is not warranted at any point during the period on appeal. For the period prior to December 13, 2019, the Board finds that a 20 percent rating is warranted because the evidence reflects that he had muscle spasms which resulted in an abnormal gait throughout the period on appeal. The Veteran’s VA treatment records reflected he had an abnormal gait and the Veteran reported throughout the period that his back disability manifested in muscle spasms. See August 2017 videoconference testimony. The June 2008 VA examiner also noted he had muscle spasms and had a left sided limp when he walks. Accordingly, in providing the Veteran with the benefit of the doubt, the Board finds that throughout the entire period on appeal his back disability manifested in muscle spasms which resulted in an abnormal gait, and the 20 percent criteria has been met under the General Formula. See Code 5235-5243. A rating higher than 20 percent is not warranted at any point during the period on appeal. The record does not reflect that at any point during the period on appeal that his service-connected back disability was manifested by forward flexion limited to 30 degrees or ankylosis. A February 2008 private chiropractic treatment showed forward flexion was limited to 30 degrees on active motion with pain, the provider noted the Veteran was seen for an intercurrent back injury from putting up a television bracket and similar range of motion was not demonstrated in other medical evidence of record. The record reflects that during the period on appeal, and with consideration of pain and after repetitive use testing, the Veteran’s service-connected lumbar spine disability manifested in forward flexion was limited to at most 65 degrees. June 2008, June 2018, and December 2019 VA examiners also each found no evidence of ankylosis. Additionally, while the December 2019 VA examiner indicated the Veteran had IVDS, there is no evidence in the record that during the period on appeal of bed rest prescribed by a physician having a total of at least 6 weeks duration during a 12 month period to warrant assigning a higher 40 percent rating alternatively under Code 5243 for IVDS. Radiculopathy of the Right and Left Lower Extremity The Veteran’s right and left lower extremity radiculopathy are rated as 20 percent disabling under 38 C.F.R. § 4.124a Code 8526 from December 13, 2019. As the radiculopathy is a manifestation of the Veteran’s service-connected back disability, the Board must consider the claim rating for the right and left lower extremities for the entire appeal period, which includes whether a compensable rating is warranted before December 2019. The Board concludes that separate compensable ratings are not warranted prior to December 13, 2019 and a rating in excess of 20 percent is not warranted from that date for the either right or left lower extremity radiculopathy. Code 8526 provides for ratings for paralysis of the anterior crural nerve (femoral). Under Code 8526, complete paralysis of the nerve (paralysis of quadriceps extensor muscles) is rated as 40 percent. Disability ratings of 30 percent, 20 percent, and 10 percent are assignable for incomplete paralysis which is moderately-severe, moderate, or mild in degree. 38 C.F.R. § 4.124a, Code 8526. The term “incomplete paralysis” with 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 involvement is wholly sensory, the rating should be for mild, or at most, moderate degree. Note preceding Code 8510. 38 C.F.R. § 4.124a. In a February 2008 private treatment note, the Veteran denied having any pain radiating down into his lower extremities. The provider noted hypoesthesia bilateral of the L4, L4, and S1 vertebrae, but attributed it to his diabetic neuropathy in his bilateral lower extremities. On June 2008 VA examination, the Veteran reported low back pain, but no radiating pain. The examiner noted he had bilateral glove and sock distribution numbness, but it was consistent with his history of diabetic neuropathy. At the August 2017 videoconference hearing, the Veteran testified that he did not have pain radiating down his legs from his back, but he did have cramping down his legs. On June 2018 VA examination, the examiner noted that the Veteran had diabetic neuropathy affecting both hands and feet with constant numbness with intermittent tingling and constant burning pain in both feet and hands. The examiner found that the Veteran did not have radicular pain or any signs of symptoms due to radiculopathy. On December 2019 VA examination, radiculopathy was diagnosed as related to his service-connected back disability. His radiculopathy manifested in severe intermittent pain (usually dull), moderate paresthesias; and moderate numbness in his bilateral lower extremities. The examiner opined that his bilateral lower extremity radiculopathy were moderate in severity. Muscle strength, reflexes, and sensory examination were all normal bilaterally. Based on a review of the record, the Board concludes that compensable ratings prior to December 13. 2019 and in excess of 20 percent from that date for the Veteran’s right and left lower extremity radiculopathies are not warranted. For the period prior to December 13, 2019, compensable ratings are not warranted as the record does not reflect that the Veteran had a neurological impairment of his right or left lower extremity related to his back disability. During this period, while the Veteran had neurological impairment of is lower extremities, such impairment was related to his service-connected diabetes, and is separately service-connected as neuropathy. The Veteran did not report any pain radiating to either of his lower extremities from his back prior to the December 2019 VA examination. Specifically, at the August 2017 VA examination, he testified that he did not have any pain radiating to his legs. Additionally, the June 2018 VA examiner specifically noted had no radiculopathy. For the period from December 13, 2019, ratings higher than 20 percent are not warranted. Throughout this period, the Veteran’s symptoms affecting his right and left lower extremities were severe intermittent pain, moderate paresthesias, and moderate numbness. The December 2019 VA examiner characterized these symptoms as moderate in severity. Additionally, the VA examiner noted muscle strength, reflexes, and sensory examinations were normal. Thus, the Board finds that the criteria for a higher 40 percent rating for severe incomplete paralysis are not more closely approximated for the period from December 13, 2019. In deciding the claims, the Board has also considered the Veteran’s lay statements that his back and right and left lower extremity radiculopathy symptoms were worse than currently evaluated. He is competent to report symptoms because this requires only personal knowledge as it comes to him through his senses. Layno v. Brown, 6 Vet. App. 465 (1994). He is not, however, competent to identify a specific level of disability of this disorder according to the appropriate diagnostic codes. Such competent evidence concerning the nature and extent of the Veteran’s disabilities has been provided by the medical personnel who have examined him during the current appeal and who have rendered pertinent opinions in conjunction with the evaluations. The medical findings (as provided in the examination reports and the clinical records) directly address the criteria under which his disabilities are evaluated. As such, the Board finds these records to be more probative than the Veteran’s subjective complaints of increased symptomatology. The Board has considered the doctrine of reasonable doubt but has determined that it is inapplicable, other than to the extent of allowing an increase in the rating from 10 to 20 percent for his lumbar spine disability prior to December 13, 2019, because otherwise the preponderance of the evidence is against higher ratings. 38 U.S.C. § 5107 (b); 38 C.F.R. §§ 4.3, 4.7, 4.71a, 4.124a. REASONS FOR REMAND Entitlement to a rating in excess of 20 percent for peripheral neuropathy lower left extremity is remanded. Entitlement to a rating in excess of 10 percent prior to December 13, 2019 for peripheral neuropathy upper left extremity, and in excess of 20 percent from that date is remanded. Entitlement to a rating in excess of 10 percent prior to December 13, 2019 for peripheral neuropathy upper right extremity, and in excess of 30 percent from that date is remanded. Entitlement to a rating in excess of 20 percent for peripheral neuropathy right lower extremity is remanded. Unfortunately, there has not been substantial compliance with the Board’s previous remand directives regarding the issues of higher ratings for peripheral neuropathy of the Veteran’s right and left upper and lower extremities. In the May 2019 remand, the Board requested a new examination to determine the severity of the peripheral neuropathy of all of his extremities. On remand, the December 2019 VA peripheral nerve examination only addressed the newly diagnosed radiculopathy and not his service-connected peripheral neuropathy. Another remand is required. Stegall v. West, 11 Vet. App. 268, 271 (1998). Entitlement to TDIU prior to December 13, 2019 is remanded. Because a decision on the remanded issues could significantly impact a decision on entitlement to TDIU, the issues are inextricably intertwined. A remand of the claim of entitlement to TDIU is required. Additionally, updated treatment records should be obtained. See 38 C.F.R. § 3.159. See also Bell v. Derwinski, 2 Vet. App. 611 (1992). The matters are REMANDED for the following action: 1. Obtain the names and addresses of all medical care providers who treated the Veteran for any diabetic neuropathy complaints since January 2020. After securing the necessary releases, take all appropriate action to obtain these records and any updated VA treatment records since January 2020. 2. After a completion of the above, schedule the Veteran for an examination by an appropriate clinician to determine the current severity of his service-connected peripheral neuropathy of ALL four extremities. The examiner should provide a full description of the disability and report all signs and symptoms necessary for evaluating the Veteran’s disability under the rating criteria. The examiner must attempt to elicit information regarding the severity, frequency, and duration of any flare-ups. To the extent possible, the examiner should identify any symptoms due to his peripheral neuropathy alone and discuss the effect of the Veteran’s peripheral neuropathy on any occupational functioning and activities of daily living. If it is not possible to provide a specific measurement, or an opinion regarding flare-ups or symptoms without speculation, the examiner must state whether the need to speculate is due to a deficiency in the state of general medical knowledge (no one could respond given medical science and the known facts), a deficiency in the record (additional facts are required), or the examiner (does not have the knowledge or training). The examiner must specifically address the severity of the peripheral neuropathy in the Veteran’s right and left upper extremities and right and left lower extremities. The examiner must provide a complete rationale for any opinion expressed. If the examiner cannot provide an opinion without resort to speculation, the examiner should provide an explanation as to why this is so and note what, if any, additional evidence would permit such an opinion to be made. 3. After the above development, and any additionally indicated development, has been completed, readjudicate the issues on appeal, including the inextricably intertwined issue of entitlement to TDIU. M.E. Larkin Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Eric Struening 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.