Citation Nr: 20041663 Decision Date: 06/18/20 Archive Date: 06/18/20 DOCKET NO. 16-11 988 DATE: June 18, 2020 ORDER Service connection for arthritis (other than in the cervical or lumbar spine), to include as secondary to the service-connected cervical or lumbar spine arthritis, is denied. Prior to November 29, 2018, entitlement to a disability rating in excess of 10 percent for lumbar spine degenerative disc disease (DDD) is denied. From November 29, 2018, entitlement to a disability rating in excess of 20 percent for lumbar spine DDD is denied. An initial rating in excess of 20 percent for left lower extremity radiculopathy is denied. REMANDED Service connection for diabetes mellitus type II, to include as secondary to hepatitis C, and service-connected chronic kidney disease or hypertension, is remanded. Service connection for hepatitis C, to include as secondary to diabetes mellitus type II, and service-connected chronic kidney disease or hypertension is remanded. FINDINGS OF FACT 1. A preponderance of the evidence is against a finding that the Veteran’s arthritis was caused or aggravated by his service-connected cervical and lumbar arthritis. 2. Prior to November 29, 2018, the Veteran’s lumbar spine DDD was characterized by forward flexion greater than 60 degrees but not greater than 85 degrees. It was not characterized by muscle spasm or guarding severe enough to result in an abnormal gait or spinal contour. Additionally, the Veteran was not diagnosed with ankylosis or incapacitating episodes having a total duration of at least two weeks but less than four weeks during the past twelve months. 3. From November 29, 2018, the Veteran’s lumbar spine DDD was characterized by the combined range of motion of the thoracolumbar spine not greater than 120 degrees. Additionally, the Veteran was not diagnosed with ankylosis or incapacitating episodes having a total duration of at least four weeks but less than six weeks during the past twelve months. 4. The Veteran’s left lower extremity radiculopathy was characterized as moderate but not as moderately severe. CONCLUSIONS OF LAW 1. The criteria are not met for service connection for arthritis. 38 U.S.C. §§ 1101, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.310. 2. Prior to November 29, 2018, the criteria are not met for a disability rating in excess of 10 percent for lumbar spine DDD. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code (DC) 5242. 3. From November 29, 2018, the criteria are not met for a disability rating in excess of 20 percent for a back disability. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.40, 4.45, 4.59, 4.71a, DC 5242. 4. The criteria are not met for an initial disability rating in excess of 20 percent for left lower extremity radiculopathy. 38 U.S.C. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.124a, DC 8520. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from June 1977 to September 1977. These matters come before the Board of Veterans’ Appeals (Board) on appeal from a February 2014 rating decision by the Department of Veteran Affairs (VA) Regional Office (RO). This case was previously before the Board in October November 2017 and December 2019. At those times, the Board remanded the case for additional development. For the reasons discussed below, another remand is required for the issues of service connection for diabetes mellitus type II and hepatitis C. See Stegall v. West, 11. Vet. App. 268 (1998). Additionally, in an April 2020 rating decision, the Veteran’s service-connected lumbar spine DDD was increased from 10 percent to 20 percent, effective November 29, 2018, and he was granted an initial 20 percent rating for his left lower extremity radiculopathy. As this does not constitute full grants, these issues remain on appeal. AB v. Brown, 6 Vet. App. 35, 39 (1993). Service Connection Legal Criteria Under 38 C.F.R. §§ 3.310(a), service connection may be established on a secondary basis for a disability which is proximately due to or the result of service-connected disease or injury. 38 C.F.R. § § 3.310(a). Establishing service connection on a secondary basis requires evidence sufficient to show (1) that a current disability exists and (2) that the current disability was either (a) proximately caused by or (b) proximately aggravated by a service-connected disability. See Allen v. Brown, 7 Vet. App. 439, 448 (1995) (en banc). Service connection for arthritis, to include as secondary to the service-connected cervical or lumbar spine arthritis, is denied. Factual Background The Veteran contends that arthritis, specifically his right shoulder arthritis, was caused or aggravated by his service-connected cervical spine or lumbar spine arthritis. The Veteran’s service treatment records (STRs) are silent for any symptoms, complaints, treatment, or diagnoses of arthritis, other than his already service-connected cervical and lumbar arthritis. In a March 2020 VA examination report, the Veteran was diagnosed with right shoulder arthritis. The Veteran stated that he was first diagnosed with this condition in either 2013 or 2014. He noted that his right shoulder swelled and was painful. The Veteran reported that the condition was aggravated by lying a certain way and with heavy lifting, which led to pain. He stated that his right arm “goes to sleep” frequently. The Veteran noted that he lost function of the right arm when this happened. X-rays taken of the Veteran’s right shoulder in July 2013 gave the impression of moderate acromioclavicular osteoarthritis and mild to moderate glenohumeral osteoarthritis. The VA examiner opined that it was less likely than not that the Veteran’s right shoulder osteoarthritis was caused by either his service-connected cervical spine arthritis or lumbar spine arthritis. The examiner also opined that it was less likely than not that the Veteran’s right shoulder osteoarthritis was aggravated by his service-connected cervical spine arthritis or lumbar spine arthritis such that resultant functional impairment is worse. The rationale for these opinions was that there was no study to suggest that one case of arthritis could lead to or aggravate another joint, in this case, the spine and the shoulder. The examiner noted that the most likely cause for the Veteran’s right shoulder arthritis was the normal aging process and/or post-service overuse or injury. Analysis The Board has not overlooked the Veteran’s statements about his right shoulder arthritis. While the Veteran is competent to observe his right shoulder arthritis symptoms, he does not have the training or credentials to provide a competent opinion as to the cause of his shoulder arthritis or whether it was caused or aggravated by his already service-connected cervical and lumbar spine arthritis. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). The Board finds that the March 2020 VA examination report, finding no connection between the Veteran’s right shoulder arthritis and his cervical and lumbar spine arthritis to be the most probative evidence of record, as the examiner reviewed the claims file and provided a detailed rationale. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008); Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007). The Veteran has not submitted any specific evidence to support his claim, and there is nothing in his claims file to support his claim for service connection for right shoulder arthritis. We do not that subsequent manifestations of the same disease process may be service connected unless clearly due to intercurrent cause. 38 C.F.R. § 3.303. Here, the medical opinion explains that the Veteran’s right shoulder arthritis is not due to his neck or back arthritis but rather to aging. Adequate explanation was provided. Therefore, the Board finds clear intercurrent cause. Service connection for the right shoulder arthritis, as part of the already service connected arthritic process in the neck and back, is not warranted in this instance. Because of this, the preponderance of the evidence is against the claim. The benefit-of-the-doubt rule does not apply, and this service connection claim must be denied. See 38 U.S.C. § 5107; 38 C.F.R. § 3.102. Increased Ratings Disability ratings are determined by applying the criteria set forth in VA’s Schedule for Rating Disabilities. Ratings are based on the average impairment of earning capacity. Individual disabilities are assigned separate diagnostic codes. See 38 U.S.C. § 1155; 38 C.F.R. § 4.1. Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating; otherwise, the lower rating will be assigned. See 38 C.F.R. § 4.7. Staged ratings are, however, appropriate for an increased rating claim when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. 1. Prior to November 29, 2018, entitlement to a disability rating in excess of 10 percent for lumbar spine DDD is denied. 2. From November 29, 2018, entitlement to a disability rating in excess of 20 percent for lumbar spine DDD is denied. As there is considerable overlap in the applicable evidence for the Veteran’s claims, the Board will discuss them together. Legal Criteria Under DCs 5235 to 5243, the minimum compensable 10 percent rating is warranted for forward flexion of the thoracolumbar spine greater than 60 degrees but not greater than 85 degrees; or, forward flexion of the cervical spine greater than 30 degrees but not greater than 40 degrees; or, combined range of motion of the thoracolumbar spine greater than 120 degrees but not greater than 235 degrees; or, combined range of motion of the cervical spine greater than 170 degrees but not greater than 335 degrees; or, muscle spasm, guarding, or localized tenderness not resulting in abnormal gait or abnormal spinal contour; or, vertebral body fracture with loss of 50 percent of more of height. 38 C.F.R. § 4.71a, DCs 5235 to 5243. A 20 percent rating is warranted for forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees; or, forward flexion of the cervical spine greater than 15 degrees but not greater than 30 degrees; or, the combined range of motion of the thoracolumbar spine not greater than 120 degrees; or, the combined range of motion of the cervical spine not greater than 170 degrees; or, muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. Id. A 30 percent rating is warranted for forward flexion of the cervical spine 15 degrees or less; or favorable ankylosis of the entire cervical spine. Id. A 40 percent rating is warranted for unfavorable ankylosis of the entire cervical spine; or, 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. The maximum 100 percent rating is warranted for unfavorable ankylosis of the entire spine. These ratings are assigned for the above criteria 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. Id. For VA compensation purposes, “unfavorable ankylosis” is a condition in which the entire cervical spine, the entire thoracolumbar spine, or the entire spine is fixed in flexion or extension, and the ankylosis results in one or more of the following: difficulty walking because of a limited line of vision; restricted opening of the mouth and chewing; breathing limited to diaphragmatic respiration; gastrointestinal symptoms due to pressure of the costal margin on the abdomen; dyspnea or dysphagia; atlantoaxial or cervical subluxation or dislocation; or neurologic symptoms due to nerve root stretching. Fixation of a spinal segment in neutral position (zero degrees) always represents favorable ankylosis. Id. Under DC 5243, intervertebral disc syndrome (IVDS) may be rated under either the General Formula or under the Formula for Rating IVDS Based on Incapacitating Episodes. Under the Formula for Rating IVDS, incapacitating episodes having a total duration of at least one week but less than 2 weeks during the past 12 months warrant a rating of 10 percent. Incapacitating episodes having a total duration of at least 2 weeks but less than 4 weeks during the past 12 months warrant a rating of 20 percent. Incapacitating episodes having a total duration of at least 4 weeks but less than 6 weeks during the past 12 months warrant a rating of 30 percent. Incapacitating episodes having a total duration of at least 6 weeks during the past 12 months warrant a rating of 60 percent. Id. For purposes of evaluating under DC 5243, an “incapacitating episode” is 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. If IVDS is present in more than one spinal segment, provided that the effects in each spinal segment are clearly distinct, evaluate each segment on the basis of incapacitating episodes or under the General Rating Formula for Diseases and Injuries of the Spine, whichever method results in a higher evaluation for that segment. Id. Concerning disabilities affecting the spine, any associated objective neurologic abnormalities are evaluated separately under an appropriate Diagnostic Code. 38 C.F.R. § 4.71a, General Formula, Note 1. The Board notes that the Veteran is service connected for his left lower extremity. This disability will be discussed in its own section below. Consideration of a higher rating for functional loss, to include during flare-ups, due to the factors listed above is warranted for Diagnostic Codes predicated on limitation of motion. 38 C.F.R. §§ 4.40, 4.45, 4.59; DeLuca v. Brown, 8 Vet. App. 202 (1995). Such factors include more or less movement than normal, weakened movement, excess fatigability, incoordination, pain on movement, swelling, and deformity or atrophy of disuse. 38 C.F.R. § 4.45. Pain itself does not constitute functional loss, and painful motion does not constitute limited motion for the purposes of rating under DCs pertaining to limitation of motion. Mitchell v. Shinseki, 25 Vet. App. 32 (2011). Pain indeed must affect the ability to perform normal working movements with normal excursion, strength, speed, coordination, or endurance in order to constitute functional loss. Id. Facts and Analysis The Veteran contends that his lumbar spine DDD is more severe than the 10 percent rating prior to November 29, 2018 and in excess of 20 percent after. The Veteran’s back disability is rated under DC 5242. 38 C.F.R. § 4.71a, DC 5242, General Rating Formula for Diseases and Injuries of the Spine. Prior to November 29, 2018 The Veteran contends that his back disability is more severe than the 10 percent rating prior to November 29, 2018. The Veteran’s back disability is rated 10 percent under DC 5242. 38 C.F.R. § 4.71a, DC 5242, General Rating Formula for Diseases and Injuries of the Spine. In a November 2013 VA examination report, the Veteran was diagnosed with degenerative disc disease/degenerative joint disease lumbar spine. The Veteran stated that he had daily pain because of his back. He reported no flare-ups which impacted the function of his thoracolumbar spine. Range of motion was forward flexion to 80 degrees, with objective evidence of painful motion beginning at 80 degrees. Extension was to 20 degrees, with objective evidence of painful motion beginning at 20 degrees. Right and left lateral flexion was to 25 degrees, with objective evidence of painful motion beginning at 25 degrees. Right and left lateral rotation was to 30 degrees, with objective evidence of painful motion beginning at 30 degrees. The Veteran was able to perform repetitive-use testing with three repetitions. After testing, there was no additional limitation in range of motion. The Veteran had functional loss and/or functional impairment of his thoracolumbar spine that consisted of less movement than normal and pain on movement. He had no localized tenderness or pain to palpation for joints and/or soft tissue, no guarding or muscle spasm, and no muscle atrophy. The Veteran had no other neurologic abnormalities or findings related to his thoracolumbar spine. The Veteran was diagnosed with intervertebral disc syndrome (IVDS) but had no incapacitating episodes over the past 12 months due to IVDS. He was not diagnosed with ankylosis and used no assistive devices. There were no other pertinent physical findings, complications, conditions, signs, or symptoms. Imaging studies were performed, and arthritis was documented. The Veteran did not have a vertebral fracture. There were no other significant diagnostic test findings and/or results. The Veteran’s thoracolumbar spine condition would impact his ability to work in that he had increased pain with heavy lifting and repetitive bending at the waist. Analysis The probative medical evidence indicates that prior to November 29, 2018, a disability rating in excess of 10 percent for lumbar spine DDD is not warranted. 38 C.F.R. § 4.71a, DC 5242. In the November 2013 VA examination report, the Veteran had flexion to 80 degrees. There is no competent and credible evidence at any point prior to November 29, 2018 that characterized the Veteran’s back symptoms as having flexion greater than 30 degrees but not greater than 60 degrees, 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. Rather, overall, the Veteran’s disability has more nearly approximated flexion of the thoracolumbar spine greater than 60 degrees but not greater than 85 degrees, and the corresponding symptoms reflect this degree of severity. Id. From November 29, 2018 In a November 2018 VA examination report, the Veteran was diagnosed with IVDS and lumbar disc disease. The examiner noted that the Veteran had a longstanding history of low back pain which he attributed to a “ruckus” in the barracks while in service. The Veteran complained of chronic pain. The Veteran reported no flare-ups of his thoracolumbar spine. He also reported no functional loss or functional impairment. Range of motion was abnormal or outside of the normal range. Forward flexion was to 70 degrees, extension was to 0 (zero) degrees, Right and left lateral flexion were to 10 degrees, and right and left lateral rotation were to 15 degrees. Range of motion itself contributed to functional loss, in that it limited motion with pain. The examiner noted pain on examination that caused functional loss. The Veteran exhibited pain during forward flexion, extension, right and left lateral flexion, and right and left lateral rotation. During the examination, there was no evidence of pain with weight bearing and no objective evidence of localized tenderness or pain on palpation of the joints or associated soft tissue. The Veteran was examined immediately after repetitive use over time and pain, weakness, fatigability, or incoordination did not significantly limit functional ability with repeated use over a period of time. The Veteran was able to perform repetitive-use testing and there was no additional loss of function or range of motion after three repetitions. The Veteran had no guarding or muscle spasm of the thoracolumbar spine and no other neurologic abnormalities or findings related to his spine condition. The Veteran was diagnosed with IVDS, but did not require bed rest prescribed by a physician in the past 12 months. He was not diagnosed with ankylosis and used no assistive devices. There were no other pertinent physical findings, complications, conditions, signs, or symptoms related to the Veteran’s thoracolumbar spine. Imaging studies were performed, and arthritis was documented. The Veteran did not have a thoracic vertebral fracture with loss of 50 percent or more of height. There were no other significant diagnostic test findings and/or results. The Veteran’s thoracolumbar spine condition impacted his ability to work in that he had difficulty with bending and lifting. The VA examiner noted that passive range of motion testing and testing of the joint used in non-weight bearing could not be performed. In a March 2020 VA examination report, the Veteran was diagnosed with degenerative disc/joint disease of the lumbar spine. The Veteran stated that his back condition had worsened. He noted that he woke up after Thanksgiving in severe pain that lasted for six weeks. The Veteran reported daily pain in his lower back that was aggravated by sitting straight up, lifting heavy items, and getting dressed. He noted that there were no alleviating factors and described the pain as a “grinding pain” that radiated down his left leg. The Veteran reported numbness and weakness to his left leg after sitting for long periods. He stated that he had been seen by a specialist who suggested surgery. The Veteran reported no flare-ups of his thoracolumbar spine. He did report having functional loss or functional impairment that he described as being unable to bend over at times. Range of motion was abnormal or outside of the normal range. Forward flexion was to 45 degrees, extension was to 5 degrees, right lateral flexion was to 10 degrees, left lateral flexion was to 20 degrees, and right and left lateral rotation was to 15 degrees. The examiner noted that range of motion contributed ot functional loss and limited the Veteran’s ability to bend down or squat. Pain was noted on the examination during forward flexion, extension, right and left lateral flexion, and right and left lateral rotation. There was no evidence of pain with weight bearing but there was objective evidence of localized tenderness or pain on palpation of the joints or associated soft tissue. The examiner described this as tenderness to palpation of the lumbar spine and left paravertebral muscles of the lumbar spine. The Veteran was able to perform repetitive-use testing and there was no additional functional loss or range of motion. The Veteran was examined immediately after repetitive use over time and pain, weakness, fatigability, or incoordination did not significantly limit functional ability. The Veteran had no guarding or muscle spasm. However, he did have disturbance of locomotion, interference with sitting, and interference with standing. The Veteran’s gait was slow, and he had difficulty sitting and standing. The Veteran had radiculopathy, but that will be discussed in the left lower extremity radiculopathy section of this decision. The Veteran had no other neurologic abnormalities or findings related to his thoracolumbar spine. The Veteran was diagnosed with IVDS, but had no episodes that required bed rest prescribed by a physician in the past 12 months. He was not diagnosed with ankylosis. The Veteran used a cane occasionally. There were no other pertinent physical findings, complications, conditions, signs, or symptoms related to his thoracolumbar spine. Imaging studies were not performed, and the Veteran did not have a thoracic vertebral fracture with loss of 50 percent or more of his height. The Veteran’s thoracolumbar spine condition impacted his ability to work in that he is not able to stand up for long periods, walk long distances, bend or squat, or engage in heavy lifting, pushing, or pulling. The examiner noted that determining if there was evidence of pain on passive range of motion testing, evidence of pain when the joint was used in non-weight bearing, and whether the opposing joint was undamaged was not medically appropriate. The Board notes that throughout the appeal period, the Veteran received medical treatment at VA and private facilities for his back. These treatment reports did not evaluate the nature, extent, and severity of his back disability during the appeal period. While not discussed specifically, the Board has reviewed them and taken them into consideration. Analysis Based on this evidence, from November 29, 2018, the assigned 20 percent rating for the Veteran’s back disability fully contemplates his range of motion and all muscle spasm and gait symptoms. The Veteran does not have flexion 30 degrees or less and has not been diagnosed with ankylosis or IVDS requiring bed rest within the past 12 months. 38 C.F.R. § 4.71a, DC 5242-5235. His symptoms do not approximate a disability rating in excess of 20 percent and the claim must be denied. The Board finds that the November 2013, November 2018, and March 2020 VA examination reports, describing the Veteran’s back symptoms, to be the most probative evidence of record because the examiners reviewed the claims file and provided detailed rationales. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008); Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007). While the Veteran is competent (qualified) to observe his back symptoms, he does not have the training or credentials to determine the current nature, extent, and severity of those symptoms, as reflected by the applicable diagnostic criteria. Additionally, he does not have the training or credentials to determine the proper disability evaluations concerning his back disability. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). The Board acknowledges the reports of constant pain associated with the Veteran’s back disability. The provisions of 38 C.F.R. §§ 4.40, 4.45, and 4.59 concerning functional loss due to pain, fatigue, weakness, lack of endurance, incoordination, and flare-ups have been considered in this analysis. See DeLuca v. Brown, 8 Vet. App. 202, 206-08 (1995), 38 C.F.R. § 4.71a, DC 5237-5243. However, the General Formula for disabilities of the spine expressly states that the criteria and ratings apply “with or without symptoms such as pain.” See 38 C.F.R. §§ 4.71a, General Rating Formula. Because of this, the presence of pain is already considered within the currently assigned disability ratings. 68 Fed. Red. 51454 (Aug. 27, 2003) (“Pain is often the primary factor limiting motion, for example, and is almost always present where there is muscle spasm. Therefore, the evaluation criteria provided are meant to encompass and consider the presence of pain, stiffness, or aching, which are generally present when there is a disability of the spine.”). The preponderance of the evidence is against a finding that the Veteran’s back disability warrants a rating in excess of 10 percent prior to November 29, 2018, and in excess of 20 percent after that period and the claims must be denied. 3. An initial rating in excess of 20 percent for left lower extremity radiculopathy is denied. Legal Criteria Under DC 8520, for paralysis of the sciatic nerve, the minimum 10 percent rating is assigned for mild incomplete paralysis of the external popliteal nerve. 38 C.F.R. § 4.124a, DC 8520. A 20 percent rating is assigned for moderate incomplete paralysis of the sciatic nerve. Id. A 40 percent rating is assigned for moderately severe incomplete paralysis of the sciatic nerve. Id. A 60 percent rating is assigned for severe paralysis of the sciatic nerve with marked muscular atrophy. Id. The maximum 80 percent rating 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. Id. 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 the evidence. 38 C.F.R. § 4.6. Factual Background The Veteran’s left lower extremity is rated 20 percent under DC 8520, effective March 12, 2020. 38 C.F.R. § 4.124a, DC 8520. In a November 2013 VA examination report, the Veteran had no radicular pain or any other signs or symptoms due to radiculopathy. The Veteran’s right and left lower extremities were not affected by radiculopathy, and the Veteran had no other neurologic abnormalities or findings related to his thoracolumbar spine. In a November 2018 VA examination report, the Veteran had no radicular pain or any other signs or symptoms due to radiculopathy. He had no other neurologic abnormalities or findings related to his thoracolumbar spine. In a March 2020 VA examination report, the Veteran was diagnosed with radiculopathy. He had no constant pain in either the right or left lower extremity. The Veteran had no intermittent pain in his right lower extremity, but had moderate intermittent pain in his left lower extremity. He had no paresthesias and/or dysesthesias in his right lower extremity, but had moderate paresthesias and/or dysesthesias in his left lower extremity. The Veteran had no numbness in his right lower extremity, but had moderate numbness in his left lower extremity. The Veteran had no other signs or symptoms of radiculopathy. The VA examiner indicated that the Veteran’s right lower extremity was not affected, but he had “moderate” radiculopathy in his left lower extremity. The Board notes that throughout the appeal period, the Veteran received medical treatment at VA and private facilities. These treatment reports did not measure the severity of his left lower extremity radiculopathy and did not evaluate the nature, extent, and severity during the appeal period. Analysis The probative medical evidence indicates that prior to March 12, 2020, the Veteran did not have radiculopathy in his right or left lower extremities. From March 12, 2020, a disability rating in excess of 20 percent for left lower extremity radiculopathy is not warranted. 38 C.F.R. § 4.124a, DC 8520. The March 2020 VA examiner characterized the Veteran’s left lower extremity radiculopathy as “moderate.” There is no competent and credible evidence at any point during the appeal period that characterized the Veteran’s left lower extremity radiculopathy as “moderately severe.” Rather, overall, the Veteran’s disability has more nearly approximated moderate symptoms, and the corresponding symptoms reflect this degree of severity. Id. The Board finds that the November 2013, November 2018, and March 2020 VA examination reports are the most probative evidence of record, as the examiners reviewed the claims file and provided detailed rationale. While the Veteran is competent to observe his left lower extremity symptoms, he does not have the training or credentials to determine the current nature, extent, and severity of those symptoms (as compared to a range of medically possible symptom severity). Additionally, he does not have the training or credentials to assign the proper disability evaluations concerning his left lower extremity. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). The preponderance of the evidence is against a finding that the Veteran’s left lower extremity radiculopathy warrants a compensable rating prior to March 12, 2020, and a rating in excess of 20 percent at any time during the appeal. The Board is sympathetic to the Veteran’s reports and understands that his lumbar spine DDD and left lower extremity radiculopathy have a significant effect on his daily life. However, these symptoms more nearly approximate the currently assigned disability evaluations and do not warrant an increase in the ratings at this time. REASONS FOR REMAND 1. Service connection for diabetes mellitus type II, to include as secondary to hepatitis C, and service-connected chronic kidney disease or hypertension, is remanded. 2. Service connection for hepatitis C, to include as secondary to diabetes mellitus type II, and service-connected chronic kidney disease or hypertension, is remanded. In the December 2019 remand, the Board requested new opinions concerning service connection for diabetes mellitus type II and Hepatitis C. In that remand, the Board mentioned two articles in the National Institute of Health (NIH) database. The first article, titled “Diabetes and Hepatitis C: A Two-Way Association,” noted, in its abstract, that “[m]ost studies...have shown that patients with chronic hepatitis C are more prone to develop type 2 diabetes” and “epidemiological studies have revealed that patients with [type 2 diabetes] may also be at higher risk for worse outcomes of their hepatitis C infection.” The second article, titled “Diabetes mellitus and hypertension,” noted, in its abstract, that “[g]lucose intolerance, insulin resistance, and hyperinsulinemia frequently occur with essential hypertension and may be aggravated by hypertension therapy, especially diuretics and beta-blockers.” In the post-remand March 2020 opinion, the VA examiner opined that it was less likely than not that the Veteran’s hepatitis C was caused or aggravated by his claimed diabetes mellitus type II. The rationale was that these were separate and distinct conditions. The examiner pointed out that hepatitic C is a viral infection caused by exposure to contaminated blood products or exposure during high risk sex and that the Veteran admitted to having had a blood transfusion and used IV drugs in the past. The examiner concluded that there was “no medical evidence that supports a causal link between hepatitis c and type 2 diabetes.” The examiner also opined that it was less likely than not that the Veteran’s diabetes mellitus type II was caused or aggravated by his hepatitis C. The rationale was that hepatitis C was a viral infection that had no bearing on diabetes. The examiner noted that “there is no medical or scientific evidence showing a causal relationship between type 2 diabetes and hepatitis C.” Additionally, the VA examiner wrote that risk factors for diabetes mellitus type II included obesity, positive family history, specific racial and ethnic groups, female sex, and conditions associated with insulin resistance. Finally, the VA examiner seemed to completely ignore the possibility that the Veteran’s hepatitis C and diabetes mellitus type II could be related to his already service-connected chronic kidney disease and hypertension. In finding that it was less likely than not that the Veteran’s hepatitis C and diabetes mellitus type II could have been caused or aggravated by his service-connected chronic kidney disease and hypertension, the examiner just repeated the same rationale for why the Veteran’s hepatitis and diabetes could not be interrelated. The Board notes that a NIH article titled “Hepatitis C” stated that “[p]eople more likely to get hepatitis C… are those who have been on kidney dialysis…” Additionally a NIH article titled “The Link Between Diabetes and Kidney Disease,” explained that “[k]idney disease in people with diabetes is caused by multiple factors, including diabetic changes in the kidneys as well as vascular changes due to hypertension,” which the Veteran is already service connected for. Finally, a NIH article entitled “Diabetes, Heart Disease, and Stroke” noted that left untreated, high blood pressure can lead to heart disease and stroke, and that high blood pressure is twice as likely to strike a person with diabetes than a person without diabetes. In reaching these opinions, the VA examiner never discussed the possible relationship between hepatitis C and diabetes mellitus type II that the Board mentioned in the remand. The examiner also never went into any detail explaining why the Veteran’s hepatitis C and diabetes mellitus type II could not have been caused or aggravated by his service-connected kidney disease and hypertension. Because of this, new VA opinions are necessary. The matters are REMANDED for the following actions: 1. In accordance with the provisions of 38 C.F.R. § 3.159(c)(1), contact the Veteran for additional information about treatment for his condition and make efforts to obtain all VA and private treatment records concerning these claims. 2. Forward the Veteran’s record to an endocrinologist or other appropriate clinician for a medical opinion on the likely cause of the Veteran’s diabetes mellitus type II. Based on a review of the record, examination of the Veteran, and any tests or studies deemed necessary, the examiner must respond to the following: Is it at least as likely as not (a 50 percent probability or greater) that the diabetes mellitus type II was proximately CAUSED BY or AGGRAVATED BY his hepatitis C or his service-connected chronic kidney disease and hypertension? In reaching any conclusion, the examiner must consider the following NIH articles: (a.) Diabetes and Hepatitis C: A Two-Way Association” (b.) “Diabetes mellitus and hypertension” (c.) “The Link Between Diabetes and Kidney Disease” (d.) “Diabetes, Heart Disease, and Stroke” 3. Forward the Veteran’s record to a nephrologist or other appropriate clinician for a medical opinion on the likely cause of the Veteran’s hepatitis C. Based on a review of the record, examination of the Veteran, and any tests or studies deemed necessary, the examiner must respond to the following: Is it at least as likely as not (a 50 percent probability or greater) that the hepatitis C was proximately CAUSED BY or AGGRAVATED BY his diabetes mellitus type II or his service-connected chronic kidney disease and hypertension? In reaching any conclusion, the examiner must consider the following NIH articles: (a.) “Diabetes and Hepatitis C: A Two-Way Association” (b.) “Hepatitis C” (Continued on the next page)   4. A detailed explanation (rationale) is requested for all opinions provided. N. RIPPEL Acting Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board J. Abrams, 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.