Citation Nr: 21000428 Decision Date: 01/05/21 Archive Date: 01/05/21 DOCKET NO. 17-16 576 DATE: January 5, 2021 ORDER Entitlement to service connection for left knee instability with subluxation is denied. Entitlement to a rating in excess of 20 percent for lumbar spine arthritis with intervertebral disc syndrome prior to March 15, 2017 is denied. Entitlement to a 40 percent rating, but no higher, for right lower extremity sciatic radiculopathy from April 4, 2015 to March 13, 2017 is granted, subject to the laws and regulations governing the award of monetary benefits. Entitlement to a rating in excess of 20 percent for right lower extremity sciatic radiculopathy since March 14, 2017 is denied. REMANDED Entitlement to compensation under 38 U.S.C. § 1151 for glaucoma is remanded. Entitlement to service connection for insomnia is remanded. Entitlement to a rating in excess of 20 percent for lumbar spine arthritis with intervertebral disc syndrome since March 15, 2017 is remanded. FINDINGS OF FACT 1. The preponderance of the evidence of record does not show a current diagnosis of left knee instability or subluxation. 2. Prior to March 15, 2017, lumbar spine arthritis with intervertebral disc syndrome was not manifested by forward thoracolumbar flexion of 30 degrees or less, favorable ankylosis of the entire thoracolumbar spine, or by incapacitating episodes having a total duration of at least four weeks but less than six weeks. 3. From April 4, 2015 to March 13, 2017, the Veteran’s right lower extremity sciatic radiculopathy was manifested by moderately severe incomplete paralysis of the sciatic nerve, but not by severe incomplete paralysis with marked muscular atrophy. 4. Since March 14, 2017, the Veteran’s right lower extremity sciatic radiculopathy was not manifested by moderately severe incomplete paralysis of the sciatic nerve. CONCLUSIONS OF LAW 1. The criteria for service connection for left knee instability with subluxation are not met. 38 U.S.C. § 1110; 38 C.F.R. §§ 3.303, 3.310, 4.71a, Diagnostic Codes (DCs) 5260, 5257. 2. The criteria for entitlement to a rating in excess of 20 percent for lumbar spine arthritis with intervertebral disc syndrome prior to March 15, 2017 have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.7, 4.40, 4.59, 4.71a, DC 5243. 3. The criteria for entitlement to a 40 percent rating, but no higher, for right lower extremity sciatic radiculopathy From April 4, 2015 to March 13, 2017 have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.7, 4.120, 4.123, 4.124a, DC 8520. 4. The criteria for entitlement to a rating in excess of 20 percent for right lower extremity sciatic radiculopathy since March 14, 2017 have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.7, 4.120, 4.123, 4.124a, DC 8520. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from September 1969 to November 1973. These matters are before the Board of Veterans’ Appeals (Board) on appeal of February and December 2015, July 2016 and May 2018 rating decisions of a Department of Veterans Affairs (VA) Regional Office (RO). In July 2019, the Board denied, in pertinent part, entitlement to a rating in excess of 20 percent for right lower extremity sciatic radiculopathy. The Veteran appealed the Board’s decision to the United States Court of Appeals for Veterans Claims (Court). In a May 2020 Order, the Court granted a Joint Motion for Remand (JMR) of the Veteran and the Secretary of Veterans Affairs (the Parties) to vacate and remand the portion of the Board’s July 2019 decision that denied entitlement to a rating in excess of 20 percent for right lower extremity sciatic radiculopathy. That issue has now been returned to the Board. The issues of entitlement to service connection for cervical spine, left shoulder and right shoulder disabilities were remanded by the Board in June 2019. Those issues have not yet been returned to the Board. Entitlement to service connection for left knee instability with subluxation is denied. The Veteran contends that he has left knee instability and subluxation which is caused by his service connected left knee osteoarthritis and warrants a separate rating. Service connection is established on a direct basis when there is competent, credible evidence of (1) a current disability, (2) in-service incurrence or aggravation of an injury or disease, and (3) a nexus, or link, between the current disability and the in-service disease or injury. 38 U.S.C. § 1110; Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009); 38 C.F.R. § 3.303(a), (d). Service connection may be granted on a secondary basis for a disability that is proximately due to a service-connected condition. 38 C.F.R. § 3.310 (a). Service connection is also possible when a service-connected condition has aggravated a claimed condition, but compensation is only payable for the degree of additional disability attributable to the aggravation. Allen v. Brown, 7 Vet. App. 439 (1995). In October 2006, VA amended 38 C.F.R. § 3.310 to incorporate the decision in Allen except that VA will not concede aggravation unless there is medical evidence showing the baseline level of the disability before its aggravation by the service-connected disability. 38 C.F.R. § 3.310 (b). The Veteran is already service connected for left knee osteoarthritis, rated under 38 C.F.R. § 4.71a, DC 5260 based on limitation of flexion. 38 C.F.R. § 4.71a DC 5257 provides ratings for recurrent subluxation or lateral instability, and the Veteran essentially seeks service connection for a left knee disability under this code, separate from his already service-connected left knee osteoarthritis, but secondary to his service-connected left knee osteoarthritis. In May 2016, the Veteran submitted a claim for “left knee instability/subluxation due to left knee arthritis.” In July 2016 the Veteran attended a VA knee examination. At that time the Veteran reported that his left knee recently “gave way” causing him to fall. The examiner noted that a June 2016 VA treatment record documented that the Veteran had “tripped.” The Veteran reported that on occasion his knees became “real weak.” The examiner found no history of recurrent subluxation or lateral instability and there was no left knee joint instability after joint stability testing. On VA examination in March 2017 the examiner again noted no history of recurrent subluxation or instability and there was no left knee instability on joint stability testing. On VA examination in November 2018 the examiner again noted no history of recurrent subluxation or instability and there was no left knee instability on joint stability testing. The Veteran is competent to report experiencing symptoms such as instability, weakness and “giving way.” However, whereas the Veteran’s complaints are generalized and appear to denote a feeling of instability of station due to lower extremity weakness, the July 2016, March 2017 and November 2018 examiners unanimously found no instability and objective testing at the examinations showed no lateral instability or subluxation. The examinations were completed by medical professionals who formulated their conclusions based on a physical examination, review of the record, and interview of the Veteran. The Board has no basis to contradict the conclusions made by the examiners. See Colvin v. Derwinski, 1 Vet. App. 171, 175 (1991). Thus, the Veteran’s lay reports have been considered as evidence with respect to knee instability and subluxation but are outweighed by significant objective evidence indicating no such instability or subluxation. Accordingly, the evidence preponderates against finding that service connection is warranted for left knee subluxation or instability, to include as to warrant a separate rating under DC 5257. 38 C.F.R. § 4.71a. Based on the foregoing, the evidence preponderates against finding that left knee instability or subluxation have been present such as to warrant a grant of service connection or separate rating. As the evidence preponderates against finding a separate disability for which service connection may be granted, service connection is not warranted, and the claim is denied. Brammer v. Brown, 3 Vet. App. 223 (1992). Entitlement to a rating in excess of 20 percent for lumbar spine arthritis with intervertebral disc syndrome prior to March 15, 2017 is denied. The Veteran contends that his lumbar spine arthritis with intervertebral disc syndrome is more severely disabling than represented by the currently assigned 20 percent rating. Disability evaluations are determined by the application of VA’s Schedule for Rating Disabilities (Rating Schedule), 38 C.F.R. Part 4. The percentage ratings in the Rating Schedule represent, as far as can be practicably determined, the average impairment in earning capacity resulting from diseases and injuries incurred or aggravated during military service and their residual conditions in civil occupations. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. Where an increase in the level of a service-connected disability is at issue, the primary concern is the present level of disability. Francisco v. Brown,7 Vet. App. 55 (1999). Nevertheless, separate ratings can be assigned for separate periods of time based on the facts found, a practice known as “staged” ratings. See Fenderson v. West, 12 Vet. App. 119, 126 (1999). The analysis is therefore undertaken with consideration of the possibility that different ratings may be warranted for different time periods within the period on appeal. Where there is a question as to which of the 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. 38 C.F.R. § 4.7. Disability of the musculoskeletal system is primarily the inability, due to damage or infection in parts of the system, to perform the normal working movements of the body with normal excursion, strength, speed, coordination, and endurance. It is essential that the examination on which ratings are based adequately portrays the anatomical damage, and the functional loss, with respect to these elements. In addition, functional loss may be due to pain, supported by adequate pathology and evidenced by the visible behavior of the veteran undertaking the motion. Weakness is as important as limitation of motion, and a part which becomes painful on use must be regarded as seriously disabled. 38C.F.R. § 4.40. The intent of the schedule is to recognize painful motion with joint or periarticular pathology as productive of disability. It is the intention to recognize actually painful, unstable, or malaligned joints, due to healed injury, as entitled to at least the minimum compensable rating for the joint. 38 C.F.R. § 4.59. The appellant’s lumbar spine arthritis with intervertebral disc syndrome is rated under the General Rating Formula for Diseases and Injuries of the Spine. 38 C.F.R. § 4.71a, DC 5243. The General Rating Formula provides a 20 percent rating when forward thoracolumbar flexion is greater than 30 degrees, but not greater than 60 degrees; or, the combined range of motion of the thoracolumbar spine is not greater than 120 degrees; or, there is 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 when forward thoracolumbar flexion is 30 degrees or less; or there is favorable ankylosis of the entire thoracolumbar spine. Id. There are alternative rating criteria for the spine available under DC 5243, for an intervertebral disc syndrome, which allows for the assignment of rating criteria based on the frequency and extent of incapacitating episodes. 38 C.F.R. § 4.71a, DC 5243. 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.” Id. at Note (1). A 20 percent rating is warranted where there are incapacitating episodes having a total duration of at least two weeks but less than four weeks during the past twelve months. A 40 percent rating is warranted where incapacitating episodes have a total duration of four weeks but less than six weeks during the past twelve months. Id. At an August 2015 VA examination the Veteran demonstrated lumbar forward flexion to 70 degrees. Lumbar symptoms included stiffness, weakness with prolonged standing, and constant pain at the low back. There was not additional loss of range of motion after repetitive use. There was no evidence of pain with weight bearing. He described flare-ups, stating “the pain comes and goes” and was worsened by standing. The examiner considered the Veteran’s reports of flare-ups but declined to opine whether flare-ups would significantly limit functional ability. The examiner reasoned that the main limiting factor affecting motion and function, as report by the Veteran was pain, but on examination there was no decreased effort as a result of pain, fear of injury, disuse or neuromuscular inhibition. There was no ankylosis. The examiner noted that the Veteran had IVDS of the thoracolumbar spine, but there were no episodes of acute symptoms requiring bed rest prescribed by a physician and treatment by a physician in the past 12 months. On VA examination on March 14, 2017, lumbar forward flexion was to 80 degrees, with no additional loss of range of motion after repetitive use. The Veteran did not report flare-ups of the lumbosacral spine. The examiner noted no pain with weight-bearing or nonweight-bearing or on passive range of motion. There was no thoracolumbar ankylosis. The examiner noted that the Veteran had IVDS of the thoracolumbar spine, but there were no episodes of acute symptoms requiring bed rest prescribed by a physician and treatment by a physician in the past 12 months. The foregoing evidence preponderates against granting a rating in excess of 20 percent for lumbar spine arthritis with intervertebral disc syndrome. In this regard, the evidence preponderates against finding 30 degrees or less of thoracolumbar forward flexion, favorable ankylosis of the entire thoracolumbar spine or incapacitating episodes with a total duration of at least four weeks. The evidence discussed above reveals no less than 70 degrees of forward flexion, no indication of ankylosis and no reports of incapacitating episodes requiring prescription of bedrest by a physician. All of the Veteran’s additional reported symptoms have been considered, to include his reports of low back pain, stiffness, weakness and flare-ups. The Board is sympathetic to the pain experienced by the Veteran. However, these symptoms do not reveal forward thoracolumbar flexion of 30 degrees or less, favorable ankylosis of the entire thoracolumbar spine, or incapacitating episodes having a total duration of at least four weeks but less than six weeks, and therefore do not approximate the criteria for a higher rating. The Board has considered the representative’s general argument regarding the adequacy of VA examinations, which does not identify any specific deficiencies in the examinations of record. In this case, the Board finds that the August 2015 and March 14, 2017 examinations are adequate to adjudicate the period prior to March 15, 2017. In this regard, while the examiner declined to provide an estimate of additional functional loss during flare-ups, the examiner reasoned that the Veteran described his flare-ups as characterized by pain, but that the evidence did not indicate pain alone resulted in additional range of motion loss. The evidence relevant to this period does not otherwise indicate that thoracolumbar flare-ups were productive of additional range of motion loss. Based on the foregoing, the preponderance of the evidence is against finding that a rating in excess of 20 percent for lumbar spine arthritis with intervertebral disc syndrome is warranted prior to March 15, 2017. The claim is denied. Entitlement to a 40 percent rating, but no higher, for right lower extremity sciatic radiculopathy from April 4, 2015 to March 13, 2017 is granted, and a rating in excess of 20 percent thereafter is denied. The Veteran contends that his right lower extremity sciatic radiculopathy is more severely disabling than represented by the 20 percent rating assigned since April 4, 2015. In the May 2020 JMR, the Parties agreed that the Board failed to provide an adequate statement of reasons or bases in failing to discuss whether an August 2015 VA examiner’s finding that right lower extremity sciatic radiculopathy was “moderately severe,” supported a higher rating, to include a staged rating. Under DC 8520 incomplete paralysis of the sciatic nerve is rated as 20 percent disabling when it is moderate, 40 percent when it is moderately severe and 60 percent when it is severe, with marked muscular atrophy. 38 C.F.R. § 4.124a. The words “mild,” “moderate,” and “severe” as used in the various DCs are not defined in the Rating Schedule. Regulations provide that ratings for peripheral neurological disorders are to be assigned based on the relative impairment of motor function, trophic changes, or sensory disturbance. 38 C.F.R. § 4.120. Consideration is also given for loss of reflexes, pain, and muscle atrophy. 38 C.F.R. §§ 4.123, 4.124. The term “incomplete paralysis” indicates a degree of lost or impaired function substantially less than the type of picture for complete paralysis given with each nerve, whether due to varied level of the nerve lesion or to partial regeneration. When the involvement is wholly sensory, the rating is for the mild, or at most, the moderate degree. The disability ratings for the peripheral nerves are for unilateral involvement; when bilateral, the ratings combine with application of the bilateral factor. 38 C.F.R. § 4.124a, Note at “Diseases of the Peripheral Nerves.” The Note to 38 C.F.R. § 4.124a establishes a maximum disability rating for conditions that are wholly sensory, as opposed to a minimum disability rating for conditions that are more than wholly sensory. See Miller v. Shulkin, 28 Vet. App. 376 (2017). In his April 4, 2015 claim for an increased rating, the Veteran reported pain and numbness from his knee to his foot with no feeling or deadness from his hip to his knee. On VA examination in August 2015, the Veteran reported shooting pain down the backs of both legs and numbness from his hips to his feet. Right lower extremity strength testing was normal, but reflexes were absent at the knee and ankle. Sensation was normal at the upper thigh and thigh/knee but decreased at the lower leg/ankle and foot/toes. Straight leg raise test was positive. The examiner stated that the Veteran had severe constant pain, moderate parasthesia and/or dysesthesias, and severe numbness. There was no muscle atrophy. The examiner indicated that the overall severity of right lower extremity radiculopathy was “moderate,” but in a separate “remarks” section, the examiner indicated that right lower extremity radiculopathy was “moderately severe.” On VA examination on March 14, 2017, the Veteran reported numbness at the right lateral hip to right knee area, with nerve pain bilaterally. Right lower extremity muscle testing and reflexes were normal, though sensation to the upper anterior thigh and thigh/knee were decreased. Straight leg raising test was negative, and there was no muscle atrophy. The examiner reported no constant pain, moderate intermittent pain, moderate paresthesias and/or dysesthesias, and moderate numbness of the right lower extremity. The overall severity of right lower extremity radiculopathy was described as moderate. With regard to the period from April 4, 2015 to March 13, 2017, the evidence is at least in equipoise as to whether the Veteran’s right lower extremity sciatic radiculopathy was moderately severe. Significantly, the April 2015 VA examiner described the Veteran’s right lower extremity radiculopathy as moderately severe. The examiner further noted severe constant pain and numbness. The fact that right lower extremity reflexes were absent on examination indicates that symptoms were more than wholly sensory. However, the evidence preponderates against finding “severe” right lower extremity symptoms during this period. Significantly in this regard, there is no evidence of marked muscle atrophy as stipulated by the criteria for a 60 percent rating. While the Veteran exhibited some severe symptoms, strength was normal, and paresthesias and/or dysesthesias were moderate. The examiner summarized the findings as only moderately severe rather than severe. Accordingly, resolving reasonable doubt in the favor of the Veteran, right lower extremity sciatic radiculopathy is found to be moderately severe for the period from April 4, 2015 to March 13, 2017. With regard to the period since March 14, 2017, however, the evidence preponderates against finding that the right lower extremity sciatic radiculopathy was manifested by moderately severe symptoms. In this regard, although there was decreased right lower extremity sensation, both lower extremity strength and reflexes were normal. Intermittent pain, paresthesias and/or dysesthesias and numbness were no more than moderate with no constant pain. No trophic changes or muscle atrophy were noted, and the VA examiner characterized the right lower extremity sciatic radiculopathy as no worse than moderate. The record primarily evidences only sensory symptoms during this period. Although there is evidence that right lower extremity pain and numbness caused difficulty with sitting, standing and walking, this evidence does not more nearly approximate moderately severe symptomatology at any point. Overall, the disability picture preponderates against finding that the disorder met or more nearly approximated moderately severe incomplete paralysis since March 14, 2017. The Board has considered the representative’s general argument regarding the adequacy of VA examinations, which does not identify any specific deficiencies in the examinations of record. In this case, the Board finds that the August 2015 and March 2017 examinations are adequate to adjudicate the claim. In this regard, while the August 2015 examiner ambiguously described right lower extremity sciatica as both “moderate” and “moderately severe” the Board has resolved reasonable doubt in the Veteran’s favor in interpreting that report. Additionally, the Board notes that, while, as discussed further below, private treatment records indicate a worsening of the Veteran’s low back pain since the March 2017 VA examination, the evidence does not demonstrate a similar worsening of the right lower extremity sciatic radiculopathy since the March 2017 VA examination. Accordingly, the examinations of record are adequate to adjudicate the claim at this time. Based on the foregoing, the evidence is in equipoise as to whether a 40 percent rating for right lower extremity sciatic radiculopathy is warranted from April 4, 2015 to March 13, 2017. The evidence preponderates against finding that a rating in excess of 20 percent is warranted since March 14, 2017. REASONS FOR REMAND Entitlement to compensation under 38 U.S.C. § 1151 for glaucoma is remanded. The Veteran attended a VA examination in October 2015 with regard to his claim for benefits for glaucoma under 38 U.S.C. § 1151. The examiner diagnosed the Veteran with open angle with high risk bilateral borderline glaucoma findings and mild stage primary open-angle glaucoma. The examiner opined that “A thorough review of this Veteran’s care at the Kansas City VA does raise concerns that an appropriate decision to start glaucoma treatment could have been made earlier” and that “measuring his central corneal thickness earlier may have helped better assess his glaucoma risk, before deciding that there was ‘not enough evidence to treat,’ as was stated several times in his chart.” The examiner went on to conclude, however, that the Veteran did not demonstrate loss of 30 percent of the visual field, as he claimed, but rather demonstrated a 94 percent visual field index in May 2015, and a “nearly normal” visual field on examination. While the Veteran has specifically alleged a “loss of 30 percent of peripheral vision,” his claim is not limited to a particular symptom or percentage of vision loss. See Clemons v. Shinseki, 23 Vet. App. 1 (2009) (stating that when a veteran files a claim he or she is not seeking benefits only for a particular diagnosis, but for the affliction his condition, whatever that is, causes him or her). Pursuant to Clemons, the claim should be interpreted to include any symptoms or additional disability related to glaucoma which resulted from VA’s failure to timely diagnose and/or properly treat the claimed disability. Accordingly, remand is required to obtain a new examination which adequately addresses this question. Entitlement to service connection for insomnia is remanded. The Veteran has not been provided a VA examination to ascertain the nature and etiology of his claimed insomnia. An April 2018 opinion of a private physician, Dr. W.Z., notes that the Veteran’s cervical spine pain had been preventing him from sleeping in his bed, although Dr. W.Z. did not specifically diagnose insomnia. The Veteran has also alleged that he has insomnia due to chronic pain from his service-connected knee and lumbar spine disabilities and radiculopathy. Remand is required to afford the Veteran an examination to determine the nature and etiology of his claimed insomnia. See McLendon v. Nicholson, 20 Vet. App. 79 (2006). Entitlement to a rating in excess of 20 percent for lumbar spine arthritis with intervertebral disc syndrome since March 15, 2017 is remanded. Private treatment records, most recently in December 2019, note worsening low back pain. As the Veteran was last provided a VA examination for his lumbar spine arthritis with intervertebral disc syndrome in March 2017, he should be provided an opportunity to report for a VA examination to ascertain the current severity and manifestation of that disability. Weggenmann v. Brown, 5 Vet. App. 281, 284 (1993). The matters are REMANDED for the following action: 1. Schedule the Veteran for an examination by an appropriate clinician to address the nature and etiology of the claimed glaucoma. The examiner is asked to review all relevant evidence in the claims file. The examiner should then address the following: a. Is it at least as likely as not (50 percent probability or greater) that the Veteran’s glaucoma, to include any symptoms of glaucoma, resulted from carelessness, negligence, lack of proper skill, error in judgment, or similar instance of fault on the part of VA? b. Is it at least as likely as not that the Veteran’s glaucoma, to include any symptoms of glaucoma, resulted from carelessness, negligence, lack of proper skill, error in judgment, or similar instance of fault on the part of VA in failing to timely evaluate the that disability? c. Is it at least as likely as not that there was failure on the part of VA to timely diagnose and/or properly treat the claimed glaucoma which allowed the disability to continue or worsen? d. Did VA fail to exercise the degree of care that would be expected of a reasonable health care provider? e. If the answer to (a), (b), (c), and (d) is NO: was the Veteran’s glaucoma due to an event not reasonably foreseeable by the health care provider? 2. Schedule the Veteran for an examination by an appropriate clinician to determine the nature and etiology of any insomnia. The examiner should state: a. What diagnosed insomnia has been present at any time since March 12, 2018? b. To the extent possible, please delineate the symptoms attributable to the Veteran’s service-connected sleep apnea vs insomnia. c. For any such insomnia: is it at least as likely as not proximately caused by chronic pain due to any service-connected disability, to specifically include knee and lumbar spine disabilities, bilateral radiculopathy, and sleep apnea? d. For any such insomnia: is it at least as likely as not aggravated beyond its natural progression by chronic pain due to any service-connected disability, to specifically include knee and lumbar spine disabilities, bilateral radiculopathy, and sleep apnea? 3. Schedule the Veteran for an examination by an appropriate clinician to determine the current severity of his service-connected lumbar spine arthritis with intervertebral disc syndrome. The examiner should provide a full description of the disabilities and report all signs and symptoms necessary for evaluating the Veteran’s disability under the rating criteria. a. The examiner must test the Veteran’s active motion, passive motion, and pain with weight-bearing and without weight-bearing. If any requested testing cannot be completed, the examiner should state why that is the case. b. The examiner must also attempt to elicit information regarding the severity, frequency, and duration of any flare-ups, and provide, to the extent possible, an estimate of the additional degrees of limited motion of the lumbar spine during flare-ups. c. If the clinician cannot provide the above-requested opinion regarding flare-ups without resorting to speculation, he or she should state whether all procurable medical evidence has been considered, to specifically include the Veteran’s description as to the severity, frequency, and duration of the flare-ups and his description as to the extent of functional loss during a flare-up and after repetitive use over time; whether the inability is due to the limits of medical community or the limits of the examiner’s medical knowledge; and whether there is additional evidence, which if obtained, would permit the opinion to be provided. Sharp v. Shulkin, 29 Vet. App. 26 (2017). LAURA E. COLLINS Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Paul J. Bametzreider 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.