Citation Nr: 21000629 Decision Date: 01/05/21 Archive Date: 01/05/21 DOCKET NO. 16-61 756 DATE: January 5, 2021 ORDER An initial 40 percent rating, but no higher, for degenerative disc disease of the lumbar spine (low back disability) prior to November 27, 2019, is granted. A rating higher than 40 percent for the low back disability since November 27, 2019, is denied. An initial 20 percent rating, but no higher, for degenerative changes of the cervical spine (cervical spine disability) prior to April 2, 2016, is granted. A rating higher than 20 percent for the cervical spine disability since April 2, 2016, is denied. REMANDED The issue of special monthly compensation (SMC) based on housebound status and/or the need for aid and attendance is remanded. FINDINGS OF FACT 1. Throughout the appeal period, the Veteran’s low back disability more nearly approximated forward flexion to 30 degrees or less; there was no incapacitating episodes as defined in the applicable regulation or ankylosis of the entire thoracolumbar spine. 2. Throughout the appeal period, the Veteran’s cervical spine disability more nearly approximated a combined range of motion of the cervical not greater than 170 degree; forward flexion of the cervical spine was not limited to 15 degrees even considering pain and flare ups and there was no ankylosis or incapacitating episodes. CONCLUSIONS OF LAW 1. With reasonable doubt resolved in favor of the Veteran, the criteria for a 40 percent rating, but no higher, for the low back disability, prior to November 27, 2019, are met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.3, 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code (DC) 5243. 2. The criteria for a rating higher than 40 percent for the low back disability, since November 27, 2019, are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.3, 4.7, 4.40, 4.45, 4.59, 4.71a, DC 5243. 3. With reasonable doubt resolved in favor of the Veteran, the criteria for a 20 percent rating, but no higher, for the cervical spine disability, prior to April 2, 2016, are met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.3, 4.7, 4.40, 4.45, 4.59, 4.71a, DC 5242. 4. The criteria for a rating higher than 20 percent for the cervical spine disability, since April 2, 2016, are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.3, 4.7, 4.40, 4.45, 4.59, 4.71a, DC 5242. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in February 1967. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a November 2014 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO). In April 2019, the Veteran presented testimony before the Board. In August 2019, the Board remanded the appeal for additional development. Specifically, the Board remanded the appeal to schedule the Veteran for VA examinations to assess the severity of his service-connected low back and cervical spine disabilities, consistent with the holding in Sharp v. Shulkin, 29 Vet. App. 26, 33 (2017). In November 2019, the Veteran was afforded VA examinations that reflect the current severity of his service-connected low back and cervical spine disabilities. The November 2019 examinations are sufficient for evaluation purposes, as the examiner rendered findings responsive to the rating criteria. See 38 C.F.R. § 4.2. Also, as will be discussed below, the November 2019 VA examination reports provide sufficient findings that complied with the requirements in Sharp. Therefore, the agency of original jurisdiction (AOJ) complied with the remand instructions. Stegall v. West, 11 Vet. App. 268, 271 (1998). During the appeal period, the Veteran was awarded higher ratings for his low back and cervical spine disabilities; however, he has not expressed satisfaction with the increased disability ratings; these issues, thus, remain in appellate status. See AB v. Brown, 6 Vet. App. 35, 38 (1993). Higher Initial Ratings Disability evaluations are determined by evaluating the extent to which a veteran’s service-connected disability adversely affects his or her ability to function under the ordinary conditions of daily life, including employment, by comparing his or her symptomatology with the criteria set forth in the Rating Schedule. 38 U.S.C. § 1155; 38 C.F.R. §§ 4.1, 4.2, 4.10. When the appeal arises from an initial assigned rating, consideration must be given to whether staged ratings should be assigned to reflect entitlement to a higher rating at any point during the pendency of the claim. Fenderson v. West, 12 Vet. App. 119 (1999). Staged ratings are also 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). Rating Criteria and Law for the Low Back and Cervical Spine Disabilities In the November 2014 rating decision, the RO granted service connection for the low back disability and the cervical spine disability and assigned a 10 percent rating and a noncompensable rating, respectively, effective July 30, 2006. In an April 2016 rating decision, the RO increased the ratings for the low back and the cervical spine disabilities to 20 percent ratings, effective April 2, 2016. In August 2019, the Board granted an effective date of August 11, 1998, for the grant of service connection for the low back disability and the cervical spine disability. The RO implemented the Board’s August 2019 decision and assigned the low back disability a 10 percent rating, effective from August 11, 1998, to April 1, 2016, and a 20 percent rating from April 2, 2016, to November 26, 2019, under DC 5242. In an August 2020 rating decision, the Decision review Officer (DRO) increased the rating for the low back disability a 40 percent rating, effective November 27, 2019, under DC 5243. The RO assigned the cervical spine a noncompensable rating from August 11, 1998, to April 1, 2016, and a 20 percent rating, effective April 2, 2016, under DC 5242. Under the applicable criteria, disabilities rated under DCs 5235 to 5243, unless 5243 is evaluated for Formula for Rating Intervertebral Disc Syndrome (IVDS) Based on Incapacitating Episodes, are rated under the General Rating Formula for Rating Diseases and Injuries of the Spine (General Rating Formula). 38 C.F.R. § 4.71a, DCs 5235, 5237. Under the General Rating Formula, with or without symptoms such as pain, stiffness or aching in the area of the spine affected by residuals of injury or disease, the following ratings apply: A 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 entire 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 or more of the height. Id. 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 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 if 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 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 and a 100 percent rating is warranted for ankylosis of the entire spine. Id. Note (2) provides that normal forward flexion, extension, and left and right lateral flexion of the cervical spine are all zero to 45 degrees and left and right lateral rotation of the cervical spine are both zero to 80 degrees. Normal forward flexion of the thoracolumbar spine is to zero to 90 degrees and extension and left and right lateral flexion and rotation of the thoracolumbar spine are all zero to 30 degrees. The combined range of motion refers to the sum of the range of forward flexion, extension, left and right lateral flexion, and left and right rotation. The normal combined range of motion of the cervical spine is 340 degrees and the normal combine range of motion of the thoracolumbar spine is 240 degrees. Each range of motion measurement is to be rounded to the nearest five degrees. Alternatively, degenerative disc disease may be rating under the Formula for Rating IVDS Based on Incapacitating Episodes. This formula provides for ratings based upon the frequency and duration of incapacitating episodes during a 12-month period. An “incapacitating episode” is a period of acute signs and symptoms due to IVDS that requires bed rest prescribed by a physician. 38 C.F.R. § 4.71a, Note (1). Under this formula, ratings are assignable based on the frequency and duration of incapacitating episodes in a 12 month period—a 10 percent rating for a total duration of at least one week but less than 2 weeks; a 20 percent rating a total duration of at least 2 weeks but less than 4 weeks; a 40 percent rating a total duration of at least 4 weeks but less than 6 weeks; and a 60 percent for a total duration of at least 6 weeks. Disabilities evaluated on the basis of limitation of motion require VA to apply the provisions of 38 C.F.R. §§ 4.40, 4.45, pertaining to functional impairment. The United States Court of Appeals for Veterans Claims (Court) has instructed that in applying these regulations VA should obtain examinations in which the examiner determines whether the disability is manifested by weakened movement, excess fatigability, incoordination, pain, or flare-ups. Such inquiry is not to be limited to muscles or nerves. These determinations, if feasible, are to be expressed in terms of the degree of additional range-of-motion loss due to any weakened movement, excess fatigability, incoordination, flare-ups, or pain. The examiner should also determine the point at which such factors cause functional impairment. Moreover, the joints involved should be tested for pain on both active and passive motion, in weight-bearing and nonweight-bearing and, if possible, with the range of the opposite undamaged joint. Correia v. McDonald, 28 Vet. App. 158 (2016); DeLuca v. Brown, 8 Vet. App. 202 (1995); 38 C.F.R. § 4.59. Further, in claims for higher ratings for musculoskeletal disabilities, where a veteran has a noncompensable rating and complaints of pain on motion, the veteran may be entitled to at least the minimum compensable rating for the joint. 38 C.F.R. § 4.59; Burton v. Shinseki, 25 Vet. App. 1 (2011). In Petitti v. McDonald, 27 Vet. App. 415 (2015), the Court held that under 38 C.F.R. § 4.59, “the trigger for a minimum disability rating is an actually painful, unstable, or malaligned joint,” and it explained that 38 C.F.R. § 4.59 speaks to both painful motion of joints and actually painful joints. Id. at 425. Moreover, the Court held that 38 C.F.R. § 4.59 does not require “objective” evidence but can be satisfied with lay and other nonmedical evidence. Id. at 429. The provisions of 38 C.F.R. § 4.59 are not limited to arthritis and must be considered when raised by the claimant or when reasonably raised by the record. Id. Moreover, the plain language of § 4.59 indicates that it is applicable to the evaluation of musculoskeletal disabilities involving actually painful, unstable, or malaligned joints or periarticular regions, regardless of whether the DC under which the disability is being evaluated is predicated on range of motion measurements. Southall-Norman v. McDonald, 28 Vet. App. 346, 354 (2016). As indicated above, the appeal period for higher ratings for the low back and cervical spine disabilities begins on August 11, 1998. The Veteran’s VA and private treatment records show that as early as 1999, the Veteran had severe, chronic low back and cervical spine pain; muscle spasms; functional impairment; x-ray evidence of severe arthritis in the lumbar and cervical spine, and lumbar lordosis. See, e.g., VA treatment record (November 1999). Specifically, during a December 1999 VA treatment visit, the Veteran described his back pain as “an ice pick” stuck in his back. During the December 1999 VA treatment visit, the Veteran indicated that sitting and walking more than 1.5 miles caused low back pain. He stated that he had occasional back spasms once a year. The examining physician assessed flattened lumbar lordosis. Throughout the appeal period, VA treatment records show that the Veteran reported to his treatment providers chronic low back and cervical spine pain. See VA treatments (January 2001, February 2002, January 2005, 2006 to 2008, August 2015). Furthermore, in February 2002, the Veteran had neck muscle spasm and tenderness to palpation. A September 2002 x-ray report shows severe cervical degenerative disc disease and chronic neck and low back pain. VA treatment records reflect that the Veteran required a walker for ambulation. See, e.g., VA treatment record (August 2015). The earliest VA examination that assessed the severity of the Veteran’s low back and cervical spine disabilities was in December 2011. Similarly, the earliest recorded range of motion testing was in December 2011. The Veteran was afforded VA examinations in December 2011, April 2016, December 2016, and November 2019. During these VA examinations, the Veteran reported low back and cervical spine pain and muscle spasms. He indicated that his pain interfered with his sleep, he required a walker, he was unable to lift more than 25 pounds due to low back spasms, he was unable to stand for more than 10 minutes due to pain, difficulty turning his neck, and that he had pain upon bending. See VA examination reports (December 2011, April 2016, December 2016, November 2019). With respect to flare-up symptoms of the Veteran’s low back and cervical spine, during every VA examination, he reported flare ups, except during the April 2016 VA examination where he denied cervical spine flare ups. The Veteran rated his low back and cervical spine pain during flare ups as a 7 out of 10, a 9 out of 10, and a 10 out of 10. See VA examination reports (April 2016, December 2016, November 2019). He indicated that he had flare ups that occurred five times a week to twice a month and that he was unable to get out of bed and that he required a heating pain. See VA examination reports (December 2016, November 2019). He stated that during flareups, he had difficulty turning his neck, increased pain, and difficulty sitting in one position. See VA examination report (December 2016). Upon physical examination of the low back and the cervical spine, the April 2016, December 2016, and November 2019 VA examiners indicated that the Veteran had low back and neck muscle spasms and guarding that resulted in abnormal gait or abnormal spinal contour. The December 2011, April 2016, December 2016, and November 2019 VA examiners indicated that there was no muscle atrophy, ankylosis, or IVDS of the thoracolumbar or cervical spine. The examiners indicated that pain and range of motion contributed to functional loss. See, e.g., VA examination report (December 2016). The Veteran had pain on weight bearing. Id. Also, most of the VA examiners agreed that pain, weakness, fatigability, and incoordination significantly limited the Veteran’s functional ability with repeated use over a period of time and his functional ability with flare ups. See, e.g., VA examination report (November 2019). Range of motion for the low back during the November 2019 VA examination was recorded as forward flexion to 35 degrees with pain and extension to 0 degrees, with pain. Upon repetitive use-testing, flexion was limited to 30 degrees and extension was to 0 degrees. The November 2019 VA examiner estimated that during periods of pain, weakness, fatigability, incoordination, and flare ups, the Veteran’s flexion would be limited to 30 degrees and that his extension would be limited to 0 degrees. Range of motion for the cervical spine during the November 2019 VA examination was recorded as forward flexion to 30 degrees, extension to 10 degrees, right and left lateral flexion to 20 degrees, and right and left lateral rotation to 30 degrees. Upon repetitive use testing, the range of motion remained the same, except extension was limited to 5 degrees. The November 2019 VA examiner estimated that during periods of pain, weakness, fatigability, incoordination, and flare ups, the Veteran’s forward flexion would be limited to 30 degrees, extension limited to 5 degrees, right and left lateral flexion limited to 20 degrees, and right and left lateral rotation limited to 30 degrees. The November 2019 VA examiner indicated that passive range of motion of the spine was not performed because it was not feasible to perform in a safe and reasonable manner. The examiner also indicated that non-weightbearing assessment was not applicable. The examiner noted that there was no objective evidence of pain when the spine was in a non-weightbearing position at rest and the opposing joint assessment was not applicable because the spine does not have an opposing joint. The VA examiners found that the Veteran’s low back and cervical spine disabilities impacted his ability to work, as he had difficulty turning to his neck and walking, standing and sitting for more than 20 minutes. See, e.g., VA examination report (November 2019). The Board notes that the November 2019 VA examiner was the only examiner who provided estimated range of motion of the low back and cervical spine during periods of pain, weakness, fatigability, flare ups and other symptoms. Furthermore, the November 2019 estimated range of motion of the low back and cervical spine were the worst recorded forward flexion for the low back and the worst combined range of motion for the cervical spine throughout the appeal period. As other examiners were unable to provide estimated ranges of motion of the low back and cervical spine during periods of pain, flare ups, and other symptoms and that there are no other recorded range of motion testing prior to December 2011, the above November 2019 range of motion findings will be applied throughout the appeal period. The Board finds that the November 2019 estimated range of motion of the low back and cervical spine during periods of pain, weakness, fatigability, flare ups, and other symptoms is the most favorable outcome for the Veteran, as the Veteran has reported that his low back and cervical spine disabilities have worsened throughout the appeal period. A. Low Back Disability 1. Initial higher ratings for the low back disability prior to November 27, 2019. For the following reasons, the Veteran’s low back disability more nearly approximated the criteria for a 40 percent rating under the General Rating Formula for Diseases and Injuries of the Spine prior to November 27, 2019. During this appeal period, the Veteran consistently reported low back flare ups, pain, pain upon walking and standing, muscle spasms, and functional impairment. He had low back muscle spasms and guarding that resulted in abnormal gait or abnormal spinal contour. Also, the evidence reflects that the Veteran’s forward flexion of lumbar spine was limited, at worst, to 30 degrees upon repetitive use-testing. The November 2019 VA examiner estimated that during periods of low back pain, weakness, fatigability, and flare ups, the Veteran’s forward flexion would be limited to 30 degrees. The Board resolves any reasonable doubt in the Veteran’s favor and finds that his forward flexion of the thoracolumbar spine more nearly approximated limitation to 30 degrees or less, as during this period. Accordingly, a 40 percent rating, but no higher, prior to November 27, 2019, for the low back disability is warranted. 2. A rating higher than 40 percent for the low back disability throughout the appeal period. For the following reasons, a rating higher than 40 percent for the low back disability throughout the appeal period is not warranted. As 40 percent is the highest schedular rating for limitation of motion (absent ankylosis), the Board does not have to consider whether he is entitled to a higher disability rating because of functional loss under §§ 4.40 and 4.45. See Johnston v. Brown, 10 Vet. App. 80, 85 (1997). In Johnston, the Court indicated that where the Veteran is in receipt of the maximum schedular evaluation based on limitation of motion and a higher rating requires ankylosis, the cited regulations are not for application. Id. at 84-85 (although the Secretary suggested remand because of the Board’s failure to consider functional loss due to pain, remand was not appropriate because higher schedular rating required ankylosis). The examination reports do not show unfavorable ankylosis of the entire thoracolumbar spine, which is required for the next higher rating. Rather, the VA examination reports contain specific findings of no ankylosis. Also, the Veteran’s statements do not indicate that there was ankylosis of the spine. Although VA must in some circumstances consider functional impairment in addition to limitation of motion due to factors such as pain, weakness, premature or excess fatigability, and incoordination, see DeLuca v. Brown, 8 Vet. App. 202, 204-7 (1995); 38 C.F.R. §§ 4.40, 4.45 (2017), this rule does not apply where, as here, the Veteran is receiving the maximum schedular evaluation based on limitation of motion and a higher rating requires ankylosis. See Johnston v. Brown, 10 Vet. App. 80, 84-5 (1997). In addition, the evidence indicates that the Veteran has not had incapacitating episodes with a duration of at least six weeks during the past 12 months, therefore a 60 percent rating is not warranted under the formula for rating IVDS. See VA examination reports (December 2011, April 2016, December 2016, November 2019). As the preponderance of the evidence is against a rating higher than 40 percent for the low back disability, the benefit-of-the-doubt doctrine is therefore not for application. 38 U.S.C. § 5107(b); 38 C.F.R. § 4.3. B. Cervical Spine Disability. 1. Initial higher ratings for the cervical spine disability prior to April 2, 2016. For the following reasons, prior to April 2, 2016, the Veteran’s cervical spine disability more nearly approximated the criteria for a 20 percent rating under the General Rating Formula for Diseases and Injuries of the Spine. During this appeal period, the Veteran consistently reported cervical spine flare ups, pain, pain when turning his neck, muscle spasms, and functional impairment. He had neck muscle spasms and guarding that resulted in abnormal gait or abnormal spinal contour. Also, the evidence reflects that the Veteran’s cervical spine disability was limited, at worst, for forward flexion to 30 degrees, extension to 10 degrees, right and left lateral flexion to 20 degrees, and right and left lateral rotation to 30 degrees. The November 2019 VA examiner considered the evidence of record and estimated that during periods of pain, weakness, fatigability, and flare ups, the Veteran’s range of motion would be limited to 30 degrees for flexion, extension limited to 5 degrees, right and left lateral flexion limited to 20 degrees, and right and left lateral rotation limited to 30 degrees, which results in a combined range of motion of the cervical spine to a total of 145 degrees. Therefore, the combined range of motion of the cervical of 145 degrees more nearly approximated the criteria in the 20 percent rating for the cervical spine under the General Rating Formula for Diseases and Injuries of the Spine. Accordingly, a 20 percent rating, but no higher, prior to April 2, 2016, for cervical spine disability is warranted. 2. A rating higher than 20 percent for the cervical spine disability throughout the appeal period. The evidence reflects that the Veteran’s cervical spine disability manifested by pain, muscle spasms, functional loss, and limitation of motion. As indicated, the November 2019 VA examination recorded the worst combined range of motion of the cervical spine during the appeal period—limited to a total of 145 degrees. The Veteran is competent to report the symptoms associated with his service connected cervical spine disability and the extent of his impairment during flare-ups of symptoms and following repetitive use, and the Board has no reason to challenge the credibility of his contentions. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007); Buchanan v. Nicholson, 451 F.3d 1331, 1337 (Fed. Cir. 2006). Regardless of the competent and credible reports of flare ups, pain, and other functional impairments, the preponderance of the evidence nonetheless supports the conclusion that the Veteran’s cervical spine symptoms have most closely approximated the criteria for a 20 percent rating under General Rating Formula for Diseases and Injuries of the Spine during the entire claim period. Importantly, the November 2019 VA examiner considered the Veteran’s reports of pain, flare ups, and functional impairments, and found that the combined range of motion of the cervical spine would be limited to a total of 145 degrees during periods of pain, flare ups, and other symptoms. Also, the November 2019 examiner estimated that during periods of pain and flare ups, the Veteran’s flexion would be limited to 30 degrees. The evidence reflects that the flare ups and other functional impairments have not been so severe, frequent and/or prolonged to warrant the next higher percent ratings. A preponderance of the evidence shows that even considering pain, flare ups, and other functional factors, the Veteran’s cervical spine symptoms have not been shown to have been so disabling to actually or effectively result in limitation of flexion more nearly approximating 15 degrees, which is shown in the rating criteria for the next higher rating, a 30 percent rating under General Rating Formula for Diseases and Injuries of the Spine. Moreover, the Veteran’s examination reports do not show favorable or unfavorable ankylosis of the cervical spine or of the entire thoracolumbar spine, which is required for the next higher ratings. Rather, the examination reports contain specific findings of no ankylosis. Also, the Veteran’s statements do not indicate that there was ankylosis of the spine. The evidence indicates that the Veteran has not had incapacitating episodes with a duration of at least six weeks during the past 12 months, therefore a 60 percent rating is not warranted under the formula for rating IVDS. See VA examination reports (December 2011, April 2016, December 2016, November 2019). As the preponderance of the evidence is against a rating higher than 20 percent for the cervical spine disability, the benefit-of-the-doubt doctrine is therefore not for application. 38 U.S.C. § 5107(b); 38 C.F.R. § 4.3. REASONS FOR REMAND The issue of SMC based on housebound status and/or the need for aid and attendance is remanded. The Veteran has not been afforded an examination for purposes of assessing housebound status or the need for regular aid and attendance. Notably, although an August 2020 examiner provided an opinion as to whether the Veteran’s low back and cervical spine disabilities impacted his ability to perform his activities of daily living, the examiner did not consider the Veteran’s service-connected disabilities collectively. As such, a remand is necessary to obtain an examination regarding his claim for SMC based on housebound status and/or the need for aid and attendance. The matter is REMANDED for the following action: Schedule the Veteran for an examination regarding his claim for SMC based on housebound status and/or the need for aid and attendance. The examiner should opine as to whether it is at least as likely as not (50 percent or greater probability) that the Veteran is in need of the regular aid and attendance of another individual and/or is permanently housebound due to his service-connected disabilities. The examiner should review the record. In determining the need for aid and attendance, the examiner’s considerations must include, but are not limited to, whether the Veteran is able to dress or undress himself, keep himself ordinarily clean and presentable, adjust any special prosthetic or orthopedic appliances which by reason of the particular disability cannot be done without aid, feed himself, attend to the wants of nature, and/or protect himself from the hazards or dangers of his daily environment. With regard to housebound status, the examiner must opine as to whether the Veteran’s service-connected disabilities alone substantially confine him to his dwelling and the immediate premises or, if institutionalized, to a ward or clinical area, and it is reasonably certain that the disability or disabilities and resultant confinement will continue throughout his lifetime. The examiner must provide a rationale for the opinion. JAMES L. MARCH Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board A. Castillo, 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.