Citation Nr: 21001313 Decision Date: 01/07/21 Archive Date: 01/07/21 DOCKET NO. 13-18 103 DATE: January 7, 2021 ORDER Entitlement to an initial rating of 10 percent, but no higher, prior to April 18, 2019, for bruxism is granted. Entitlement to an initial rating in excess of 50 percent from April 18, 2019 forward for bruxism is denied. Entitlement to an initial rating in excess of 20 percent for thoracolumbar degenerative disc disease is denied, excluding the period during which a temporary total rating pursuant to 38 C.F.R. § 4.30 was assigned. FINDINGS OF FACT 1. Prior to April 18, 2019, the Veteran’s bruxism was manifested by grinding teeth, worn teeth, removed teeth and pain in the temporomandibular joint, but not by abnormal interincisal range. 2. From April 18, 2019 forward, the Veteran’s bruxism was manifested by interincisal range from 0 to 10 millimeters with dietary restriction to all mechanically altered foods. 3. Throughout the period on appeal, the Veteran’s thoracolumbar degenerative disc disease was manifested by pain, aching, flare-ups occurring two to three times per month and lasting two to five days, and limitation of flexion to 35 degrees at worst. CONCLUSIONS OF LAW 1. The criteria for an initial rating of 10 percent, but no higher, prior to April 18, 2019 for bruxism have been met. 38 U.S.C. § 1155; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.40, 4.45, 4.59, 4.150, Diagnostic Code 9905. 2. The criteria for an initial rating in excess of 50 percent from April 18, 2019 forward for bruxism have not been met. 38 U.S.C. § 1155; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.40, 4.45, 4.59, 4.150, Diagnostic Code 9905. 3. The criteria for an initial rating in excess of 20 percent for a low back disability have not been met. 38 U.S.C. § 1155; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5242. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from January 1978 to April 1978. This matter is before the Board of Veterans’ Appeals (Board) on appeal from a rating decision issued in February 2013, July 2016, and November 2016 by a Department of Veterans Affairs (VA) Regional Office (RO). By way of background, in February 2013 the RO denied entitlement to a total disability rating based on individual unemployability (TDIU). In July 2016, the RO granted service connection for thoracolumbar degenerative disc disease (“low back disability”), assigning a 20 percent rating effective February 22, 2012. In November 2016, the RO granted service connection for bruxism, assigning a noncompensable rating effective September 8, 2016. The Veteran separately perfected appeals of the denial of a TDIU and the ratings assigned for the low back disability and bruxism. The issues have been combined into a single appeal for the purposes of Board review. During the pendency of the above appeals, in February 2017 the RO granted a temporary total rating for the lumbar DDD pursuant to 38 C.F.R. § 4.30. As the Veteran is therefore in receipt of a 100 percent rating for the lumbar DDD from June 26, 2016 to September 1, 2016, the Board need not address that portion of the appellate period herein. See Ab v. Brown, 6 Vet. App. 35 (1993). The Veteran and his spouse testified at a hearing before the undersigned Veterans Law Judge (VLJ) in December 2017. A transcript of the hearing is of record. The Board most recently remanded the issues on appeal for additional development in June 2018. VA treatment records were obtained, and the requested medical examinations were obtained in April 2019. As such, the directives have been substantially complied with and the matter is again properly before the Board. D’Aries v. Peake, 22 Vet. App. 97, 105 (2008); Stegall v. West, 11 Vet. App. 268, 271 (1998). In a decision issued in May 2019 the RO granted entitlement to a TDIU, effective April 18, 2019. This effective date was then revised in an August 2019 rating decision so that the award of a TDIU was effective June 16, 2016. As this constitutes a full grant of the benefits sought from that date forward, entitlement to a TDIU is moot from June 16, 2016 forward. Id. As to the period prior to June 16, 2016 forward, the Board notes that in response to the August 2019 rating decision awarding a new effective date of June 16, 2016, the Veteran, through his attorney, filed an appeal to the Board as to the assigned effective date, and requested a hearing before a VLJ. Generally, a grant of entitlement to a TDIU that does not span the entire period on appeal does not bifurcate the issue of entitlement to a TDIU. Harper v. Wilkie, 30 Vet. App. 356, 359–62 (2018). However, this case is distinguishable from Harper, in two respects. First, the Veteran’s TDIU claim in this case did not arise as part and parcel of an increased rating claim, and instead stems from an informal claim received on February 22, 2013, the day on which the Veteran filed a claim for service connection for the low back disability. Thus, the TDIU claim is not part and parcel of either of the increased rating claims on appeal, and indeed predated the existence of either increased rating claim on appeal by several years. Second, unlike in Harper and the other cases cited therein, the Veteran and his attorney elected to separately appeal the effective date assigned for the award of TDIU to the Board and further specifically requested a hearing on that particular issue. As the TDIU claim was not part and parcel of the increased rating claims on appeal and the Veteran and his attorney elected to separately appeal the effective date assigned, and requested a hearing, the Board finds that Harper does not control in this case. As such, the award of a TDIU, and the Veteran and his attorney’s subsequent appeal of the assigned effective date and request for a hearing, bifurcated the issue of entitlement to a TDIU from the current appeal. As such, the issue of entitlement to a TDIU is no longer before the Board. The appeal of the assigned effective date for the award of a TDIU will be the subject of a Board decision issued at a later date. The Board notes that entitlement to special monthly compensation (SMC) has been found to be an inferable issue when a veteran is requesting increased benefits. Akles v. Derwinski, 1 Vet. App. 118 (1991). To this end, in September 2019 the Veteran filed a claim for SMC based on housebound status or the need for aid and attendance (A&A). Entitlement to SMC was denied in a November 2019 agency of original jurisdiction (AOJ) decision. 38 C.F.R. § 3.2400(a). In December 2019, the Veteran appealed the denial of SMC to the Board and requested a hearing before a Veterans Law Judge (VLJ). 38 C.F.R. §§ 3.2500(a)(1)(ii), 20.202, 20.203. As the December 2019 appeal is being processed in a separate appellate system from the one that is the subject of this decision, the Board cannot address the SMC claim in this decision. Further, as the Veteran has requested a hearing on that issue, to decide the SMC claim as part and parcel of the increased rating claims on appeal would deprive the Veteran the opportunity to have a hearing on that issue before it is decided, and thus deprive him of due process. As such, the claim for SMC will be the subject of a Board decision at a later date. Finally, the Board also acknowledges that as part of the December 2019 appeal the Veteran and his attorney have requested a hearing on the issue of entitlement to an increased rating for a low back disability, the same issue that is currently part of this appeal. However, as the appeal currently before the Board and the December 2019 appeal are being processed under different appellate systems, the two appeals cannot be combined. As such, the Board will issue its decision on the legacy appeal currently before it, and the December 2019 appeal will be the subject of a later Board decision as needed. Increased Rating Disability evaluations are determined by the application of the facts presented to VA’s Schedule for Rating Disabilities (Rating Schedule) at 38 C.F.R. Part 4. The percentage ratings contained 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 the residual conditions in civilian occupations. 38 U.S.C. § 1155; 38 C.F.R. §§ 3.321(a), 4.1. In evaluating the severity of a particular disability, it is essential to consider its history. 38 C.F.R. § 4.1; Peyton v. Derwinski, 1 Vet. App. 282 (1991). Where entitlement to compensation has already been established and an increase in the disability rating is at issue, the present level of disability is of primary importance. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). Nevertheless, the Board acknowledges that a claimant may experience multiple distinct degrees of disability that might result in different levels of compensation from the time the increased rating claim was filed until a final decision is made. Hart v. Mansfield, 21 Vet. App. 505 (2007). The analysis in the following decision is therefore undertaken with consideration of the possibility that different ratings may be warranted for different time periods. If the evidence for and against a claim is in equipoise, the claim will be granted. 38 C.F.R. § 4.3. A claim will be denied only if the preponderance of the evidence is against the claim. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; see Gilbert v. Derwinski, 1 Vet. App. 49, 56 (1990). Any reasonable doubt regarding the degree of disability should be resolved in favor of the claimant. 38 C.F.R. § 4.3. Where there is a question as to which of two evaluations shall be applied, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that evaluation. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. When evaluating disabilities of the musculoskeletal system, functional loss due to pain and weakness causing additional disability beyond that reflected on range of motion measurements must be considered. 38 C.F.R. § 4.40; see DeLuca v. Brown, 8 Vet. App. 202 (1995). Consideration must also be given to weakened movement, excess fatigability and incoordination. 38 C.F.R. § 4.45. 1. Entitlement to an increased rating for bruxism. The Veteran’s bruxism is currently rated under Diagnostic Code 9905. Under Diagnostic Code 9905, a 10 percent rating is warranted for lateral excursion range of motion from 0 to 4 millimeters (mm.). 38 C.F.R. § 4.150, Diagnostic Code 9905. A 10 percent rating is warranted for interincisal range limited to 30 to 34 mm. of maximum unassisted vertical opening without dietary restriction to mechanically altered foods. Id. A 20 percent rating is warranted for the same degree of limitation with dietary restriction to soft and semi-solid foods. Id. A 30 percent rating is warranted for the same degree of limitation with dietary restriction to full liquid and pureed foods. Id. A 20 percent rating is warranted for interincisal range limited to 21 to 29 mm. of maximum unassisted vertical opening without dietary restrictions to mechanically altered foods. Id. A 30 percent rating is warranted for the same degree of limitation with dietary restriction to soft and semi-solid foods. Id. A 40 percent rating is warranted for the same degree of limitation with dietary restriction to full liquid and pureed foods. Id. A 30 percent rating is warranted for interincisal range limited to 11 to 20 mm. of maximum unassisted vertical opening without dietary restrictions to mechanically altered foods. Id. A 40 percent rating is warranted for the same degree of limitation with dietary restriction to all mechanically altered foods. Id. Finally, a 40 percent rating is warranted for interincisal range limited to 0 to 10 mm. of maximum unassisted vertical opening without dietary restrictions to mechanically altered foods. Id. A 50 percent rating is warranted for the same degree of limitation with dietary restriction to all mechanically altered foods. Id. Ratings for limited interincisal movement are not to be combined with ratings for limited lateral excursion. Id., Note 1. For VA compensation purposes, the normal maximum unassisted range of cervical jaw opening is from 35 to 50 mm. Id., Note 2. Mechanically altered foods are defined as altered by blending, chopping, grinding, or mashing so that they are easy to chew and swallow. Id., Note 3. There are four levels of mechanically altered foods: full liquid, puree, soft, and semisolid foods. Id. To warranted elevation based on mechanically altered foods, the use of texture modified diets must be recorded or verified by a physician. Id. During the period on appeal, the Veteran has reported that due to his bruxism he has worn down his teeth substantially. During his hearing before the undersigned, the Veteran further stated that he grinds his teeth which caused him to lose some and wore the remaining teeth down. The Veteran further testified that he experienced temporomandibular joint (TMJ) pain two to three times a day, particularly when eating and opening his mouth. The Veteran is competent to report such symptoms and there is no evidence that he is not credible. Jandreau, 492 F.3d 1372. As such, the statements are entitled to probative weight as to the severity of his disability. The Veteran was provided with VA examinations in October 2016 and April 2019. In October 2016 the Veteran reported that he would grind his teeth. The examiner noted that there was no anatomical loss or bony injury of the mandible or maxilla, or any anatomical loss or bony injury or any teeth. There was no anatomical loss or injury of the mouth, lips or tongue, nor any evidence of osteomyelitis, tumors or neoplasms. A dental x-ray taken was noted to be normal. In April 2019 the Veteran reported gum and TMJ pain which ranged from shooting pain to achiness, but denied flare-ups of the disability. Sharp v. Shulkin, 29 Vet. App. 26, 34–36 (2017). The Veteran further reported increased pain with chewing and speech difficulties. The examiner noted functional issues with chewing, swallowing and communication, as the Veteran’s speech would be unclear due to having his teeth removed. The examiner noted that the Veteran had interincisal distance of 0 to 10 mm., with lateral excursion greater than 4 mm. Pain was present on examination, as well as on passive range of motion and in weightbearing and non-weightbearing. Correia v. McDonald, 28 Vet. App. 158, 168 (2016). No further range of motion loss was present after repetitive testing. Finally, the examiner noted that the Veteran had dietary restriction to all mechanically altered foods, to include full liquid, puree foods, soft foods and semi-solid foods. There is no evidence that the above examiners were either not competent or credible. Further, both assessments of the disability were based on both the Veterans reports of his symptoms and each examiner’s own objective examination of the dental disability. As such, the Board finds that each respective examination report is entitled to significant probative weight as to the severity of the Veteran’s disability during the period on appeal. Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). Treatment records reflect that the Veteran has received continuous VA dental treatment for his bruxism, including the removal of his teeth in March 2018. However, none of the records show that the Veteran was prescribed a texture modified diet by either medical or dental professionals, nor do any of the records contain any information concerning the Veteran’s interincisal range. Based on the foregoing, an increased rating of 10 percent, but no higher, is warranted prior to April 18, 2019. The evidence of record, specifically the Veteran’s lay testimony, reflects that the Veteran’s bruxism resulted in TMJ pain. While there is no evidence that the Veteran had limitation of interincisal range of lateral excursion range during this period, the presence of painful motion of a joint requires the assignment of the minimal compensable rating under a particular Diagnostic Code. 38 C.F.R. § 4.59. As such, a 10 percent rating for bruxism is warranted prior to April 18, 2019. 38 C.F.R. § 4.150, Diagnostic Code 9905. However, an increased rating in excess of 10 percent prior to April 18, 2019 is not warranted. The evidence of record reflects only that the Veteran would grind his teeth, and as a result experienced TMJ pain and had his teeth eventually removed and replaced in March 2018. None of the evidence prior to that date reflects any limitation of interincisal range or lateral excursion. As there is no evidence of limited interincisal range prior to April 18, 2019, the Veteran’s disability did not more nearly approximate the level of severity contemplated by higher rating for TMJ disabilities. Further, none of the evidence reflects that prior to April 18, 2019, the Veteran TMJ disability resulted in any dietary restrictions. Dietician notes throughout the period prior to April 18, 2019 show that the Veteran was eating a wide range of foods, including sandwiches, vegetables, hamburgers, chicken, chips, cookies and hard candy. While a February 2018 dietician record noted that following his March 2018 surgery to have his teeth removed the Veteran would have to significantly change his diet, subsequent records also do not reflect that the Veteran’s was required to mechanically alter his food. Indeed, dietician records from prior and subsequent to the March 2018 surgery generally reflect that the Veteran’s diet remained largely the same, as he continued to eat a variety of foots including hamburgers, sandwiches, potatoes, bread and crackers, and continued to eat out at restaurants on a regular basis. There is no evidence that the Veteran had to mechanically alter any of the foods noted in the dietician records. 38 C.F.R. § 4.150, Diagnostic Code 9905, Note 3. Based on the foregoing, there is no evidence of limitation of interincisal range accompanied by any dietary restrictions prior to the April 18, 2019 VA examination report. As such, a rating in excess of 10 percent prior to that date is not warranted in this case. 38 C.F.R. §§ 4.3, 4.7, 4.150, Diagnostic Code 9905. Concerning the period from April 18, 2019 forward, the Veteran is already in receipt of the maximum allowable rating for TMJ disorders. As such, an increased rating from April 18, 2019 forward is not warranted in this case. 38 C.F.R. §§ 4.3, 4.7, 4.150, Diagnostic Code 9905. No additional higher or alternative ratings under different Diagnostic Codes can be applied. While the Veteran testified to having an overbite during his hearing before the undersigned, there is no medical evidence reflecting malunion or nonunion of the mandible at any point during the period on appeal, with the October 2016 examiner specifically noting that there were no disabilities affecting the mandible or maxilla. 38 C.F.R. § 4.150, Diagnostic Codes 9903, 9904. Further, while the Veteran has had all of his teeth removed, the medical evidence reflects that this was not the result of loss of substance of the body of the maxilla or mandible, with the October 2016 examiner again having noted that there were no disabilities of the maxilla or mandible present on examination. 38 C.F.R. § 4.150, Diagnostic Code 9900 to 9902, 9913. All potentially applicable Diagnostic Codes have been considered. See Schafrath v. Derwinski, 1 Vet. App. 589, 593 (1991). Based on the evidence, an increased rating of 10 percent prior to April 18, 2019 is warranted in this case. However, the preponderance of the evidence is against an initial rating in excess of 10 percent prior to April 18, 2019, and in excess of 50 percent thereafter for the Veteran’s service-connected bruxism. As such, the benefit-of-the-doubt doctrine is inapplicable. 38 C.F.R. § 4.3. For these reasons, the claim is denied. 2. Entitlement to an increased rating for a low back disability. The Veteran’s low back disability is rated under Diagnostic Code 5242. All spine disabilities covered by Diagnostic Codes 5235 to 5242 are rated according to the General Rating Formula for Diseases and Injuries of the Spine (General Formula) based on limitation of motion. 38 C.F.R. § 4.71a, General Formula. Under the General Formula, the spine is evaluated 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. Under the General Formula, a 20 percent rating is warranted for forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees, combined range of motion of the thoracolumbar spine not greater than 120 degrees, muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. Id. A 40 percent rating is warranted for forward flexion of the thoracolumbar spine of 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 unfavorable ankylosis of the entire spine. 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. For VA compensation purposes, normal forward flexion of the thoracolumbar spine is zero to 90 degrees, extension is zero to 30 degrees, left and right lateral flexion are zero to 30 degrees, and left and right lateral rotation are zero to 30 degrees. Id. at Note 2. 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 lateral rotation, with the normal combined range of motion of the thoracolumbar spine being 240 degrees. Id. Unfavorable ankylosis is a condition in which the entire thoracolumbar spine is fixed in flexion or extension, and the ankylosis results in one of 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. Id. at Note 5. Fixation of a spinal segment in neutral position always represents favorable ankylosis. Id. Back disabilities may also be evaluated under the Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes (Incapacitating Episodes Formula), which applies to Intervertebral Disc Syndrome (IVDS). See 38 C.F.R. § 4.71a, Incapacitating Episodes Formula. An “incapacitating episode” for purposes of totaling the cumulative time is defined as “period of acute signs and symptoms due to intervertebral disc syndrome that requires bed rest prescribed by a physician and treatment by a physician.” 38 C.F.R. § 4.71a, Diagnostic Code 5243, Incapacitating Episodes Formula, Note 1. During the period on appeal, the Veteran has stated that he experiences significant back pain and reduced range of motion. During his December 2017 hearing, the Veteran and his spouse again reported significant back pain and limitation of motion. Both also stated that the Veteran’s back disability requires him to lay in bed and that he has significant limitation with walking and ambulating due to his low back pain. These statements are competent and there is no evidence they are not credible. Jandreau, 492 F.3d 1372. As such, they are entitled to probative weight as to the severity of the Veteran’s low back disability. The Veteran was provided with VA examinations in November 2015, April 2019 and November 2019. In November 2015 the Veteran reported symptoms of pain and limitation of motion, with limitations on walking, standing and bending. The Veteran further reported flare-ups of the disability manifested by increased pain. The examiner noted the Veteran was capable of forward flexion to 55 degrees, with no further loss of motion after repetitive testing. Pain was present on motion in all planes, as well as on weightbearing. The examiner stated that there was no evidence of ankylosis, IVDS, or loss of use. In April 2019, the Veteran reported aching as well as sharp pain radiating into his lower extremities. The Veteran denied flare-ups of the disability. Sharp, 29 Vet. App. at 34–36. The examiner noted that the Veteran was capable of forward flexion to 70 degrees, with pain present in all planes. Pain was also present on weightbearing, but not with non-weightbearing. The examiner stated that passive range of motion testing could not be conducted as it was not safe to do so. Correia, 28 Vet. App. at 168. There was no further loss of motion after repetitive testing. The examiner stated that there was no evidence of ankylosis of the spine or loss of use of the extremities. The examiner did note that the Veteran had a diagnosis of IVDS, but stated that there were no incapacitating episodes, i.e. periods of physician prescribed bed rest and treatment by a physician. In November 2019 the Veteran reported constant pain, stiffness, spasms, aching, and burning. The Veteran further reported flare-ups of the disability occurring two to three times per month and lasting approximately two to five days each. The examiner noted that the Veteran was capable of forward flexion to 35 degrees, with pain present in all planes. The examiner noted that there was no evidence of pain on weightbearing or non-weightbearing, and that testing for pain on passive motion was not possible as such testing could not be conducted in a safe manner. Correia, 28 Vet. App. at 168. The examiner further estimated that during the flare-ups the Veteran would be capable of forward flexion to 35 degrees. Sharp, 29 Vet. App. at 34–36. The examiner stated that there was a diagnosis of IVDS, but that there were no periods of acute symptoms requiring physician prescribed bed rest and physician treatment. There was no evidence of ankylosis of loss of use of the extremities. There is no evidence that the above examiners were either not competent or credible. The Board notes that the required testing for pain and an estimate concerning range of motion loss during flare-ups were not obtained during the November 2015 VA examination. However, such testing and estimates have since been conducted or provided in subsequent examinations, and therefore the defect in the November 2015 examination has been cured. Otherwise, each assessment was based on the Veteran’s own account of his symptoms and the examiner’s objective examination of the lumbar spine. As such, the Board finds that each respective examination report is entitled to significant probative weight as to the severity of the Veteran’s disability during the period on appeal. Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). In December 2017 the Veteran submitted an assessment of his low back disability conducted by a private examiner. The examiner noted that the Veteran reported severe pain in his low back and that he had trouble walking. The examiner further stated that on examination the Veteran had decreased range of motion of the lumbar spine, as well as spasms, tenderness and radiating pain. On an accompanying sheet the examiner noted that the Veteran had forward flexion to 40 degrees, unfavorable ankylosis of the entire thoracolumbar spine, and IVDS with incapacitating episodes totaling more than six weeks in the past 12 months. Private and VA treatment records during the period on appeal reflect on-going treatment for a low back disability, with consistent reports of low back pain, limitation of motion and limitations on prolonged walking and standing. However, the records do not contain any further range of motion testing. Further, none of the records reflect that the Veteran was prescribed bed rest by either a VA or private physician or received treatment from a VA or private physician for a period of acute signs and symptoms of his IVDS. Based on the foregoing, the preponderance of the evidence is against an increased rating in excess of 20 percent for the low back disability. Both the VA examiners and the private examiner noted that the Veteran was capable of forward flexion to greater than 30 degrees. Further, in estimating the Veteran’s range of motion, the most recent examiner specifically considered additional loss due to pain and other factors and during flare-ups of the disability. However, even when considering the Veteran’s reports of his symptoms during flare-ups the examiner noted that during a flare-up the Veteran was still capable of forward flexion in excess of 30 degrees. 38 C.F.R. §§ 4.40, 4.45, 4.59. Further, each of the VA examiners noted that no further limitation of motion was elicited following observed repetitive testing due to pain, incoordination or other factors. As such, an increased rating based on limitation of motion, even when considering further functional loss during flare-ups and other factors, is not warranted in this case. 38 C.F.R. §§ 4.3, 4.7, 4.71a, Diagnostic Code 5242. The Board notes that the private examiner noted that the Veteran had unfavorable ankylosis of the entire thoracolumbar spine, which generally would warrant an increased rating for the low back disability. However, none of the other medical or lay evidence of record reflects that the Veteran’s thoracolumbar spine is fixed in flexion or extension, nor is there any evidence of the accompanying symptoms required for a finding of unfavorable ankylosis for VA purposes. 38 C.F.R. § 4.71a, General Formula, Note 5. Indeed, the examiner’s statement that the Veteran has unfavorable ankylosis is contradicted by his own range of motion findings, in which he noted that the Veteran was capable of forward flexion, extension, right and left lateral flexion and right and left lateral rotation to at least some degree. As such, the Board finds that the preponderance of the evidence is against a finding that the low back disability is manifested by unfavorable ankylosis of the thoracolumbar spine. As such, an increased rating in excess of 20 percent for the low back disability is not warranted based on ankylosis of the spine. 38 C.F.R. §§ 4.3, 4.7, Diagnostic Code 4.71a, Diagnostic Code 5242. No additional higher or alternative ratings under different Diagnostic Codes can be applied. The Veteran has been diagnosed with IVDS, and therefore may be rated based on incapacitating episodes. See 38 C.F.R. § 4.71a, Diagnostic Code 5243, Incapacitating Episodes Formula, Note 1. To this end, the Veteran and his spouse, both of whom are nurses, stated that his low back disability requires bed rest. Further, the June 2017 private opinion noted that the Veteran had incapacitating episodes totaling more than six weeks during the past twelve months. As noted, an incapacitating episode for VA purposes is a period of acute signs and symptoms due to IVDS that requires bed rest prescribed by a physician and treatment by a physician. 38 C.F.R. § 4.71a, Incapacitating Episodes Formula, Note 1. First, while the Veteran and his spouse are nurses, and while they are also competent to report that the low back disability requires that the Veteran lay down for periods of time, the regulation requires physician prescribed bed rest. A physician is an individual who is an authorized practitioner of medicine, as one graduated from a college of medicine or osteopathy and licensed by the appropriate board. DORLAND’S ILLUSTRATED MEDICAL DICTIONARY 1443 (32d ed. 2012). Thus, by definition neither the Veteran nor his spouse are physicians, and therefore their own bed rest assessments do not constitute “physician prescribed bed rest” as contemplated by the formula. Id. at 1305–06, 1443. While the June 2017 examiner noted that the Veteran had incapacitating episodes totalling greater than six weeks in the past twelve months, this statement did not constitute an actual prescription for bed rest and instead was offered as an assessment of the severity of the disability. Further, the examiner provided no rationale or basis for the conclusion that the Veteran was prescribed bed rest by a physician for any length of time, thus rendering the assessment of minimal weight. McLendon v. Nicholson, 20 Vet. App. 79, 85 (2006) (opinions that are general in nature do not provide a sufficient basis upon which to support a claim). Finally, the assertions concerning prescribed bed rest are directly contradicted by the numerous VA and private treatment records associated with the file. Despite records documenting years of treatment for low back pain, there is no evidence in either the private or VA treatment records that the Veteran has ever been prescribed bed rest by his treating physicians for a period of acute symptoms of IVDS, nor is there any evidence that such a period of acute symptoms also required physician treatment. In addition, after reviewing the medical evidence of record each of the three VA examiners stated that there was no evidence that the Veteran had any periods of acute symptoms requiring prescribed bed rest and physician treatment. In light of the foregoing, the Board finds that the preponderance of the evidence is against a finding that the Veteran’s IVDS is manifested by incapacitating episodes as defined by the regulation. As such, an increased rating is not warranted under the Incapacitating Episodes Formula. 38 C.F.R. §§ 4.3, 4.7, 4.71a, Diagnostic Code 5243. When evaluating disabilities of the spine, any associated objective neurologic abnormalities are to be rated separately under an applicable Diagnostic Code. 38 C.F.R. § 4.71a, General Formula, Note 1. Here, service connection for the Veteran’s left and right lower extremity radiculopathy affecting the sciatic nerve bilaterally has already been granted, and therefore those neurologic abnormalities are already contemplated by their assigned ratings. No other neurologic abnormalities have been noted as being associated with the Veteran’s low back disability. As such, additional separate compensable ratings during the period on appeal are not warranted. 38 C.F.R. § 4.71a, General Formula, Note 1. All potentially applicable Diagnostic Codes have been considered. See Schafrath, 1 Vet. App. at 593. The preponderance of the evidence is against an initial rating in excess of 20 percent for the Veteran’s service-connected low back disability. As such, the benefit-of-the-doubt doctrine is inapplicable. 38 C.F.R. § 4.3. For these reasons, the claim is denied. LESLEY A. REIN Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board C. Wendell, 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.