Citation Nr: 21001417 Decision Date: 01/08/21 Archive Date: 01/08/21 DOCKET NO. 17-58 932 DATE: January 8, 2021 ORDER Entitlement to a rating of 40 percent, but not greater, for degenerative arthritis of the lumbar spine from August 27, 2012 is granted. Restoration of the 20 percent disability rating for service-connected chondromalacia, effective February 1, 2013, is granted. Entitlement to a rating greater than 20 percent, for chondromalacia of the right knee, for the entire period on appeal, is denied. Entitlement to a separate rating of 10 percent for painful motion, but not greater, for chondromalacia of the right knee, is granted. Entitlement to an initial compensable rating for a service-connected surgical scar on the pelvis is denied. Entitlement to a rating greater than 70 percent for service-connected major depressive disorder is denied. Entitlement to an initial compensable rating for radiculopathy of the right internal saphenous nerve is denied. Entitlement to an initial compensable rating for radiculopathy of the right obturator nerve is denied. Entitlement to an initial compensable rating for radiculopathy of the right external cutaneous nerve is denied. Entitlement to an initial compensable rating for radiculopathy of the right ilio-inguinal nerve is denied. Entitlement to an effective date earlier than June 27, 2015 for the grant of a separate compensable rating for radiculopathy of the right internal saphenous nerve is denied. Entitlement to an effective date earlier than September 14, 2017 for the grant of a separate compensable rating for radiculopathy of the right obturator nerve is denied. Entitlement to an effective date earlier than September 14, 2017 for the grant of a separate compensable rating for radiculopathy of the right external cutaneous nerve is denied. Entitlement to an effective date earlier than September 14, 2017 for the grant of a separate compensable rating for radiculopathy of the right ilio-inguinal nerve is denied. Entitlement to an effective date of November 25, 2008, but not earlier, for the grant of service connection for a surgical scar of the pelvis is granted. REMANDED Entitlement to a separate compensable rating of 20 percent for left lower extremity radiculopathy is remanded. Entitlement to a rating for radiculopathy of the right sciatic nerve greater than 10 percent from January 22, 2013, and greater than 40 percent from June 27, 2015 is remanded. FINDINGS OF FACT 1. The appellant’s service-connected arthritis of the lumbar spine, when considering additional functional loss during flare-ups and after repeated use over time, has manifested with symptoms analogous to forward flexion limited to 30 degrees or less from August 27, 2012. At no time during the period on appeal has the appellant’s disability, even when considering additional functional loss during flare-ups or after repeated use over time, manifested with symptoms analogous to unfavorable ankylosis of the entire thoracolumbar spine. 2. In a November 2012 rating decision, the appellant’s rating for his service-connected chondromalacia of the right knee, rated under 38 C.F.R. § 4.71a, Diagnostic Code 5257, was reduced from 20 percent to 10 percent, effective February 1, 2013. The 20 percent rating had been in effect since June 12, 2000, a period greater than 5 years but less than 20 years. The reduction did not result in a reduction in the appellant’s overall disability rating or in a reduction of compensation payments. 3. The evidence of record at the time of the November 2012 rating decision did not clearly reflect a material improvement in the appellant’s service-connected chondromalacia of the right knee. 4. The appellant’s chondromalacia of the right knee does not manifest with symptoms more nearly approximating severe recurrent subluxation or lateral instability. 5. The appellant’s chondromalacia of the right knee manifests with symptoms of painful flexion of the knee, with noncompensable range of motion. 6. The appellant’s surgical scar of the pelvis covers a total area of 1.8 centimeters square, is linear and superficial, does not manifest with pain, and causes no additional functional limitation. 7. The severity, frequency, and duration of the appellant’s symptoms related to his service-connected major depressive disorder do not more closely approximate total occupational and social impairment. 8. The appellant’s radiculopathy of the right internal saphenous nerve manifests with symptoms approximating no more than moderate severity. 9. The appellant’s radiculopathy of the right obturator nerve manifests with symptoms approximating no more than moderate severity. 10. The appellant’s radiculopathy of the right external cutaneous nerve manifests with symptoms approximating no more than moderate severity. 11. The appellant’s radiculopathy of the right ilio-inguinal nerve manifests with symptoms approximating no more than moderate severity. 12. Separate service connection claims were never filed for radiculopathy of the right internal saphenous, obturator, external cutaneous, and ilio-inguinal nerves. The earliest ascertainable onset of the appellant’s radiculopathy of the right internal saphenous nerve was June 27, 2015. The earliest ascertainable onset of the appellant’s radiculopathy of the obturator, external cutaneous, and ilio-inguinal nerves was September 14, 2017. 13. The appellant was left with a residual scar following surgery he had to treat his service-connected lumbar spine disability. The surgery was completed on November 25, 2008. CONCLUSIONS OF LAW 1. The criteria for a disability rating of 40 percent, but not greater, for degenerative arthritis of the lumbar spine from January 22, 2013, are met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, Diagnostic Code 5242. 2. The reduction of the rating for chondromalacia of the right knee from 20 percent to 10 percent, effective February 1, 2013, was improper. Restoration of the 20 percent rating, effective February 1, 2013, is warranted. 38 U.S.C. §§ 1155, 5112, 5107; 38 C.F.R. §§ 3.105, 3.344, 4.71a, Diagnostic Code 5257. 3. The criteria for a rating in excess of 20 percent for chondromalacia of the right knee are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, Diagnostic Code 5257. 4. The criteria for a separate rating of 10 percent, but not greater, for painful noncompensable loss of flexion in the right knee due to service-connected chondromalacia are met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.59, 4.71a, Diagnostic Code 5260. 5. The criteria for a compensable rating during any of the period on appeal for a service-connected surgical scar on the pelvis are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.118, Diagnostic Code 7805. 6. The criteria for a disability rating in excess of 70 percent for major depressive disorder are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.126, 4.130, Diagnostic Code 9434. 7. The criteria for a compensable rating for radiculopathy of the right internal saphenous nerve have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.124a, Diagnostic Code 8527. 8. The criteria for a compensable rating for radiculopathy of the right obturator nerve have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.124a, Diagnostic Code 8528. 9. The criteria for a compensable rating for radiculopathy of the right external cutaneous nerve have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.124a, Diagnostic Code 8529. 10. The criteria for a compensable rating for radiculopathy of the right ilio-inguinal nerve have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.124a, Diagnostic Code 8530. 11. The criteria for an effective date earlier than June 27, 2015 for the grant of a separate evaluation for radiculopathy of the internal saphenous nerve of the right lower extremity are not met. 38 U.S.C. § 5110, 5107; 38 C.F.R. §§ 3.155, 3.156, 3.400. 12. The criteria for an effective date earlier than September 24, 2017 for the grant of a separate evaluation for radiculopathy of the obturator nerve of the right lower extremity are not met. 38 U.S.C. § 5110, 5107; 38 C.F.R. §§ 3.155, 3.156, 3.400. 13. The criteria for an effective date earlier than September 24, 2017 for the grant of a separate evaluation for radiculopathy of the external cutaneous nerve of the right lower extremity are not met. 38 U.S.C. § 5110, 5107; 38 C.F.R. §§ 3.155, 3.156, 3.400. 14. The criteria for an effective date earlier than September 24, 2017 for the grant of a separate evaluation for radiculopathy of the ilio-inguinal nerve of the right lower extremity are not met. 38 U.S.C. § 5110, 5107; 38 C.F.R. §§ 3.155, 3.156, 3.400. 15. The criteria for an effective date of November 25, 2008, but not earlier, for the grant of service connection for a surgical scar of the pelvis are met. 38 U.S.C. § 5110, 5107; 38 C.F.R. §§ 3.155, 3.156, 3.400. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The appellant served on active duty in the United States Navy from September 1986 to December 1989. This case comes before the Board of Veterans’ Appeals (Board) on appeal from a rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) which, in pertinent part, denied a rating greater than 20 percent for arthritis of the thoracolumbar spine, denied a rating greater than 10 percent for chondromalacia of the right knee, denied a rating greater than 70 percent for major depressive disorder, and granted a 10 percent rating for radiculopathy affecting the sciatic nerve of the right lower extremity. Additional disabilities related to the appellant’s lumbar spine disability, to include a residual surgical scar near the pelvis and radiculopathy of other nerve branches of the right lower extremity, and radiculopathy in the left lower extremity were all implicitly denied in these decisions. The denials of increased ratings for the lumbar spine disability and major depressive disorder were appealed in a notice of disagreement (NOD) received by VA in February 2015. A Statement of the Case (SOC) was issued by VA in November 2017. VA received the appellant’s Substantive Appeal (Form 9) in November 2017, perfecting the appeal and declining an optional Board hearing. The claims for an increased rating for the chondromalacia of the right knee and the initial rating assigned for right lower extremity radiculopathy were appealed in a NOD received by VA in June 2015. A SOC relating to these claims was issued in October 2017. VA received the appellant’s Form 9, declining an optional Board hearing in November 2017. The claims for an increased rating and earlier effective date for the grant of a separate evaluation for a surgical scar related to surgery the appellant underwent for his service-connected lumbar spine disability were appealed in a NOD received by VA in November 2017. The separate noncompensable evaluation for the scar had been granted in an October 2017 rating decision and assigned an effective date of August 26, 2009. A SOC relating to these claims was issued by VA in November 2017. VA received the appellant’s Form 9, declining an optional Board hearing in November 2017. The effective dates and initial noncompensable ratings for radiculopathy of the right internal saphenous, obturator, external cutaneous, and ilio-inguinal nerves were appealed in a NOD received by VA in December 2017. Separate evaluations for these nerves and the effective dates of those evaluations were granted in an October 2017 rating decision, with an effective date of June 27, 2015 being assigned for the internal saphenous nerve and an effective date of September 14, 2017 being assigned for the obturator, external cutaneous, and ilio-inguinal nerves. As these claims are part of the larger claim for an increased rating for the lumbar spine disability, and these do not represent the maximum allowable ratings for these disabilities for the entire period on appeal, the Board has jurisdiction over these ratings and their effective dates. See AB v. Brown, 6 Vet. App. 35, 38 (1993). The Board also notes that in an October 2017 rating decision, the RO granted the appellant a 40 percent rating for his degenerative arthritis of the lumbar spine, effective from September 14, 2017. Although a higher rating was granted in this rating decision, the issue remains in appellate status as described above, as the RO did not assign the maximum schedular rating for the period on appeal. See AB v. Brown, 6 Vet. App. 35, 38 (1993). Similarly, in a separate October 2017 rating decision, the RO granted the appellant a 40 percent rating, effective from June 27, 2015, for his radiculopathy of the sciatic nerve of the right lower extremity. As the RO did not assign the maximum schedular rating for the entire period on appeal, the issue remains in appellate status as described above. See AB v. Brown, 6 Vet. App. 35, 38 (1993). Increased Rating Disability evaluations are determined by the application of a schedule of ratings, which is based on the veteran’s average impairment of earning capacity. 38 U.S.C. § 1155; 38 C.F.R. § Part 4. Separate diagnostic codes identify the various disabilities. The basis of disability evaluations is the ability of the body to function under the ordinary conditions of daily life, including employment. Evaluations are based upon lack of usefulness of the part or system affected, especially in self-support. 38 C.F.R. § 4.10. Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. Any reasonable doubt regarding the degree of disability is resolved in favor of the Veteran. 38 C.F.R. § 4.3. In considering the severity of a disability, it is essential to trace the medical history of the Veteran. 38 C.F.R. §§ 4.1, 4.2, 4.41. Consideration of the whole-recorded history is necessary so that a rating may accurately reflect the elements of disability present. 38 C.F.R. § 4.2; Peyton v. Derwinski, 1 Vet. App. 282 (1991). Where a claimant appeals the initial rating assigned following an award of service connection, evidence contemporaneous with the claim for service connection and with the rating decision granting service connection would be most probative of the degree of disability existing at the time that the initial rating was assigned and should be the evidence used to decide whether an [initial] rating on appeal was erroneous. Fenderson v. West, 12 Vet. App. 119, 126 (1999). If later evidence obtained during the appeal period indicates that the degree of disability increased or decreased following the assignment of an initial rating, staged ratings may be assigned for separate periods of time based on facts found. Fenderson v. West, 12 Vet. App. 119, 126 (1999). The standard of proof to be applied in decisions on claims for VA benefits is set forth in 38 U.S.C. § 5107(b). Under that provision, VA shall consider all information and lay and medical evidence of record in a case before the Secretary with respect to benefits under laws administered by the Secretary. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107(b); see also Gilbert v. Derwinski, 1 Vet. App. 49 (1990). 1. Entitlement to a rating of 40 percent, but not greater, for degenerative arthritis of the lumbar spine from August 27, 2012 is granted. The appellant contends that his degenerative arthritis of the lumbar spine is more disabling than currently rated. He reports symptoms of pain, increasing with activity, that necessitates frequent changes in position, and limitations on doing activities such as exercise, yard work, and climbing ladders. The RO opened a claim for an increased rating for this disability based on receipt of a claim for a TDIU received on January 22, 2013. At the time he filed his claim, he was assigned a 20 percent rating for his degenerative arthritis of the lumbar spine, effective since June 4, 2009. The appellant’s arthritis of the lumbar spine is rated under 38 C.F.R. § 4.71a, Diagnostic Code 5242. Under the General Rating Formula for Diseases and Injuries of the Spine, a 10 percent rating is warranted for forward flexion of the thoracolumbar spine greater than 60 degrees but not greater than 85 degrees; or, combined range of motion of the thoracolumbar spine greater than 120 degrees but not greater than 235 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. A 20 percent rating is warranted for forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees; or the combined range of motion of the thoracolumbar spine not greater than 120 degrees; or, muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. A 40 percent rating is warranted for forward flexion of the thoracolumbar spine to 30 degrees or less; or, favorable ankylosis of the entire thoracolumbar spine. A 50 percent rating is warranted for unfavorable ankylosis of the entire thoracolumbar spine. A 100 percent evaluation is warranted for unfavorable ankylosis of the entire spine. 38 C.F.R. § 4.71a, General Rating Formula for Diseases and Injuries of the Spine. Any associated objective neurological abnormalities, including, but not limited to, bowel or bladder impairment, are to be evaluated separately under an appropriate diagnostic code. Id. at Note 1. Unfavorable ankylosis is defined as “a condition in which the entire cervical spine, the entire thoracolumbar spine, or the entire spine is fixed in flexion or extension, and the ankylosis results in one or more of the following: difficulty walking because of a limited line of vision; restricted opening of the mouth and chewing; breathing limited to diaphragmatic respiration; gastrointestinal symptoms due to pressure of the costal margin on the abdomen; dyspnea or dysphagia; atlantoaxial or cervical subluxation or dislocation; or neurologic symptoms due to nerve root stretching.” Id. at Note 5. Additionally, fixation of a spinal segment in neutral position (zero degrees) is “always” considered favorable ankylosis. Id. When evaluating musculoskeletal disabilities based on limitation of motion, 38 C.F.R. § 4.40 requires consideration of functional loss caused by pain or other factors listed in that section that could occur during flare-ups or after repeated use and, therefore, not be reflected on range-of-motion testing. 38 C.F.R. § 4.45 requires consideration also be given to less movement than normal, more movement than normal, weakened movement, excess fatigability, incoordination, and pain on movement. See DeLuca v. Brown, 8 Vet. App. 202 (1995); see also Mitchell v. Shinseki, 25 Vet. App. 32, 44 (2011). Nonetheless, even when the background factors listed in § 4.40 or 4.45 are relevant when evaluating a disability, the rating is assigned based on the extent to which motion is limited, pursuant to 38 C.F.R. § 4.71a; a separate or higher rating under § 4.40 or 4.45 itself is not appropriate. See Thompson v. McDonald, 815 F.3d 781, 785 (Fed. Cir. 2016) (“[I]t is clear that the guidance of § 4.40 is intended to be used in understanding the nature of the veteran’s disability, after which a rating is determined based on the § 4.71a criteria.”). Under 38 C.F.R. § 4.59, painful motion is a factor to be considered with any form of arthritis; however, 38 C.F.R. § 4.59 is not limited to disabilities involving arthritis. See Burton v. Shinseki, 25 Vet. App. 1 (2011). In Correia v. McDonald, 28 Vet. App. 158 (2016), the Court held that the final sentence of 38 C.F.R. § 4.59 requires that the examiner record the results of range of motion testing “for pain on both active and passive motion [and] in weight-bearing and non-weight-bearing and, if possible, with range of motion measurements of the opposite undamaged joint.” The spine has no opposite joint. In Sharp v. Shulkin, 29 Vet. App. 26 (2017), the Court held that VA examiners must obtain information about the severity, frequency, duration, precipitating and alleviating factors, and extent of functional impairment of flares from the veterans themselves, when a flare-up is not observable at the time of examination. Prior to the filing of this claim for TDIU, the appellant underwent a VA examination on August 27, 2012. At that examination, he was noted to have 40 degrees of flexion in his lumbar spine on initial testing; however, the examiner observed that an objective onset of pain began at 30 degrees of flexion. Range of motion testing in each of the other planes of movement was limited to 10 degrees. The appellant reported daily flare-ups of the condition which caused additional functional limitation due to pain, fatigue, and weakness. Repetitive use testing did not produce additional range of motion loss. An estimate of additional range of motion loss during flare-ups or after repeated use over time was not provided. The examiner noted that there was no evidence of any incapacitating episodes, treated with bed rest prescribed by a physician. There were no signs of muscle atrophy or of any ankylosis of the thoracolumbar spine. No bowel or urinary issues were noted. There were also signs and symptoms of radiculopathy present in both lower extremities; however, radiculopathy was not diagnosed and instead these symptoms were attributed to bilateral neuropathy, with no opinion provided as to whether that neuropathy was due to the service-connected degenerative arthritis of the lumbar spine. The appellant underwent a subsequent VA examination in November 2013. Range of motion testing found him able to complete forward flexion to 65 degrees, with an objectively observable onset of pain at 60 degrees. Range of motion testing in the other planes of movement was 20 degrees each in extension, left lateral flexion, right lateral rotation, and left lateral rotation, and 25 degrees in right lateral flexion. Repetitive use testing did not reveal a decrease in range of motion after testing. An estimate of additional range of motion loss during flare-ups or after repeated use over time was not provided. The appellant reported daily flare-ups, brought on by sitting, standing, or laying down on his back, that prevented him from doing the types of tasks he normally did in his usual occupation of construction. The examiner noted that there was no evidence of any incapacitating episodes, treated with bed rest prescribed by a physician. There were no signs of muscle atrophy or of any ankylosis of the thoracolumbar spine. No bowel or urinary issues were noted. There were also signs and symptoms of radiculopathy present in both lower extremities; however, radiculopathy was only diagnosed for the right lower extremity. VA treatment records from April 2015 show the appellant only capable of performing forward flexion to 20 degrees. The appellant underwent another VA examination of his lumbar spine in September 2017. Range of motion testing found forward flexion limited to 15 degrees, extension limited to 5 degrees, right and left lateral flexion and right and left lateral rotation all limited to 10 degrees. Repetitive use testing did not reveal any additional decrease in range of motion testing. Estimates were not provided for additional range of motion lost during a flare-up as the appellant did not report experiencing flare-ups. The examiner found no evidence and the appellant did not report any incapacitating episodes, treated with bed rest prescribed by a physician. There were no signs of muscle atrophy or any ankylosis of the thoracolumbar spine. No bowel or urinary issues were noted. There were also signs and symptoms of radiculopathy present in the right lower extremity, and a diagnosis of right lower extremity radiculopathy was given. An April 2016 affidavit from the appellant’s wife indicates that he experiences significant pain in the low back, which requires the appellant to use a large amount of prescribed pain killers. She generally reported his symptoms as being difficulty moving around, needing to change positions frequently, and being unable to help with many chores around the house. After a review of the evidence of record, the Board finds that a 40 percent rating is warranted for the entire period from August 27, 2012 to the present. Within a year prior to the appellant’s having filed his claim, he presented with symptoms of forward flexion limited to 40 degrees with an onset of pain at 30 degrees. He reported additional symptoms during flare-ups. Considering the forward flexion where the appellant developed an onset of pain, the Board finds that the evidence is in equipoise as to whether the appellant meets the criteria for a 40 percent rating from that date. August 27, 2012 is the appropriate date to assign this increase. The effective date of an increased rating will be set at the date the claim was filed, or the date at which a discernible increase in disability can be ascertained, if that increase occurred within the one-year period prior to the filing of the claim. 38 C.F.R. § 3.400(o). The Board has considered that the findings from the November 2013 VA examination do show improved forward flexion and do not rise to the level of severity necessary for a 40 percent rating. However, range of motion testing in April 2015 showed symptoms much closer to the findings of the August 2012 VA examination rather than the November 2013 VA examination. Additionally, the Board notes that the November 2013 VA examination did not address whether there was additional range of motion loss during flare-ups or after repeated use over time. As such, granting the appellant the benefit of the doubt and considering the rule on stabilization of ratings, the Board finds that a 40 percent rating for the entire period is warranted. 38 C.F.R. §§ 3.344, 4.3, 4.7. While the Board finds that the evidence at least as likely as not establishes that a 40 percent rating is warranted for the entire period on appeal, the Board also finds that the preponderance of the evidence is against a rating in excess of 40 percent for the appellant’s claimed disability. The Board acknowledges the appellant’s lay reports of symptoms and that there was functional loss due to pain, weakened movement, excess fatigability, incoordination, repetitive use, pain during flare-ups, and pain during repetitive use over time. However, even considering the appellant’s lay reports of symptoms and noted functional loss, as well as the report of similar symptoms submitted by his wife, the degree of additional limitation would not result in symptoms more nearly approximating unfavorable ankylosis of the entire thoracolumbar spine. VA examinations have shown significantly decreased range of motion in the appellant’s thoracolumbar spine, particularly in forward flexion. Despite this, even at the appellant’s most limited range of motion, he was able to perform forward flexion from 0 to 15 degrees. At no time has he reported symptoms of being or feeling stuck in forward flexion or extension of his thoracolumbar spine, or any other non-neutral position. Additionally, there are no signs of muscle atrophy, indicating disuse which might be caused by ankylosis. As such, the Board finds that the preponderance of the evidence is against the assignment of a rating greater than 40 percent for any of the period on appeal. Consideration has also been given to assigning a rating under the Formula for Rating Intervertebral Disc Syndrome (IVDS) Based on Incapacitating Episodes. However, the evidence of record is against a finding that the appellant was ever prescribed bed rest by a physician for a duration that meets the criteria for a higher rating. See 38 C.F.R. § 4.71a, Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes. The appellant has not contended that he has incapacitating episodes treated with bed rest prescribed by a physician. The Board has considered whether an additional evaluation for an associated neurological abnormality is warranted. The appellant has denied having any symptoms of bowel or urinary incontinence which might be related to his service-connected disability, and as such a separate compensable rating on these grounds is not warranted. The appellant has already been granted service connection for radiculopathy of multiple nerve branches in the right lower extremity and additional development is being ordered to determine the nature and etiology of reported symptoms possibly linked to radiculopathy in the left lower extremity. For the foregoing reasons, the preponderance of the evidence is against the appellant’s claim for a rating in excess of 40 percent for arthritis of the lumbar spine. In denying such a rating, the Board finds the benefit of the doubt doctrine is not applicable. 38 U.S.C. § 5107; 38 C.F.R. §§ 4.3, 4.7. 2. Restoration of the 20 percent disability rating for service-connected chondromalacia, effective February 1, 2013, is granted. 3. Entitlement to a rating greater than 20 percent for chondromalacia of the right knee, for any of entire period on appeal, is denied. 4. Entitlement to a separate rating of 10 percent for painful motion, but not greater, for chondromalacia of the right knee, is granted. The appellant contends that he is entitled to a higher rating for his right knee because the assigned rating of 10 percent from February 1, 2013 did “not fully account for loss of range of motion because of pain, fatigue, loss of coordination, or loss of endurance,” and that a 20 percent rating was warranted for the entire period on appeal. See June 2015 NOD. The appellant’s right knee disability was rated as 20 percent disabling from June 12, 2000 to January 31, 2013, and 10 percent disabling from February 1, 2013 to the present. The appellant was notified in a November 2012 rating decision that due to a finding that he had sustained improvement in his right knee, his rating was being reduced to 10 percent beginning on February 1, 2013. The 20 percent rating had been in effect for a period of 5 years or more, but less than 20 years. When a disability rating has been in effect for at least 5 years, where material improvement in the physical or mental condition is clearly reflected, the rating agency will consider whether the evidence makes it reasonably certain that the improvement will be maintained under the ordinary conditions of life. 38 C.F.R. § 3.344(a). In Brown v. Brown, , the Court of Appeals for Veterans Claims (Court) held that there are general substantive requirements that apply to all rating reductions, notwithstanding how many years the rating has been in effect, including ratings in effect for less than five years. 5 Vet. App. 413 (1993). Specifically, the Court requires that adjudicators must: (1) review the entire record of examinations and medical and industrial history to ascertain whether the recent examination(s) on which the reduction was based were full and complete; (2) decline to use examinations which are less full and complete than those on which payments were authorized or continued; (3) not reduce an evaluation except in cases where all the evidence clearly warrants a finding of material improvement. In addition, where material improvement in the physical condition is clearly shown, the rating agency must consider whether the evidence makes it reasonably certain that the improvement will be maintained under the ordinary conditions of life. Brown v. Brown, at 419-20. In considering the propriety of a reduction, the Board must focus on the evidence available to the RO at the time the reduction was effectuated, although post-reduction medical evidence may be considered in the context of evaluating whether the conditions had demonstrated actual improvement. Dofflemyer v. Derwinski, 2 Vet. App. 277 (1992). The RO rated the appellant’s chondromalacia of the right knee under 38 C.F.R. § 4.71a, Diagnostic Code 5257, for other impairment of the knee. Under Diagnostic Code 5257, a 10 percent rating is warranted for slight recurrent subluxation or lateral instability. A 20 percent rating is warranted for moderate recurrent subluxation or lateral instability. A 30 percent rating is warranted for severe recurrent subluxation or lateral instability. 38 C.F.R. § 4.71a, Diagnostic Code 5257. According to MERRIAM WEBSTER’S COLLEGIATE DICTIONARY 999 (11th Ed. 2007), “slight” means small in amount. “Moderate” means limited in scope or effect. “Severe” means very painful or harmful or of a great degree. Objective medical evidence is not required to establish lateral knee instability under Diagnostic Code 5257, so objective medical evidence cannot be categorically found more probative than lay evidence with respect to this Diagnostic Code. See English v. Wilkie, 30 Vet. App. 347, 352-53 (2018). To begin, the Board must address the propriety of the appellant’s decrease for his right knee disability rating. As his 20 percent rating had been in effect for more than 5 years, reduction was only appropriate upon a showing of sustained improvement in the joint. In reviewing the evidence of record, the Board finds that the preponderance of the evidence does not show sustained improvement in the appellant’s right knee. The appellant’s 20 percent rating for his right knee was based on the findings of a November 2000 VA examination. At the time of the examination, the appellant reported symptoms of pain, weakness, constant stiffness, swelling with overuse, difficulty climbing stairs and ladders, fatigability and lack of endurance while working, and instability, with feeling like the knee is giving out on him when carrying heavy equipment for work. He reported daily pain at 7 out of 10, increased to 9 out of 10 during a flare-up. He reported wearing a support wrap when doing sports. Range of motion testing showed flexion of the knee to 120 degrees and extension to 0 degrees, with complaints of pain on movement. Based on these findings the appellant was awarded a 20 percent rating under 38 C.F.R. § 4.71a, Diagnostic Code 5257. At an August 2012 VA examination, the appellant reported pain and daily flare-ups of symptoms with prolonged use, with standing, walking or kneeling too long being the primary causes of flare-ups. He reported that the pain in his knee had become so bad that he had to stop working construction and had begun working in a law office. Range of motion testing found the appellant to have flexion to 80 degrees, with an onset of pain at 70 degrees, and full extension to 0 degrees. Range of motion in the left knee was normal. The disability was found to cause functional loss of less movement than normal, weakened movement, excess fatigability, incoordination, pain on movement, disturbance of locomotion, and interference with sitting, standing, and weight bearing. Joint stability testing was normal. He reported wearing a mechanical brace for the knee all the time, noting that he did not wear it to the appointment because it needed to be cleaned. Based on these two examinations, it is clear that the appellant exhibited less range of motion in his right knee at the August 2012 examination than he did at the November 2000 VA examination, which had been the basis for his 20 percent rating. Additionally, reports of functional loss indicate that the disability had become more troublesome over the years, as the appellant reported he now had to regularly use a more significant joint support brace, where as in 2000 he would only use a knee support when playing sports. The Board finds that these later findings do not meet the criteria necessary to warrant a reduction, as they show an increase in symptoms rather than sustained improvement. To warrant a reduction, the evidence must have shown that the appellant’s disability materially improved overall, resulting in an improvement in his ability to function under the ordinary conditions of life and work. With a decrease in range of motion over the years and the need for more regular use of a knee support device, the Board does not find any material improvement. In claims for restoration, the central question is not whether the schedular criteria for a particular rating are met as in a claim for increase, but whether the criteria for reduction were met. See e.g. Peyton v. Derwinski, 1 Vet. App. 282 (1990). As such, the Board finds that as the criteria for the initial reduction have not been established, the 20 percent rating in effect from June 12, 2000 should be restored. The Board now turns to the question of whether a rating in excess of 20 percent is warranted for any of the period on appeal. After a review of the evidence of record, the Board finds that the preponderance of the evidence is against a rating in excess of 20 percent for his chondromalacia of the right knee. At a VA examination in August 2012, the appellant was found to have no signs of instability after examination of the ligaments of his right knee. Anterior instability, posterior instability, and medial-lateral instability testing were all normal, showing no defects in the ligaments of the appellant’s knee. The appellant reported no history of recurrent patellar subluxation or dislocation. The appellant did report symptoms of pain and of the knee giving out on him. At a VA examination in November 2013, the appellant was similarly found with no signs of instability of the ligaments after diagnostic testing. Anterior instability, posterior instability, and medial-lateral instability testing were all normal, showing no defects in the ligaments of the appellant’s knee. He was found to have had a history of slight subluxation of the knee though. At a VA examination in September 2017, the appellant was again found with no signs of instability of the ligaments after diagnostic testing. Anterior instability, posterior instability, and medial-lateral instability testing were all normal, showing no defects in the ligaments of the appellant’s knee. The examiner also noted no history of any subluxation or dislocation of the right knee. Considering these findings, the Board finds that entitlement to an increased rating for symptoms of recurrent subluxation or lateral instability is not warranted. In making this finding, the Board has carefully considered the appellant’s reports about feeling like his knee is unstable and will “give out” on him. English, 30 Vet. App. 347, 352-53. However, overall, the lay and medical evidence indicates that these reported symptoms do not suggest the presence of symptoms of subluxation or instability more nearly approximating severe level of impairment. While the appellant has reported symptoms of feeling as if his knee was unstable or giving out, diagnostic testing of the appellant’s knee has consistently shown no objective signs of instability. His ligaments have been consistently found to be normal. Even based on his lay statements, the reported instability is associated with periods of exertion, and are not asserted to be frequent. Additionally, it has not been asserted that these subjective episodes of instability cause frequent falls or loss of ability to ambulate. Moreover, the Board notes that while the appellant has reported symptoms of the knee giving way, this may be a different symptom than instability, and based on lay reports, more closely resembles weakness and fatigability in the knee rather than instability. This is bolstered by the appellant’s report of symptoms at his September 2017 VA examination in which he stated that his knee gets weak and begins to shake even climbing up a small step ladder. As discussed below, the appellant is also being assigned a separate 10 percent rating based on painful, noncompensable limitation of flexion, which is based in part on factors such as weakness and fatigability. See DeLuca v. Brown, 8 Vet. App. 202 (1995); see also Mitchell v. Shinseki, 25 Vet. App. 32, 44 (2011). As such, the Board finds that the preponderance of the evidence is against the assignment of a rating greater than 20 percent for the appellant’s right knee chondromalacia, as rated under Diagnostic Code 5257 for symptoms of recurrent subluxation and lateral instability. 38 C.F.R. § 4.71a, Diagnostic Code 5257. In denying such a rating, the Board finds the benefit of the doubt doctrine is not applicable. 38 C.F.R. §§ 4.3, 4.7. The Board has also considered the other Diagnostic Codes pertaining to the knee and leg. Other disability ratings may be assigned only if the symptomatology for a disability is not duplicative or overlapping with the symptomatology of any other disability. See Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994); Lyles v. Shulkin, 29 Vet. App. 107 (2017) (holding that 38 C.F.R. § 4.14 prohibits paying compensation twice for the same symptoms or functional impairment). The evidence of record shows no evidence of any symptoms of ankylosis of the knee, dislocation or removal of the cartilage, limitation of extension, impairment of the tibia and fibula, or genu recurvatum. 38 C.F.R. § 4.71a, Diagnostic Codes 5256, 5268, 5259, 5261, 5262, and 5263. However, during the period on appeal, the appellant has demonstrated consistent symptoms of pain with flexion of the knee, with a noncompensable amount of range of motion loss. See 38 C.F.R. § 4.71a, Diagnostic Code 5260. As discussed above, range of motion testing in August 2012 found the appellant capable of flexion to 80 degrees, with an objective onset of pain at 70 degrees. Results from range of motion testing in November 2013 appear to be unreliable, as they indicate no capacity for flexion on initial examination, but full range of motion of 140 degrees after repetitive use testing. At a September 2017 VA examination, the appellant was capable of flexion to 80 degrees in the right knee. At all of these examinations, the appellant was noted with objective signs of pain, weakness, excess fatigability, and incoordination related to his right knee disability. Considering this, the Board finds that an additional 10 percent rating for noncompensable loss of flexion, with evidence of pain, is warranted for this claim. 38 C.F.R. §§ 4.59, 4.71a, Diagnostic Code 5260. A higher rating is not warrant absent range of motion loss equivalent to flexion limited to 30 degrees, which has not been shown at any point during the period on appeal and which is inconsistent with the appellant’s own reports of symptoms, to include during flare-ups or after repeated use over time. 5. Entitlement to an initial compensable rating for a service-connected surgical scar on the pelvis is denied. The appellant has asserted that an initial compensable rating is warranted for a service-connected surgical scar on his pelvis, related to surgery he had for his service-connected lumbar spine disability. No specific contentions have been raised regarding why a compensable rating is warranted for this disability. The appellant’s surgical scar on the pelvis is rated under Diagnostic Code 7805 for other scars (including linear scars) and other effects of scars evaluated under Diagnostic Codes 7800, 7801, 7802, and 7804. The Board notes that VA amended the criteria for rating skin disabilities effective from August 13, 2018. However, Diagnostic Code 7805 was not changed by the August 13, 2018, amendments. Diagnostic Code 7805 instructs that any disabling effect(s) not considered in a rating provided under Diagnostic Codes 7800-04 be rated under any other appropriate Diagnostic Code. The appellant’s scar was first observed at an August 2009 VA examination, where it was diagnosed as a well healed back scar. At a September 2017 VA examination, the scar was not found to be painful, measured 9 centimeters by 0.2 centimeters, and was observed to superficial and linear, with no evidence of instability or underlying tissue damage. No additional functional limitation was recorded as being due to the scar itself. Considering this, the Board finds that the preponderance of the evidence is against the assignment of a compensable rating for the appellant’s scar under Diagnostic Code 7805, as there are no other disabling effects not considered in a rating provided under Diagnostic Codes 7800-04. The Board has also considered the other Diagnostic Codes pertaining to scars in assigning the noncompensable rating. However, the appellant’s scar is not of the head, face, or neck, is not deep and nonlinear, and is not associated with underlying soft tissue damage. Although it is superficial and not associated with underlying soft tissue damage, it does not cover an area or areas of 144 square inches or greater. Moreover, the appellant’s scar is not unstable or painful. Therefore, Diagnostic Codes 7800, 7801, 7802, and 7804, both prior to and from August 13, 2018, are inapplicable. The appellant has provided no argument or reasons why his scar should be assigned a compensable rating for any of the period on appeal. The Board acknowledges that the appellant believes that the disability on appeal has been more severe than the assigned disability rating reflects. However, he does not assert, and the record does not show, that the appellant’s scar manifests with any disabling effect(s) not considered in a rating provided under Diagnostic Codes 7800-04, or any of the criteria under Diagnostic Codes 7800-04. In conclusion, the Board finds that the preponderance of the evidence is against the appellant’s claim for a compensable rating for his service-connected scar of the pelvis. In denying such a rating, the Board finds the benefit of the doubt doctrine is not applicable. 38 U.S.C. § 5107; 38 C.F.R. §§ 4.3, 4.7. 6. Entitlement to a rating greater than 70 percent for service-connected major depressive disorder is denied. The appellant contends that his major depressive disorder is more disabling than it is currently rated. Specifically, he has contended in his February 2015 NOD that a change in medication dosage indicated a worsening of his condition. Under the General Formula for Mental Disorders (General Formula), the Board must conduct a “holistic analysis” that considers all associated symptoms, regardless of whether they are listed as criteria. Bankhead v. Shulkin, 29 Vet. App. 10, 22 (2017); 38 C.F.R. § 4.130. The Board must determine whether unlisted symptoms are similar in severity, frequency, and duration to the listed symptoms associated with specific disability percentages. Then, the Board must determine whether the associated symptoms, both listed and unlisted, caused the level of impairment required for a higher disability rating. Vazquez-Claudio v. Shinseki, 713 F.3d 112, 114-118 (Fed. Cir. 2013). The issue in this appeal is whether the appellant’s associated symptoms caused the level of impairment required for a disability rating of 100 percent. After a review of the evidence of record, the Board concludes that the appellant’s symptoms did not cause the level of impairment required for a disability rating of 100 percent. The appellant’s symptoms more closely approximated the symptoms associated with a 70 percent rating, and resulted in a level of impairment that most closely approximated the level of impairment associated with a 70 percent rating. A 70 percent rating is assigned when symptoms such as suicidal ideation; obsessional rituals which interfere with routine activities; intermittently illogical, obscure, or irrelevant speech; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a worklike setting); or inability to establish and maintain effective relationships cause occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood. A 100 percent rating is assigned for total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; or memory loss for names of close relatives, own occupation or own name. At an August 2012 VA examination, the appellant was noted with symptoms of depressed mood, anxiety, panic attacks more than once a week, near-continuous panic or depression affecting his ability to function independently, appropriately, and effectively, chronic sleep impairment, flattened affect, disturbances of motivation and mood, difficulty in establishing and maintaining effective work relationships, an inability to establish and maintain effective relationships, and suicidal ideations. The appellant reported a history of four divorces, and having 5 children, with good relationships with some and poor relationships with others. He also reported a prior bankruptcy, and a psychiatric hospitalization in 1987 following the death of his grandfather. The examiner noted the appellant was receiving treatment for his mental health disability through the VA at the time. After a review of the record and after an examination of the appellant, to include the appellant’s lay reports of his mental health history, the examiner opined that his mental health disability was consistent with the criteria for a 70 percent rating, based on occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgement, thinking, and/or mood. At a November 2013 VA examination, the appellant was noted with symptoms of depressed mood and anxiety. The examiner opined that the severity of the condition had not changed since the prior VA examination in August 2012. The examiner opined that the functional impact of the appellant’s mental health disability alone was not so severe as to prevent him from obtaining or maintaining any gainful employment, citing to the appellant’s musculoskeletal disabilities as well as other factors as contributing to unemployability. After a review of the record and after an examination of the appellant, to include the appellant’s lay reports of his mental health history, the examiner opined that his mental health disability was consistent with the criteria for a 70 percent rating, based on occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgement, thinking, and/or mood. At a September 2017 VA examination, the appellant was noted with symptoms of depressed mood, anxiety, suspiciousness, panic attacks more than once a week, chronic sleep impairment, disturbances of motivation and mood, and difficulty in establishing and maintaining effective work and social relationships. He also reported experiencing nightmares, teeth grinding, dwelling on the misfortunes of life, and poor memory. The examiner observed the appellant’s demeanor at the examination and found him to be dressed appropriately, with intact though process and no signs of any psychotic process. He was also noted as being pleasant and cooperative. The examiner also noted a diagnosis of posttraumatic stress disorder (PTSD) but stated that it was not possible to separate symptoms between the service-connected major depressive disorder and the nonservice-connected PTSD. VA treatment records for the period on appeal indicate that the appellant was prescribed medication to treat symptoms of his service-connected major depressive disorder. Records from December 2013 show the appellant reporting anxiety around people, but an overall reduction in symptoms due to a change in medication. At an April 2014 appointment, the appellant reported he was stable on his current medications, with no symptoms of depression or suicidal or homicidal ideation. An accompanying examination found him to be in no distress with normal mood. At a July 2014 appointment, the appellant reported continuing anxiety, and noted that his nightmares had returned. He reported that symptoms had worsened after he ran out of his medications and was waiting on a refill of the prescription. At an April 2015 appointment, the appellant was noted to be fully oriented, with clear speech, adequate mood and affect, rational and intact cognitions and thoughts, and intact insight and judgement with no evidence of delusions, hallucinations, suicidal ideations, or homicidal ideations. He was noted to have a strong relationship with his girlfriend. At a September 2014 appointment, the appellant reported an increase in symptoms, but also noted that he had been out of his medications for a week. He did explain that he was having legal problems that were exacerbating his depression. He was observed to be fully oriented, with slow but coherent speech, restricted mood and affect, intact and goal directed cognitions and thoughts, and adequate insight and judgement, with no signs of delusions, hallucinations, suicidal ideations, or homicidal ideations. The treating provider opined that the overall mental health condition appeared to be of mild severity, based on the appellant having an active support system to deal with his exacerbating stressors. At a September 2015 VA appointment, the appellant recounted his medical and personal history to the treating clinician. He was observed to be alert and oriented x4, with a cooperative and pleasant attitude, a good mood, euthymic affect. He denied current anxiety but endorsed symptoms of PTSD such as nightmares and chronic sleep impairment, flashbacks, hypervigilance, and hyperreactivity. He reported a long history of five marriages with children from three of them. He reported good relationships with some of his ex-spouses and most of his children, and reported a very successful and enjoyable relationship with his current wife, with whom he was very active. At a December 2015 VA appointment, the appellant recounted an improvement in his depressive symptoms, but a worsening of his PTSD symptoms, to include fighting in his sleep that had led to him waking up with his hands around his wife’s throat. He denied persistent depression, explaining that symptoms were largely tied to a pending legal case for driving on a suspended license. He was not found to be experiencing any hallucinations, delusions, suicidal ideations, or homicidal ideations. At an April 2016 appointment, the appellant reported some increase in his symptoms, to include panic attacks in the past month. He denied persistent depression, but noted that he was dealing with a difficult legal case, but had luckily been able to avoid having to do any jail time. He reported a decrease in his nightmares. He was not found to be experiencing any hallucinations, delusions, suicidal ideations, or homicidal ideations. At a July 2016 appointment, the appellant was noted with an increase in symptoms due to increased loss of mobility related to his musculoskeletal disabilities. He reported increasing depression and financial problems. He was observed with monotone speech, depressed mood and affect, but with full orientation, intact cognitions, and rational thoughts. He was not found to be experiencing any hallucinations, delusions, suicidal ideations, or homicidal ideations. At a November 2016 appointment, the appellant was noted with a brief improvement of his mental health symptoms following a shot which reduced his back pain for a significant period. Unfortunately, those symptoms returned when the shot wore off 10 days later. He was observed with slow speech, dysphoric mood and affect, slowed thoughts and cognition, and intact judgement and insight. He was not found to be experiencing any hallucinations, delusions, suicidal ideations, or homicidal ideations. At a February 2017 appointment, the appellant was noted with an improvement in his sleep amount and quality after an adjustment of his medication, and he noted no recurrent nightmares. He reported some symptoms of hypervigilance and hyperreactivity but discussed plans to build a large addition for his home which would be used for large family gatherings. He observed as being in a good mood, with neutral affect, normal and organized speech, and intact cognitive function. He was not found to be experiencing any hallucinations, delusions, suicidal ideations, or homicidal ideations. The appellant discussed that he had begun making dining tables out of oak. A March 2013 Social Security Administration mental health evaluation noted that the appellant’s mental health disorders may inhibit his understanding and remembering detailed instructions and extended concentration as well as responding appropriately to supervisor criticism. However, the examiner also opined that the appellant’s cognitive and attentional skills for simple one and two step tasks were intact, that he was capable of routine activities of daily living and chores, and that his mental status was within normative limits. The examiner also opined that the appellant had the ability to relate and communicate with others and tolerate work pressures, with most of the appellant’s ability to do work related tasks being not significantly limited by his mental health disability. A lay statement from the appellant’s fifth wife was received by VA in May 2016 and indicated that they got married in June 2015. She reported that the appellant is routinely depressed and treats these depressive symptoms by retreating and spending time alone. She reported he has difficulty focusing due to his disabilities and routinely receiving poor sleep. She also reported symptoms of him avoiding crowds when possible. After a review of all the evidence of record, the Board finds that the preponderance of the evidence, to include VA and private treatment records, the multiple VA examinations, the appellant’s lay statements, and the lay statement from his spouse show that the appellant’s service-connected major depressive disorder is manifested by symptoms associated with a 70 percent rating. The Board finds the severity, frequency, and duration of the appellant’s symptoms more closely approximate the symptoms contemplated by a 70 percent rating, which are less severe, less frequent, and shorter in duration than those contemplated by a 100 percent rating. See 38 C.F.R. § 4.126. While the appellant did report periodic increases in the severity of his symptoms, these were not lasting, and even during these flare-ups his symptoms did not rise to the level of causing total occupational and social impairment. Throughout the period on appeal, the appellant has shown the ability to maintain certain relationships, to include those with some of his children, and grandchildren. He also pursued and established a strong romantic relationship with his current spouse, which has been maintained since it began. While it does not appear that he worked or maintained a career during this period, he does appear to have been active socially, and to have taken on hobbies, such as wood working. He also was able to resolve several legal difficulties and was able to avoid incarceration. At no time did he experience hallucinations, delusional thinking, suicidal ideation, homicidal ideation, or any of the symptoms contemplated by the 100 percent rating for mental health disabilities. The Board notes that the appellant expressed past suicidal ideation at his August 2012 VA examination, which is similar to persistent danger of self-harm, which is contemplated by the 100 percent criteria. Bankhead v. Shulkin, 29 Vet. App. 10, 19 (2017). However, the severity, frequency, and duration of the appellant’s suicidal ideation has not risen to the level contemplated by the 100 percent disability rating. The appellant regularly denied thoughts, intent, or a plan involving self-harm in existing treatment records, and during his VA examinations throughout the period on appeal, indicating that the suicidal ideations were not present during this period. Ultimately, the preponderance of the evidence weighs against finding that the severity, frequency, and duration of the appellant’s symptoms resulted in the level of impairment required for a 100 percent rating. 38 C.F.R. § 4.130, General Rating Formula for Mental Disorders. The criteria for a 100 percent or higher rating are not met and the appeal must be denied. As the preponderance of the evidence is against the claim, the benefit of the doubt rule is inapplicable. 38 C.F.R. § 4.3. 7. Entitlement to an initial compensable rating for radiculopathy of the right internal saphenous nerve is denied. 8. Entitlement to an initial compensable rating for radiculopathy of the right obturator nerve is denied. 9. Entitlement to an initial compensable rating for radiculopathy of the right external cutaneous nerve is denied. 10. Entitlement to an initial compensable rating for radiculopathy of the right ilio-inguinal nerve is denied. The appellant contends that he is entitled to initial compensable ratings for the diagnosed mild radiculopathy of the internal saphenous, obturator, external cutaneous, and ilio-inguinal nerves of the right lower extremity. No specific arguments or reasoning has been presented by the appellant as to why this increase is warranted. Paralysis of the internal saphenous, obturator, external cutaneous, and ilio-inguinal nerves is evaluated in accordance with the criteria set forth in 38 C.F.R. § 4.124a, Diagnostic Codes 8527-30. Neuritis and neuralgia of that group are evaluated under Diagnostic Codes insert relevant Diagnostic Codes 8627-30 Diagnostic Codes 8727-30. Under these criteria, mild to moderate paralysis is rated as noncompensable. Severe to complete paralysis is rated as 10 percent disabling. 38 C.F.R. § 4.124a. There are five nerve branches in the lower extremities. Each branch has its separate and distinct functions. The sciatic branch includes the sciatic nerve, external popliteal nerve (common peroneal), musculocutaneous (superficial peroneal), anterior tibial nerve (deep peroneal), internal popliteal (tibial), and posterior tibial nerves. The femoral branch includes the anterior crural (femoral) and the internal saphenous nerves. The obturator, external cutaneous thigh, and ilio-inguinal nerve branches only include one nerve each. The words “mild,” “moderate,” and “severe” as used in the various Diagnostic Codes are not defined in the Rating Schedule. Regulations provide that ratings for peripheral neurological disorders are to be assigned based 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. See 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 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). For years prior to the June 2015 VA examination, the appellant reported symptoms of pain and numbness in his lower extremities, manifesting difficulty walking, or standing too long, and climbing stairs. These symptoms were also partially related to his service-connected musculoskeletal disabilities. At a June 2015 VA examination, the appellant was found to have moderate incomplete paralysis of the right internal saphenous nerve, along with moderately severe incomplete paralysis of the entire right sciatic nerve branch. There were no observable signs of symptoms that the obturator, external cutaneous, or ilio-inguinal nerves were impaired in any way, as all were found to be normal upon examination. He reported symptoms of moderate pain, severe intermittent pain, severe paresthesias, and moderate numbness. There were no measurable signs of muscle strength loss or atrophy. He was found to have hypoactive reflexes in the knees and ankles. He had absent light touch sensation in the right lower leg and foot, but normal in the thigh to the knee. He was observed with an antalgic gait, but there were no trophic changes measured. After the complete examination, the examiner opined that these signs and symptoms indicated no more than incomplete paralysis of the internal saphenous nerve that was best characterized as moderate considering the rating criteria. At a September 2017 VA examination, the appellant was found to have moderate incomplete paralysis of the internal saphenous nerve, obturator nerve, external cutaneous nerve of the thigh, and the ilio-inguinal nerve of the right lower extremity, along with moderate incomplete paralysis of all the nerves of the sciatic nerve branch. The appellant reported experiencing shooting pain down his right leg and an inability to maintain prolonged standing and sitting, limiting his ability to drive long distances. He described symptoms of severe constant pain, severe paresthesias and/or dysesthesias, and severe numbness in the right lower extremity. Muscle strength testing showed muscle strength of 4/5, meaning he was capable of active movement against some resistance, in right knee extension, right ankle plantar flexion, and right ankle dorsiflexion in the right lower extremity. There were no signs of muscle atrophy or trophic changes. Reflex testing showed hypoactive reflexes in the right knee and ankle. Results for light touch sensation testing showed decreased, but not absent, light touch sensation in the right upper anterior thigh, the thigh and knee, the lower leg and ankle, and in the right foot and toes. Based on these findings, the examiner opined that these signs and symptoms indicated no more than incomplete paralysis of the internal saphenous, obturator, external cutaneous, and ilio-inguinal nerves of the right lower extremity, which were best characterized as moderate considering the rating criteria. Lay statements from the appellant and his wife, along with statements made at VA treatment appointments demonstrate symptoms of frequent pain and numbness in the right lower extremity, manifesting with mobility impairments, increased fall risk with more frequent falls, and general discomfort. Based on the above, the Board finds that these disabilities are primarily manifested by impairment of motor functions, sensory disturbances, loss of reflexes, pain, all resulting from incomplete paralysis of the internal saphenous, obturator, external cutaneous, and ilio-inguinal nerves. The Board also finds that the most probative evidence of record is against a finding that the disability is manifest by trophic changes, muscle atrophy, or complete paralysis of these nerves. The Board thus finds that the level of impairment is most analogous moderate incomplete paralysis. While the appellant does have significant disability in the right lower extremity to include some non-sensory deficits such as an antalgic gait, symptoms appear to be more pronounced in the lower half of the extremity, with additional muscle strength loss and reflex loss, corresponding with the moderately severe diagnosis he has been assigned for the sciatic nerve. Symptoms affecting the thigh, which is where the nerves being discussed are located, have tended to be less severe on examination. Light touch sensation testing revealed only decreased, as opposed to absent sensation. Muscle strength was somewhat reduced, but was still measured at 4 out of 5 with 5 being normal. There was no atrophy of the muscles of the thigh, and no signs of trophic change. Considering these factors, the examiner opined that the severity of the incomplete paralysis of the internal saphenous, obturator, external cutaneous, and ilio-inguinal nerves was no more than moderate. The examiner reached this opinion in consideration of the examination results, the appellant’s lay reports, and a consideration of his medical history. As the opinion is well-reasoned and consistent with the observable and reported symptoms, the Board affords that opinion great probative weight. See Nieves - Rodriguez v. Peake, 22 Vet. App. 295 (2008). While the appellant has expressed general disagreement with the ratings assigned, he has not articulated any basis for the disagreement and VA has not received any credible and competent evidence which establishes there being a basis for the assignment of a higher rating for any of these individual nerves. The appellant is competent to report signs and symptoms he experiences; however, there is nothing of record indicating that he is competent to provide an opinion regarding which nerves of the right lower extremity were contributing to which symptoms in his right lower extremity. See Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). The issue is medically complex as it involves the interpretation of diagnostic testing of unobservable internal processes, and thus, requires medical training or experience to decipher. The Board affords more probative weight to the June 2015 and September 2017 VA examinations in this case, as the opinions on the severity of the appellant’s condition rely on diagnostic testing and a consideration of his lay reports of symptoms and a review of his medical history. See King v. Shinseki, 700 F.3d 1339, 1345 (Fed. Cir. 2012). The Board has considered all other potentially applicable Diagnostic Codes, but there is no evidence showing the appellant has neurological impairment associated with any other peripheral nerves that have not already been service-connected. Therefore, a separate or higher rating for these nerves under a different Diagnostic Code is not warranted. While the June 2015 VA examination did reveal incomplete paralysis of other nerves in the right lower extremity, the nerves affected were all those within the sciatic nerve branch. Assigning separate ratings for each nerve within the sciatic group would violate the rule against pyramiding. 38 C.F.R. § 4.14. In conclusion, the Board finds that the preponderance of the evidence is against the appellant’s claim for a compensable rating for moderate incomplete paralysis of the internal saphenous, obturator, external cutaneous, and ilio-inguinal nerves. In denying such a rating, the Board finds the benefit of the doubt doctrine is not applicable. 38 U.S.C. § 5107; 38 C.F.R. §§ 4.3, 4.7. Earlier Effective Date As a preliminary matter, the Board notes that effective March 24, 2015, VA amended its regulations to require that all claims governed by VA’s adjudication regulations be filed on a standard form. The amendments also, inter alia, eliminated the constructive receipt of VA reports of hospitalization or examination and other medical records as informal claims. See 79 Fed. Reg. 57,660 (Sept. 25, 2014), codified as amended at 38 C.F.R. §§ 3.151, 3.155, 3.157. The amended regulations only apply to claims filed on or after March 24, 2015. Unless specifically provided otherwise, the effective date of an award based on an original claim, a claim reopened after final disallowance, or a claim for increase shall be fixed in accordance with the facts found, but shall not be earlier than the date of receipt of application therefor. 38 U.S.C. § 5110(a); see also 38 C.F.R. § 3.400(b)(ii). In claims for an earlier effective date for an increased rating, the effective date of the award may also be set as the earliest date as of which it is factually ascertainable based on all the evidence of record that an increase in disability had occurred, if a complete claim or intent to file a claim is received within 1 year from such date; otherwise, the effective date is the date of receipt of the claim. 38 C.F.R. § 3.400(o)(2). A claim is defined as a formal or informal communication, in writing, requesting a determination of entitlement, or evidencing a belief in entitlement to a benefit. 38 C.F.R. §§ 3.1(p), 3.151. Any communication or action indicating intent to apply for one or more VA benefits may be considered an informal claim. 38 C.F.R. § 3.155. Such an informal claim must identify the benefit sought. Id. 38 C.F.R. § 3.1(p) defines application as a formal or informal communication in writing requesting a determination of entitlement or evidencing a belief in entitlement to a benefit. See also Rodriguez v. West, 189 F.3d. 1351 (Fed. Cir. 1999). The date of receipt of a claim is the date on which a claim, information, or evidence is received by VA. 38 C.F.R. § 3.1(r). Under 38 C.F.R. § 3.157(b)(1), a report of examination or hospitalization may constitute an informal claim. However, “[t]he mere existence of medical records generally cannot be construed as an informal claim; rather, there must be some intent by the claimant to apply for a benefit.” Criswell v. Nicholson, 20 Vet. App. 501, 504 (2006). Thus, the essential elements for any claim, whether formal or informal, are (1) an intent to apply for benefits, (2) an identification of the benefits sought, and (3) a communication in writing. Brokowski v. Shinseki, 23 Vet. App. 79, 84 (2009); see also MacPhee v. Nicholson, 459 F.3d 1323, 1326-27 (Fed. Cir. 2006) (holding that the plain language of the regulations requires a claimant to have an intent to file a claim for VA benefits); but see Sellers v. Wilkie, 30 Vet. App. 157 (2018) (a general statement of intent to seek benefits, combined with a reasonably identifiable in-service medical diagnosis reflected in service treatment records in VA’s possession prior to the RO decision on the claim, may be sufficient to constitute a claim for benefits). 11. Entitlement to an effective date earlier than June 27, 2015 for the grant of a separate compensable rating for radiculopathy of the right internal saphenous nerve is denied. In an October 2017 rating decision, the RO granted the appellant a separate noncompensable rating for radiculopathy of the internal saphenous nerve of the right lower extremity. The effective date set for this award of a separate rating was June 27, 2015, the date that this additional neurological deficit related to the appellant’s service-connected degenerative arthritis of the lumbar spine was first diagnosed. After a review of the evidence of record, the Board finds that the preponderance of the evidence is against the assignment of an effective date earlier than June 27, 2015 for the grant of a separate evaluation for radiculopathy of the internal saphenous nerve of the right lower extremity. The appellant did not file a separate claim for service connection for the additional neurological abnormality affecting his right internal saphenous nerve. The grant of service connection came as a result of the ongoing increased rating claim for the appellant’s degenerative arthritis of the lumbar spine. 38 C.F.R. § 4.71a, General Rating Formula for Diseases and Injuries of the Spine, Note 1. This additional neurological abnormality was first identified during testing conducted at the appellant’s June 27, 2015 VA examination. VA treatment and private medical records do not include any indication of disability in this nerve of the right lower extremity prior to this date. As such, the earliest ascertainable date that this additional neurological abnormality was present is June 27, 2015, the date it was first diagnosed. Considering this, the Board finds that the preponderance of the evidence establishes that June 27, 2015 is the appropriate effective date for the grant of a separate evaluation for additional neurological abnormalities of the internal saphenous nerve of the right lower extremity, as related to service-connected degenerative arthritis of the lumbar spine. 38 C.F.R. §§ 3.400, 4.71a, General Rating Formula for Diseases and Injuries of the Spine, Note 1. As the preponderance of the evidence is against the claim, the benefit of the doubt rule is inapplicable. 38 C.F.R. §§ 3.102, 4.3. 12. Entitlement to an effective date earlier than September 14, 2017 for the grant of a separate compensable rating for radiculopathy of the right obturator nerve is denied. 13. Entitlement to an effective date earlier than September 14, 2017 for the grant of a separate compensable rating for radiculopathy of the right external cutaneous nerve is denied. 14. Entitlement to an effective date earlier than September 14, 2017 for the grant of a separate compensable rating for radiculopathy of the right ilio-inguinal nerve is denied. In an October 2017 rating decision, the RO granted the appellant separate noncompensable ratings for radiculopathy of the obturator, external cutaneous, and ilio-inguinal nerves of the right lower extremity. The effective date set for this award was September 14, 2017, the date that these additional neurological deficits related to the appellant’s service-connected degenerative arthritis of the lumbar spine were first diagnosed. After a review of the evidence of record, the Board finds that the preponderance of the evidence is against the assignment of an effective date earlier than September 14, 2017 for the grant of separate evaluations for radiculopathy of the obturator, external cutaneous, and ilio-inguinal nerves of the right lower extremity. The appellant did not file a separate claim for service connection for these additional neurological abnormalities. The grant of service connection came as a result of the ongoing increased rating claim for the appellant’s degenerative arthritis of the lumbar spine. 38 C.F.R. § 4.71a, General Rating Formula for Diseases and Injuries of the Spine, Note 1. These additional neurological abnormalities were first discovered during the September 14, 2017 VA examination. A previous VA examination in June 2015 did test all of these nerves and found no evidence of any abnormality or defect. VA treatment and private medical records do not include any indication of disability in these three nerves of the right lower extremity prior to September 14, 2017. As such, the earliest ascertainable date that these additional neurological abnormalities developed was September 14, 2017. Considering this, the Board finds that the preponderance of the evidence establishes that September 14, 2017 is the appropriate effective date for the grant of separate evaluations for additional neurological abnormalities of the obturator, external cutaneous, and ilio-inguinal nerves of the right lower extremity, as related to service-connected degenerative arthritis of the lumbar spine. 38 C.F.R. §§ 3.400, 4.71a, General Rating Formula for Diseases and Injuries of the Spine, Note 1. As the preponderance of the evidence is against these claims, the benefit of the doubt rule is inapplicable. 38 C.F.R. §§ 3.102, 4.3. 15. Entitlement to an effective date of November 25, 2008, but not earlier, for the grant of service connection for a surgical scar of the pelvis is granted. In an October 2017 rating decision, the RO granted the appellant a rating for a non-painful surgical scar related to a November 25, 2008 surgery the appellant underwent for his service-connected degenerative arthritis of the lumbar spine. The decision initially set an effective date of August 25, 2009 for the grant of service connection, based on VA examination findings that the scar was present on August 26, 2009. In a November 2017 NOD, the appellant challenged the effective date of the grant of a separate compensable rating for a surgical scar of the pelvis, as a separate rating related to the service-connected arthritis of the lumbar spine. Considering the scar was a result of surgery for a service-connected disability, which occurred on November 25, 2008, the Board finds that the appropriate date for service connection for the scar should be the date the additional disability arose, which would have been when the surgery occurred on November 25, 2008. An effective date earlier than November 25, 2008 is not appropriate, as this additional disability was not present prior to that date. REASONS FOR REMAND 1. Entitlement to a separate compensable rating for left lower extremity radiculopathy is remanded. This issue is on appeal as part of the broader issue of entitlement to an increased rating for the appellant’s service-connected lumbar spine disability, which includes separate evaluations for any associated neurological abnormalities. After a review of the evidence of record, the Board finds that an addendum medical opinion is needed prior to adjudicating this claim. At an August 2012 VA examination, the appellant was noted to have a diagnosis of “mild sensory neuropathy” that affected both feet. The examiner noted symptoms of decreased sensation to light touch in the left lower leg, ankle, foot, and toes. The examiner also noted symptoms of moderate constant pain, moderate intermittent pain, mild paresthesias and/or dysesthesias, and mild numbness in the left lower extremity. The examiner noted that a straight leg raise test could not be performed. Despite these symptoms, the examiner determined the appellant’s left leg was unaffected by radiculopathy. No rationale was provided for this opinion though, and as such, the Board finds it inadequate. See Nieves - Rodriguez v. Peake, 22 Vet. App. 295 (U.S. 2008). Similarly, the November 2013 VA examination found symptoms typically associated with radiculopathy present in the appellant’s left lower extremity, to include mild numbness. While the examiner did mark that the left lower extremity was not affected by radiculopathy, the examiner did not provide a rationale for this opinion. A subsequent VA examination in June 2015 found the appellant to have radiculopathy of the left leg affecting the sciatic, external popliteal, musculocutaneous, internal popliteal, and internal saphenous nerves. However, an opinion was not provided as to whether this diagnosis of radiculopathy was related to the appellant’s service-connected lumbar spine disability. The examiner also did not opine as to the earliest possible date it was ascertainable that these diagnosed conditions had developed, particularly in light of the symptoms previously reported at the August 2012 and November 2013 VA examinations. Another VA examination in September 2017 found the appellant to have no diagnosis of radiculopathy in the left lower extremity. The examiner diagnosed peripheral neuropathy of both feet, but then found all the nerves of the appellant’s left lower extremity to be “normal” upon examination. The examiner observed the appellant with an abnormal gait. Reflex and sensory testing were normal in the left lower extremity. No symptoms of constant pain, intermittent, pain, paresthesias and/or dysesthesias, or numbness were noted in the left lower extremity. The examiner did not address the findings of the previous examinations. Considering this, the Board finds that an addendum opinion should be obtained addressing whether the appellant does indeed have a diagnosis of an associated neurological abnormality in the left lower extremity. If the examiner finds that the evidence does establish a diagnosis of any neurological abnormality associated with the left lower extremity that is due to the appellant’s service-connected lumbar spine disability, the examiner should provide an opinion regarding the onset date of the condition and the severity of the diagnosed condition throughout the entire period on appeal. 2. Entitlement to a rating for radiculopathy of the right sciatic nerve greater than 10 percent from January 22, 2013, and greater than 40 percent from June 27, 2015 is remanded. The appellant contends that his radiculopathy of the right sciatic nerve has been more disabling during the period on appeal. After a review of the evidence of record, the Board finds that additional development is necessary prior to adjudicating this claim. At an August 2012 VA examination, the appellant was noted to have a diagnosis of “mild sensory neuropathy” that affected both feet. The examiner noted symptoms of decreased sensation to light touch in the right lower leg, ankle, foot, and toes. The examiner also noted symptoms of moderate constant pain, moderate intermittent pain, mild paresthesias and/or dysesthesias, and mild numbness in the right lower extremity. The examiner noted that a straight leg raise test could not be performed. Despite these symptoms, the examiner determined the appellant’s right lower extremity was unaffected by radiculopathy. No rationale was provided for this opinion though, and as such, the Board finds it inadequate. See Nieves - Rodriguez v. Peake, 22 Vet. App. 295 (2008). Considering this, the Board finds that remand is necessary to obtain an addendum opinion addressing whether the symptoms diagnosed at the August 2012 VA examination are indicative of right lower extremity radiculopathy of the sciatic nerve. If it is the examiner’s opinion that those symptoms are indicative of right lower extremity radiculopathy related to the appellant’s service-connected degenerative arthritis of the lumbar spine, the examiner should provide an opinion regarding the severity of those symptoms. The matters are REMANDED for the following action: 1. Obtain an addendum opinion from an appropriate clinician reconciling the conflicting medical evidence regarding whether the appellant has a diagnosis of a left lower extremity neurological abnormality that is at least as likely as not related to his service-connected degenerative arthritis of the lumbar spine. The examiner must consider the conflicting diagnoses made in the August 2012, November 2013, June 2015, and September 2017 VA examinations regarding the appropriate diagnosis for the appellant’s reported symptoms relating to his left lower extremity and should opine on the etiology of any diagnosis. In rendering an opinion, the examiner must provide an opinion regarding the earliest ascertainable onset date of any diagnosed condition and the severity of that condition throughout the period on appeal. The examiner should provide a complete rationale for the opinion provided. The examiner must consider the symptoms of radiculopathy found on the August 2012 and November 2013 examinations, as well as the total lack of symptoms noted on the September 2017 examination, despite the diagnosis of peripheral neuropathy of the left foot. 2. Obtain an addendum opinion from an appropriate clinician regarding whether the August 2012 VA examination findings that the appellant had symptoms of decreased sensation to light touch, constant pain, intermittent pain, paresthesias and/or dysesthesias, and numbness were evidence of right lower extremity radiculopathy being present at that time. If so, the examiner should opine as to the severity of the radiculopathy at that time based on the symptoms recorded. K. Conner Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board K. Kleponis, Associate 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.