Citation Nr: 21002553 Decision Date: 01/14/21 Archive Date: 01/14/21 DOCKET NO. 15-41 001 DATE: January 14, 2021 ORDER Entitlement to service connection for erectile dysfunction, to include as secondary to service-connected disability is denied. Entitlement to an increased rating of 30 percent, but no higher, prior to December 18, 2019, for multilevel cervical disc disease status post anterior cervical discectomy and fusion C7-T1, is granted. Entitlement to an increased rating above 30 percent since December 18, 2019, for multilevel cervical disc disease status post anterior cervical discectomy and fusion C7-T1 is denied. REMANDED Entitlement to service connection for a right lower extremity (RLE) neurological disability is remanded. Entitlement to service connection for a left lower extremity (LLE) neurological disability is remanded. Entitlement to an increased rating above 20 percent for left upper extremity (LUE) radiculopathy is remanded. FINDINGS OF FACT 1. The preponderance of the probative evidence weighs against finding that the Veteran’s erectile dysfunction began during active service, is otherwise related to an in-service injury or disease, or is secondary to a service-connected condition or medication. 2. For the appeal period prior to December 18, 2019, the preponderance of the probative evidence weighs in favor of finding that the cervical spine disability did not manifest in ankylosis. 3. For the appeal period since December 18, 2019, the preponderance of the probative evidence weighs in favor of finding that the cervical spine disability did not manifest in ankylosis. CONCLUSIONS OF LAW 1. The criteria for entitlement to service connection for erectile dysfunction have not been met. 38 U.S.C. §§ 1110, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.310 (2018). 2. The criteria for entitlement to an increased rating of 30 percent, but no higher, from January 18, 2012, for multilevel cervical disc disease status post anterior cervical discectomy and fusion C7-T1 have been met. 38 U.S.C. §§ 1155, 5100, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.326, 3.655, 4.1, 4.2, 4.3, 4.7, 4.10, 4.20, 4.27, 4.71a, Diagnostic Code (DC) 5242-5237, General Rating Formula for Diseases and Injuries of the Spine (2018). 3. The criteria for entitlement to an increased rating above 30 percent since December 18, 2019, for multilevel cervical disc disease status post anterior cervical discectomy and fusion C7-T1 have not been met. 38 U.S.C. §§ 1155, 5100, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.326, 3.655, 4.1, 4.2, 4.3, 4.7, 4.10, 4.20, 4.27, 4.71a, Diagnostic Code (DC) 5242-5237, General Rating Formula for Diseases and Injuries of the Spine (2018). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had qualifying service from September 1967 to May 1969, including in the Republic of Vietnam. See DD Form 214; Military Personnel Record. In January 2019, the Veteran testified at a Board videoconference hearing before the undersigned Veterans Law Judge. In a June 2019 Decision, the Board remanded the issues herein for further development and adjudication. In a September 2020 Rating Decision, the agency of original jurisdiction (AOJ) increased the rating for multilevel cervical disc disease status post anterior cervical discectomy and fusion C7-T1 from 20 percent to 30 percent effective December 18, 2019. However, because higher ratings are still available, the issue remains properly before the Board. AB v. Brown, 6 Vet. App. 35 (1993). Preliminarily, in a November 2020 Correspondence, the Veteran, in addition to discussing the issues herein, also discussed an issue that is not currently before the Board (entitlement to an earlier effective date of service connection for obstructive sleep apnea). The Board has considered whether it could decide the effective date issue in the decision herein; however, the effective date issue is not currently ripe for adjudication because that issue is still pending scheduling of a Board hearing, which the Veteran requested in his August 2019 VA Form 9. Accordingly, after the Veteran is afforded his pending Board hearing on the effective date issue, the Board will issue a separate decision on that matter. Service Connection Direct service connection generally requires evidence showing: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Secondary service connection may be granted for disabilities which were proximately due to, the result of, or aggravated beyond natural progression by a service-connected disability. 38 C.F.R. § 3.310(a). On June 14, 2019, the Court issued the precedential decision in Ward v. Wilkie, 17-1204, holding that a “permanent worsening” of a non-service-connected disability is not required to establish secondary service connection on the basis of aggravation (i.e., aggravation may include temporary worsening of a disability). Although a competent medical opinion is generally required to establish etiology, competent and credible lay evidence of chronicity and continuity of symptomology may also establish etiology. 38 C.F.R. § 3.303(b); Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007); Layno v. Brown, 6 Vet. App. 465 (1994). Notably, in this case, the evidence does not show that the Veteran has the medical background necessary to competently identify or opine regarding symptoms or diagnoses that are not lay observable; however, the Veteran, as a layperson, is competent to identify or opine regarding any lay-observable symptoms or diagnoses. Jandreau, supra; Layno, supra. 1. Entitlement to service connection for erectile dysfunction The Veteran generally contends that his erectile dysfunction is etiologically related to his service, to include as secondary to his service-connected lumbar spine disability, service-connected cervical spine disability, and service-connected medications. See October 2013 VA Form 21-526b; July 2015 Decision Review Officer hearing transcript; January 2019 Board hearing transcript. The June 1967 entrance examination, May 1969 separation examination, and other service treatment records fail to document any pertinent abnormalities. In an August 2013 male reproductive organ conditions DBQ, private provider Dr. GW found: erectile dysfunction for over three to four years that was as likely as not attributable to hypertension and hyperlipidemia (Box 5B) and as likely as not impacted by neck pain (Box 10B). However, because Dr. GW provided no rationale to support that conclusion, the Board finds it to be inadequate and of no probative value. Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). In a January 2014 Statement, the Veteran highlighted the August 2013 male reproductive organ conditions Disability Benefits Questionnaire (DBQ) completed by private provider Dr. GW, stated that the cumulative effect of his service-connected disabilities makes it virtually impossible to perform activities of daily living (including dressing, personal hygiene, general mobility, and having sexual relations with his spouse), and stated that he lives in a constant state of pain. During the July 2015 Decision Review Officer hearing, the Veteran contended that his erectile dysfunction was secondary to his service-connected lumbar spine disability, service-connected cervical spine disability, and service-connected medications; he explained that he was in a lot of pain all the time and had a lot of different medications, so he thought it was from the “cumulative impact” of that. During the January 2019 Board hearing, the Veteran again contended that his erectile dysfunction was secondary to his service-connected lumbar spine disability, service-connected cervical spine disability, and service-connected medications. He further highlighted the August 2013 DBQ by Dr. GW and explained that Dr. GW opined that the Veteran’s erectile dysfunction was caused by the pain from his “other injuries” (neck, back, and other joint pain) because the Veteran “can’t stand to touch” his spouse because it hurts too badly and “it turns her off because she’ll touch [the Veteran] the wrong way and [he] scream[s].” During the December 2019 VA male reproductive organ conditions examination, the Veteran reported onset of erectile dysfunction in 2009 that worsened when he started having neck pain and after neck surgery (the neck pain is too excruciating when attempting to get an erection during intercourse, such that he is unable to have intercourse due to the pain). The December 2019 VA examiner, after noting the August 2013 DBQ findings by Dr. GW, opined that the erectile dysfunction was less likely than not etiologically related to service or a service-connected disability because: (a) the in-service GSW would not cause erectile dysfunction to develop 40 years after service in approximately 2009 (if the severity of the wound and or subsequent surgery affected the function of the penis/erections it would have been more proximate to the date of injury/surgery); (b) neither lumbar strain nor cervical ruptured disc cause erectile dysfunction (the Veteran would have to have a spinal cord injury, incomplete or complete with significant paralysis to result in erectile dysfunction, which he does not); and (c) Dr. GW’s 2013 opinion that the cause is hypertension and hyperlipidemia is accurate because the main reasons for erectile dysfunction are vascular (blood pressure/other circulatory conditions) or neurological/nerve damage such as significant spinal cord injury (not lumbar strain or a cervical herniated disc). The VA examiner also cited medical literature published by the National Institutes of Health in support of the opinion. However, the VA examiner also included a contradictory comment that it is “plausible” that the Veteran’s neck pain contributed to/aggravated his erectile dysfunction, despite not causing it. In a September 2020 Exam Request, the AOJ found that the December 2019 VA examiner’s opinion was inadequate regarding: (a) whether the erectile dysfunction was secondary to the service-connected cervical spine condition (as discussed above, the examiner indicated that it was not secondary, but then commented that it was “plausible,” which is not legally acceptable language for VA purposes); and (b) whether the erectile dysfunction was secondary to the service-connected medications (the examiner simply did not address this theory). As such, the AOJ requested further development. In an October 2020 VA addendum opinion, the examiner opined that the erectile dysfunction was less likely than not etiologically related to service, a service-connected disability, or service-connected medication because: (a) there is no anatomic or pathophysiological relationship between a musculoskeletal condition (such as lumbar strain and cervical disc disease) and the development of erectile dysfunction (lumbar strain is related to an overuse, inflammation, and/or stretching of the muscles in the lower back and muscle strain does not impact the vascular system or nerve conduction that is involved with getting and maintaining erections; cervical disc disease is related to an inflammation, impingement, or bulging intervertebral cervical disc that can affect the peripheral nerves of the upper extremities, but does not impact the vascular system or nerve conduction that is involved with getting and maintaining erections); (b) the risk factors for developing erectile dysfunction include alcoholism, depression, hypogonadism with testosterone deficiency, systemic illnesses, and certain medications such as selective serotonin reuptake inhibitors (SSRI’s), antiandrogens, or 5-alpha reductase inhibitors; and (c) erectile dysfunction was first documented in a May 2011 Hampton VAMC record, at which time the Veteran had an active problem list including other conditions (chronic back pain, subjective tinnitus, knee pain, personal history of exposure to Agent Orange, obesity, depression, and Vitamin D deficiency) and at which time he was service connected for several conditions (residuals GSW right thigh, bilateral knee arthritis, right hip bursitis, and lumbar strain; the active medications at that time were Cholecalciferol for Vitamin D deficiency and Meloxicam for back pain [he had also previously been prescribed Naproxen for back pain]; he was diagnosed with impotence and prescribed Levitra for erectile dysfunction symptoms); however, there is no established etiological basis for the development of erectile dysfunction due to these prescribed medications. The VA examiner also cited medical literature published on UpToDate in support of the opinion. Based on this evidence, the preponderance of the probative evidence weighs against finding that the Veteran’s erectile dysfunction began during active service, is otherwise related to an in-service injury or disease, or is secondary to a service-connected condition or medication. Specifically, as discussed above, although the Veteran contends that his erectile dysfunction is secondary to his service-connected conditions and medications, the evidence does not show that the Veteran has the medical background necessary to competently render an etiological opinion about this disability (the vascular system and nerve conduction involved with getting and maintaining erections is not lay observable). Jandreau, supra; Layno, supra. Further, as discussed above, the August 2013 DBQ by Dr. GW is inadequate and of no probative value because Dr. GW provided no rationale to support his conclusion. Barr, supra. Finally, the October 2020 VA addendum opinion is the only adequate and probative etiological opinion currently of record because the examiner supported the opinion with sufficient rationale based on the comprehensive medical and lay evidence and bolstered the rationale with citation to medical literature. Accordingly, although the Board has considered the Veteran’s contentions regarding etiology, the Board finds that the October 2020 VA examiner’s opinion is more probative because that individual has specific medical training that the Veteran is not shown to have. Thus, service connection is not warranted and the claim must be denied. Increased Ratings Disability evaluations are determined by the application of a schedule of ratings which is based, as far as can practically be determined, on the average impairment of earning capacity. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. Each service-connected disability is rated on the basis of specific criteria identified by a Diagnostic Code. 38 C.F.R. § 4.27. When rating the Veteran’s service-connected disability, the entire medical history must be borne in mind. Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Separate higher or lower compensable evaluations may be assigned for separate periods of time if such distinct periods are shown by the competent evidence of record during the appeal, a practice known as “staged” ratings. Hart v. Mansfield, 21 Vet. App. 505 (2007); Fenderson v. West, 12 Vet. App. 119, 126 (1999). Regulations require that where there is a question as to which of two evaluations is to 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. In evaluating the evidence, the Board has been charged with the duty to assess the credibility and weight given to evidence. Davidson v. Shinseki, 581 F. 3d 1313 (Fed. Cir. 2009); Jandreau v. Nicholson, 492 F. 3d 1372 (Fed. Cir. 2007). Indeed, the Court has declared that in adjudicating a claim, the Board has the responsibility to do so. Bryan v. West, 13 Vet. App. 482, 488-89 (2000). In doing so, the Board is free to favor one medical opinion over another, provided it offers an adequate basis for doing so. Owens v. Brown, 7 Vet. App. 429, 433 (1995). Except as otherwise provided by law, a claimant has the responsibility to present and support a claim for benefits under the laws administered by VA. VA shall consider all information and medical and lay evidence of record. Where there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, VA shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). Under the General Rating Formula for Disease and Injuries of the Spine, a 20 percent rating is warranted for: forward flexion of the cervical spine greater than 15 degrees but not greater than 30 degrees; or, the combined range of motion of the cervical spine not greater than 170 degrees; or, muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. 38 C.F.R. § 4.71a, DC 5242-5237. A 30 percent rating is warranted for: forward flexion of the cervical spine 15 degrees or less; or, favorable ankylosis of the entire cervical spine. Id. A 40 percent rating is warranted for: unfavorable ankylosis of the entire cervical spine. Id. A 100 percent (maximum schedular) rating is warranted for: unfavorable ankylosis of the entire spine. Id. Note (1) also articulates that neurologic abnormalities, including, but not limited to, bowel or bladder impairment, should be evaluated separately, under an appropriate diagnostic code. Id. Normal motion of the cervical spine is: forward flexion from zero to 45 degrees, extension from zero to 45 degrees, left and right lateral flexion from zero to 45 degrees, and left and right lateral rotation from zero to 80 degrees. 38 C.F.R. § 4.71a, Note (2), Plate V. When evaluating joint disabilities rated on the basis of limitation of motion, VA must consider granting a higher rating in cases in which functional loss due to pain, weakness, excess fatigability, or incoordination is demonstrated, and those factors are not contemplated in the relevant rating criteria. 38 C.F.R. §§ 4.40, 4.45, 4.59; DeLuca v. Brown, 8 Vet. App. 202 (1995). The U.S. Court of Appeals for Veterans Claims (Court) has clarified that although pain may be a cause or manifestation of functional loss, limitation of motion due to pain is not necessarily rated at the same level as functional loss where motion is impeded. Mitchell v. Shinseki, 25 Vet. App. 32 (2011); cf. Powell v. West, 13 Vet. App. 31, 34 (1999); Hicks v. Brown, 8 Vet. App. 417, 421 (1995); Schafrath v. Derwinski, 1 Vet. App. 589, 592 (1991). Instead, the Mitchell Court explained that, pursuant to 38 C.F.R. §§ 4.40 and 4.45, the possible manifestations of functional loss include decreased or abnormal excursion, strength, speed, coordination, or endurance, as well as less or more movement than is normal, weakened movement, excess fatigability, and pain on movement (as well as swelling, deformity, and atrophy) that affects stability, standing, and weight-bearing. 38 C.F.R. §§ 4.40, 4.45. Thus, functional loss caused by pain must be rated at the same level as if the functional loss were caused by any of the other factors cited above. Thus, in evaluating the severity of a joint disability, VA must determine the overall functional impairment due to these factors. The provisions of 38 C.F.R. § 4.59, which relate to painful motion, are not limited to disabilities involving arthritis and must be considered when raised by the claimant or when reasonably raised by the record. Burton v. Shinseki, 25 Vet. App. 1 (2011). Moreover, the Court in Southall-Norman v. McDonald, 28 Vet. App. 346, 352 (2016) held that the provisions of 38 C.F.R. § 4.59, which relate to painful motion, are not limited to the evaluation of musculoskeletal disabilities under Diagnostic Codes predicated on range of motion measurements. Furthermore, in Jones v. Shinseki, 26 Vet. App. 56, 61-63 (2012), the Court held that the Board may not deny entitlement to an increased rating on the basis of relief provided by medication when those effects are specifically contemplated by the rating criteria. Additionally, in Correia v. McDonald, 28 Vet. App. 158 (2016), the Court held that, when possible, examiners must include range of motion testing on active and passive motion and in weight-bearing and non-weight-bearing conditions. Further, in Sharp v. Shulkin, 29 Vet. App. 26, 34-36 (2017), the Court held that an examiner must attempt to elicit information regarding the severity, frequency, duration, and functional loss during flare-ups before determining that additional range of motion loss due to flare-ups cannot be estimated. 2. Entitlement to an increased rating above 20 percent prior to December 18, 2019, for multilevel cervical disc disease status post anterior cervical discectomy and fusion C7-T1 The Veteran generally contends that, throughout the appeal period, he has met the criteria for a higher rating for his cervical spine disability. The Veteran’s cervical spine disability is currently rated under DC 5242-5237 at: 20 percent from January 18, 2012, through December 17, 2019; and 30 percent since December 18, 2019. See September 2020 Codesheet; 38 C.F.R. § 4.71a, DC 5242-5237, General Rating Formula for Diseases and Injuries of the Spine. Additionally, the cervical spine disability has already been granted separate ratings for associated neurological manifestations and scars. See September 2020 Codesheet. The Veteran has been afforded two VA examinations in connection with this increased rating appeal. See June 2013 VA neck conditions examination; December 2019 VA neck conditions examination. However, the December 2019 VA examination is the only examination consistent with the holdings in DeLuca, Correia, and Sharp. DeLuca, supra; Correia, supra; Sharp, supra. As such, the Board focuses its attention on the findings of the December 2019 VA examination and applies them retroactively to the entire appeal period, to the Veteran’s advantage. During the December 2019 VA neck conditions examination, the Veteran reported: (a) constant neck pain of varying severity; (b) radiculopathy in the upper extremities; and (c) very limited range of motion (can barely bend his neck forward and has to sleep in just the right position to avoid excruciating pain). The examiner, in pertinent part: (a) measured inial forward flexion from 0 to 15 degrees and noted pain causing functional loss; (b) noted that the Veteran was unable to perform observed repetitive use testing due to fear of pain; (c) found that pain significantly limits functional ability with repeated use over a period of time and estimated forward flexion to be from 0 to 15 degrees; (d) documented the Veteran’s denial of flare-ups; (e) found no ankylosis; and (f) found no intervertebral disc syndrome (IVDS). Based on this evidence, the Board finds that, throughout the appeal period, the Veteran’s cervical spine disability has manifested in symptoms consistent with a 30 percent rating, but no higher. Specifically, considering the functional loss contemplated by the holdings in DeLuca, Correia, and Sharp, the December 2019 VA examination findings, which are representative of the entire appeal period and applied retroactively, clearly meet the schedular criteria for the 30 percent rating (a 30 percent rating is warranted, in pertinent part, for forward flexion of the cervical spine 15 degrees or less; in this case, the Veteran’s forward flexion during the December 2019 examination measured to 15 degrees initially and when estimated for repeated use over time). However, the Board finds that, throughout the appeal period, the Veteran’s cervical spine disability has not manifested in symptoms consistent with a rating higher than 30 percent. Specifically, ratings higher than 30 percent require ankylosis. 38 C.F.R. § 4.71a, DC 5242-5237, General Rating Formula for Diseases and Injuries of the Spine. Neither the December 2019 VA examination nor the other pertinent evidence (VA medical records, private medical records, and lay contentions) indicates that the cervical spine disability manifested in ankylosis; moreover, the Board finds that the Veteran is not competent to provide the missing diagnosis of ankylosis because this is a medical finding and the evidence does not indicate that he has the required medical background to make such a finding. Davidson, supra. In sum, because the absence of ankylosis precludes a rating higher than 30 percent, the Board: (a) grants entitlement to an increased rating of 30 percent, but no higher, prior to December 18, 2019; and (b) denies entitlement to an increased rating above 30 percent since December 18, 2019. 3. Entitlement to an increased rating above 30 percent since December 18, 2019, for multilevel cervical disc disease status post anterior cervical discectomy and fusion C7-T1 This issue is denied for the same reasons and bases discussed above. REASONS FOR REMAND 1. Entitlement to service connection for a RLE neurological condition (claimed as numbness in legs) The Veteran generally contends that his neurological condition of the lower extremities was caused by his service, to include his herbicide agent exposure, his service-connected residuals GSW right thigh, his service-connected lumbar spine disability, and his service-connected cervical spine disability. See July 2015 Decision Review Officer hearing transcript; January 2019 Board hearing transcript. The June 2019 Board Decision explained that medical clarification was required because the June 2013 VA peripheral nerves conditions examiner failed to consider potentially favorable lay and medical evidence, including: (a) the Veteran’s July 2015 Decision Review Officer hearing, in which the Veteran testified that he told the June 2013 VA peripheral nerves conditions examiner about the numbness in his lower extremities since being shot in service, but that the examiner focused his testing solely on the upper extremities; (b) the May 1969 separation examination noting paresthesia due to the GSW; (c) a December 2012 note by private provider Dr. GW showing a past medical history of leg pain/tingling; and (d) a January 2013 note by private provider Dr. JAB showing a past medical history of leg pain/tingling. Barr, supra; Reonal v. Brown, 5 Vet. App. 458, 461 (1993). Due to these deficiencies, the Board remanded for medical clarification regarding: (a) whether the chronic numbness/tingling was diagnosable and/or results in functional impairment; and, if so, (b) whether any lower extremity neurological condition was at least as likely as not etiologically related to the Veteran’s service, to include his herbicide agent exposure, his service-connected residuals GSW right thigh, his service-connected lumbar spine disability, and his service-connected cervical spine disability. Upon remand, the AOJ obtained January 2020 etiological opinions. Crucially, however, the January 2020 VA opinions are inadequate because they: (a) did not address the potentially favorable evidence outlined in the June 2019 Board Remand; (b) failed to address whether herbicide agent exposure directly, rather than presumptively, caused this condition; and (c) contained inadequate rationale regarding secondary service connection (the rationale listed under the direct service connection analysis was seemingly copied and pasted into the rationale listed under the secondary service connection analysis, and failed to analyze whether this condition is secondary to the service-connected GSW residuals, service-connected lumbar spine condition, or service-connected cervical spine condition). Barr, supra; Stegall v. West, 11 Vet. App. 268, 271 (1998). As such, the Board must remand for further medical development. 2. Entitlement to service connection for a LLE neurological condition (claimed as numbness in legs) This issue is remanded for the same reasons discussed above. 3. Entitlement to an increased rating above 20 percent for LUE radiculopathy associated with multilevel cervical disc disease status post anterior cervical discectomy and fusion C7-T1 The Veteran generally contends that his LUE radiculopathy is more severe than contemplated by the current rating of 20 percent under DC 8514, which rates paralysis of the radial nerve (musculospiral nerve). See September 2020 Codesheet; 38 C.F.R. § 4.124a, DC 8514. The June 2019 Board Decision explained that a new examination was required to assess the current severity of the condition because the evidence indicated worsening since the June 2013 VA peripheral nerves conditions examination. See June 2013 VA peripheral nerves conditions examination; July 2015 Decision Review Officer hearing transcript (the Veteran testified that it is difficult to move his whole arm [especially his thumb, index finger, and long finger], that his fingers cramp and “knot up” causing excruciating pain, and that his symptoms flare up with prolonged use); January 2019 Board hearing transcript (the Veteran testified that his LUE radiculopathy had worsened over time to the point of being in a “constant state of pain”); Proscelle v. Derwinski, 2 Vet. App. 629, 632 (1992); Olson v. Principi, 3 Vet. App. 480, 482 (1992). Notably, the June 2013 VA peripheral nerves conditions examination found, in pertinent part, that: (a) the left radial nerve (musculospiral nerve) had moderate, incomplete paralysis; and (b) the left middle radicular group was normal. As such, the AOJ rated this condition under DC 8514 for paralysis of the radial nerve (musculospiral nerve). Upon remand, the AOJ obtained a December 2019 VA neck conditions examination, a December 2019 VA peripheral nerves conditions examination, and a December 2019 VA diabetic sensory-motor peripheral neuropathy examination. Crucially, the December 2019 examiner found, in pertinent part, that: (a) the left middle radicular group had moderate, incomplete paralysis; and (b) the left radial nerve (musculospiral nerve) was normal. The December 2019 examiner’s assessment that the left middle radicular group is solely affected contradicts the June 2013 examiner’s assessment that the left radial nerve (musculospiral nerve) is solely affected; further, the Board highlights that this distinction is important because there are different schedular criteria and ratings available for paralysis of the middle radicular group under DC 8511 than for paralysis of the radial nerve (musculospiral nerve) under DC 8514. 38 C.F.R. § 4.124a, DC’s 8511, 8514. As such, the Board must remand for medical clarification to resolve this conflicting medical information. The matters are REMANDED for the following action: 1. Re-examine the etiology of the neurological condition of the lower extremities, specifically, whether any lower extremity neurological condition was at least as likely as not etiologically related to the Veteran’s service, to include his herbicide agent exposure, his service-connected residuals GSW right thigh, his service-connected lumbar spine disability, and his service-connected cervical spine disability. Due to COVID-19, the Board defers to the examiner’s discretion to determine whether in-person examination is required to render the requested opinion. 2. Regarding the LUE radiculopathy, obtain medical clarification to resolve conflicting medical information about whether the middle radicular group or the radial nerve (musculospiral nerve) is affected. Due to COVID-19, the Board defers to the examiner’s discretion to determine whether in-person examination is required to render the requested opinion. 3. Readjudicate the appeal. R. FEINBERG Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board H. Daus, 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.