Citation Nr: 21003296 Decision Date: 01/21/21 Archive Date: 01/21/21 DOCKET NO. 16-26 410 DATE: January 21, 2021 ORDER An initial rating in excess of 10 percent prior to August 11, 2011, for radiculopathy, left lower extremity is denied. A 20 percent rating for radiculopathy, left lower extremity is granted, effective August 11, 2011. A rating in excess of 20 percent from August 11, 2011 for radiculopathy, left lower extremity, is denied. An initial rating in excess of 10 percent for hypertension is denied. A rating in excess of 10 percent for gastroesophageal reflux disease (GERD) is denied. REMANDED Entitlement to service connection for a heart disorder, to include coronary artery disease (CAD) and myocardial infarction, is remanded. Entitlement to service connection for left upper extremity carpal tunnel syndrome is remanded. Entitlement to an effective date earlier than June 21, 2018, for the award of a 20 percent disability rating for service-connected radiculopathy, right lower extremity is remanded. FINDINGS OF FACT 1. The evidence demonstrates that, prior to August 11, 2011, the Veteran’s service-connected radiculopathy, left lower extremity was manifested by no more than mild incomplete paralysis. 2. Resolving all reasonable doubt in the Veteran’s favor, effective August 11, 2011, his service-connected radiculopathy, left lower extremity was manifested by moderate incomplete paralysis. 3. The preponderance of the evidence demonstrates that, since August 11, 2011, the Veteran’s service-connected radiculopathy, left lower extremity has been manifested by no more than moderate incomplete paralysis. 4. At no point during the appeal period has the Veteran’s service-connected hypertension been manifested by diastolic pressure predominately 110 or more, or systolic pressure predominantly 200 or more. 5. At no point during the appeal period has the Veteran’s service-connected GERD been manifested by persistently recurrent epigastric distress, or symptoms that are productive of a considerable impairment of health. CONCLUSIONS OF LAW 1. The criteria for an initial rating in excess of 10 percent prior to August 11, 2011, for service-connected radiculopathy, left lower extremity are not met. 38 U.S.C. §§ 1155, 5107 (2018); 38 C.F.R. §§ 4.1, 4.3, 4.124a, Diagnostic Code 8620 (2020). 2. The criteria for a 20 percent rating, effective August 11, 2011, for service-connected radiculopathy, left lower extremity are met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.124a, Diagnostic Code 8620. 3. The criteria for a rating in excess of 20 percent since August 11, 2011, for service-connected radiculopathy, left lower extremity are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.124a, Diagnostic Code 8620. 4. The criteria for an initial rating in excess of 10 percent rating prior for service-connected hypertension are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.104, Diagnostic Code 7101 (2020). 5. The criteria for an initial rating in excess of 10 percent rating prior for service-connected GERD are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.114, Diagnostic Code 7436 (2020). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from April 1976 to August 1993 and from July 2007 to June 2008. This appeal was previously before the Board in March 2019, at which time it included the issues of entitlement to service connection for a left shoulder disorder, left upper extremity radiculopathy, and a neck disability. In an April 2020 rating decision, the agency of original jurisdiction (AOJ) awarded service connection for a cervical spine disability, left upper extremity radiculopathy, and left shoulder degenerative arthritis. This represents a full grant of the benefits sought on appeal as to those issues; therefore, they are no longer before the Board. See Grantham v. Brown, 114 F.3d 1156 (Fed. Cir. 1997). Finally, the RO has granted entitlement to a total disability rating based on individual unemployability due to service-connected disabilities (TDIU) from the day following the Veteran’s last day at work so the TDIU issue is not before the Board. I. Increased Ratings Disability evaluations are determined by the application of the facts presented to VA’s Schedule for Rating Disabilities (Rating Schedule) at 38 C.F.R. Part 4. The percentage ratings contained in the Rating Schedule represent, as far as can be practicably determined, the average impairment in earning capacity resulting from diseases and injuries incurred or aggravated during military service and the residual conditions in civilian occupations. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. 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 for that rating. Otherwise the lower rating will be assigned. 38 C.F.R. § 4.7. Reasonable doubt will be resolved in the Veteran’s favor. 38 C.F.R. § 4.3. A veteran’s entire history is to be considered when making disability evaluations. See generally 38 C.F.R. § 4.1; Schafrath v. Derwinski, 1 Vet. App. 589 (1995). Where an increase in the level of a service-connected disability is at issue, the primary concern is the present level of disability. Francisco v. Brown, 7 Vet. App. 55 (1994). Staged ratings are appropriate when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. See Fenderson v. West, 12 Vet. App. 119, 126 (1999). 1. Left Lower Extremity Radiculopathy In a July 2013 rating decision, the AOJ awarded service connection for radiculopathy, left lower extremity, and assigned an initial 10 percent disability rating under Diagnostic Code 8699-8620, effective June 26, 2008. In an April 2016 rating decision, the AOJ awarded an increased rating of 20 percent for his service-connected radiculopathy, left lower extremity under Diagnostic Code 8620, effective November 3, 2015. Under Diagnostic Code 8620 (neuritis of the sciatic nerve), a 10 percent rating is warranted for mild incomplete paralysis. A 20 percent rating is warranted when there is moderate incomplete paralysis. A 40 percent rating is warranted when there is moderately-severe incomplete paralysis. A 60 percent rating is warranted when there is severe incomplete paralysis, with marked muscular atrophy. Complete paralysis warrants an 80 percent rating where the foot dangles and drops, there is no active movement possible of muscle below the knee and flexion of the knee is weakened or (very rarely) lost. 38 C.F.R. § 4.124a. Under 38 C.F.R. § 4.124a, 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 should be for the mild, at most, the moderate degree. The ratings for peripheral nerves are for unilateral involvement; when bilateral, combine with application of the bilateral factor. Words such as “mild,” “moderate” and “severe” are not defined in the Rating Schedule. Rather than applying a mechanical formula, the Board must evaluate all of the evidence to the end that its decisions are “equitable and just.” 38 C.F.R. § 4.6. Use of terminology such as “severe” by VA examiners and others, although evidence to be considered by the Board, is not dispositive of an issue. All evidence must be evaluated in arriving at a decision regarding an increased rating. 38 C.F.R. §§ 4.2, 4.6. A January 2008 private treatment record noted that the Veteran’s report of low back pain that radiated down his left leg with some numbness. Straight leg raise testing was negative. The Veteran’s March 2008 report of medical history noted his report of leg pain and numbness in his feet. An April 2008 private treatment record noted the Veteran’s report of left leg pain, along with a pull feeling with walking. An August 2008 VA treatment record noted that the Veteran was being treated for radiculopathy of the left lower extremity, and that he was experiencing minimal symptoms. He reported pain that radiated down his left leg, along with numbness. Upon examination, straight leg raise testing was negative. Deep tendon reflexes were normal, and strength was normal. Monofilament sensation was intact but slightly less on the left foot. During his February 2009 VA examination, the Veteran recalled experiencing an increasing amount of radiating pain to his left leg during service. It was noted that the Veteran had no difficulty with ambulation, but he did report problems with driving for long periods of time, but he denied radiation of pain down his lower extremities. Upon examination, there was no drift or tremors, there was no focal weakness, and coordination appeared to be intact. Vibratory sensation, gait, and deep tendon reflexes were normal. There was no muscle atrophy or wasting, and straight leg raise testing was normal. An August 2009 VA treatment record noted the Veteran’s report of pain that always went down his left leg. The examiner noted that the Veteran’s left leg seemed weaker. The Veteran underwent another VA lumbar spine examination in August 2011, and the examiner noted his diagnosis of lower extremity radiculopathy. He reported a numbness when sitting for long periods of time, as well as a burning/stabbing pain. Upon examination, muscle strength testing was normal, and there was no evidence of muscle atrophy. He displayed a decreased response to light touch testing in the left lower leg/ankle and the left foot/toes; but his sensation was normal in the upper anterior thigh and thigh/knee. Straight leg raise testing was negative. The examiner indicated that the Veteran’s symptoms included mild constant pain, moderate intermittent pain, moderate paresthesias and/or dysesthesias, and moderate numbness. Overall, based on the examination results, the examiner concluded that the Veteran experienced moderate incomplete paralysis of left sciatic nerve. The Veteran also underwent a VA peripheral nerves examination in August 2011, and the examiner noted his diagnosis of lower extremity radiculopathy. The examiner indicated that the Veteran’s symptoms included mild paresthesias and/or dysesthesias and mild numbness. Muscle strength testing was normal, and there was no evidence of muscle atrophy. He displayed a decreased response to light touch testing in the left lower leg/ankle and the left foot/toes; but his sensation was normal in the upper anterior thigh and thigh/knee. Straight leg raise testing was negative. Overall, based on the examination results, the examiner concluded that the Veteran did not experience paralysis, complete or incomplete, in his left lower extremity. In a September 2013 statement, the Veteran’s former representative argued that the Veteran’s left lower extremity radiculopathy was manifested by near constant pain, alternating numbness, tingling, and shooting pain. He also noted a difficulty driving and problems walking. The Veteran underwent another VA lumbar spine examination in November 2015, and the examiner noted his diagnosis of lower extremity radiculopathy. He reported a burning at the base of his spine. He also indicated that he would occasionally have to drag his leg. He also reported left foot numbness. Upon examination, muscle strength testing was normal, except for active movement against some resistance in left great toe extension; and there was no evidence of muscle atrophy. He displayed a decreased response to light touch testing in the left lower leg/ankle and the left foot/toes; but his sensation was normal in the upper anterior thigh and thigh/knee. Straight leg raise testing was negative. The examiner indicated that the Veteran’s symptoms included severe constant pain, severe intermittent pain, moderate paresthesias and/or dysesthesias, and moderate numbness. Overall, based on the examination results, the examiner concluded that the Veteran experienced moderate incomplete paralysis of left sciatic nerve. The Veteran also underwent a VA peripheral nerves examination in November 2015, and the examiner noted his diagnosis of lower extremity radiculopathy. The examiner indicated that the Veteran’s symptoms included severe intermittent pain, moderate paresthesias and/or dysesthesias; and moderate numbness. Muscle strength testing was normal, and there was no evidence of muscle atrophy. He displayed a decreased response to light touch testing in the left lower leg/ankle and the left foot/toes; but his sensation was normal in the upper anterior thigh and thigh/knee. Straight leg raise testing was negative. Overall, based on the examination results, the examiner concluded that the Veteran experienced moderate incomplete paralysis of left sciatic nerve. The examiner noted that the Veteran could not stand for longer periods of time due to radicular pain. A July 2016 private examination noted the Veteran’s report of numbness in his left leg, along with pain. Upon examination straight leg raise was negative, there was no sensory deficit noted, and strength was five out of five. The Veteran underwent another VA peripheral nerves examination in September 2016, and the examiner noted his diagnosis of lower extremity radiculopathy. The examiner indicated that the Veteran’s symptoms included moderate constant pain, mild intermittent pain, mild paresthesias and/or dysesthesias; and mild numbness. Muscle strength testing was normal, and there was no evidence of muscle atrophy. He displayed a decreased response to light touch testing in the upper anterior thigh, thigh/knee, and the lower leg/ankle; but his left foot/toes sensation was normal. Overall, based on the examination results, the examiner concluded that the Veteran experienced mild incomplete paralysis of left sciatic nerve. A November 2016 private treatment record noted that the Veteran had normal motor strength and sensation in all extremities, and that his reflexes were brisk. An April 2017 private examination noted the Veteran’s report of pain that radiated to his leg. He described the pain as an aching pain that was occasionally sharp. He was noted to occasionally use a cane for ambulation. Upon examination straight leg raise was positive at 30 degrees. There was no sensory deficit noted, and strength was five out of five. The Veteran underwent another VA lumbar spine examination in September 2018, and the examiner noted his diagnosis of lower extremity radiculopathy. He reported a pain, numbness, and tingling in his lower extremities. Upon examination, muscle strength testing was normal, and there was no evidence of muscle atrophy. He displayed a decreased response to light touch testing in the foot/toes; but his sensation was normal in the upper anterior thigh, thigh/knee, and lower leg/ankle. Straight leg raise testing was positive. The examiner indicated that the Veteran’s symptoms included mild constant pain, moderate intermittent pain, moderate paresthesias and/or dysesthesias, and mild numbness. Overall, based on the examination results, the examiner concluded that the Veteran experienced mild incomplete paralysis of left sciatic nerve. The Veteran underwent another VA examination in October 2019, and the examiner noted his diagnosis of left lower extremity radiculopathy. The Veteran reported difficulty walking long distances, being limited in his ability to drive, needed a ne for balance and leg weakness. He also reported numbness and pain. He stated that his symptoms were aggravated by prolonged sitting, walking, and standing. Upon examination, his symptoms included moderate constant pain, moderate intermittent pain, moderate paresthesias and/or dysesthesias, and moderate numbness. Muscle strength testing in knee extension and ankle plantar flexion was normal, and the Veteran displayed active movement against gravity in ankle dorsiflexion. There was no evidence of muscle atrophy, and deep tendon reflexes were normal. He displayed a decreased response to light touch/monofilament testing in the upper anterior thigh, thigh/knee, lower leg/ankle, and foot/toes. The Veteran’s gait was abnormal due to left leg weakness. Overall, based on the examination results, the examiner concluded that the Veteran experienced moderate incomplete paralysis of left sciatic nerve. There were no other pertinent physical findings, complications, conditions, signs, or symptoms associated with his left lower extremity radiculopathy. As for the functional impairment, the examiner noted that he had pain and weakness, and that he ambulated with a cane due to the weakness. He also could not stand or walk for long periods of time. Based on the foregoing, and after resolving all reasonable doubt in his favor, the Board finds that a 20 percent disability rating is warranted for the Veteran’s service-connected radiculopathy, left lower extremity, effective August 11, 2011. Indeed, the examiner who performed the August 2011 VA lumbar spine examination concluded that he experienced moderate incomplete paralysis of left sciatic nerve. Although the peripheral nerves examination concluded that he did not experience paralysis, complete or incomplete, in his left lower extremity, the Board will resolve this discrepancy in the Veteran’s favor and finds that a 20 percent disability rating is warranted under Diagnostic Code 8620, effective August 11, 2011. However, the preponderance of the evidence is against a rating greater than the 10 percent assigned to the Veteran’s service-connected radiculopathy, left lower extremity for the period prior to August 11, 2011. Furthermore, the preponderance of the evidence is against a rating greater than the 20 percent assigned for the period from August 11, 2011. As to the period prior to August 11, 2011, the evidence of record fails to show that his service-connected radiculopathy, left lower extremity was manifested by moderate incomplete paralysis. As noted above, the August 2008 VA treatment record noted that the Veteran was being treated for radiculopathy of the left lower extremity, and that he was experiencing minimal symptoms. He reported pain that radiated down his left leg, along with numbness. Upon examination, straight leg raise testing was negative. Deep tendon reflexes were normal, and strength was normal. Monofilament sensation was intact but slightly less on the left foot. Likewise, during his February 2009 VA examination, the Veteran denied radiation of pain down his lower extremities. Upon examination, there was no drift or tremors, there was no focal weakness, and coordination appeared to be intact. Vibratory sensation, gait, and deep tendon reflexes were normal, there was no muscle atrophy or wasting, and straight leg raise testing was normal. The Board finds that this evidence supports no more than 10 percent disability ratings prior to August 11, 2011, for mild incomplete paralysis of the left lower extremity. For the period from August 11, 2011, to the present, the evidence of record fails to demonstrate a disability manifested by moderately severe incomplete paralysis or worse. As noted above, the August 2011 VA examinations concluded that the Veteran experienced only mild and moderate symptoms. Furthermore, muscle strength testing was normal, and there was no evidence of muscle atrophy. Although the November 2015 VA examinations indicated that the Veteran experienced severe constant and intermittent pain, muscle strength testing was normal, and there was no evidence of muscle atrophy. Despite these severe symptoms, the examiners concluded that the Veteran’s service-connected radiculopathy, left lower extremity was manifested by no more than moderate incomplete paralysis of the sciatic nerve. As noted above, when the involvement is wholly sensory, the rating should be for the mild, or at most, the moderate degree. There is no competent and credible evidence of record that the Veteran has any symptoms that are more than wholly sensory. Thus, the Board finds that this evidence supports no more than a 20 percent disability rating since August 11, 2011, for moderate incomplete paralysis of the left lower extremity. In summation, after resolving all reasonable doubt in the Veteran’s favor, the Board finds that a 20 percent disability rating under Diagnostic Code 8620 is warranted for the Veteran’s service-connected radiculopathy, left lower extremity, effective August 11, 2011. However, the Board finds that the preponderance of the evidence is against a rating in excess of 10 percent prior to August 11, 2011; and in excess of 20 percent from August 11, 2011. Because the preponderance of the evidence is against higher ratings at any point during the appeal, the benefit-of-the-doubt doctrine is not applicable. See 38 U.S.C. § § 5107(b); 38 C.F.R. §§ 3.102, 4.3; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). 2. Hypertension In the June 2009 rating decision on appeal, the AOJ awarded service connection for the Veteran’s hypertension and assigned an initial noncompensable disability rating under Diagnostic Code 7101, effective June 26, 2008. In a December 2015 rating decision, the AOJ awarded an increased rating of 10 percent for his service-connected hypertension under Diagnostic Code 7101, effective June 26, 2008. Under Diagnostic Code 7101, a 10 percent rating is assigned if diastolic pressure is predominantly 100 or more or systolic pressure is predominantly 160 or more, or the minimum 10 percent evaluation is assigned for an individual with a history of diastolic pressure predominantly 100 or more who requires continuous medication for control. A 20 percent rating is warranted when the diastolic pressure is predominantly 110 or more or systolic pressure is predominantly 200 or more. A 40 percent rating is assigned if the diastolic pressure is predominantly 120 or more, and a 60 percent rating is warranted if the diastolic pressure is predominantly 130 or more. 38 C.F.R. § 4.104. A January 2008 private treatment record noted that the Veteran’s blood pressure was 134/92. The Veteran’s March 2008 discharged examination noted blood pressure readings of 141/91 and 156/96. An August 2008 VA treatment record noted that the Veteran’s blood pressure was 122/80. During his February 2009 VA examination, the examiner noted that such was noted on discharge, and that he was placed on medication at that time. He denied any chest pain, shortness of breath, or swelling. Blood pressure readings during the examination were as follows: 140/86, 136/84, and 134/82. An August 2009 VA treatment record noted that the Veteran’s blood pressure was 173/99, and 160/87 on recheck. A November 2009 VA treatment record notes that the Veteran’s blood pressure was 146/92. A January 2010 VA treatment record noted that the Veteran’s blood pressure was 168/110. The treatment record also noted that his first blood pressure reading was 190/110, that the 168/110 was the second reading, and that a third reading was 170/108. A November 2010 VA treatment record noted that the Veteran’s blood pressure was 128/83. A July 2011 VA treatment record noted that the Veteran’s blood pressure was 132/84. A March 2012 VA treatment record noted that the Veteran’s blood pressure was 130/82. A January 2013 VA treatment record noted that the Veteran’s blood pressure was 156/100. After a recheck, his blood pressure was 130/90. A May 2013 VA treatment record noted that the Veteran’s blood pressure was 134/93. An April 2014 VA treatment record noted that the Veteran’s blood pressure was 128/77. A May 2014 VA treatment record noted that the Veteran’s blood pressure was 138/91. After a recheck, his blood pressure was 136/86. A May 2014 VA treatment record noted that the Veteran’s blood pressure response to a routine stress test was normal, going from 124/84 to 184/76. A November 2014 VA treatment record noted that the Veteran’s blood pressure was 138/87. It was noted that the Veteran’s hypertension was controlled. A July 2015 VA treatment record noted that the Veteran’s blood pressure was 130/88. In November 2015, the Veteran underwent another VA examination, and the examiner noted that his hypertension was treated with medication. The examiner then indicated that the Veteran had a history of diastolic blood pressure elevation that was predominantly 100 or more. Current blood pressure readings included 130/88, 140/78, and 138/78. A March 2016 VA treatment record noted that the Veteran’s blood pressure was 150/92. A May 2016 VA treatment record noted blood pressure readings of 142/80 and 156/88. A July 2016 VA treatment record noted blood pressure readings of 165/98 and 138/80. A November 2016 VA treatment record noted a blood pressure reading of 170/100. A December 2016 VA treatment record noted a blood pressure reading of 158/98. January 2017 VA treatment records note that the Veteran’s blood pressure was 140/92 and 132/86. A February 2017 VA treatment record noted that the Veteran’s blood pressure was 154/80. A June 2017 VA treatment record noted that the Veteran’s blood pressure was 152/86. A July 2017 VA treatment record noted that the Veteran’s blood pressure was 134/80 and 149/93. An October 2017 VA treatment record noted that the Veteran’s blood pressure was 140/80, and that his hypertension was stable. In September 2018, the Veteran underwent another VA examination, and the examiner noted that his hypertension was treated with medication. The examiner then indicated that the Veteran did not have a history of diastolic blood pressure elevation that was predominantly 100 or more, and his current blood pressure readings included 144/92, 150/90, and 153/86. Based on the evidence discussed above, the Board finds that the preponderance of evidence is against a higher rating for the Veteran’s hypertension at any point during the appeal period under Diagnostic Code 7101. Significantly, throughout the course of the appeal (which extends from the date of the Veteran’s claim on June 26, 2008), the Veteran’s hypertension has not more nearly approximated diastolic pressure predominantly 110 or more, or systolic pressure predominantly 200 or more as contemplated by the 20 percent rating under Diagnostic Code 7101. The Board notes that the Veteran’s had blood pressure readings in January 2010 that showed diastolic readings of 110. However, both prior to and following this, his blood pressure readings were consistently below 110 diastolic and 200 systolic. Accordingly, the criteria for a rating in excess of 10 percent under Diagnostic Code 7101 are not met. In summation, the Board finds that the preponderance of the evidence is against the assignment of a higher rating at any point during the appeal period for the Veteran’s service-connected hypertension. Therefore, the benefit-of-the-doubt doctrine is not applicable, and his claim must be denied. See 38 U.S.C. § 5107; 38 C.F.R. §§ 3.102, 4.3; Gilbert, supra. 3. IR GERD In the December 2015 rating decision on appeal, the AOJ awarded service connection for the Veteran’s GERD and assigned an initial 10 percent disability rating under Diagnostic Code 7399-7346, effective June 26, 2008. Hyphenated diagnostic codes are used when a rating under one diagnostic code requires use of an additional diagnostic code to identify the basis for the evaluation assigned; the additional code is shown after the hyphen. 38 C.F.R. § 4.27 (2019). Under Diagnostic Code 7346, a 10 percent disability rating is warranted for two or more of the symptoms for the 30 percent disability rating of less severity. A 30 percent disability rating is warranted for persistently recurrent epigastric distress with dysphagia, pyrosis, and regurgitation, accompanied by substernal or arm or shoulder pain, productive of considerable impairment of health. A 60 percent rating is warranted for symptoms of pain, vomiting, material weight loss and hematemesis or melena with moderate anemia; or other symptom combinations productive of considerable impairment of health. Id. An August 2008 VA treatment record noted that the Veteran’s symptoms did not include dysphagia, abdominal pain, or heartburn. During his February 2009 VA examination, the Veteran reported that his peptic ulcer disease began in 2002. He denied any nausea, vomiting, hematemesis, melena, and diarrhea, but he reported occasional constipation. There were no periods of incapacitation due to his stomach or duodenal disease. The examiner noted that his condition had not impact his daily activities. The condition was deemed to be benign, although it was noted that he was taking medication. There were no signs of anemia. An August 2009 VA treatment record noted the Veteran’s denial of problems nausea, vomiting, abdominal pain, and diarrhea. A November 2010 VA treatment record noted that the Veteran’s GERD was controlled, he denied abdominal pain, and his bowels were regular without blood. The treatment records note that the Veteran’s GERD was asymptomatic. July 2011 and March 2012 VA treatment records noted that the Veteran’s GERD was stable, he denied abdominal pain, and his bowels were regular without blood. The treatment records note that the Veteran’s GERD was asymptomatic. A January 2013 VA treatment record noted that the Veteran was not experiencing abdominal pain, that his bowels were regular without blood, and that there was no evidence of dysuria or hematuria. The treatment record noted that the Veteran’s GERD was asymptomatic. A July 2015 VA treatment record noted that the Veteran’s GERD was controlled. A November 2015 VA treatment record noted the Veteran’s report of abdominal pain, nausea, bloating, and regurgitation; however, he denied heartburn. In November 2015, the Veteran underwent a VA esophageal conditions examination, and he was diagnosed with GERD. He reported epigastric pain off and on since 2002. He also reported nausea with regurgitation, decrease appetite, and some bloating. Upon examination, his symptoms included persistently recurrent epigastric distress, reflux, regurgitation, and nausea, and the frequency of the episodes was four or more times per year, having a duration of less than one day. There were no other pertinent findings, but the examiner indicated that the Veteran’s GERD would impact his ability to work because he was irritable and because he would be uncomfortable, especially with nausea. A January 2016 VA treatment record noted the Veteran’s report of feeling nauseated al of the time, as well as episodes of regurgitation off and on. A March 2016 VA treatment record noted that the Veteran’s GERD was stable. A November 2016 private treatment record noted the Veteran’s denial of abdominal pain and heartburn. A February 2017 VA treatment record noted that the Veteran’s GERD was controlled, and that his symptoms, including dysphagia, occurred less than two times per week. The Veteran also denied a change in appetite, dysphagia, heartburn, abdominal pain, hematochezia, melena, constipation, and diarrhea. An October 2017 VA treatment record noted that the Veteran denied a change in appetite, dysphagia, heartburn, abdominal pain, hematochezia, melena, constipation, and diarrhea. It was also noted that the Veteran’s GERD was stable. In January 2019, the Veteran underwent another VA esophageal conditions examination, and he was diagnosed with GERD and helicobacter pylori. He stated that his current symptoms included epigastric pain, burning, indigestion, belching, and vomiting. Upon examination, his symptoms included infrequent episodes of epigastric distress; dysphagia; pyrosis (heartburn); reflux; regurgitation; substernal, arm, and shoulder pain; and vomiting four or more times per year. Nevertheless, the examiner indicated that the Veteran’s symptoms were not productive of a considerable impairment of health, and they were not productive of severe impairment of health. There were no other pertinent findings, but the examiner indicated that the Veteran’s GERD would impact his ability to work because he was irritable and because he had difficulty concentrating. He stated that he would not go out to eat due to the possibility of vomiting, and that he would lay down due to the severity of the pain. In December 2019, the Veteran underwent another VA esophageal conditions examination, and he was diagnosed with GERD and helicobacter pylori. He stated that his current symptoms included an inability to eat certain food at times, as well as trouble sleep due to burning in his esophagus. Other reported symptoms included heartburn, chronic cough, and difficulty swallowing. He indicated that he monitored his diet and took medication. Upon examination, his symptoms included dysphagia, reflux, regurgitation, substernal pain, and sleep disturbances four or more times per year, nausea four or more times per year, and vomiting four or more times per year. Nevertheless, the examiner indicated that the Veteran’s symptoms were not productive of a considerable impairment of health, and they were not productive of severe impairment of health. There were no other pertinent findings, but the examiner indicated that the Veteran’s GERD would impact his ability to work because he had difficulty sleeping and because certain foods aggravated his symptoms. Based on the evidence discussed above, the Board finds that the preponderance of evidence is against a higher rating for the Veteran’s GERD at any point during the appeal period. Significantly, the pertinent evidence of record fails to demonstrate that the Veteran experienced persistently recurrent epigastric distress, or that his symptoms were productive of a considerable impairment of health so as to warrant a 30 percent disability rating. Indeed, as noted above, the Veteran’s VA treatment records consistently indicate that the Veteran’s GERD was stable and controlled, and the January 2019 and December 2019 VA examinations note that the Veteran’s GERD was not productive of a considerable impairment of health. The Board notes that 38 C.F.R. § 4.114 prohibits simultaneous evaluations under Diagnostic Codes 7301 to 7329, inclusive; Diagnostic Codes 7331 and 7342; and Diagnostic Codes 7345 to 7348. A single evaluation is assigned under the diagnostic code which reflects the predominant disability picture, with elevation to the next higher evaluation where the severity of the overall disability warrants such elevation. 38 C.F.R. § 4.114. Indeed, 38 C.F.R. § 4.113 notes that “there are diseases of the digestive system, particularly within the abdomen, which, while differing in the site of pathology, produce a common disability picture characterized in the main by varying degrees of abdominal distress or pain, anemia and disturbances in nutrition,” and, therefore, the diseases represented by the Diagnostic Codes above “do not lend themselves to distinct and separate disability evaluations without violating the fundamental principle relating to pyramiding as outlined in [38 C.F.R.] § 4.14.” The Board finds that no other Diagnostic Code would provide for a higher disability rating for the Veteran’s GERD. In assessing the severity of the Veteran’s GERD, the Board has considered his assertions regarding his symptoms, which he is certainly competent to provide. In this case, these symptoms were contemplated by the clinicians assessing the overall severity of the Veteran’s disability, and the assessments do not demonstrate a level of disability that would warrant the assignment of a higher rating. In summation, the Board finds that the preponderance of the evidence is against the assignment of higher ratings at any point during the appeal period for the Veteran’s service-connected GERD. Therefore, the benefit-of-the-doubt doctrine is not applicable, and his claim must be denied. See 38 U.S.C. § 5107; 38 C.F.R. §§ 3.102, 4.3; Gilbert, supra. REASONS FOR REMAND 1. Entitlement to service connection for a heart disorder, to include CAD and myocardial infarction, is remanded. In connection with the Board’s March 2019 remand, the Veteran underwent a VA examination in October 2019, and he was diagnosed with a myocardial infarction, atherosclerotic cardiovascular disease, coronary artery disease, stable angina, and hypertensive heart disease. The examiner noted the Veteran’s report that his symptoms began in 1992. However, the examination report does not include an opinion as to whether the Veteran’ diagnoses were related to his military service. The Board notes that the April 2020 supplemental statement of the case indicates that an opinion was provided; however, such is not of record. As such, the Board finds that a remand is necessary so that the opinion cited in the April 2020 supplemental statement of the case can be associated with the claims file. See Bell v. Derwinski, 2 Vet. App. 611 (1992). On remand, any updated VA treatment records should be associated with the claims file, and the Veteran should be provided another opportunity to identify any outstanding evidence. 2. Entitlement to service connection for left upper extremity CTS is remanded. In connection with the Board’s March 2019 remand, the Veteran underwent a VA examination in October 2019. The examiner noted the Veteran’s diagnosis of CTS in the left upper extremity dating back to the September 2016; however, the examiner ultimately opined that such was less likely than not related to his military service. The examiner reasoned that the 2016 diagnosis was many years after discharge, and that CTS was traditionally caused by repetitive motions of the hands and wrist. The examiner continued that it was less likely than not that his carpal tunnel syndrome was related to his carrying of a 45-pound apparatus on his back. The examiner also noted that there were no symptoms of carpal tunnel syndrome shown during the examination. The examiner also opined that the Veteran’s carpal tunnel syndrome was less likely than not related to his atypical chest pain during service because carpal tunnel syndrome was caused by nerve entrapment. The Board finds that the October 2019 opinion is insufficient to adjudicate the Veteran’s claim for service connection for CTS as the examiner failed to provide sufficient rationale supporting the conclusions provided. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008); Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007) (“[A] medical opinion... must support its conclusion with an analysis that the Board can consider and weigh against contrary opinions.”). Further, the opinion fails to reflect consideration of the Veteran’s lay statements concerning the onset and continuity of his CTS symptoms. See Dalton v. Nicholson, 21 Vet. App. 23, 39-40 (2007); Miller v. Wilkie, 32 Vet. App. 249, 260 (2020). When VA undertakes to obtain an evaluation, it must ensure that the evaluation is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). Given that the medical evidence of record fails to adequately address the issues raised, a new examination and etiology opinion is necessary. 3. Entitlement to an effective date earlier than June 21, 2018, for the award of a 20 percent disability rating for service-connected radiculopathy, right lower extremity is remanded. Unfortunately, the Veteran’s claim for an effective date earlier than June 21, 2018, for the award of a 20 percent for service-connected radiculopathy, right lower extremity must be remanded so that the AOJ can correct an error that occurred in the December 2018 rating decision on appeal. By way of background, the AOJ issued a rating decision in October 2015 that awarded service connection for radiculopathy, right lower extremity and assigned a 10 percent disability rating, effective June 26, 2008. The AOJ notified the Veteran of its decision in a letter dated October 19, 2015. Thereafter, although the Veteran did not file a notice of disagreement with the October 2015 rating decision, the AOJ scheduled him for a VA lumbar spine examination that was performed in November 2015 and included an assessment of his service-connected radiculopathy, right lower extremity. Because the November 2015 VA examination was added to the record prior to the expiration of the appeal period stemming from the October 2015 rating decision, and because the November 2015 VA examination report constitutes new and material evidence within the meaning of 38 C.F.R. § 3.156 (2019), the Board finds that the October 2015 rating decision remained pending until his June 21, 2018, claim for an increased rating was received. See Beraud v. McDonald, 766 F.3d 1402, 1406 -07 (Fed. Cir. 2014) (holding that a claim remains pending where VA failed to fulfill a statutory duty to determine the character of newly submitted evidence). To ensure the Veteran’s right to due process, the Board must defer consideration of the claim for effective date earlier than June 21, 2018, for the award of a 20 percent for radiculopathy, right lower extremity until the AOJ can fully adjudicate the Veteran’s applicable disability rating for his radiculopathy, right lower extremity for the period prior to June 21, 2018, in the first instance. See Disabled Am. Veterans v. Sec’y of Veterans Affairs, 327 F.3d 1339, 1345-48 (Fed. Cir. 2003). The matters are REMANDED for the following action: 1. Associate with the file any updated VA treatment records, as well as the October 2019 VA medical opinion addressing whether the Veteran’s current heart disorder(s) is related to his military service that was cited in the April 2020 supplemental statement of the case. 2. Give the Veteran an opportunity to identify any outstanding pertinent evidence that has not already been associated with the claims file. The AOJ should then attempt to obtain those records if the appropriate authorization is provided. 3. The Veteran should be afforded a VA examination to determine whether his left upper extremity CTS diagnosed in 2016 had its onset during, or is otherwise related to, his military service. The record and a copy of this Remand must be made available to the examiner. Any indicated evaluations, studies, and tests should be conducted. The examiner should take a history from the Veteran as to the progression of his claimed left upper extremity CTS. Following a review of the entire record, the examiner should address the following question: For the Veteran’s left upper extremity CTS (diagnosed in 2016), is it at least as likely as not that such had its onset during, or is otherwise related to, his military service, to specifically include the requirement to wear a 45-pound breathing apparatus on his back in service for course training, as he so claims? In offering any opinion, the examiner must consider the lay statements from the Veteran concerning the onset and recurrence of his symptoms. STEVEN D. REISS Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board James R. Springer, 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.