Citation Nr: 21004070 Decision Date: 01/25/21 Archive Date: 01/25/21 DOCKET NO. 15-46 587 DATE: January 25, 2021 ORDER An initial 30 percent evaluation for chronic obstructive pulmonary disease (COPD), but no higher, is granted, subject to regulations governing the payment of monetary awards. Entitlement to an evaluation in excess of 10 percent for lumbosacral strain with degenerative joint disease (DJD), lumbar spine prior to December 19, 2019, and in excess of 20 percent thereafter is denied. REMANDED Entitlement to service connection for hypertension is remanded. Entitlement to an evaluation in excess of 10 percent for DJD of the left knee is remanded. Entitlement to an evaluation in excess of 10 percent for DJD of the right knee is remanded. Entitlement to a compensable evaluation for tina pedis, onychomycosis, bilateral feet (previously evaluated as dermatophytosis) prior to October 23, 2020, and in excess of 10 percent thereafter is remanded.   FINDINGS OF FACT 1. For the period on appeal, the Veteran’s service-connected COPD required daily inhalational bronchodilator or inhalational anti-inflammatory medication. 2. Prior to December 19, 2019, the Veteran’s lumbosacral strain with DJD, lumbar spine is manifested by pain and forward flexion to 90 degrees. 3. From December 19, 2019, the Veteran’s lumbosacral strain with DJD, lumbar spine is manifested by pain and forward flexion limited to 60 degrees with repetitive use over time. CONCLUSIONS OF LAW 1. The criteria for an initial evaluation of 30 percent, but no higher, for service-connected COPD are met. 38 U.S.C. § 1155 (2012); 38 C.F.R. §§ 4.96, 4.97, Diagnostic Code 6602 (2020). 2. The criteria for a rating in excess of 10 percent for lumbosacral strain with DJD, lumbar spine prior to December 19, 2019, and in excess of 20 percent thereafter are not met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, Diagnostic Code 5242 (2020). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from November 1963 to November 1987. This matter is before the Board of Veterans’ Appeals (Board) on appeal from May 2014 and June 2014 rating decisions of a Department of Veterans Affairs (VA) Regional Office (RO). In September 2019, a hearing was held before the undersigned. A transcript of the hearing is of record. The case was previously before the Board in November 2019 when it was remanded for further development. While the case was on remand status, the RO, in an October 2020 rating decision, assigned an increased 20 percent rating for the Veteran’s lumbosacral strain with DJD, lumbar spine effective December 19, 2019. The RO also assigned an increased 10 percent rating for the Veteran’s tina pedis, onychomycosis, bilateral feet (previously evaluated as dermatophytosis) effective October 23, 2020. However, as the increases did not constitute a full grant of the benefits sought, the Veteran’s claims for increased ratings remain on appeal. See AB v. Brown, 6 Vet. App. 35, 38-39 (1993). Increased Rating Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities found in 38 C.F.R. Part 4. The percentage ratings are based on the average impairment of earning capacity as a result of a service-connected disability, and separate diagnostic codes identify the various disabilities and the criteria for specific ratings. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. If 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. All reasonable doubt as to the degree of disability will be resolved in favor of the claimant. 38 C.F.R. § 4.3. Where entitlement to disability compensation has already been established and an increase in the assigned rating is at issue, the primary concern is the present level of disability. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). The Board must also consider staged ratings, which are appropriate when the evidence establishes that the claimed disability manifested symptoms that would warrant different ratings for distinct time periods. Hart v. Mansfield, 21 Vet. App. 505, 509-10 (2007). COPD The Veteran’s COPD is currently rated as noncompensable under 38 C.F.R. § 4.97, Diagnostic Code 6604. Under Diagnostic Code 6604, Forced Expiratory Volume in one second (FEV-1) of 71- to 80-percent predicted value, or; the ratio of Forced Expiratory Volume in one second to Forced Vital Capacity (FEV-1/FVC) of 71 to 80 percent, or; Diffusion Capacity of the Lung for Carbon Monoxide by the Single Breath Method (DLCO (SB)) is 66- to 80-percent predicted, is rated 10 percent disabling. FEV-1 of 56- to 70-percent predicted, or; FEV-1/FVC of 56 to 70 percent, or; DLCO (SB) 56- to 65-percent predicted, is rated 30 percent disabling. FEV-1 of 40- to 55-percent predicted, or; FEV-1/FVC of 40 to 55 percent, or; DLCO (SB) of 40- to 55-percent predicted, or; maximum oxygen consumption of 15 to 20 ml/kg/min (with cardiorespiratory limit), is rated 60 percent disabling. FEV-1 less than 40 percent of predicted value, or; FEV-1/FVC less than 40 percent, or; DLCO (SB) less than 40-percent predicted, or; maximum exercise capacity less than 15 ml/kg/min oxygen consumption (with cardiac or respiratory limitation), or; cor pulmonale (right heart failure), or; right ventricular hypertrophy, or; pulmonary hypertension (shown by Echo or cardiac catheterization), or; episode(s) of acute respiratory failure, or; requires outpatient oxygen therapy, is rated 100 percent disabling. 38 C.F.R. § 4.97. Ratings under Diagnostic Codes 6600 through 6817 and 6822 through 6847 will not be combined with each other. 38 C.F.R. § 4.96(a). Additionally, there are special provisions for the application of evaluation criteria for Diagnostic Codes 6600, 6603, 6604, 6825-6833, and 6840-6845. 38 C.F.R. § 4.96(d). When there is a disparity between the results of different Pulmonary Function Tests (PFTs) (FEV-1, FVC, etc.), so that the level of evaluation would differ depending on which test result is used, use the test result that the examiner states most accurately reflects the level of disability. 38 C.F.R. § 4.96(d)(6). When evaluating based on PFTs, post-bronchodilator results are to be used, unless the post-bronchodilator results are poorer than the pre-bronchodilator results. In those cases, use the pre-bronchodilator results. 38 C.F.R. § 4.96(d)(5). Finally, if the FEV-1 and the FVC are both greater than 100 percent, a compensable evaluation based on a decreased FEV-1/FVC ratio should not be assigned. 38 C.F.R. § 4.96(d)(7). Treatment records from July 2013 from Robinson Clinic note that the Veteran had been treated at the ER for shortness of breath and was determined to have an exacerbation of his COPD. Treatment records from September 2013 note the Veteran was doing better after finishing a course of steroids for an acute exacerbation. The Veteran underwent a VA examination in November 2013. He reported difficulty breathing, shortness of breath, and mucus. COPD did not require the use of oral or parenteral corticosteroid medications but required the use of daily inhalational bronchodilator therapy and anti-inflammatory medication. The Veteran also used albuterol/Advair. Also required was daily use of oral bronchodilators, but no antibiotics and no outpatient oxygen therapy. PFT showed pre-bronchodilator results of FEV-1 at 87 percent, FVC at 93 percent, and FEV-1/FVC at 96 percent. The test which most accurately reflected the Veteran’s level of disability was FEV-1. Post-bronchodilator testing was not completed because pre-bronchodilator results were normal. DLCO testing was not completed because it was not indicated for the Veteran’s condition. The examiner indicated that the Veteran’s respiratory condition did not impact his ability to work. Treatment records from Womack Army Medical Center show that on various dates, including in September 2016, May 2017, September 2017, and January 2018, the Veteran had various complaints, including shortness of breath and difficulty breathing, and was assessed with acute COPD exacerbations. VA treatment records from January 2018 note that the Veteran has COPD but is not on home oxygen. In September 2019, his COPD was noted to be moderate to severe. March 2018 treatment records from Womack Army Medical Center noted worsening shortness of breath. In March 2019, the Veteran complained of shortness of breath and in May 2019 difficulty breathing. He was assessed with acute COPD exacerbation. Records from November 2018 included PFT testing results from August 2016, which showed FVC at 85 percent and FEV-1 at 98 percent. In August 2017, FVC was at 89 percent and FEV-1 at 88 percent. In October 2018, FVC was at 92 percent and FEV-1 at 94 percent. The Veteran underwent a VA examination in December 2019. He reported difficulty breathing, shortness of breath, cough, and mucus. There was a gradual worsening of COPD, he used nebulized inhalation medications and an inhaler. COPD did not require the use of oral or parenteral corticosteroid medications but required the use of daily inhalational bronchodilator therapy and inhaled corticosteroid and long-acting bronchodilator combination inhaler. No oral bronchodilators, antibiotics, and no outpatient oxygen therapy was required. PFT showed pre-bronchodilator results of FEV-1 at 72 percent, FVC at 75 percent, and FEV-1/FVC at 93 percent. Post-bronchodilator testing showed FEV-1 at 81 percent, FVC at 97 percent, and FEV-1/FVC at 80 percent. The test which most accurately reflected the Veteran’s level of disability was FVC. DLCO testing was not completed because it was not indicated for the Veteran’s condition. The examiner indicated that the Veteran’s respiratory condition did impact his ability to work, as COPD restricted his ability to walk or do physical exertion. Treatment records from December 2019 indicate that the Veteran is prescribed Advair, one puff twice a day for asthma. After a review of the evidence, the Board finds that a compensable rating is not warranted. During the appeal period, the VA examiners and treatment providers found the Veteran to have FEV-1 values of 87 percent, 98 percent, 89 percent, 94 percent, and 81 percent. FVC values were 93 percent, 85 percent, 89 percent, 92 percent, and 97 percent. FEV-1/FVC values were 96 percent and 93 percent. The results do not warrant a compensable rating. As noted above, the November 2013 VA examiner specifically instructed that the Veteran’s FEV-1 score was the most accurate test result to rely upon in rating her disability and the December 2019 VA examiner indicated that the FVC was the most accurate. Given the disparity regarding which testing was the most accurate, the Board has considered all of the results in evaluating the condition. There is no evidence of record to support the assignment of a compensable rating. In regard to an evaluation under another appropriate diagnostic code, the Board finds that as the other applicable codes require the same PFT ratings, the Veteran would not receive a higher rating under Diagnostic Codes 6600, 6603, 6825-6833, or 6840-6845. The Board recognizes that the record includes a diagnosis of asthma coexisting with his service-connected COPD. However, as indicated, under the provisions of 38 C.F.R. § 4.96(a), ratings under Diagnostic Codes 6602 (bronchial asthma) and 6604 will not be combined with each other. This is because they are coexisting respiratory conditions with overlapping symptomatology. Rather, a single rating will be assigned under the diagnostic code which reflects the predominant disability with elevation to the next higher rating only where the severity of the overall disability warrants such elevation. Id. On this issue, with regard to Diagnostic Codes 6602 and 6604, assigning separate ratings for both the service-connected asthma and COPD disabilities under these diagnostic codes would constitute pyramiding, contrary to the provisions of 38 C.F.R. § 4.14. However, in rating his service-connected COPD disability, application of 38 C.F.R. § 4.14 does not prohibit the Board from comparing the rating criteria for both Diagnostic Codes 6602 and 6604 and considering which provides a higher evaluation based on the manifestations of the disability. Butts v. Brown, 5 Vet. App. 532 (1993) (choice of diagnostic code should be upheld if it is supported by explanation and evidence). Diagnostic Code 6602 (bronchial asthma) provides the following evaluations: a 10 percent evaluation is warranted for an FEV-1 of 71 to 80 percent of predicted value, or, an FEV-1/FVC of 71 to 80 percent, or, intermittent inhalational or oral bronchodilator therapy. A 30 percent evaluation is warranted for an FEV-1 of 56 to 70 percent of predicted value, or, an FEV-1/FVC of 56 to 70 percent, or, daily inhalational or oral bronchodilator therapy, or, inhalational anti-inflammatory medication. A 60 percent evaluation is warranted for an FEV-1 of 40 to 55 percent of predicted value, or, an FEV-1/FVC of 40 to 55 percent, or, at least monthly visits to a physician for required care of exacerbations, or, intermittent (at least three per year) courses of systemic (oral or parenteral) corticosteroids. A maximum 100 percent disability rating is assigned for an FEV-1 less than 40 percent of the predicted value, or, FEV-1/FVC less than 40 percent, or, demonstrates more than one attack per week with episodes of respiratory failure, or, requires daily use of systemic (oral or parenteral) high dose corticosteroids or immune-suppressive medications. 38 C.F.R. § 4.97. The Board concludes that the Veteran’s symptoms warrant a 30 percent disability rating under Diagnostic Code 6602. Specifically, the Veteran’s prescribed and daily utilization of inhalational and oral bronchodilator therapy for his service-connected COPD is sufficient for the increased, 30 percent rating. Therefore, the Veteran’s service-connected COPD is more appropriately rated under Diagnostic Code 6602. However, a higher 60 percent evaluation is not warranted under Diagnostic Code 6602, because the Veteran has not demonstrated an FEV-1 of 40 to 55 percent of predicted value, or, an FEV-1/FVC of 40 to 55 percent, or, at least monthly visits to a physician for required care of exacerbations, or, intermittent (at least three per year) courses of systemic (oral or parenteral) corticosteroids. The Board has elected to change the rating code to Diagnostic Code 6602 because it affords the Veteran a higher rating than is currently assigned under Diagnostic Code 6604, while still compensating him for all the respiratory disability symptoms. See Butts v. Brown, 5 Vet. App. 532, 538 (1993). Accordingly, the Board finds that an increased 30 percent rating under Diagnostic Code 6602 is warranted for the Veteran’s service-connected COPD. See Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990); 38 U.S.C. § 5107(b). Lumbosacral Strain with DJD, Lumbar Spine The Veteran contends that he is entitled to a rating in excess of 10 percent for service-connected lumbosacral strain with DJD, lumbar spine prior to December 19, 2019, and in excess of 20 percent thereafter. The Veteran’s lumbosacral strain with DJD, 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. 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). The Veteran underwent a VA examination in November 2013. The Veteran reported flare-ups of the back, the impact being pain and stiffness. Range of motion testing showed forward flexion to 90 degrees or greater, with objective evidence of painful motion beginning at 85 degrees. Extension, right lateral flexion, left lateral flexion, right lateral rotation, and left lateral rotation ended at 30 degrees or greater, with objective evidence of painful motion beginning at 25 degrees. The Veteran was able to perform repetitive use testing with no change in range of motion. Functional loss and/or functional impairment was shown with contributing factor of disability being pain on movement. There was no localized tenderness or pain to palpation for joints and/or soft tissue, and no guarding ot muscle spasm. Muscle strength testing was normal and there was no muscle atrophy. Deep tendon reflexes and sensory exam were normal. Straight leg raising test was normal and the Veteran did not have signs or symptoms of radiculopathy. There were no other neurologic abnormalities. The Veteran did not have intervertebral disc syndrome. The examiner indicated that the Veteran’s back disability impacted his ability to work in that he could not do physical activities and heavy lifting. The Veteran’s gait was antalgic due to his knees. There was additional limitation of functional ability during flare-ups or repeated use over time based on pain, weakness, fatigability and/or incoordination, but there was no objective evidence to show additional range of motion. The examiner described the additional limitations as unable to do extended walking and heavy lifting due to pain. Treatment records from Cape Fear Health System show that in March 2015, the Veteran was treated for back pain. He was given instructions on back injury prevention. Treatment records from Womack Army Medical Center from December 2017 note the Veteran’s complaints of low back pain radiating down the legs, but the Veteran was not assessed with any neurologic conditions. Records from Womack Amy Medical Center note that in January 2018, the Veteran indicated that he had back pain, and that his left leg would go numb sometimes. He denied urinary and bowel incontinence. Examination showed full range of motion of the lumbar spine and painful T9 to L3 spinous processes. April 2018 VA x-rays showed no acute fracture or subluxation of the lumbar spine. Mild degenerative changes/osteophytosis were noted. A back exam showed no spine tenderness, no spasm, no focal motor/sensory deficit of the legs. At his September 2019 hearing, the Veteran complained of back pain which had severely worsened over the years. The Veteran underwent another VA examination in December 2019. The Veteran complained of low back pain and stiffness. He did not report flare-ups of the back. He reported having functional loss or functional impairment, which was difficulty bending and carrying moderately heavy objects. Range of motion testing showed forward flexion to 75 degrees, extension to 25 degrees, right lateral flexion to 20 degrees, left lateral flexion to 20 degrees, right lateral rotation to 25 degrees, and left lateral rotation to 25 degrees. Range of motion itself did not contribute to functional loss. Pain was described as noted on examination and causes functional loss. Pain was noted on forward flexion, right lateral flexion, and left lateral flexion. There was pain with weight bearing. There was objective evidence of dull, aching pain in the lumbar spine with radiation to the paraspinals which was moderate. The Veteran was able to perform repetitive use testing, but there was no additional loss of range of motion. Pain, weakness, fatigability, or incoordination significantly limited functional ability with repeated use over time. Factors that caused functional loss was pain. Range of motion was after repeated use over time was estimated to be flexion to 60 degrees, extension and right and left lateral flexion to 15 degrees, and right and left lateral rotation to 20 degrees. Pain, weakness, fatigability, or incoordination did not significantly limit functional ability with flare-ups. There was no guarding or muscle spasm, and no additional factors contributing to disability. Muscle strength testing was normal and there was no muscle atrophy. Deep tendon reflexes and sensory exam were normal. Straight leg raising test was negative and the Veteran did not have signs or symptoms of radiculopathy. There were no other neurologic abnormalities. There was no ankylosis of the spine. The Veteran did not have intervertebral disc syndrome. He used a cane on a regular basis due to his knees. The examiner indicated that the Veteran’s back disability impacted his ability to work in that he was restricted in bending and carrying moderately heavy objects. Prior to December 19, 2019 For the period prior to December 19, 2019, the Board finds that the preponderance of the evidence is against a rating in excess of 10 percent. The Board acknowledges the Veteran’s lay reports of symptoms and that there was functional loss due to back pain. However, even considering the Veteran’s lay reports of symptoms and noted functional loss, the degree of additional limitation reflected by the statements that he has difficulty with physical activity and heavy lifting would not result in limitation of motion more nearly approximating 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. Additionally, the Veteran did not have muscle spasm or guarding resulting in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. While it was noted in the November 2013 VA examination that the Veteran had an antalgic gait, it was noted to be the result of his knee disabilities and not his service-connected lumbosacral strain with DJD. The 10 percent evaluation assigned for limitation of motion of the lumbosacral spine, contemplates a reduction in the Veteran’s demonstrated active ROM of forward flexion to 90 degrees. To warrant a higher, 20 percent rating, the evidence would need to show forward flexion greater than 30 degrees but not greater than 60 degrees. There is no indication from the November 2013 VA examination or contemporary VA treatment records that his lumbosacral spine symptoms more nearly approximated forward flexion limited to greater than 30 degrees but not greater than 60 degrees during the period prior to December 19, 2019. Thus, even when considering the reported functional loss, the Veteran’s disability picture does not more nearly approximate forward flexion 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. Therefore, with consideration of the provisions of §§ 4.40, 4.45, and 4.59, the Veteran’s lumbar spine disability most nearly approximates the criteria for a 10 percent rating prior to December 19, 2019. 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 does not indicate that the Veteran has IVDS and the evidence of record is against a finding that the Veteran 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. Regarding neurological impairment, the medical evidence of record does not show that the Veteran has any other neurological abnormality associated with his service-connected lumbosacral strain with DJD, lumbar spine. The Board acknowledges that December 2017 and January 2018 treatment records note that the Veteran indicated that he had back pain radiating down his legs and that his left leg would go numb sometimes. While the Veteran is competent to report symptomatology that he experiences, he has not shown that he has the medical experience or training to relate the condition to his service-connected lumbosacral strain with DJD, lumbar spine, which is a medically complex determination that cannot be based on lay observation alone. See Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). Instead, such a determination must be made by a medical professional with appropriate expertise. Id. The November 2013 and December 2019 VA examiner concluded that the Veteran did not have signs or symptoms of radiculopathy into either lower extremity or any other neurological impairment. For the foregoing reasons, the preponderance of the evidence is against the Veteran’s claim for a rating in excess of 10 percent for lumbosacral strain with DJD, lumbar spine prior to December 19, 2019. 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. From December 19, 2019 For the period from December 19, 2019, the Board finds that the preponderance of the evidence is against a rating in excess of 20 percent. The Board acknowledges the evidence of pain and the Veteran’s lay reports of symptoms and that there was functional loss due to back pain. However, even considering the Veteran’s lay reports of symptoms of pain and noted functional loss, the degree of additional limitation reflected by the statements that he has difficulty bending and carrying and lifting moderately heavy objects would not result in limitation of motion more nearly approximating forward flexion of the thoracolumbar spine to 30 degrees or less; or, favorable ankylosis of the entire thoracolumbar spine. As noted above, on December 2019 VA examination, the examiner estimated that additional range of motion loss after repeated use over time would be limited to 60 degrees, which is most nearly approximated by the currently assigned 20 percent rating. Moreover, during the December 2019 VA examination, the Veteran denied having flare-ups. The weight of the evidence is also against a finding that the Veteran had ankylosis of the spine. Thus, even when considering the reported functional loss, the Veteran’s disability picture does not more nearly approximate forward flexion of the thoracolumbar spine to 30 degrees or less or favorable ankylosis of the entire thoracolumbar spine. Therefore, with consideration of the provisions of §§ 4.40, 4.45, and 4.59, the Veteran’s lumbar spine disability most nearly approximates the criteria for a 20 percent rating from December 19, 2019. Consideration has also been given to assigning a rating under the Formula for Rating IVDS Based on Incapacitating Episodes. However, the evidence of record does not indicate that the Veteran has IVDS and the evidence of record is against a finding that the Veteran 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. Regarding neurological impairment, the medical evidence of record does not show that the Veteran has any other neurological abnormality associated with his service-connected lumbosacral strain with DJD, lumbar spine. While the Veteran is competent to report symptomatology that he experiences, he has not shown that he has the medical experience or training to relate any symptoms to his service-connected lumbosacral strain with DJD, lumbar spine, which is a medically complex determination that cannot be based on lay observation alone. See Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). As noted above, the December 2019 VA examiner specifically concluded after examination that the Veteran did not have signs or symptoms of radiculopathy in either lower extremity or any other neurologic abnormalities. For the foregoing reasons, the preponderance of the evidence is against the Veteran’s claim for a rating in excess of 20 percent for lumbosacral strain with DJD, lumbar spine from December 19, 2019. 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. REASONS FOR REMAND Hypertension The Board’s November 2019 remand directed that the Veteran be afforded a VA examination and opinion which addressed whether it was at least as likely as not that the Veteran’s hypertension was related to service, including as directly related to his presumed exposure to herbicide agents. In a December 2019 medical opinion, a VA examiner opined that hypertension was less likely than not related to service. There was no evidence in the claims file that the Veteran was diagnosed with hypertension prior to 2012. There was no evidence that herbicidal agents contributed to the development of hypertension 25 years after service. Hypertension was due to specific causes in a small fraction of cases but in the vast majority of individuals etiology cannot be determined. Aging and obesity are significant factors in the development of hypertension and both conditions pertain to the Veteran and are the likely causes of hypertension. However, the examiner provided only a general conclusion without sufficient rationale when stating that there was no evidence that herbicidal agents contributed to the development of hypertension 25 years after service. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 301 (2008) (stating that a medical examination report must contain not only clear conclusions with supporting data, but also a reasoned medical explanation connecting the two). As such, remand for a supplemental medical opinion is necessary.   DJD of the Left Knee and DJD of the Right Knee VA treatment records from December 2019 received in September 2020 indicate that the Veteran was to receive orthopedic treatment for his painful knees through VA’s Choice Program. Remand is necessary to obtain records of orthopedic treatment through VA’s Choice Program. 38 C.F.R. § 3.159. Tina Pedis, Onychomycosis, Bilateral Feet Private treatment records from Carolina Footcare received in February 2020 include an August 2016 record which note that the Veteran returned for his routine footcare. Also, the Veteran last sought treatment in February 2020 for athlete’s foot with scaling and dry skin. The treatment provider indicated that the Veteran needed to follow-up in four weeks. As there are no records prior to August 2016 and since February 2020, remand is needed to obtain any outstanding relevant treatment records. All Issues Updated VA treatment records should also be obtained on remand. The matters are REMANDED for the following actions: 1. Ask the Veteran to complete a VA Form 21-4142 for all private providers who have treated him for his knee disabilities at any time during the appeal period, including for all VA Choice-authorized orthopedic treatment. Make two requests for the authorized records from each identified provider, unless it is clear after the first request that a second request would be futile. 2. Ask the Veteran to complete a VA Form 21-4142 for the complete treatment records from Carolina Footcare. Make two requests for the authorized records, unless it is clear after the first request that a second request would be futile. 3. Obtain the Veteran’s VA treatment records for the period from September 2020 to the present. 4. Obtain a supplemental medical opinion from a medical professional with the appropriate expertise with regard to the Veteran’s claim of entitlement to service connection for hypertension. The electronic claims file, including a copy of this Remand, must be made available to and reviewed by the examiner. After reviewing the claims file, the clinician is asked to provide an opinion as to whether it is at least as likely as not (i.e., a 50 percent probability or greater) that the Veteran’s hypertension is related to his active service, including his presumed exposure to herbicide agents, such as Agent Orange? The examiner must note that applicable VA law establishes that the legal provision for presumptive service connection does not otherwise preclude a veteran from establishing service connection with proof of actual direct causation, even if a disorder is not one for which service connection is presumed. A complete rationale for all opinions must be provided. The examiner is reminded that a medical examination report must contain not only clear conclusions with supporting data, but also a reasoned medical explanation connecting the two. Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008); Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007). If the clinician cannot provide a requested opinion without resorting to speculation, it must be so stated, and the clinician must provide the reasons why an opinion would require speculation. The clinician must indicate whether there was any further need for information or testing necessary to make a determination. Additionally, the clinician must indicate whether any opinion could not be rendered due to limitations of knowledge in the medical community at large and not those of the particular examiner. M. SORISIO Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Bonnie Yoon, 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.