Citation Nr: 21064103 Decision Date: 10/19/21 Archive Date: 10/19/21 DOCKET NO. 14-31 138A DATE: October 19, 2021 ORDER Effective from January 28, 2011, entitlement to a 30 percent disability rating for cervical spine, degenerative disc disease with cervical spondylosis (previously with radiculopathy) is granted. Entitlement to an initial increased disability rating in excess of 40 percent for radiculopathy of the right upper extremity is denied. Entitlement to an initial increased disability rating in excess of 30 percent for radiculopathy of the left upper extremity is denied. REMANDED Entitlement to an increased disability rating in excess of 10 percent for patellofemoral syndrome, chondromalacia, degenerative joint disease, left knee, is remanded. Entitlement to an initial compensable evaluation for patellofemoral syndrome, chondromalacia, degenerative joint disease, left knee (limited flexion), is remanded. Entitlement to an increased disability rating in excess of 10 percent for patellofemoral syndrome, chondromalacia, degenerative joint disease, right knee, is remanded. Entitlement to an initial compensable evaluation for patellofemoral syndrome, chondromalacia, degenerative joint disease, right knee (limited flexion), is remanded. Entitlement to special monthly compensation (SMC) based on the need for regular aid and attendance or by reason of being housebound is remanded. Eligibility for financial assistance in the purchase of one automobile or other conveyance and automobile adaptive equipment or automobile adaptive equipment only is remanded. FINDINGS OF FACT 1. Effective from January 28, 2011, the Veteran's cervical spine disability has more nearly approximated 15 degrees of forward flexion, but not unfavorable ankylosis of the entire cervical spine or incapacitating episodes of intervertebral disc syndrome (IVDS). 2. During the appeal period, the Veteran's radiculopathy of the right upper extremity has been manifested by moderate incomplete paralysis, but not severe incomplete paralysis. 3. During the appeal period, the Veteran's radiculopathy of the left upper extremity has been manifested by moderate incomplete paralysis, but not severe incomplete paralysis. CONCLUSIONS OF LAW 1. Effective from January 28, 2011, the criteria for entitlement to a 30 percent disability rating for cervical spine, degenerative disc disease with cervical spondylosis (previously with radiculopathy) have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.159, 3.321, 4.1-4.14, 4.40-4.45, 4.59, 4.71a, Diagnostic Codes 5293-5290, 5243. 2. The criteria for entitlement to an initial increased disability rating in excess of 40 percent for radiculopathy of the right upper extremity have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 8511. 3. The criteria for entitlement to an initial increased disability rating in excess of 30 percent for radiculopathy of the left upper extremity have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 8511. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active duty service in the United States Army from June 1974 to June 1994. This matter comes to the Board of Veterans' Appeals (Board) on appeal from a May 2012 rating decision. In decisions dated in September 2018 and September 2020, the Board remanded the case to the agency of original jurisdiction (AOJ). Regarding the issues decided herein, the Board finds that the AOJ substantially complied with prior remand directives, to the extent possible, and no further action in this regard is warranted. See Dyment v. West, 13 Vet. App. 141, 146-47 (1999) (concluding that a remand is not required under Stegall v. West, 11 Vet. App. 268 (1998) where there was substantial compliance with the Board's remand instructions). The Board notes that the Veteran was previously represented by attorney Joseph Michael Woods. In a March 2019 statement, Joseph Michael Woods notified the AOJ that he was no longer representing the Veteran and stated that the Veteran had been notified of this withdrawal. In an April 2019 letter to this representative, the AOJ acknowledged his withdrawal of representation for the Veteran. A July 2020 Report of General Information also noted that the Veteran called to remind the Department of Veterans Affairs (VA) of the attorney revocation in April 2019. The Veteran has not yet appointed a new representative. The May 2012 rating decision granted separate evaluations for radiculopathy of the left upper extremity and radiculopathy of the right upper extremity as secondary to the service-connected cervical spine disability. The AOJ assigned an initial 20 percent disability rating for both disabilities effective from the date of the Veteran's increased rating claim for his cervical spine disability was received on January 28, 2011. During the pendency of the Veteran's appeal of these ratings, a May 2020 rating decision awarded increased ratings of 40 percent for the right upper extremity and 30 percent for the left upper extremity effective from January 28, 2011. As the assigned evaluations are less than the maximum available rating, the issues remain on appeal. See AB v. Brown, 6 Vet. App. 35, 38 (1993). The May 2012 rating decision also denied increased ratings in excess of 10 percent for the Veteran's patellofemoral syndrome, chondromalacia, degenerative joint disease, of the left and right knee. While the Veteran's appeal of these issues was still pending, a December 2020 rating decision granted entitlement to separate noncompensable evaluations for patellofemoral syndrome, chondromalacia, degenerative joint disease of the left and right knee (limited flexion) effective from November 23, 2020. As these separate noncompensable evaluations are included in the Veteran's current increased rating claims for his left and right knee disabilities, the Board has added the issues to the appeal. The Board also notes that during the pendency of the Veteran's increased rating claims, he raised the issues of entitlement to SMC based on the need for regular aid and attendance or by reason of being housebound, and eligibility for financial assistance in the purchase of one automobile or other conveyance and automobile adaptive equipment or automobile adaptive equipment only. The Veteran submitted a VA Form 21-4502 Application for Automobile or Other Conveyance and Adaptive Equipment, in June 2018; and an August 2018 rating decision subsequently determined that entitlement to automobile or other conveyance and adaptive equipment was not established. The Veteran additionally submitted a VA Form 21-2680, Examination for Housebound Status or Permanent Need for Regular Aid and Attendance, in August 2021 that indicated that the relevant diagnoses included his lumbar spine disability and associated radiculopathy in the left and right lower extremities. An October 2021 rating decision later denied entitlement to SMC based on aid and attendance/housebound. Under 38 C.F.R. § 3.155(d)(2), "VA will adjudicate as part of [a] claim entitlement to any ancillary benefits that arise as a result of the adjudication decision (e.g., entitlement to 38 U.S.C. Chapter 35 Dependents' Educational Assistance benefits, entitlement to special monthly compensation under 38 C.F.R. § 3.350, entitlement to adaptive automobile allowance, etc.). The claimant may, but need not, assert entitlement to ancillary benefits at the time the complete claim is filed." As such, the Board has assumed jurisdiction over these issues. An April 2018 rating decision during the appeal period of the increased rating claims also granted entitlement to a total disability rating based on individual unemployability (TDIU) effective from September 1, 2017. The rating decision explained that the grant was effective from the day after the Veteran's last day of employment. This finding is consistent with the Veteran's report in his November 2017 VA Form 21-8940, Veteran's Application for Increased Compensation Based on Unemployability, that he last worked full-time, and became too disabled to work on August 31, 2017. A Standard Form 52, Request for Personnel Action, received in January 2018 also noted that the effective date of the Veteran's retirement was August 31, 2017. The Veteran's adjusted basic pay, and total salary/award was additionally noted to be 63,491.00 dollars in his position as a property disposal specialist. The Veteran indicated in the VA Form 21-8940 that he worked in the position for 40 hours a week throughout the appeal period from December 1997 to August 2017. The record also does not otherwise suggest that the position was marginal employment or not substantially gainful. See 38 C.F.R. § 4.16. In the September 2018 remand, the Board assumed jurisdiction over the issue of entitlement to a TDIU under Rice v. Shinseki, 22 Vet. App. 447, 453 (2009) without acknowledging the grant of the Veteran's claim effective from September 1, 2017. However, the Board later found in introduction of the September 2020 decision that the April 2018 rating decision's grant of entitlement to a TDIU effective from September 1, 2017 based on his apparent final date of work that he provided in the VA Form 21-8940 resolved his claim for entitlement to a TDIU. Based on the foregoing, the Board finds that the issue of entitlement to a TDIU is no longer before the Board. The Board further notes that additional, relevant evidence was obtained by the Department of Veterans Affairs (VA) after the December 2020 Supplemental Statement of the Case. This additional evidence includes VA examinations and medical opinions dated in March 2021 and April 2021. In July 2021, the Board sent the Veteran a letter requesting that he provide a waiver of the AOJ's initial review of this additional evidence. The Veteran later provided the requested waiver in August 2021. The record also shows that following the Veteran's submission of the waiver, the AOJ obtained additional VA treatment records dated from January 2020 to September 2021. However, these records provide information that is either duplicative of the prior evidence of record or has no material effect on the outcome of the Veteran's increased rating claims for his cervical spine disability and radiculopathy of the left and right upper extremities adjudicated herein. As such, the Board finds that a remand for initial AOJ review of this evidence in relation these claims is not necessary, and there is no prejudice to the appellant in proceeding with the adjudication of these claims. See also Sabonis v. Brown, 6 Vet. App. 426, 430 (1994). I. Duties to Notify and Assist The Veteran has not raised any issues with the duty to notify or duty to assist. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015) (holding that "the Board's obligation to read filings in a liberal manner does not require the Board . . . to search the record and address procedural arguments when the veteran fails to raise them before the Board."); Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016) (applying Scott to a duty to assist argument). Increased Rating 1. Entitlement to an increased rating in excess of 20 percent for cervical spine, degenerative disc disease with cervical spondylosis (previously with radiculopathy). Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (rating schedule), found in 38 C.F.R. Part 4. Disability ratings are intended to compensate impairment in earning capacity due to a service-connected disorder. 38 U.S.C. § 1155. The evaluation of a service-connected disorder requires a review of a veteran's entire medical history regarding that disorder. 38 U.S.C. § 4.1, 4.2; Schafrath v. Derwinski, 1 Vet. App. 589 (1991). When a reasonable doubt arises regarding the degree of disability, 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. Evidence to be considered in an appeal from an initial disability rating was not limited to that reflecting the then current severity of the disorder. Fenderson v. West, 12 Vet. App. 119 (1999). In contrast, for an already established service-connected disability, the present disability level is the primary concern and past medical reports do not take precedence over current findings. See Francisco v. Brown, 7 Vet. App. 55 (1994). For both types of increased rating claims, it is possible for a veteran to be awarded separate percentage evaluations for separate periods based on the facts found during the appeal period. See Fenderson, 12 Vet. App. at 126-27; Hart v. Mansfield, 21 Vet. App. 505, 509 (2007). Such separate disability ratings are known as staged ratings. Disability of the musculoskeletal system is primarily the inability, due to damage or infection in the parts of the system, to perform the normal working movements of the body with normal excursion, strength, speed, coordination, and endurance. It is essential that the examination on which ratings are based adequately portray the anatomical damage and the functional loss with respect to all of these elements. In evaluating disabilities of the musculoskeletal system, it is necessary to consider, along with the schedular criteria, functional loss due to flare-ups of pain, fatigability, incoordination, pain on movement, and weakness. DeLuca v. Brown, 8 Vet. App. 202 (1995). The functional loss may be due to absence of part, or all, of the necessary bones, joints and muscles, or associated innervation, or other pathology and evidenced by visible behavior of the claimant undertaking the motion. Weakness is as important as limitation of motion, and a part that becomes painful on use must be regarded as seriously disabled. 38 C.F.R. § 4.40. Pain on movement, swelling, deformity or atrophy of disuse as well as instability of station, disturbance of locomotion, interference with sitting, standing and weight bearing are relevant considerations for determination of joint disabilities. 38 C.F.R. § 4.45. Painful, unstable, or malaligned joints, due to healed injury, are entitled to at least the minimal compensable rating for the joint. 38 C.F.R. § 4.59. Although pain may cause functional loss, pain itself does not constitute functional loss. Rather, pain must affect some aspect of "the normal working movements of the body," such as "excursion, strength, speed, coordination, and endurance," in order to constitute functional loss. See Mitchell v. Shinseki, 25 Vet. App. 32, 38-43 (2011). Painful, unstable, or malaligned joints, due to healed injury, are entitled to at least the minimal compensable rating for the joint. 38 C.F.R. § 4.59. As the Veteran filed his increased rating claim for his cervical spine disability on January 28, 2011, the appeal period begins on January 28, 2010. 38 C.F.R. § 3.400(o)(2). The Veteran has been in receipt of a 20 percent disability rating for the entire period on appeal. The Veteran's cervical spine disability is evaluated under 38 C.F.R. § 4.71a, Diagnostic Code (DC) 5293-5290. Hyphenated diagnostic codes are used when a rating under one diagnostic code requires the 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. The record shows that a September 1995 rating decision originally granted entitlement to service connection for the Veteran's cervical spine disability and assigned an initial 10 percent disability rating under DC 5293 effective from July 1, 1994. A subsequent April 2004 rating decision increased that disability rating to 20 percent effective under DC 5293-5290 effective from August 28, 2003. Although the April 2004 Rating Codesheet included a handwritten note that crossed out DC 5293-5290 and wrote 5241, recent rating codesheets indicate that the disability has continued to be evaluated under DC 5293-5290 since August 28, 2003. See, e.g., Rating Codesheets dated in May 2012 and October 2021. The Board notes that under the law administered by VA, a disability rating that has been continuously rated at or above a certain percentage for at least 20 years is a protected rating. A protected rating cannot be reduced, let alone eliminated, absent a showing of fraud. 38 U.S.C. § 110; 38 C.F.R. § 3.951. The Board notes that prior to the current appeal period, the rating criteria for evaluating spine disabilities were amended in September 2002 and September 2003. See 67 Fed. Reg. 54,345-54,349 (Aug. 22, 2002); 68 Fed. Reg. 51,454 (Aug. 27, 2003). The change, effective September 26, 2003, renumbered all of the spine diagnostic codes, and provides for the rating of all spine disabilities under a new General Rating Formula for Diseases and Injuries of the Spine, which combined the thoracic spine under the thoracolumbar spine. 38 C.F.R. § 4.71a. Separate ratings are no longer available for the thoracic spine and the lumbar spine. Rather, the General Rating Formula for Diseases and Injuries of the Spine currently in place assigns ratings for the thoracolumbar spine, which includes the thoracic spine and the lumbar spine. A review of the September 1995 rating decision indicates that the initial 10 percent rating under DC 5293 was originally awarded based on mild symptoms associated with intervertebral disc syndrome (IVDS). The April 2004 rating decision then awarded a 20 percent evaluation under DC 5293-5290 based on the criteria of DC 5290 for moderate limitation of motion. See 38 C.F.R. § 4.71a, Diagnostic Code 5290 (prior to September 26, 2003). However, neither DC 5290 nor DC 5293 is included in the amended rating criteria. Diagnostic Code 5293 was later renumbered and amended as present Diagnostic Code 5243 effective September 26, 2003. As the Veteran filed his current claim after September 2003, only the new rating criteria outlined below are applicable in this case. The disabilities of the spine that are rated under the General Rating Formula for Diseases and Injuries of the Spine include vertebral fracture or dislocation (DC 5235), sacroiliac injury and weakness (DC 5236), lumbosacral or cervical strain (DC 5237), spinal stenosis (DC 5238), spondylolisthesis or segmental instability (DC 5239), ankylosing spondylitis (DC 5240), spinal fusion (DC 5241), degenerative arthritis of the spine (DC 5242) (for degenerative arthritis of the spine, see also DC 5003) (prior to Feb. 7, 2021), degenerative arthritis, degenerative disc disease other than intervertebral disc syndrome (IVDS) (also, see either DC 5003 or DC 5010) (effective Feb. 7, 2021), IVDS (DC 5243), and complete traumatic paralysis (DC 5244) (effective Feb. 7, 2021). The Board notes that the criteria for rating musculoskeletal disabilities, including disabilities of the spine, have changed once during the period covered by this appeal, effective February 7, 2021. See 85 Fed. Reg. 76453 (Nov. 30, 2020). When a law or regulation changes during the pendency of a Veteran's appeal, the version most favorable to the Veteran applies, absent congressional intent to the contrary. The amended rating criteria, if favorable to the claim, can be applied only for periods from the effective date of the regulatory change; however, the old regulations will be considered for the periods both before and after the change was made. See 38 U.S.C. § 5110(g); 38 C.F.R. § 3.114; VAOPGCPREC 3-2000, 65 Fed. Reg. 33422 (2000); Kuzma v. Principi, 341 F.3d 1327 (Fed. Cir. 2003). Thus, the Veteran is entitled to application of the criteria that are most favorable to his claim, except that an award based on the amended regulations may not be made effective before the effective date of the change. The Board notes that, effective February 7, 2021, DC 5242 was amended to include degenerative disc disease other than IVDS. DC 5244 was also added to add paraplegia and quadriplegia. The Board notes that the spine regulations were also amended to state that Diagnostic Code 5243 governing IVDS should only be assigned when there is disc herniation with compression and/or irritation of the adjacent nerve root; and that Diagnostic Code 5242 should apply to all other disc diagnoses. See 85 Fed. Reg. 76462 (Nov. 30, 2020) (effective 2/7/2021). The Board notes that this change does not impact the evaluation in this case as the Veteran does not have any evidence of incapacitating episodes that would warrant a compensable rating under Diagnostic Code 5243. Under the General Rating Formula with or without symptoms such as pain (whether or not it radiates), stiffness, or aching in the area of the spine affected by residuals of injury or disease, a 30 percent evaluation is warranted when there is forward flexion of the cervical spine of 15 degrees or less; or favorable ankylosis of the entire cervical spine. A 40 percent evaluation is warranted when there is unfavorable ankylosis of the entire cervical spine. A 100 percent evaluation is warranted for unfavorable ankylosis of the entire spine. 38 C.F.R. § 4.71a, General Rating Formula for Diagnostic Codes 5235-5243. Any associated objective neurological abnormalities, including, but not limited to, bowel or bladder impairment, are to be evaluated separately, under an appropriate diagnostic code. 38 C.F.R. § 4.71a, General Rating Formula, Note (1). For VA compensation purposes, normal range of motion for the cervical spine is 45 degrees of forward flexion, 45 degrees of extension, 45 degrees of left and right lateral flexion, and 80 degrees of left and right lateral rotation. The normal combined range of motion of the cervical spine is 340 degrees, consisting of the sum of the range of forward flexion, extension, left and right lateral flexion, and left and right lateral rotation. 38 C.F.R. § 4.71a, General Rating Formal, Note (2) and Plate V. Moreover, for VA compensation purposes, unfavorable ankylosis is a condition in which the entire cervical spine, the entire thoracolumbar spine, or the entire spine is fixed in flexion or extension, and the ankylosis results in one or more of the following: difficulty walking because of a limited line of vision; restricted opening of the mouth and chewing; breathing limited to diaphragmatic respiration; gastrointestinal symptoms due to pressure of the costal margin on the abdomen; dyspnea or dysphagia; atlantoaxial or cervical subluxation or dislocation; or neurological symptoms due to nerve root stretching. Fixation of a spinal segment in neutral position (zero degrees) always represents favorable ankylosis. See 38 C.F.R. § 4.71a, General Rating Formula, Note (5). Diagnostic Code 5243 indicates that IVDS should be rated either under the General Rating Formula for Diseases and Injuries of the Spine or under the Formula for Rating IVDS Based on Incapacitating Episodes; using whichever method results in the higher evaluation when all disabilities are combined under 38 C.F.R. § 4.25. Under the Formula for Rating IVDS Based on Incapacitating Episodes, a 10 percent evaluation is warranted for incapacitating episodes having a total duration of at least one week, but less than 2 weeks during the past 12 months. A 20 percent evaluation is warranted for incapacitating episodes having a total duration of at least 2 weeks, but less than 4 weeks during the past 12 months. A 40 percent evaluation is warranted for incapacitating episodes having a total duration of at least 4 weeks, but less than 6 weeks during the past 12 months. A 60 percent evaluation is warranted for incapacitating episodes having a total duration of at least 6 weeks during the past 12 months. An incapacitating episode is defined as a period of acute signs and symptoms due to IVDS that requires bed rest prescribed by a physician and treatment by a physician. 38 C.F.R. § 4.71a, Formula for Rating IVDS Based on Incapacitating Episodes, Note (1). If IVDS is present in more than one spinal segment, provided that the effects in each spinal segment are clearly distinct, evaluate each segment on the basis of chronic orthopedic and neurologic manifestations or incapacitating episodes, whichever method results in a higher evaluation of that segment. Id., Note (2). In May 2011, the Veteran underwent a VA examination to evaluate his cervical spine disability. The problem was identified as cervical spine degenerative disc disease with cervical spondylosis. The examiner stated that the Veteran was being seen for an increase examination for cervical degenerative joint disease/degenerative disc disease with radiculopathy. An MRI showed canal stenosis with a herniated disc at C6-C7. The Veteran's current treatment included medication, a transcutaneous electrical nerve stimulator (TENS) unit, and home traction. The Veteran's response to treatment had been fair. In terms of side effects, the Veteran reported having a "medicine head" when he felt out of tune with his surroundings. He was uncertain which medication caused these symptoms. There was no history of hospitalization or surgery, spine trauma, or spine neoplasm. The Veteran did not report a history of flare ups of his cervical spine disability that were severe and occurred 3 to 5 times a week. Increased physical activity at work was a precipitating factor, and turning the head sometimes caused an onset of symptoms. The symptoms were relieved with rest and medication. The examiner stated that the extent of additional limitation of motion or other functional impairment during a flare up was 60 to 70 percent limitation of motion. There was no history of urinary incontinence, urgency, or retention requiring catheterization, or frequency. In addition, there was no history of nocturia, fecal incontinence, obstipation, numbness, paresthesias, leg or foot weakness, falls, or unsteadiness. Although there was a history of erectile dysfunction, the examiner stated that there was no pathology to support that the cervical spine disability was causing the erectile dysfunction, adding that it was most likely secondary to a history of cigarette smoking. The examiner also stated that the Veteran did not have symptoms of fatigue, decreased motion, or weakness. He did have stiffness; spasm; and deep, aching spine pain that was located on the posterior neck. The pain was moderate, constant, and it radiated to the left shoulder and left lateral arm as well as to the left thumb and left 5th digit in the right arm. The type of radiating pain was noted to be a deep ache to the left shoulder and arm as well as numbness and tingling in the right arm when he slept at night. The examiner noted that there were no incapacitating episodes of spine disease and indicating that the Veteran did not use assistive devices. He was able to walk more than 0.25 miles, but less than one mile. A physical examination showed that the Veteran had normal posture and a normal head position with symmetry in appearance. His gait was noted to be antalgic, and he was using a cane. The examiner did not find that there were any abnormal spinal curvatures, including gibbus, kyphosis, lumbar lordosis, lumbar flattening, reverse lordosis, list, scoliosis, cervical spine ankylosis, or thoracolumbar spine ankylosis. On examination, there no objective evidence of spasm, atrophy, guarding, or weakness. Tenderness was present on the left, but not on the right side. However, the tenderness was not severe enough to be responsible for an abnormal gait or spinal contour. Active range of motion testing revealed that the cervical spine had 25 degrees of flexion, 10 degrees of extension, 15 degrees of left lateral flexion, 10 degrees of right lateral flexion, and 20 degrees of left and right lateral rotation. Following repetitive use testing, there was no objective evidence of pain or additional limitations. The reflex examination produced normal (2+) results bilaterally for the peripheral nerve reflex, biceps, triceps, brachioradialis, finger jerk, knee jerk, ankle jerk, and plantar (Babinski). The sensory examination of the upper extremities showed no affected nerves (a non-dermatomal sensory loss pattern). Vibration testing showed decreased findings in the right thumb and little finger. The position sense was normal. The pain or pinprick test and light touch test revealed absent findings in the upper extremities, specifically a patchy area of sensory loss of the bilateral arms or non-dermatomal distribution. Dysesthesias was not present on testing. The motor examination of the upper extremities, including the bilateral elbow flexion and extension, wrist flexion and extension, finger flexion, finger abduction, and thumb opposition showed active movement against full resistance (5). The Veteran had normal muscle tone with no muscle atrophy. The lasègue's sign was not positive. Although testing for non-organic physical signs was conducted, the examiner noted that three or more positive Waddell signs made range of motion and sensory examination results unreliable. The examiner stated that the Veteran was currently employed fulltime as a property disposal specialist. He had been in this employment position for 10 to 20 years. In the past 12 months, he had lost 6 weeks due to chronic neck pain and stiffness. The examiner noted that the cervical spine disability affected the Veteran's occupation in that his work involved climbing, walking, squatting, crawling, bending, and lifting. These physical activities aggravated the chronic neck pain. The cervical spine disability also affected usual daily activities, and the Veteran enlisted the help of relatives when doing heavier home maintenance and repair. However, he was independent in all activities of daily living. The diagnosis was cervical degenerative joint disease/degenerative disc disease with herniated disc, spinal stenosis with radiculopathy. In April 2014, a letter to the Veteran that was included in his VA treatment records stated that his x-rays results of the neck and back ad been returned and were found to be normal, indicating that moderate degenerative arthritis was seen in the shoulders. An additional VA examination was conducted in December 2018 to evaluate the Veteran's cervical spine disability. The diagnoses were IVDS, spinal stenosis, cervical spine degenerative disc disease with cervical spondylosis, and bilateral upper extremity radiculopathy. The Veteran reported that his cervical spine disability had worsened in the last 18 months. He reported going to the neurologist last month and being told that he had bone spurs compressing his nerves and affecting his upper extremities. His current symptoms included pain, numbness, and tingling in the bilateral upper extremities. The current treatment included medication, TENS unit, twice weekly use of a traction device, and a cervical pillow. The examiner noted that the Veteran's right hand was his dominant hand. The Veteran reported having flare ups of his cervical spine disability. During these events, the Veteran had difficulty turning and twisting his neck and experienced increased stiffness of the cervical spine. In terms of functional loss or impairment, the Veteran reported having loss of mobility in the cervical spine. The initial range of motion measurements showed that the Veteran had 35 degrees of forward flexion, 10 degrees of extension, 30 degrees of right lateral flexion, 25 degrees of left lateral flexion, 60 degrees of right lateral rotation, and 70 degrees of left lateral rotation. The range of motion itself did not contribute to functional loss. The examiner observed that pain was noted on examination and caused functional loss in all planes of motion. There was also evidence of pain with weight-bearing. There was no objective evidence of localized tenderness or pain on palpation of the joint or associated soft tissue of the cervical spine. In addition, there was no additional loss of function or range of motion after three repetitions. The examiner noted that passive range of motion of the spine was not performed as it was not feasible to do this testing in a safe and reasonable manner. In addition, a non-weight bearing assessment was inapplicable as there was no objective evidence of pain when the spine was in a non-weight bearing position at rest. The examiner noted that the Veteran was not being examined immediately after repetitive use over time or during a flare ups, and the examination was neither medically consistent nor inconsistent with the Veteran's statements describing functional loss with repetitive use over time or during a flare ups. The examiner also noted that he was unable to say without resorting to mere speculation whether pain, weakness, fatigability, or incoordination significantly limited functional ability with repeated use over a period time or during flare ups; or to provide an estimate of loss of range of motion under these circumstances, as there was no conceptual or empirical basis for making such a determination without directly observing function under these conditions. Although the examiner marked that the examination showed that the Veteran had tenderness, guarding, or muscle spasm of the cervical spine, the examiner indicated that only muscle spasm was present. It did not result in an abnormal gait or abnormal spinal contour. There were no additional factors contributing to disability. With muscle strength testing, the Veteran's bilateral elbow flexion and extension, wrist flexion and dorsiflexion, and finger flexion and abduction demonstrated active movement against some resistance (4 out of 5). The Veteran did not have muscle atrophy. His deep tendon reflexes were normal (2+) in the bilateral biceps. triceps, and brachioradialis. The sensory examination findings were decreased in the right and left shoulder area (C5), inner/outer forearm (C6-T1), and hand/fingers (C6-8). Additional signs or symptoms due to radiculopathy included moderate intermittent pain (usually dull), mild paresthesias and/or dysesthesias, and mild numbness in the bilateral upper extremities. Constant pain (may be excruciating at times) was not present. The Veteran did not have any other signs or symptoms due to radiculopathy. The nerve roots involved included the right and left C7 nerve root (middle radicular group), and the right and left C8/T1 nerve roots (lower radicular group). The examiner stated that the severity of the radiculopathy was moderate on the right and left side. There was no ankylosis of the spine, to include favorable ankylosis of the entire cervical spine, unfavorable ankylosis of the entire cervical spine, and unfavorable ankylosis of the entire spine. The Veteran did not have any other neurologic abnormalities related to the cervical spine disability, such as a bowel or bladder problem due to cervical myelopathy. Although the Veteran had IVDS, the examiner stated that he had not experienced any episodes of acute signs and symptoms due to IVDS that required bed rest prescribed by a physician and treatment by a physician in the past 12 months. The Veteran also regularly used a cane as a normal mode of locomotion although other modes of locomotion might be possible, but this assistive device was related to his bilateral knee disability. The examiner added that there was no functional impairment of an extremity such that no effective function remained other than which would be equally well served by an amputation with prosthesis. There were no other pertinent physical findings, complications, conditions, signs or symptoms. In addition, there were no relevant scars. The examiner noted that imaging studies of the cervical spine had been performed, and arthritis (degenerative joint disease) was documented. The Veteran did not have a cervical vertebral fracture with loss of 50 percent or more of height. The examiner stated that the Veteran was retired with a loss of 0 to 1 week of work time in the last 12 months. His cervical spine disability impacted his ability to turn and twist his neck. In November 2020, the Veteran attended an additional VA examination related to his cervical spine disability. The diagnoses were IVDS, cervical spine degenerative disc disease with IVDS and cervical spondylosis, right upper extremity radiculopathy, and left upper extremity radiculopathy. The Veteran reported that he had been going to a pain management provider since his last disability examination. The Veteran's pain medication had changed, and he was going once a month to physical therapy. He reported that the condition had been worsening, and physical therapy was not providing much help. His current symptoms included sharp pain in the cervical spine with numbness and tingling that radiated down the arms and into the fingers. He reported having flare ups of the cervical spine that occurred once or twice a month, lasted for 1 to 2 days, and had a severity of 10 out of 10. During a flare ups, he experienced a sharp, icepick sensation of pain in the cervical spine with stiffness. The Veteran also reported having functional loss or impairment of the cervical spine in that he experienced difficulty with gripping things; he dropped things often; and he had difficulty with motions that required turning his neck, especially to the left. Range of motion testing revealed that the Veteran had 30 degrees of forward flexion, 25 degrees of extension, 25 degrees of right and left lateral flexion, 45 degrees of right lateral rotation, and 40 degrees of left lateral rotation. Pain was noted on examination and caused functional loss in all planes of motion. There was no evidence of pain with weight-bearing or non-weight bearing. The examiner reported that passive range of motion testing was not performed as it was not feasible to do so in a safe and reasonable manner. The Veteran did not have evidence objective evidence of localized tenderness or pain on palpation of the joint or associated soft tissue of the cervical spine. Although the Veteran was able to perform repetitive use testing with at least 3 repetitions, there was no additional loss of function or range of motion after such testing. The examiner noted that the Veteran was not being examined immediately after repetitive use or during a flare ups, but the examination was medically consistent with the Veteran's statements describing functional loss under these circumstances. The examiner opined that pain would significantly limit functional ability with repeated use over a period of time and during flare ups. The examiner opined that in terms of range of motion, such function loss with repeated use over a period of time would be 25 degrees of forward flexion, 20 degrees of extension, 20 degrees of right and left lateral flexion, 40 degrees of right lateral rotation, and 35 degrees of left lateral rotation. During flare ups, the functional loss would be 20 degrees of forward flexion, 15 degrees of extension, 15 degrees of right and left lateral flexion, 35 degrees of right lateral rotation, and 30 degrees of left lateral rotation. The examiner noted that the Veteran did not have localized tenderness, guarding, or muscle spasm of the cervical spine; and there were no additional factors contributing to disability. The muscle strength testing results were generally unchanged from the December 2018 VA examination, with the Veteran showing 4 out of 5 with his bilateral elbow flexion and extension, wrist flexion and extension, and finger flexion and abduction. There continued to be no muscle atrophy. The reflex examinations findings also continued to be normal bilaterally. The sensory examination findings were still decreased in the right and left shoulder area, inner/outer forearm, and hand/fingers. The Veteran now experienced moderate intermittent pain (usually dull), moderate paresthesias and/or dysesthesias, and moderate numbness in the right and left upper extremities. There continued to be no symptoms of constant pain (may be excruciating at times). There were no other signs or symptoms of radiculopathy. The relevant bilateral nerve root involvement was still the C7 nerve root (middle radicular group) and C8/T1 nerve roots (lower radicular group). The examiner stated that the severity of the radiculopathy was moderate on both the right and left side. The examiner further stated that there was no ankylosis of the spine, including favorable ankylosis of the entire cervical spine, unfavorable ankylosis of the entire cervical spine, and unfavorable ankylosis of the entire spine. There were also no other neurologic abnormalities related to the cervical spine disability. Similar to the December 2018 VA examination, the examiner stated that the despite the Veteran's IVDS, he had not had any episodes of acute signs and symptoms due to IVDS that required bed rest prescribed by a physician and treatment by a physician in the past 12 months. The examiner added that the Veteran regularly used a brace in relation to his bilateral knee disability. The examiner found that due to the cervical spine disability, there was no impairment of an extremity such that no effective function remained other than that which would be equally well-served by an amputation with prosthesis. There were no other pertinent findings and no relevant scars. The examiner stated that although imaging studies of the cervical spine had been performed and the results were available, arthritis (degenerative joint disease) was not documented. The examiner included the findings from a May 2007 MRI and stated that x-rays on the day of the examination were not clinically indicated. There was also no cervical vertebral fracture with loss of 50 percent or more of height. The examiner opined that the Veteran's cervical spine disability impacted his ability to work as he reported difficulty with motions that required turning his neck, especially to the left. Due to the left and right upper extremity radiculopathy, he also had difficulty with gripping things and dropped things often. The Veteran was retired and had not worked in the last 12 months. The examiner also explained that the new diagnosis of cervical spine degenerative disc disease with IVDS and cervical spondylosis was directly due to, or related to, the service-connected diagnosis. The same VA examiner completed a November 2020 Disability Benefits Questionnaire (DBQ) for peripheral nerves conditions in relation to the Veteran's bilateral upper extremity radiculopathy. The Veteran reported that he began to experience aching in his shoulders on active duty, and the condition worsened. He then began to notice numbness. He reported that he was started on Gabapentin around 2003 to 2004, and he reported that the condition was worsening as he aged. He began to notice more numbness and tingling. The examiner noted relevant symptoms in the bilateral upper extremities that were largely a reiteration of those noted in the separate DBQ specific to the cervical spine disability. The muscle strength testing was still a 4 out of 5 in the bilateral elbow flexion and extension, and wrist flexion and extension, and these results were also found in the bilateral grip and pinch (thumb to index finger). There were no trophic changes. The Veteran's gait was abnormal, but the examiner indicated that this abnormality was due to his bilateral knee disability. No special tests were indicated and performed for median nerve evaluation. The examiner noted that the radial nerve (musculospiral nerve), median nerve, ulnar nerve, musculocutaneous nerve, circumflex nerve, and long thoracic nerve were normal bilaterally. The upper radicular group (5th and 6th cervicals), middle radicular group, and lower radicular group had incomplete paralysis on the right and left that was of moderate severity. The examiner opined that due to the peripheral nerve conditions, there was no functional impairment of an extremity such that no effective function remained other than that which would be equally well served by an amputation with prosthesis. There were no other pertinent findings and no relevant scars. The examiner opined that the right and left upper extremity radiculopathy would impact the Veteran's ability to work as he reported difficulty with gripping things and dropping things often. The Board notes that although the examiner also documented a diagnosis of bilateral lower extremity radiculopathy in the lumbar region, the examiner explained that the finding of lower extremity radiculopathy was incidental and unrelated to the cervical spine disability. A subsequent March 2021 DBQ related to muscle injuries including muscle strength testing findings for the upper extremities. The examiner stated that the shoulder abduction, elbow flexion, elbow extension, wrist flexion, and wrist extension all showed normal strength (5 out of 5) bilaterally. Although a separate DBQ related to peripheral nerves conditions was also completed by a VA examiner in March 2021, it appears that the examination was obtained to specifically evaluate the radiculopathy of the left and right lower extremities rather than the bilateral upper extremities as the examiner only noted diagnoses for the lower extremity disabilities in the diagnosis section. Consequently, no relevant symptoms in the upper extremities were documented in the report as attributable to any peripheral nerves conditions; and the examiner did not identify any specific nerves pertinent to the upper extremities as being affected by peripheral neuropathy. The examination did include some findings related to the upper extremities. However, as neither this examination report nor the other evidence of records suggests that the Veteran's right and left upper extremity disabilities underwent a material worsening since the November 2020 VA examination, the Board finds that there is adequate evidence of record to rate the disabilities and it is unnecessary to remand the issues to obtain another VA examination. Similar to the information in the muscle injuries DBQ, the March 2021 examiner noted that the Veteran had normal muscle strength (5 out of 5), in the bilateral elbow flexion and extension, wrist flexion extension, grip, and pinch (thumb to index finger). There was no muscle atrophy. The deep tendon reflexes were normal (2+) in the bilateral biceps, triceps, and brachioradialis. The sensory examination produced normal findings in the shoulder area, inner/outer forearm, and hand/fingers. There continued to be no trophic changes. The examiner stated that the Veteran had an abnormal gait due to his bilateral knee and back condition. The examiner also noted that the Veteran constantly used a cane for hip strain, lumbar radiculopathy, and degenerative disc disease of the lumbar spine. No special tests were indicated for a median nerve evaluation. The examiner did not indicate that functioning in the left or right upper extremity was so diminished that no effective function remained other than that which would be equally well-served by an amputation with prosthesis. While the examiner completed the section of the report related to functional impact, it appears that these findings were related to the bilateral lower extremity radiculopathy noted in the diagnosis section of the report. After considering the foregoing evidence, the Board finds that an increased disability rating of 30 percent is warranted for the Veteran's cervical spine disability effective from his date of claim on January 28, 2011. During the May 2011 VA examination, the examiner noted that the Veteran had 25 degrees of forward flexion on range of motion testing. However, the Veteran also reported having severe flare ups 3 to 5 times a week that lasted for hours. The medical history section of the report further indicated that the Veteran described having an additional 60 to 70 percent limitation of motion during a flare up, and the examiner did not indicate that there was any basis to doubt this report. This report suggests that the Veteran had at most 10 degrees of forward flexion during a flare up event. 35 degrees of forward flexion was found during the December 2018 VA examination, and the Veteran reported that he continued to experience flare ups. Although the Veteran specifically described difficulty turning and twisting his neck, he also indicated that he experienced general increased stiffness and an overall loss of mobility. While the December 2018 VA examiner did not provide an opinion regarding the degree of forward flexion that the Veteran would experience during a flare up, the November 2020 VA examiner opined that it would be reduced from the 30 degrees that was present on active range of motion testing during that examination to 20 degrees during a flare up. The Board finds that the information documented by the May 2011 VA examiner and the November 2020 VA examiner as to the additional loss of motion experienced by the Veteran during flare ups both provide probative value as they were based on the Veteran's reported history of symptoms. The Board has also considered the Veteran's report from the November 2020 VA examination that the severity of his flare ups was a 10 out of 10 with symptoms of sharp pain and stiffness 1 to 2 times a month for 1 to 2 days at a time. In addition, the Board finds it significant that the 60 percent additional loss of motion with flare ups that was described during the May 2011 VA examination would approximate a reduction in forward flexion from 35 to 14 degrees based on the findings of the December 2018 VA examination, and from 30 to 12 degrees based on the findings from the November 2020 VA examination. In light of the above discussion, the Board finds that the evidence is at least in a state of equipoise as to whether the range of motion of the cervical spine during this period more nearly approximated 15 degrees of forward flexion. As such, the benefit of the doubt is resolved in the Veteran's favor, and a 30 percent disability granted. 38 U.S.C. § 5107(b). Briefly, the Board also notes the one year look back period for increased rating claims. 38 C.F.R. § 3.400(o). As noted above, the Veteran filed his increased rating claim on January 28, 2011. The evidence one year prior to the January 28, 2011 increased rating claim does not suggest any worsening or increase in cervical spine disability. Further consideration of an earlier effective date is not warranted. Id. However, the Board finds that a disability rating in excess of 30 percent is not warranted for the Veteran's lumbar spine disability. An evaluation in excess of 30 percent requires either unfavorable ankylosis of the entire cervical spine or IVDS with incapacitating episodes having a total duration of at least 4 weeks but less than 6 weeks during the past 12 months. During the appeal period, there was no objective evidence of ankylosis during the May 2011, December 2018, and November 2020 VA examinations. In so finding, the Board has considered the provisions of 38 C.F.R. §§ 4.40, 4.45, 4.59, and the holdings in DeLuca. The Board has also considered Correia v. McDonald, 28 Vet. App. 158, 169-70 (2016) and Sharp v. Shulkin, 29 Vet. App. 26, 33 (2017). Although the Veteran has experienced functional loss, pain, and flare ups during this period, the evidence reflects that Veteran retained limited range of motion in his spine during active range of motion testing with no additional functional loss demonstrated upon repetitive use testing during the May 2011, December 2018, and November 2020 VA examinations. As noted above, the December 2018 VA examiner did not provide a specific opinion regarding the effect of flare ups or repeated use on range of motion. However, the May 2011 VA examination report suggested that the Veteran's cervical spine would retain some range of motion during flare ups despite the fact that it would be reduced by a significant percentage. The November 2020 VA examiner also considered the Veteran's reported symptoms during flare ups as well as the clinical findings from the examination before determining that the Veteran's cervical spine would still have some degree of motion in all planes of motion with repeated use over time and during flare ups. The Board finds that the examiner's determinations are highly probative as the examiner obtained a detailed medical history from the Veteran and conducted a physical evaluation before reaching a conclusion. These findings do not support that the Veteran's symptoms of functional loss during the appeal period more nearly approximated unfavorable ankylosis of the entire cervical spine. See Chavis v. McDonough, 34 Vet. App. 1, 3-4 (2021) (the Court explained that the ankylosis requirement "can be met with evidence of the functional equivalent of ankylosis during a flare."). In addition, the record does not indicate that the Veteran experienced incapacitating episodes related to his cervical spine disability during this period. In light of the findings of arthritis in the cervical spine during this period, the Board has evaluated whether a higher or separate rating is available under Diagnostic Code 5003 at any time during the appeal period. 38 C.F.R. § 4.71a. In this regard, the Board acknowledges that the November 2020 VA examiner noted that there was no degenerative joint disease despite findings from the May 2011 and December 2018 VA examination reports that indicated that such arthritis was present. However, this discrepancy has no material effect on the appeal as there is no rating higher than 20 percent under Diagnostic Code 5003. In addition, the Veteran's disability rating during this period contemplates his limitation of motion. Diagnostic Code 5003 does not allow for a separate rating based on arthritis of a joint when a compensable rating has already been assigned under a diagnostic code related to limitation of motion. See 38 C.F.R. § 4.71a, Diagnostic Code 5003; see also 38 C.F.R. § 4.14. Accordingly, no higher or separate rating is warranted pursuant to Diagnostic Code 5003. To the extent that the newly amended DC 5003 indicates that this diagnostic code is now limited to degenerative arthritis other than post-traumatic, this change does not impact the case as the record indicates that the Veteran has degenerative rather than post-traumatic arthritis of the cervical spine and therefore does not suggest that a rating under the revised criteria of Diagnostic Code 5010 for post-traumatic arthritis would be appropriate. Based on the foregoing, higher or separate ratings under the relevant pre-amendment criteria or application of the post-amendment criteria are not warranted at any time during the appeal period. The Board has additionally considered whether the Veteran is entitled to a separate evaluation for any neurological abnormalities associated with his cervical spine disability. However, the VA examinations from the appeal period did not suggest that the Veteran had any neurological abnormality related to his cervical spine disability, to include a bowel or bladder impairment, apart from his already service-connected radiculopathy in the bilateral upper extremities. Thus, no other separate disability rating on this basis is warranted. As previously discussed, the May 2012 rating decision granted entitlement to separate evaluations for the Veteran's right and left upper extremity radiculopathy effective from the date of his increased rating claim for his cervical spine disability on January 28, 2011. As indicated in the characterization of the Veteran's cervical spine disability, radiculopathy was previously included in the rating with his cervical spine disability. The April 2004 rating decision that awarded an increased rating of 20 percent for the cervical spine disability effective from August 28, 2003 characterized the disability as cervical spine, degenerative disc disease with cervical spondylosis and radiculopathy. The rating decision also explained that radiculopathy was included with the evaluation of degenerative disc disease of the cervical spine as the evidence did not establish that radiculopathy of the upper extremities was separately compensable at that time as there were no objective findings of a mild neurological deficit. In this regard, Diagnostic Code 5293, effective prior to September 23, 2002, provided disability ratings for IVDS. Postoperative IVDS that was cured warranted a 0 percent rating. Mild IVDS merited a 10 percent rating. Moderate IVDS with recurring attacks warranted a 20 percent rating. Severe IVDS manifested by recurring attacks with intermittent relief warranted a 40 percent rating. Pronounced IVDS with persistent symptoms compatible with sciatic neuropathy with characteristic pain and demonstrable muscle spasm, absent ankle jerk, or other neurological findings appropriate to site of diseased disc, little intermittent relief, warranted a 60 percent rating. See 38 C.F.R. § 4.71a, Diagnostic Code 5293 (prior to September 23, 2002). Effective September 23, 2002, Diagnostic Code 5293 (later renumbered and amended as present Diagnostic Code 5243 effective September 26, 2003), was amended to provide for evaluation of IVDS either on the total duration of incapacitating episodes over the past 12 months or by combining under 38 C.F.R. § 4.25 separate evaluations of its chronic orthopedic and neurologic manifestations along with evaluations for all other disabilities, whichever method results in the higher evaluation. 38 C.F.R. § 4.71a, Diagnostic Code 5293 (effective September 23, 2002) (interim IVDS criteria). "Chronic orthopedic and neurologic manifestations" means orthopedic and neurologic signs and symptoms resulting from IVDS that are present constantly, or nearly so. Diagnostic Code 5293, Note (1). Note (2) to Diagnostic Code 5293 provides that when evaluating on the basis of chronic manifestations; evaluate orthopedic disabilities using evaluation criteria for the most appropriate orthopedic diagnostic code or codes. Evaluate neurologic disabilities separately using evaluation criteria for the most appropriate neurologic diagnostic code or codes. Although the Board has considered the one year look back period for increased rating claims to the extent that separate evaluations for the right and left upper extremity radiculopathy were granted in the context of the Veteran's January 28, 2011 increased rating claim for his cervical spine disability, the available evidence from the evidence one year prior to the January 28, 2011 increased rating claim does not suggest worsening or increase in radiculopathy of the left or right upper extremity. 38 C.F.R. § 3.400(o)(2), See 38 C.F.R. § 4.71a, General Rating Formula, Note (1). Further consideration of an earlier effective date for these separate evaluations is not warranted. 38 C.F.R. § 3.400(o)(2), Based on the foregoing, the Board concludes that a 30 percent rating for the cervical spine disability, but no higher, is warranted under DC 5243 based on the General Rating Formula for Diseases and Injuries of the Spine. In reaching this conclusion, the Board has considered the applicability of the benefit of the doubt doctrine. However, that doctrine is not applicable based on these facts as the preponderance of the evidence is against the award of rating higher than the rating awarded herein. See 38 U.S.C. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). 2. Entitlement to an initial increased disability rating in excess of 40 percent for radiculopathy of the right upper extremity. 3. Entitlement to an initial increased disability rating in excess of 30 percent for radiculopathy of the left upper extremity. As indicated above the Veteran has been in receipt of initial 40 percent rating for his radiculopathy of the right upper extremity and 30 percent for his radiculopathy of the right upper extremity, with each rating effective from January 28, 2011. The disabilities are both rated under 38 C.F.R. § 4.124a, DC 8511, which addresses paralysis of the middle radicular group. The record shows that the disabilities were initially rated under 38 C.F.R. § 4.124a, DC 8514 for paralysis of the musculospiral nerve (radial nerve) before the DC was changed to 8511 at the time of the May 2020 rating decision. See Rating Codesheets dated in May 2012 and May 2020. Handedness for the purpose of a dominant rating will be determined by the evidence of record, or by testing on VA examination. Only one hand shall be considered dominant. The injured hand, or the most severely injured hand, of an ambidextrous individual will be considered the dominant hand for rating purposes. 38 C.F.R. § 4.69. In this case, the VA examinations from the appeal period indicate the Veteran is right hand dominant. Therefore, the Board finds that the Veteran's left upper extremity is the minor, i.e., non-dominant side. Under DC 8511, mild incomplete paralysis of the middle radicular group warrants a 20 percent evaluation. 40 and 30 percent evaluations are warranted for moderate incomplete paralysis of the middle radicular group of the major and minor extremities, respectively. 50 and 40 percent evaluations are warranted for severe incomplete paralysis of the middle radicular group of the major and minor extremities, respectively. A maximum 70 and 60 percent evaluations are warranted with complete paralysis of the middle radicular group of the major and minor extremities, respectively. The Board notes that DC 8514 for paralysis of the musculospiral nerve (radial nerve), DC 8510 for paralysis of the upper radicular group (fifth and sixth cervicals), and DC 8512 for paralysis of the lower radicular group provide the same respective ratings for symptoms of mild incomplete paralysis, moderate incomplete paralysis, severe incomplete paralysis, and complete paralysis. For diseases of the peripheral nerves, disability ratings are based on whether there is complete or incomplete paralysis of the particular nerve. The term "incomplete paralysis" with this and other peripheral nerve injuries indicates a degree of lost or impaired function substantially less than the type pictured 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, or at most, the moderate degree. The ratings for the peripheral nerves are for unilateral involvement; when there is bilateral involvement, the VA adjudicator is to combine the ratings for the peripheral nerves, with application of the bilateral factor. 38 C.F.R. § 4.124a. After reviewing the above evidence, the Board finds that a disability rating in excess of 40 percent for right upper extremity radiculopathy and in excess of 30 percent for left upper extremity radiculopathy is not warranted. Respective higher ratings under DC 8511 contemplate severe incomplete paralysis. During the May 2011 VA examination, the examiner noted that the Veteran's symptoms of radiating pain in the left upper extremity were moderate; and the Veteran experienced numbness and tingling in the right arm. The reflex examination findings were normal, and no specific nerve was found to be affected on sensory testing. While the Veteran had decreased findings on vibration testing in the right thumb and little finger, and absent findings in the bilateral upper extremities; the motor examination findings were normal with no atrophy. In addition, the sensory findings in the bilateral upper extremities during the subsequent December 2018 VA examination were noted to be decreased rather than absent. This finding was unchanged during the November 2020 VA examination, and the March 2021 VA examination noted that there was no deficiency bilaterally on sensory testing. Although the Veteran reported having trouble gripping and dropping objects during the appeal period, the Veteran's muscle strength in the upper extremities was 4 out of 5 bilaterally during the December 2018 and November 2020 VA examinations. In addition, the March 2021 VA examination showed that the Veteran had normal muscle strength bilaterally, including his grip strength. In addition, the Veteran had normal reflexes bilaterally in the upper extremities during the December 2018, November 2020, and March 2021 VA examinations. The Veteran's reported symptoms of intermittent pain, numbness, and paresthesias and/or dysesthesias were also noted to be no more than moderate during the December 2018 and November 2020 VA examinations. The December 2018 VA examiner further stated that the severity of the involvement in the middle radicular groups and lower radicular group was moderate on the left and right side. In addition, the November 2020 VA examiner found that the middle radicular group involvement was best described as moderate incomplete paralysis bilaterally. In light of this evidence, the Board finds that the Veteran's right and left upper extremity radiculopathy symptoms are less severe than the severe symptoms of incomplete paralysis contemplated by the next higher rating. As noted above, the radiculopathy in the right and left upper extremity have been assigned evaluations based on DC 8511 related to middle radicular group paralysis. See 38 C.F.R. § 4.124a. To the extent that the November 2020 VA examination report indicated that the Veteran's right and left upper extremity radiculopathy also involved paralysis of the upper radicular group (fifth and sixth cervicals) and the lower radicular group, the Board notes that a separate rating for each nerve group involving the right and left upper extremities may not be assigned as it would constitute pyramiding. See 38 C.F.R. § 4.14. The Note following Diagnostic Code 8719 states that "[c]ombined nerve injuries should be rated by reference to the major involvement or if sufficient in extent, consider radicular group ratings." 38 C.F.R. § 4.124a. Thus, while at least three different nerves are affected in the Veteran's upper extremities, rating the same symptomatology based on separate nerves under separate Diagnostic Codes would constitute pyramiding and is prohibited under 38 C.F.R. § 4.14. In addition, the record does not suggest that rating the symptomatology under DC 8510 or 8512 would warrant a higher rating as the November 2020 VA examiner reported that the Veteran similarly experienced no more than moderate incomplete paralysis bilaterally of the upper radicular group (fifth and sixth cervicals) and the lower radicular group. For the foregoing reasons, the preponderance of the evidence is against awarding a disability ratings greater than the currently assigned 40 percent and 30 percent ratings for the Veteran's right and left upper extremity radiculopathy. In reaching these conclusions, the Board has considered the applicability of the benefit of the doubt doctrine. However, that doctrine is not applicable to these facts. 38 U.S.C. § 5107(b); Gilbert, 1 Vet. App. at 53-56. REASONS FOR REMAND 1. Entitlement to an increased disability rating in excess of 10 percent for patellofemoral syndrome, chondromalacia, degenerative joint disease, left knee, is remanded. 2. Entitlement to an initial compensable evaluation for patellofemoral syndrome, chondromalacia, degenerative joint disease, left knee (limited flexion), is remanded. 3. Entitlement to an increased disability rating in excess of 10 percent for patellofemoral syndrome, chondromalacia, degenerative joint disease, right knee, is remanded. 4. Entitlement to an initial compensable evaluation for patellofemoral syndrome, chondromalacia, degenerative joint disease, right knee (limited flexion), is remanded. In response to the Board's September 2020 remand, the Veteran was provided with a VA examination to evaluate his left and right knee disabilities in November 2020. Although the examiner noted under the details of onset in the report that the Veteran was running and his knees gave way before he underwent a debridement and arthroscopy of the right knee in 1991, the Veterans current symptoms in the right and left knee were only noted to include a sharp, shooting, icepick sensation in the middle portion of the knee. The examiner additionally did not mark that additional factors contributing to disability for the right or left knee included instability of station. The examiner also stated that there was no history bilaterally of recurrent subluxation, lateral instability, or recurrent effusion. In addition, joint stability testing produced normal results in the right and left knee. Following this examination, an April 2021 VA treatment record included the Veteran's report that his knees were giving out on him at times. As this report at least suggests a worsening in the severity of the Veteran's right and left knee disabilities since the November 2020 VA examination, the Board finds that an additional VA examination should be obtained on remand. See Snuffer v. Gober, 10 Vet. App. 400 (1997); Caffrey v. Brown, 6 Vet. App. 377 (1994). 5. Entitlement to SMC based on the need for regular aid and attendance or by reason of being housebound is remanded. 6. Eligibility for financial assistance in the purchase of one automobile or other conveyance and automobile adaptive equipment or automobile adaptive equipment only is remanded. In support of the Veteran's claim for SMC based on the need for regular aid and attendance or by reason of being housebound, he submitted a VA Form 21-2680, Examination for Housebound Status or Permanent Need for Regular Aid and Attendance, that was completed by G.B.H., PA-C, in August 2021. G.B.H. also suggested in the diagnosis section that the Veteran's service-connected lumbar spine disability and radiculopathy of the left and right lower extremities were relevant to his claim for SMC. However, G.B.H. did not compete several pertinent sections of the report, including a question regarding whether the Veteran required nursing home care; and a question requesting for the examining provider to address how often and under what circumstances the Veteran was able to leave his home or immediate premises. As this information is relevant to the Veteran's claim, the Board finds that the Veteran should be afforded a VA examination on remand that addresses whether he needs regular aid and attendance or is housebound as a result of his service-connected disabilities. The Board also notes that financial assistance may be provided to an "eligible person" in acquiring an automobile or other conveyance and adaptive equipment, or automobile adaptive equipment only. 38 U.S.C. § 3902(a), (b). Eligibility for financial assistance in the purchase of a vehicle or other conveyance and adaptive equipment is warranted where one of the following exists as the result of injury or disease incurred or aggravated during active service: (1) loss or permanent loss of use of one or both feet; (2) loss or permanent loss of use of one or both hands; (3) permanent impairment of vision of both eyes, meaning central visual acuity of 20/200 or less in the better eye, with corrective glasses, or central visual acuity of more than 20/200 if there is a field defect in which the peripheral field has contracted to such an extent that the widest diameter of visual field subtends an angular distance no greater than 20 degrees in the better eye; (4) severe burn injury precluding effective operation of an automobile; (5) amyotrophic lateral sclerosis; or, (6) for adaptive equipment only, ankylosis of one or both knees or one or both hips. 38 C.F.R. § 3.808. In chapter 39 of title 38 of the U.S. Code, Congress established the program authorizing funding for automobiles and adaptive equipment for veterans with certain service-connected disabilities. 38 U.S.C. §§ 3901-04. Pursuant to the authority established in 38 U.S.C. § 3902, the Secretary promulgated 38 C.F.R. § 3.808, which reiterates the § 3901(a) requirement that entitlement to automobile and adaptive equipment is warranted for "the loss or permanent loss of use" of one or both feet or one or both hands. 38 C.F.R. § 3.808(b)(i), (ii). The regulation does not further define the phrase "loss or permanent loss of use." Under the applicable eligibility criteria for financial assistance in the purchase of an automobile or other conveyance and adaptive equipment, found in statutory § 3901 and regulatory § 3.808, the appellant must show that they lost their foot or hand or permanently lost the use of a foot or hand as a result of service-connected disability. As findings from the VA examinations obtained on remand in connection with the Veteran's increased ratings claims for his left and right knee disabilities and SMC claim might impact a decision on the issue of eligibility for financial assistance in the purchase of one automobile or other conveyance and/or automobile adaptive equipment, the issues are inextricably intertwined. See Harris v. Derwinski, 1 Vet. App. 180 (1991). Final appellate review of this claim must be deferred until the appropriate actions concerning the Veteran's SMC and increased rating claims are completed and the matters are either resolved or prepared for appellate review. The matters are REMANDED for the following action: 1. The AOJ should request that the Veteran provide the names and addresses of any and all health care providers who have provided treatment related to the issues on appeal. After acquiring this information and obtaining any necessary authorization, the AOJ should obtain and associate these records with the claims file. The AOJ should also secure any outstanding VA medical records, to include records dated since September 2021. 2. After completing the preceding development in paragraph 1, the Veteran should be afforded a VA examination to address the current severity and manifestations of his right and left knee disabilities. Any and all studies, tests, and evaluations deemed necessary by the examiner should be performed. The examiner is requested to review all pertinent records associated with the claims file and to comment on the severity of the Veteran's service-connected disabilities. It should be noted that the Veteran is competent to attest to matters of which he has first-hand knowledge, including observable symptoms. If there is a medical basis to support or doubt the history provided by the Veteran, the examiner should provide a fully reasoned explanation. The examiner should report all signs and symptoms necessary for rating the right and left knee disabilities under the rating criteria. In particular, the examiner should provide the range of motion for both knees in degrees and test the range of motion and for pain in (1) active motion, (2) passive motion, (3) weight-bearing, and (4) nonweight-bearing. The examiner is also asked to indicate the point during range of motion testing that motion is limited by pain. If the examiner is unable to conduct the required testing or concludes that the required testing is not necessary in this case, he or she should clearly explain why this is so. The presence of objective evidence of pain, excess fatigability, incoordination, and weakness should also be noted, as should any additional disability (including limitation of motion) due to these factors. In addition, based on examination results and the Veteran's documented history and assertions, the examiner should indicate whether, and to what extent, the Veteran experiences functional loss due to pain and/or any of the other symptoms noted above during flare-ups and/or with repeated use; to the extent possible, the examiner should express any such additional functional loss in terms of additional degrees of limited motion. In this regard, even if the Veteran is not experiencing a flare-up at the time of the examination, the examiner must elicit relevant information as to the Veteran's flares or ask him to describe the additional functional loss, if any, he suffers during flares and then estimate the Veteran's functional loss due to flares based on all the evidence of record-including the Veteran's lay information-or explain why he or she could not do so. 3. After completing the preceding development in paragraph 1, schedule the Veteran for a VA examination for the purposes of determining whether he needs regular aid and attendance or is housebound due to his service-connected disabilities. The electronic claims file must be made available to and reviewed by the examiner in conjunction with the examination. The examination should be conducted in accordance with the relevant Disability Benefits Questionnaire or examination worksheet. 4. After the above development, and any additionally indicated development, has been completed, readjudicate the issues on appeal, to include the inextricably intertwined issue of eligibility for financial assistance in the purchase of one automobile or other conveyance and automobile adaptive equipment or automobile adaptive equipment only. If the benefit sought is not granted to the Veteran's satisfaction, send the Veteran a supplemental statement of the case and provide an opportunity to respond. If necessary, return the case to the Board for further appellate review. GAYLE STROMMEN Veterans Law Judge Board of Veterans' Appeals Attorney for the Board K.C. Spragins, 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.