Citation Nr: 21065701 Decision Date: 10/27/21 Archive Date: 10/27/21 DOCKET NO. 18-36 928 DATE: October 27, 2021 ORDER Entitlement to an increased rating for lumbar spine disability is denied. Entitlement to a 40 percent rating, but no higher, for left lower extremity radiculopathy of the sciatic nerve is granted effective November 7, 2018. Entitlement to a rating greater than 20 percent for left lower extremity radiculopathy of the sciatic nerve prior to November 7, 2018 is denied. Entitlement to a 40 percent rating, but no higher, for right lower extremity radiculopathy of the sciatic nerve is granted effective November 7, 2018. Entitlement to a rating greater than 20 percent for right lower extremity radiculopathy of the sciatic nerve prior to November 7, 2018 is denied. Entitlement to a 20 percent rating, but no higher, for left lower extremity femoral nerve radiculopathy is granted effective March 3, 2019. Entitlement to an effective date prior to March 3, 2019 for service connection for left lower extremity femoral nerve radiculopathy is denied. Entitlement to a 20 percent rating, but no higher, for right lower extremity femoral nerve radiculopathy is granted effective March 3, 2019. Entitlement to an effective date prior to March 3, 2019 for service connection for right lower extremity femoral nerve radiculopathy is denied. Entitlement to an earlier effective date of October 13, 2017 for service connection for erectile dysfunction is granted. Entitlement to special monthly compensation (SMC) for loss of use of a creative organ effective October 13, 2017 is granted. Entitlement to a compensable rating for erectile dysfunction associated with lumbar spine disability is denied. Entitlement to an increased rating for incontinence associated with lumbar spine disability is denied. FINDINGS OF FACT 1. Except for the periods where the Veteran is in receipt of temporary total ratings for his back condition, the Veteran's lumbar spine disability is manifest by forward flexion of the thoracolumbar spine 30 degrees or less. 2. Effective November 7, 2018, the Veteran's left lower extremity radiculopathy of the sciatic nerve is manifest by no more than moderately severe, incomplete paralysis. 3. Prior to November 7, 2018, the Veteran's left lower extremity radiculopathy of the sciatic nerve is manifest by no more than moderate incomplete paralysis. 4. Effective November 7, 2018, the Veteran's right lower extremity radiculopathy of the sciatic nerve is manifest by no more than moderately severe, incomplete paralysis. 5. Prior to November 7, 2018, the Veteran's right lower extremity radiculopathy of the sciatic nerve is manifest by no more than moderate incomplete paralysis. 6. Effective March 3, 2019, the Veteran's left lower extremity femoral nerve radiculopathy is manifest by no more than moderate incomplete paralysis. 7. Entitlement to service connection for left lower extremity femoral nerve radiculopathy arose no earlier than March 3, 2019. 8. Effective March 3, 2019, the Veteran's right lower extremity femoral nerve radiculopathy is manifest by no more than moderate incomplete paralysis. 9. Entitlement to service connection for right lower extremity femoral nerve radiculopathy arose no earlier than March 3, 2019. 10. The Veteran's claim for service connection for erectile dysfunction can be inferred no earlier than the October 13, 2017 VA examination. 11. Effective October 13, 2017, the Veteran has loss of use of a creative organ. 12. The Veteran's erectile dysfunction is not manifested by deformity of the penis. 13. Prior to March 3, 2019, the Veteran's incontinence resulted in nocturia four times per night; from March 3, 2019 to July 15, 2021 the Veteran's incontinence resulted in daytime voiding interval less than one hour; thereafter, the Veteran's incontinence resulted in requiring the use of an appliance. CONCLUSIONS OF LAW 1. The criteria for a rating in excess of 40 percent for lumbar spine disability have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, Diagnostic Code 5237. 2. Effective November 7, 2018, the criteria for a disability rating of 40 percent rating, but no higher, for left lower extremity radiculopathy of the sciatic nerve have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.124a, Diagnostic Code 8520. 3. Prior to November 7, 2018, the criteria for a disability rating in excess of 20 percent for left lower extremity radiculopathy of the sciatic nerve have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.124a, Diagnostic Codes 8520, 8620. 4. Effective November 7, 2018, the criteria for a disability rating of 40 percent rating, but no higher, for right lower extremity radiculopathy of the sciatic nerve have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.124a, Diagnostic Code 8520. 5. Prior to November 7, 2018, the criteria for a disability rating in excess of 20 percent for right lower extremity radiculopathy of the sciatic nerve have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.124a, Diagnostic Codes 8520, 8620. 6. Effective March 3, 2019, the criteria for a disability rating of 20 percent, but no higher, for left lower extremity femoral nerve radiculopathy have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.124a, Diagnostic Code 8526. 7. The criteria for an effective date prior to March 3, 2019 for service connection for left lower extremity femoral nerve radiculopathy have not been met. 38 U.S.C.§ 5110(a); 38 C.F.R. § 3.400. 8. Effective March 3, 2019, the criteria for a disability rating of 20 percent, but no higher, for right lower extremity femoral nerve radiculopathy have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.124a, Diagnostic Code 8526.The criteria for an effective date prior to March 3, 2019 for service connection for right lower extremity femoral nerve radiculopathy have not been met. 38 U.S.C.§ 5110(a); 38 C.F.R. § 3.400. 9. The criteria for entitlement to an effective date of October 13, 2017 for service connection for erectile dysfunction have been met. 38 U.S.C.§ 5110(a); 38 C.F.R. § 3.400. 10. Effective October 13, 2017, the criteria for entitlement to SMC pursuant to 38 U.S.C. § 1114(k) for loss of use of a creative organ have been met. 11. The criteria for a compensable rating for erectile dysfunction have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. § 4.115; Diagnostic Code 7522. 12. The criteria for a disability rating for incontinence greater than 20 percent prior March 3, 2019, greater than 40 percent for the period of March 3, 2019 to July 15, 2021, and greater than 60 percent thereafter, have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.1, 4.3, 4.7, 4.115a, 4.115b, Diagnostic Code 7542. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from January 1991 to January 1995. This matter comes before the Board of Veterans' Appeals (Board) from a November 2017 rating decision from the Department of Veterans Affairs (VA) Regional Office (RO). The Veteran appeared for a hearing before the undersigned Veterans Law Judge in November 2017. A transcript of the proceeding is of record. Although the Board has an obligation to provide adequate reasons and bases supporting this decision, there is no requirement that the evidence submitted by the appellant or obtained on his behalf be discussed in detail. Rather, the Board's analysis below will focus specifically on what evidence is needed to substantiate the claim and what the evidence in the file shows, or fails to show, with respect to the claim. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000); Timberlake v. Gober, 14 Vet. App. 122, 128-30 (2000). Where there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, VA shall resolve reasonable doubt in favor of the claimant. 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). To deny a claim on its merits, the evidence must preponderate against the claim. Alemany v. Brown, 9 Vet. App. 518 (1996). The Board has considered whether entitlement to a total disability based on individual employability (TDIU) is raised as part and parcel of this appeal, to include the question of whether the spine disability alone causes unemployability. See Buie, 24 Vet. App. 242 (2010); see also Bradley v. Peake, 22 Vet. App. 280, 293 (2008). Throughout the period that the Veteran has not been fully-time employed during this appeal period, his service-connected disabilities combine for a 100 percent rating. As to entitlement to Special Monthly Compensation based on statutory housebound criteria, as one rated sdisability does not meet schedular criteria for TDIU, the Board finds that this situation is distinct from that outlined in Buie and Bradley, and therefore, finds that further discussion of this benefit is not warranted based on this record and procedural history. Increased Rating Generally, the effective date of compensation based on a claim for increase will be on the date of receipt of the claim or the date entitlement arose, whichever is later. 38 U.S.C.§ 5110 (a); 38 C.F.R. § 3.400. However, the effective date for an increased rating claim may date back as much as one year before the date of the claim for increase if it is factually "ascertainable that an increase in disability had occurred" within that timeframe. See 38 U.S.C. § 5110 (b)(2). The VA's Schedule for Rating Disabilities is used to determine disability ratings once a disability is service connected. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. In the Rating Schedule, Diagnostic Codes (DC) are assigned to specific disabilities. These DCs designate percentage ratings based on the average functional impairment of the Veteran due to a service-connected disability. 38 C.F.R. §§ 3.321, 4.10. Where there is a question as to which of two evaluations shall be applied, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that evaluation. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. After careful consideration of the evidence, any reasonable doubt remaining is resolved in favor of the Veteran. 38 C.F.R. § 4.3. The Veteran's entire history is to be considered when assigning disability ratings. 38 C.F.R. § 4.1; Schafrath v. Derwinski, 1 Vet. App. 589 (1995). A claimant may experience multiple distinct degrees of disability that may result in different levels of compensation from the time the increased rating claim was filed until a final decision is made. Hart v. Mansfield, 21 Vet. App. 505 (2007). The following analysis is therefore undertaken with consideration of the possibility that different ratings may be warranted for different time periods. 1. Entitlement to an increased rating for lumbar spine disability The Veteran contends that his lumbar spine disability warrants a rating in excess of 40 percent. The Veteran's condition is rated as follows: 10 percent from September 2009; 40 percent from September 2012; 100 percent from August 7, 2015; 40 percent from April 1, 2016; 100 percent from March 4, 2019; and 40 percent from July 1, 2019. For the reasons that follow, the Board finds the Veteran's rating as currently assigned adequately compensates for his lumbar spine disability; therefore, a higher rating is denied. The Board notes that during the pendency of the Veteran's appeal, VA amended the criteria for rating musculoskeletal disabilities. The new regulation applies to claims received on or after February 7, 2021 or previously filed claims that are pending on February 7, 2021 if the new regulation will render more favorable result for the Veteran. However, Diagnostic Code 5237 was not changed with the February 27, 2021 revisions of the rating schedule. The Veteran's lumbar spine disability is rated under 38 C.F.R. § 4.71a, Diagnostic Code 5010-5237. Hyphenated codes are used when a rating under one diagnostic code requires use of an additional diagnostic code to identify the basis for the evaluation assigned; the additional code is shown after the hyphen. 38 C.F.R. § 4.27. Diagnostic Code 5237 is part of the General Rating Formula for Disease and Injuries of the Spine (General Rating Formula). Under the General Rating Formula, with or without symptoms such as pain, stiffness or aching in the area of the spine affected by residuals of injury or disease, the following ratings will apply: 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 assigned for forward flexion of the thoracolumbar spine 30 degrees or less; or, favorable ankylosis of the entire thoracolumbar spine. A 50 percent rating is assigned for unfavorable ankylosis of the entire thoracolumbar spine. A 100 percent rating is assigned for unfavorable ankylosis of the entire spine. 38 C.F.R. § 4.71a, Diagnostic Code 5237. 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. The Board has addressed all associated neurological abnormalities in the sections below. Unfavorable ankylosis is defined as "a condition in which the entire cervical spine, the entire thoracolumbar spine, or the entire spine is fixed in flexion or extension, and the ankylosis results in one or more of the following: difficulty walking because of a limited line of vision; restricted opening of the mouth and chewing; breathing limited to diaphragmatic respiration; gastrointestinal symptoms due to pressure of the costal margin on the abdomen; dyspnea or dysphagia; atlantoaxial or cervical subluxation or dislocation; or neurologic symptoms due to nerve root stretching." Id. at Note 5. Additionally, fixation of a spinal segment in neutral position (zero degrees) is "always" considered favorable ankylosis. Id. When evaluating musculoskeletal disabilities based on limitation of motion, 38 C.F.R. § 4.40 requires consideration of functional loss caused by pain or other factors listed in that section that could occur during flare-ups or after repeated use and, therefore, not be reflected on range-of-motion testing. 38 C.F.R. § 4.45 requires consideration also be given to less movement than normal, more movement than normal, weakened movement, excess fatigability, incoordination, and pain on movement. See DeLuca v. Brown, 8 Vet. App. 202 (1995); see also Mitchell v. Shinseki, 25 Vet. App. 32, 44 (2011). Nonetheless, even when the background factors listed in § 4.40 or 4.45 are relevant when evaluating a disability, the rating is assigned based on the extent to which motion is limited, pursuant to 38 C.F.R. § 4.71a; a separate or higher rating under § 4.40 or 4.45 itself is not appropriate. See Thompson v. McDonald, 815 F.3d 781, 785 (Fed. Cir. 2016) ("[I]t is clear that the guidance of § 4.40 is intended to be used in understanding the nature of the veteran's disability, after which a rating is determined based on the § 4.71a criteria."). Under 38 C.F.R. § 4.59, painful motion is a factor to be considered with any form of arthritis; however, 38 C.F.R. § 4.59 is not limited to disabilities involving arthritis. See Burton v. Shinseki, 25 Vet. App. 1 (2011). The Board finds that the preponderance of the evidence is against a rating in excess of 40 percent for lumbar spine disability. The Board acknowledges the Veteran's lay reports of symptoms and that there was functional loss due to [include causes of additional functional loss i.e., pain, weakened movement, excess fatigability, incoordination, repetitive use, pain during flare-ups, and pain during repetitive use over time, etc.]. However, even considering the Veteran's lay reports of symptoms and noted functional loss, the degree of additional limitation reflected by the statements that [insert the Veteran's description of how frequent and severe the flare-ups are] would not result in symptoms more nearly approximating unfavorable ankylosis of the entire thoracolumbar spine. Except for the periods where the Veteran is in receipt of temporary total (100 percent) ratings for his back condition, the Veteran's back is rated as 40 percent throughout the appellate period. To be entitled to a higher rating, the evidence must show the Veteran has unfavorable ankylosis of the entire thoracolumbar spine. Here, however, the competent medical evidence does not show ankylosis. Though the Veteran's range of motion is severely limited, all VA examinations have shown he does retain some range of motion and have found no ankylosis. Further, the Veteran has not contended, and the competent evidence does not show, ankylosis during periods of exacerbations, such as during flare-ups or after repeated use over time. Thus, there is no basis upon which to award a higher rating. Consideration has also been given to assigning a rating under the Formula for Rating Intervertebral Disc Syndrome (IVDS) Based on Incapacitating Episodes. However, except for periods of convalescence for which the Veteran is already in receipt of temporary total evaluations, 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 Veteran has already been granted service connection for radiculopathy of the sciatic and femoral nerves of the bilateral lower extremities, incontinence/urinary frequency, and erectile dysfunction, which are discussed in more detail below. The lay and medical evidence of record is against a finding that the Veteran has any other neurological abnormality associated with his spine disability. For the foregoing reasons, the preponderance of the evidence is against the Veteran's claim for a rating in excess of 40 percent for lumbar spine disability. 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. Sciatic Nerve Radiculopathy 2. Entitlement to a 40 percent rating, but no higher, for left lower extremity radiculopathy of the sciatic nerve is granted effective November 7, 2018 3. Entitlement to a rating greater than 20 percent for left lower extremity radiculopathy of the sciatic nerve prior to November 7, 2018 4. Entitlement to a 40 percent rating, but no higher, for right lower extremity radiculopathy of the sciatic nerve is granted effective November 7, 2018 5. Entitlement to a rating greater than 20 percent for right lower extremity radiculopathy of the sciatic nerve prior to November 7, 2018 The Veteran contends that his bilateral sciatic nerve radiculopathy warrants a higher rating. Prior to March 2019, the Veteran's sciatic nerve disability was evaluated under DC 8520 for paralysis of the sciatic nerve. Thereafter, the diagnostic code was changed to 8620 for neuritis. However, the Veteran's rating has remained at 20 percent for each leg since July 2015. For the reasons that follow, the Board finds that a rating of 40 percent is warranted effective November 7, 2018. Under the criteria for DC 8620, neuritis, cranial or peripheral, characterized by loss of reflexes, muscle atrophy, sensory disturbances, and constant pain, at times excruciating, is to be rated on the scale provided for injury of the nerve involved, with a maximum equal to severe, incomplete, paralysis. The maximum rating which may be assigned for neuritis not characterized by organic changes referred to in this section will be that for moderate, or with sciatic nerve involvement, for moderately severe, incomplete paralysis. 38 C.F.R. § 4.123 Paralysis of the sciatic nerve is evaluated in accordance with the criteria set forth in 38 C.F.R. § 4.124a, Diagnostic Code 8520. Under these criteria, mild incomplete paralysis is rated as 10 percent disabling. Moderate incomplete paralysis is rated as 20 percent disabling. Moderately severe incomplete paralysis is rated as 40 percent disabling. Severe incomplete paralysis, with marked muscular atrophy is rated as 60 percent disabling. Complete paralysis, with the foot dangles and drops, no active movement possible of muscles below the knee, flexion of knee weakened or (very rarely) lost is rated as 80 percent disabling. 38 C.F.R. § 4.124a. The words "mild," "moderate," and "severe" as used in the various Diagnostic Codes are not defined in the Rating Schedule. Regulations provide that ratings for peripheral neurological disorders are to be assigned based the relative impairment of motor function, trophic changes, or sensory disturbance. 38 C.F.R. § 4.120. Consideration is also given for loss of reflexes, pain, and muscle atrophy. See 38 C.F.R. §§ 4.123, 4.124. The term "incomplete paralysis" indicates a degree of lost or impaired function substantially less than the type picture for complete paralysis given with each nerve, whether due to varied level of the nerve lesion or to partial regeneration. When the involvement is wholly sensory, the rating is for the mild, or at most, the moderate degree. The disability ratings for the peripheral nerves are for unilateral involvement; when bilateral, the ratings combine with application of the bilateral factor. 38 C.F.R. § 4.124a, Note at "Diseases of the Peripheral Nerves." The Note to 38 C.F.R. § 4.124a establishes a maximum disability rating for conditions that are wholly sensory, as opposed to a minimum disability rating for conditions that are more than wholly sensory. See Miller v. Shulkin, 28 Vet. App. 376 (2017). July 2015 private treatment records revealed radiculopathy in the right leg and MRI evidence of herniation compressing L5 and S1 on the right involving the sciatic nerve. Strength was normal. The December 2015 VA examination noted moderate involvement of the sciatic nerve in both legs. In July 2016 VA treatment records the Veteran had no motor-sensory deficit in either leg. In August 2017 the Veteran reported a significant worsening of his pain since the L4-S1 fusion. Upon examination, he had hyperesthesia in his lateral thighs and calves, though strength and reflexes were normal. At the October 2017 VA examination, the Veteran reported moderate constant and intermittent pain bilaterally which changes depending on the day. He also reported pins and needles feeling down both legs to the toes. In September 2018 VA treatment records the Veteran reported some chronic weakness of the left leg, no numbness, and pain resulting in decreased strength on the left. However, as of November 7, 2018, the medical evidence shows a worsening of the Veteran's condition. On November 7, 2018, the Veteran reported to his VA treating provider that his pain increased since the August 2017 office visit, and that he experiences diffuse numbness in both legs after any prolonged activity. His physical examination was greatly limited by pain and showed some weakness due to pain in bilateral hip and knee flexion, and knee extension. Two days later the Veteran reported that his radicular pain increased since the appointment two days prior, and he was now using a cane to help with the pain during standing and ambulation. He reported his numbness and paresthesias have been nearly constant since the office visit two days prior. He further reported weakness in his legs due to pain, and that he was only able to sit or stand 10 minutes at a time. He reported needing help with self-care activities. The March 2019 and July 2021 VA examinations noted severe involvement of bilateral sciatic nerves. The July 2021 VA examination indicated severe symptoms, in that the Veteran experienced constant and intermittent pain, paresthesias/dysthesias, and numbness bilaterally. Upon examination, sensation was decreased in L4/L5/S1 and L5 distributions. His gait was unstable due to his symptoms, and the Veteran was noted to use a cane at all times for walking. The examiner indicated his condition manifests in moderately severe incomplete paralysis. The VA examinations and VA treatment records associated with the file do not show any competent evidence of trophic changes, muscle atrophy, or complete paralysis. Additionally, his reflexes have remained intact. Based on the above, the Board finds that the Veteran's sciatic radiculopathy is primarily manifest by impairment of motor functions, sensory disturbance, and pain. The Board also finds that the most probative evidence of record is against a finding that the disability is manifest by trophic changes, loss of reflexes, muscle atrophy, and complete paralysis. The Board thus finds that the level of impairment is most analogous to moderately severe incomplete paralysis effective November 7, 2018. Prior to that date, the Board finds the level of impairment is most analogous to moderate incomplete paralysis, as the findings regarding pain and impairment of motor functions were less severe at that time. The Board has considered all other potentially applicable Diagnostic Codes, but there is no evidence showing the Veteran has neurological impairment associated with any other peripheral nerves that have not already been service-connected. Therefore, a separate or higher rating under a different Diagnostic Code is not warranted. In conclusion, the Board finds that the preponderance of the evidence is against the Veteran's claim for a rating greater than 20 percent prior to November 7, 2018, and greater than 40 percent thereafter. 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. Femoral Nerve Radiculopathy 6. Entitlement to a 20 percent rating, but no higher, for left lower extremity femoral nerve radiculopathy is granted effective March 3, 2019 7. Entitlement to an effective date prior to March 3, 2019 for left lower extremity femoral nerve radiculopathy 8. Entitlement to a 20 percent rating, but no higher, for right lower extremity femoral nerve radiculopathy is granted effective March 3, 2019. 9. Entitlement to an effective date prior to March 3, 2019 for right lower extremity femoral nerve radiculopathy The Veteran contends that his bilateral femoral nerve radiculopathy warrants a higher rating. Service connection for bilateral femoral nerve radiculopathy was granted in a May 2019 rating decision with a 20 percent rating effective March 3, 2019 under DC 8626 for neuritis. Effective July 15, 2021, the diagnostic code was changed to 8526, for paralysis of the femoral nerve, and his rating was reduced to 10 percent. For the reasons that follow, the Board finds that a rating of 20 percent is warranted from March 3, 2019, to present. However, the Board finds no basis upon which to award an earlier effective date for service connection for this disability. Paralysis of the femoral nerve is evaluated in accordance with the criteria set forth in 38 C.F.R. § 4.124a, Diagnostic Code 8526. Neuritis and neuralgia of that group are evaluated under Diagnostic Codes 8626 and 8726. Under these criteria, mild incomplete paralysis is rated as 10 percent disabling. Moderate incomplete paralysis is rated as 20 percent disabling. Severe incomplete paralysis is rated as 30 disabling. Complete paralysis is rated as 40 percent disabling. 38 C.F.R. § 4.124a. Regarding neuritis and neuralgia, evaluated under DC 8626 and 8726 respectively, the criteria discussed in the section above remain the same when addressing the femoral nerve. The Veteran contend that his femoral nerve radiculopathy has been present since 2017, and he is therefore entitled to a rating for femoral nerve radiculopathy from 2017 to present. However, there is no competent evidence that impairment of the femoral nerve has been present since 2017. The first evidence of any involvement of the femoral nerve is found in March 2019 VA treatment records and the March 2019 VA examination. The March 5, 2019 MRI indicated a bulging disc at L2-3 which was new since the prior examination of February 28, 2019. Generally, the effective date of compensation based on a claim for increase will be on the date of receipt of the claim or the date entitlement arose, whichever is later. 38 U.S.C.§ 5110(a); 38 C.F.R. § 3.400. Accordingly, the evidence indicates a progression of the Veteran's back condition which was first shown by VA treatment records and VA examination in March 2019, consistent with the effective date assigned of March 3, 2019. Additionally, the Board finds the severity of the Veteran's impairment more nearly approximates the 20 percent rating for moderate incomplete paralysis from March 3, 2019 to present. The March 2019 VA examination noted severe symptoms pertaining to the femoral nerve, and the July 2021 VA examination noted the Veteran's condition manifests in moderate incomplete paralysis. The July 2021 examiner noted unstable gait and constant use of a cane due to radiculopathy. The Veteran reported severe symptoms, including pain, numbness, and paresthesias/dysthesias. In summary, the competent medical evidence indicates the Veteran's condition manifests in more than mild incomplete paralysis. Based on the above, the Board finds that the disability is primarily manifest by impairment of motor functions, sensory disturbance, and pain. The Board also finds that the most probative evidence of record is against a finding that the disability is manifest by trophic changes, sensory disturbance, loss of reflexes, muscle atrophy, or complete paralysis. The Board thus finds that the level of impairment is most analogous to moderate incomplete paralysis. The Board has considered all other potentially applicable Diagnostic Codes, but there is no evidence showing the Veteran has neurological impairment associated with any other peripheral nerves that have not already been service-connected. Therefore, a separate or higher rating under a different Diagnostic Code is not warranted. In conclusion, the Board finds the evidence warrants a rating of 20 percent, but no higher, effective March 3, 2019. In denying any higher ratings, 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. Erectile Dysfunction 10. Entitlement to an earlier effective date of October 13, 2017 for service connection for erectile dysfunction The Veteran contends he has had erectile dysfunction due to his back condition since at least 2017 and is therefore entitled to an effective date for service connection in 2017. A September 2018 rating decision granted service-connection for erectile dysfunction with an initial noncompensable disability rating effective July 28, 2018. For the reasons that follow, the Board finds an effective date for service connection for erectile dysfunction of October 13, 2017 is warranted. The Board acknowledges that the Veteran did not submit a formal application for service connection for erectile dysfunction prior to his July 2018 claim. Generally, the effective date of a claim is the date the claim was filed, or the date entitlement arise, whichever is later. 38 U.S.C. § 5110(a); 38 C.F.R. § 3.400. However, new and material evidence received prior to the expiration of the appeal period, or prior to the appellate decision if a timely appeal has been filed, will be considered as having been filed in connection with the claim which was pending at the beginning of the appeal period. 38 C.F.R. § 3.156(b). Here, the Veteran's appeal of his rating for erectile dysfunction stems from the November 2017 rating decision, which was initiated by the October 13, 2017 VA examination of his back. Thus, the Veteran did not file a formal increased rating claim in this case for the underlying back condition. Within one year of the November 2017 rating decision, however, new and material evidence was added to the record that showed that the Veteran's erectile dysfunction was due to his back condition. See July 2018 VA 21-526EZ; August 2018 VA examination. The Veteran is presumed to be seeking the maximum benefits available. Thus, the claim for service connection for erectile dysfunction was raised in connection with the appropriate rating for his underlying back disability. Here, VA treatment records show that he was first prescribed medication for erectile dysfunction in March 2017. At the time, the Veteran reported that his back pain caused his erectile dysfunction, and the September 2018 VA examination opined his back condition caused his erectile dysfunction. The Veteran testified at the Board hearing that his erectile dysfunction condition has been present of the same severity since 2017. Accordingly, an effective date of October 13, 2017 for service connection for erectile dysfunction is granted. 11. Entitlement to special monthly compensation (SMC) for loss of use of a creative organ is granted, effective October 13, 2017 Under 38 U.S.C. § 1114 (k) and 38 C.F.R. § 3.350 (a)(1), special monthly compensation is payable at a specified rate if the Veteran, as the result of service-connected disability, has suffered the anatomical loss or loss of use of one or more creative organs. Id. Loss of a creative organ will be shown by acquired absence of one or both testicles (other than undescended testicles) or ovaries or other creative organ. Id. In this case, SMC for loss of use of a creative organ is based on the grant of service connection for erectile dysfunction associated with the Veteran's service-connected back condition. As the Board has granted an earlier effective date of October 13, 2017 for the grant of service connection, the Board also grants an effective date of October 13, 2017 for the grant of SMC for loss of use. 12. Entitlement to a compensable rating for erectile dysfunction The Veteran contends he is entitled to a higher rating for his erectile dysfunction associated with his back impairment. VA has rated the Veteran's erectile dysfunction as noncompensable under 38 C.F.R. § 4.115b, Diagnostic Code 7522. For the reasons that follow, the Board finds the Veteran's rating as currently assigned adequately compensates for his erectile dysfunction; therefore, a higher rating is denied. As above, the Veteran has already been awarded special monthly compensation under 38 U.S.C. § 1114, subsection (k) and 38 C.F.R. § 3.350(a) for loss of a creative organ effective October 13, 2017. For a compensable schedular rating, under Diagnostic Code 7522, a 20 percent rating is warranted for deformity of the penis with the loss of erectile power. This is the only schedular rating provided under this Diagnostic Code. The Board notes that, pursuant to 38 C.F.R. § 4.31, when the rating schedule does not provide a zero percent rating for a Diagnostic Code, a zero percent evaluation shall be assigned when the requirements for a compensable rating are not met. The Board further notes that no other schedular criteria apply to erectile dysfunction. The Board finds that the medical evidence shows no deformity of the penis either externally or internally. Thus, a compensable rating is not warranted. To the extent that the Veteran contends entitlement to higher ratings, the preponderance of the evidence is against the claim; there is no reasonable doubt to be resolved; and any further increased rating is not warranted. 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Incontinence 13. Entitlement to an increased rating for incontinence The Veteran contends he is entitled to a higher rating for urinary incontinence related to his back disability. He is rated 20 percent disabled under DC 7517 from September 2009, and under DC 7542, 40 percent disabled from March 2019 and 60 percent disabled from July 2021. For the reasons that follow, the Board finds the Veteran's rating as currently assigned adequately compensates for his urinary incontinence; therefore, a higher rating is denied. The Veteran's urinary incontinence has been rated using Diagnostic Code 7542 (Neurogenic Bladder). This disability is to be rated as a voiding dysfunction under the criteria of 38 C.F.R. § 4.115a. 38 C.F.R. § 4.115b, Diagnostic Code 7542. Under the rating criteria for a voiding dysfunction, the condition is to be rated as urine leakage, frequency, or obstructed voiding. Only the predominant area of dysfunction shall be considered for rating purposes. 38 C.F.R. § 4.115a The rating criteria for urine leakage are as follows: the required the use of absorbent materials which must be changed less than 2 times per day warrants a 20 percent rating; the required use of absorbent materials which must be changed 2 to 4 times daily warrants a 40 percent rating; and the required use of an appliance or the wearing of absorbent materials which must be changed more than 4 times per day is assigned a 60 percent rating. The rating criteria for urinary frequency are as follows: a 10 percent rating is assigned where there is daytime voiding interval between two and three hours, or awakening to void two times per night; a 20 percent rating is assigned where there is daytime voiding interval between one and two hours, or awakening to void three to four times per night; and a 40 percent rating is assigned where there is daytime voiding interval less than one hour, or; awakening to void five or more times per night. In the Veteran's case, there is no evidence of obstructed voiding. At a July 2017 VA office visit, the Veteran reported nocturia four times per night, consistent with the 20 percent rating criteria for urinary frequency. In subsequent VA treatment records he continued to endorse urinary frequency but denied incontinence until March 2019, at which time he reported incontinence over the last four to six weeks. At that examination, his daytime voiding interval was noted to be less than one hour, consistent with the 40 percent rating criteria under urinary frequency. This examination did not indicate that he required the use of an appliance or the wearing of absorbent materials which must be changed more than 4 times per day. His incontinence resolved after the March 2019 surgery, but he continued to endorse urinary urgency manifest by nocturia three to four times per night and a daytime voiding interval of less than one hour. See March 2019 VA examination. Later VA treatment records show his urinary frequency continued, but do not provide information regarding frequency. See, e.g., July 2020 VA treatment records. At the July 2021 VA examination the examiner noted his condition requires him to wear an appliance, consistent with the 60 percent rating requirement under continual urine leakage. In summary, prior to March 3, 2019, the preponderance of the evidence is consistent with a 20 percent rating under urinary frequency; there is no competent medical evidence indicating daytime voiding interval less than one hour, awakening to void five or more times per night, or requiring the wearing of absorbent materials which must be changed 2 to 4 times per day. As of the March 2019 VA examination, the preponderance of the evidence is consistent with the 40 percent rating criteria under urinary frequency; there is no competent medical evidence of voiding dysfunction which requires the use of an appliance or the wearing of absorbent materials which must be changed more than 4 times per day. Further, as of the July 2021 VA examination, the preponderance of the evidence is consistent with the 60 percent rating criteria under continual urine leakage; this is the highest schedular rating permitted for voiding dysfunction. Thus, there is no basis upon which to award a higher rating for any portion of the period on appeal. To the extent that the Veteran contends entitlement to higher ratings, the preponderance of the evidence is against the claim; there is no reasonable doubt to be resolved; and any further increased rating is not warranted. 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). The Board has also considered whether a higher rating is warranted under any other potentially applicable diagnostic code related to the genitourinary system. However, the Board further finds that other diagnostic codes pertaining to the kidneys and urethra are not relevant, as the record does not reflect involvement of her kidneys or urethra. See 38 C.F.R. § 4.115b, Diagnostic Codes 7500-7519. Nathaniel J. Doan Veterans Law Judge Board of Veterans' Appeals Attorney for the Board K.L. Blevins, Associate Counsel The Board's decision in this case is binding only with respect to the instant matter decided. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.