Citation Nr: 21071198 Decision Date: 11/30/21 Archive Date: 11/30/21 DOCKET NO. 13-33 289 DATE: November 30, 2021 ORDER Entitlement to a 20 percent rating for left knee osteoarthritis from June 9, 2010, to December 20, 2017, excluding a period of temporary total evaluation from September 27, 2011, to January 1, 2012, is granted. Entitlement to a rating in excess of 30 percent for left knee osteoarthritis from December 20, 2017, to October 22, 2019, is denied. Entitlement to a 30 percent rating for left knee osteoarthritis from October 22, 2019, to October 19, 2020, is granted. Entitlement to a 20 percent rating for left knee osteoarthritis from October 19, 2020, is granted. Entitlement to a separate 20 percent rating for left knee dislocated semilunar cartilage from August 7, 2021, is granted. Entitlement to a 20 percent rating for right knee osteoarthritis from June 9, 2010, to December 20, 2017, excluding a period of temporary total evaluation from March 10, 2011, to July 1, 2011, is granted. Entitlement to a rating in excess of 20 percent rating for right knee osteoarthritis from December 20, 2017, to October 22, 2019, is denied. Entitlement to a 20 percent rating for right knee osteoarthritis from October 22, 2019, to October 19, 2020, is granted. Entitlement to a rating in excess of 10 percent for right knee osteoarthritis from October 19, 2020, is denied. Entitlement to a separate 20 percent rating for right knee dislocated semilunar cartilage from August 7, 2021, is granted. Entitlement to special monthly pension (SMP) based on the need for aid and attendance prior to September 10, 2019, is granted. REMANDED Entitlement to service connection for an acquired psychiatric disorder is remanded. Entitlement to special monthly compensation is remanded. Entitlement to SMP at the housebound rate is remanded. FINDINGS OF FACT 1. For the period from June 9, 2010, to December 20, 2017, the Veteran's left knee osteoarthritis was manifested by dislocated semilunar cartilage with frequent episodes of "locking," pain, and effusion. 2. For the period from December 20, 2017, to October 19, 2020, the Veteran's left knee osteoarthritis was manifested by severe recurrent subluxation. 3. For the period from October 19, 2020, the Veteran's left knee osteoarthritis is manifested by moderate recurrent lateral instability. 4. For the period from August 7, 2021, the Veteran's left knee ostearthritis is also manifested by dislocated semilunar cartilage with frequent episodes of "locking," pain, and effusion. 5. For the period from June 9, 2010, to December 20, 2017, the Veteran's right knee osteoarthritis was manifested by dislocated semilunar cartilage with frequent episodes of "locking," pain, and effusion. 6. For the period from December 20, 2017, to October 19, 2020, the Veteran's right knee osteoarthritis was manifested by moderate recurrent subluxation. 7. For the period from October 19, 2020, the Veteran's right knee osteoarthritis is manifested by slight recurrent lateral instability. 8. For the period from August 7, 2021, the Veteran's right knee ostearthritis is also manifested by dislocated semilunar cartilage with frequent episodes of "locking," pain, and effusion. 9. Prior to September10, 2019, the preponderance of the evidence indicates that the Veteran was in need of the aid and attendance of another person due to nonservice-connected disabilities. CONCLUSIONS OF LAW 1. The criteria for a 20 percent rating for left knee osteoarthritis from June 9, 2010, to December 20, 2017, are met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, Diagnostic Code 5258. 2. The criteria for a rating in excess of 30 percent for left knee osteoarthritis from December 20, 2017, to October 22, 2019, are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, Diagnostic Code 5257. 3. The criteria for a 30 percent rating for left knee osteoarthritis from October 22, 2019, to October 19, 2020, are met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, Diagnostic Code 5257. 4. The criteria for a 20 percent rating for left knee osteoarthritis from October 19, 2020, are met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, Diagnostic Code 5257. 5. The criteria for a separate 20 percent rating for left knee dislocated semilunar cartilage from August 7, 2021, are met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, Diagnostic Code 5258. 6. The criteria for a 20 percent rating for right knee osteoarthritis from June 9, 2010, to December 20, 2017, are met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, Diagnostic Code 5258. 7. The criteria for a rating in excess of 20 percent for right knee osteoarthritis from December 20, 2017, to October 22, 2019, are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, Diagnostic Code 5257. 8. The criteria for a 20 percent rating for right knee osteoarthritis from October 22, 2019, to October 19, 2020, are met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, Diagnostic Code 5257. 9. The criteria for a rating in excess of 10 percent rating for right knee osteoarthritis from October 19, 2020, are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, Diagnostic Code 5257. 10. The criteria for a separate 20 percent rating for right knee dislocated semilunar cartilage from August 7, 2021, are met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, Diagnostic Code 5258. 11. The criteria for entitlement to SMP based on the need for aid and attendance prior to September 10, 2019, are met. 38 U.S.C. §§ 1502, 1521, 5307; 38 C.F.R. §§ 3.102, 3.159, 3.350, 3.351, 3.352, 4.3. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active service from March to September 1973, and from December 1973 to October 1975. He testified before the undersigned Veterans Law Judge during a December 2016 hearing. This matter is on appeal from an October 2010 rating decision. The case was remanded by the Board of Veterans' Appeals (Board) in October 2018, and then denied in an August 2020 decision. The Veteran thereafter appealed the Board's decision to the United States Court of Appeals for Veterans Claims (Court). In an Order dated in May 2021, the Court granted a Joint Motion for Partial Remand (JMPR) by the Veteran and VA General Counsel, which was incorporated by reference, to vacate the Board's decision and remand the case for readjudication in accordance with the JMPR. Additional evidence has been added to the claims file; the Veteran waived agency of original jurisdiction (AOJ) review of such evidence in September 2021. 38 C.F.R. §§ 19.37, 20.1304(c). Increased Ratings Disability ratings are determined by applying the criteria set forth in VA's Schedule for Rating Disabilities. Ratings are based on the average impairment of earning capacity. Individual disabilities are assigned separate diagnostic codes. See 38 U.S.C. § 1155; 38 C.F.R. § 4.1. Where entitlement to compensation has already been established, and an increase in the disability rating is at issue, the present level of disability is of primary concern. Although a rating specialist is directed to review the recorded history of a disability in order to make a more accurate evaluation, the regulations do not give past medical reports precedence over current findings. See Francisco v. Brown, 7 Vet. App. 55 (1994); 38 C.F.R. § 4.2. Staged ratings are, however, appropriate for an increased rating claim when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. The relevant focus for adjudicating an increased rating claim is on the evidence concerning the state of the disability from the time period one year before the claim was filed until VA makes a final decision on the claim. See generally Hart v. Mansfield, 21 Vet. App. 505 (2007). Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating; otherwise, the lower rating will be assigned. See 38 C.F.R. § 4.7. 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). In Correia v. McDonald, 28 Vet. App. 158 (2016), the Court held that the final sentence of 38 C.F.R. § 4.59 requires that the examiner record the results of range of motion testing "for pain on both active and passive motion [and] in weight-bearing and non-weight-bearing and, if possible, with range of motion measurements of the opposite undamaged joint." The spine has no opposite joint. In Sharp v. Shulkin, 29 Vet. App. 26 (2017), the Court held that VA examiners must obtain information about the severity, frequency, duration, precipitating and alleviating factors, and extent of functional impairment of flares from the veterans themselves, when a flare-up is not observable at the time of examination. In making the below determinations, the Board notes that neither the Veteran nor his representative has raised any other issues, nor has the record reasonably raised any other issues. See Doucette v. Shulkin, 28 Vet. App. 366 (2017). 1. Entitlement to a rating in excess of 10 percent for left knee osteoarthritis from June 9, 2010 to December 20, 2017 The Veteran contends that he is entitled to a higher rating because of his symptomatology. For this period, the Veteran's left knee osteoarthritis for this period is rated under 38 C.F.R. § 4.71a, Diagnostic Code 5260, for limitation of flexion of the leg. Under Diagnostic Code 5260, a noncompensable rating is warranted for flexion limited to 60 degrees. A 10 percent rating is warranted for flexion limited to 45 degrees. A 20 percent rating is warranted for flexion limited to 30 degrees. A 30 percent rating is warranted for flexion limited to 15 degrees. 38 C.F.R. § 4.71a, Diagnostic Code 5260. After a review of all the evidence of record, and resolving reasonable doubt in favor of the Veteran, the Board finds that, for the period from June 9, 2010, to December 20, 2017, the left knee osteoarthritis disability has more nearly approximated dislocated semilunar cartilage with frequent episodes of "locking," pain, and effusion warranting a 20 percent rating under Diagnostic Code 5258. A September 2010 VA examination shows that the Veteran reported knee stiffness, swelling with walking, locking, popping, and his knee giving out. A January 2015 VA examination reveals that the Veteran had a meniscal tear with frequent episodes of joint "locking," joint pain and joint effusion. The only rating available under Diagnostic Code 5258 is 20 percent. 38 C.F.R. § 4.71a, Diagnostic Code 5258. The Board has also considered the other Diagnostic Codes pertaining to the knee and leg. Separate disability ratings may be assigned only if the symptomatology for a disability is not duplicative or overlapping with the symptomatology of any other disability. See Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994); Lyles v. Shulkin, 29 Vet. App. 107 (2017) (holding that 38 C.F.R. § 4.14 prohibits paying compensation twice for the same symptoms or functional impairment). Since the Board is granting a 20 percent rating under Diagnostic Code 5258, the 10 percent rating under Diagnostic Code 5260 will be discontinued because assigning separate ratings under both Diagnostic Codes 5260 and 5258 would constitute pyramiding. The Diagnostic Codes overlap in symptoms, or findings of pain and locking as forms of limitation of motion, such that assigning separate ratings under both codes would violate the prohibition against pyramiding because it would compensate the Veteran twice for the same symptomatology. The Board has also considered whether the criteria for a 30 percent rating instead under Diagnostic Code 5260 were met. The Board finds that the preponderance of the evidence is against a rating in excess of 20 percent for left knee osteoarthritis for this period based on limitation of flexion. The Board acknowledges the Veteran's lay reports of symptoms and that there was functional loss due to pain, fatigue, weakness, and lack of endurance. However, even considering the Veteran's lay reports of symptoms and noted functional loss, the degree of additional limitation reflected by the statements that he experienced daily severe flare-ups lasting for five minutes, would not result in limitation of motion more nearly approximating flexion limited to 15 degrees. The September 2010 VA examination shows that the Veteran had a daily flare of symptoms. He could only walk half a block, and was unable to run or kneel. He had difficulty sitting more than 20-30 minutes. Range of motion showed flexion to 90 degrees before and after repetition. A January 2015 VA examination reveals that the Veteran reported his flare-ups were severe and lasted for five minutes daily. He reported having increased knee pain when standing after sitting for more than five minutes, and could only stand or walk for five minutes before his knees bothered him. Range of motion showed flexion to 140 degrees before and after repetition. Flexion with repeated use over time and during flare-ups was opined to be to 140 degrees. Pain, fatigue, weakness, and lack of endurance were opined to limit functional ability during flare-ups. The Veteran testified at his December 2016 hearing that his mobility within the last year had "gotten to be a problem." December 2016 Hearing Transcript at 3. Even with considering the Veteran's testimony, the objective medical evidence of record does not show limitation of flexion approximating flexion limited to 15 degrees. The Veteran's statements during this period do not indicate that flexion was limited to 15 degrees. The Board is unable to conclude that a 30 percent rating under Diagnostic Code 5260 is warranted for the period from June 9, 2010, to December 20, 2017. With regards to other diagnostic codes used to rate the knee, none of the examinations or any treatment records reflect ankylosis. The evidence also does not show recurrent subluxation or lateral instability during this period. The September 2010 examination showed that the knee was ligamentously stable. Varus/valgus stress, Lachman examination, and anterior and posterior drawer tests for instability were all negative. The January 2015 examination also shows that instability tests were all normal. Separate ratings under Diagnostic Codes 5256 and 5257 are therefore not warranted. The only rating available under Diagnostic Code 5259 is 10 percent for symptomatic removal of semilunar cartilage. The evidence does not show that the Veteran had removal of semilunar cartilage. Further, the Veteran is compensated for the symptoms of his meniscal condition with the 20 percent rating under Diagnostic Code 5258. To assign a separate rating under Diagnostic Code 5259 would constitute pyramiding. The evidence also does not show limitation of extension warranting a separate rating under Diagnostic Code 5261 for this period. The September 2010 and January 2015 examinations both showed extension to zero degrees. The Board assigned an earlier effective date of December 20, 2017, in August 2020 for the separate limitation of extension rating. The Veteran did not appeal that part of the Board's decision assigning an effective date of December 20, 2017, and no earlier. Finally, the evidence does not reflect impairment of tibia and fibula or genu recurvatum such that separate ratings under Diagnostic Codes 5262 and 5263 are warranted. In conclusion, the Board finds that the preponderance of the evidence supports a 20 percent rating under Diagnostic Code 5258 for this period. To this extent, the Veteran's appeal for a rating in excess of 10 percent for left knee osteoarthritis for the period from June 9, 2010, to December 20, 2017, is granted. 2. Entitlement to a rating in excess of 30 percent for left knee osteoarthritis from December 20, 2017, to October 22, 2019 The Veteran contends that he is entitled to a higher rating because of the severity of his symptomatology. For this period, the Veteran's left knee osteoarthritis is rated under 38 C.F.R. § 4.71a, Diagnostic Code 5257, which evaluates other impairment of the knee. See December 2019 rating codesheet. Under Diagnostic Code 5257, a 10 percent rating is warranted for slight recurrent subluxation or lateral instability. A 20 percent rating is warranted for moderate recurrent subluxation or lateral instability. A 30 percent rating is warranted for severe recurrent subluxation or lateral instability. 38 C.F.R. § 4.71a, Diagnostic Code 5257. According to MERRIAM WEBSTER'S COLLEGIATE DICTIONARY 999 (11th Ed. 2007), "slight" means small in amount. "Moderate" means limited in scope or effect. "Severe" means very painful or harmful or of a great degree. Objective medical evidence is not required to establish lateral knee instability under Diagnostic Code 5257, so objective medical evidence cannot be categorically found more probative than lay evidence with respect to this Diagnostic Code. See English v. Wilkie, 30 Vet. App. 347, 352-53 (2018). As the Veteran is in receipt of the highest schedular rating for other impairment of the knee for this period, there is no basis to award a higher evaluation under this Diagnostic Code. The Board has also considered the other Diagnostic Codes pertaining to the knee and leg. Other disability ratings may be assigned only if the symptomatology for a disability is not duplicative or overlapping with the symptomatology of any other disability. See Esteban, 6 Vet. App. at 261-62; Lyles, 29 Vet. App. 107. The December 2017 VA examination shows that the Veteran did not have ankylosis. The examination also shows that while the Veteran had a meniscal condition, he had no current symptoms. Treatment records during this period do not reflect complaints of "locking," pain, and effusion into the joint associated with his meniscal condition or any symptoms associated with removal of semilunar cartilage. As such, separate ratings under Diagnostic Codes 5256, 5258, and 5259 are not warranted. The evidence also does not show that a separate rating for limitation of flexion is warranted. The December 2017 examination shows that the Veteran had flexion to 115 degrees with pain both before and after repetition. He had functional loss due to pain and weakness. The examiner reported that with repeated use over time, the Veteran's functional ability was limited due to pain, fatigue, weakness, lack of endurance and incoordination. With flare-ups, the Veteran's functional ability was limited due to pain and incoordination. The Veteran was unable to quantitate his limitation of motion both with repeated use over time and during flare-ups. A noncompensable rating is warranted for flexion limited to 60 degrees under Diagnostic Code 5260. Since the Veteran's flexion is shown to be to 115 degrees during this period, a separate rating under Diagnostic Code 5260 is not warranted. As discussed above, the Board already assigned a separate 20 percent rating for limitation of extension under Diagnostic Code 5261 effective December 20, 2017. Lastly, the evidence does not reflect impairment of tibia and fibula or genu recurvatum such that separate ratings under Diagnostic Codes 5262 and 5263 are warranted. In conclusion, the Board finds that the preponderance of the evidence is against the Veteran's claim for a rating in excess of 30 percent for left knee osteoarthritis for the period from December 20, 2017, to October 22, 2019. In denying such a rating, the Board finds the benefit of the doubt doctrine is not applicable. 38 U.S.C. § 5107; 38 C.F.R. §§ 4.3, 4.7. 3. Entitlement to a rating in excess of 10 percent for left knee osteoarthritis from October 22, 2019 The Veteran contends that he is entitled to a higher rating because of the severity of his symptomatology. For this period, the Veteran's left knee osteoarthritis is rated under 38 C.F.R. § 4.71a, Diagnostic Code 5260, for limitation of flexion of the leg. The criteria under Diagnostic Code 5260 were discussed above, and will not be repeated. Effective February 7, 2021, VA amended the rating criteria for disabilities of the knee and leg; however, Diagnostic Code 5260 was unchanged. The Veteran's disability also shows symptomatology considered under 38 C.F.R. § 4.71a, Diagnostic Code 5257, for other impairment of the knee. The Board also discussed the criteria under Diagnostic Code 5257 above and will not be repeated. For this period, effective February 7, 2021, VA amended the rating criteria for disabilities of the knee and leg. The amended Diagnostic Code 5257 provides ratings for other impairment of the knee based on recurrent subluxation or instability, and patellar instability. For recurrent subluxation or instability, a 10 percent rating is warranted for sprain, incomplete ligament tear, or complete ligament tear (repaired, unrepaired, or failed repair) causing persistent instability, without a prescription from a medical provider for an assistive device (e.g., cane(s), crutch(es), walker) or bracing for ambulation. A 20 percent rating is warranted for one of the following: (a) Sprain, incomplete ligament tear, or repaired complete ligament tear causing persistent instability, and a medical provider prescribes a brace and/or assistive device (e.g., cane(s), crutch(es), walker) for ambulation; or (b) Unrepaired or failed repair of complete ligament tear causing persistent instability, and a medical provider prescribes either an assistive device (e.g., cane(s), crutch(es), walker) or bracing for ambulation. A maximum 30 percent rating is warranted for unrepaired or failed repair of complete ligament tear causing persistent instability, and a medical provider prescribes both an assistive device (e.g., cane(s), crutch(es), walker) and bracing for ambulation. For patellar instability, a 10 percent rating is warranted for a diagnosed condition involving the patellofemoral complex with recurrent instability (with or without history of surgical repair) that does not require a prescription from a medical provider for a brace, cane, or walker. A 20 percent rating is warranted for a diagnosed condition involving the patellofemoral complex with recurrent instability after surgical repair that requires a prescription by a medical provider for one of the following: A brace, cane, or walker. A maximum 30 percent rating is warranted for a diagnosed condition involving the patellofemoral complex with recurrent instability after surgical repair that requires a prescription by a medical provider for a brace and either a cane or a walker. Note (1) provides that, for patellar instability, the patellofemoral complex consists of the quadriceps tendon, the patella, and the patellar tendon. Note (2) provides that a surgical procedure that does not involve repair of one or more patellofemoral components that contribute to the underlying instability shall not qualify as a surgical repair for patellar instability (including, but not limited to, arthroscopy to remove loose bodies and joint aspiration). After a review of all the evidence of record, and resolving reasonable doubt in favor of the Veteran, the Board finds that, for the period from October 22, 2019, to October 19, 2020, the left knee osteoarthritis disability more nearly approximated severe recurrent subluxation or lateral instability warranting a 30 percent rating under Diagnostic Code 5257. As discussed in the May 2021 JMR, the October 2019 examination is not adequate for rating purposes as the examination report shows that the Veteran had not ever had a meniscal condition, despite evidence to the contrary. The December 2019 rating decision awarding a 30 percent rating from December 20, 2017, to October 22, 2019, also assigned a 10 percent rating from October 22, 2019, based on the results of the examination that same day. In light of the inadequacy of that examination, the Board concludes that the 30 percent rating continued to be warranted as the medical evidence does not show symptomatology contrary to severe recurrent subluxation or lateral instability. However, adequate examinations considering all of the Veteran's symptomatology, including his meniscal conditions, were provided to him on October 19, 2020, and in August 2021. For the period beginning October 19, 2020, the Board concludes that the preponderance of the evidence shows that the left knee osteoarthritis is manifested by moderate recurrent lateral instability warranting a 20 percent rating under the pre-February 7, 2021, Diagnostic Code 5257. The October 2020 VA examination shows that the Veteran had slight recurrent subluxation, but moderate lateral instability. As such, a 20 percent rating is warranted from October 19, 2020, is warranted. However, an even higher rating is not warranted. Under the former Diagnostic Code 5257, the Board finds that the preponderance of the evidence is against a rating in excess of 20 percent. The Board has carefully considered the Veteran's reports about subluxation. English, 30 Vet. App. at 352-53. However, overall, the lay and medical evidence indicates that the subluxation/instability symptoms do not suggest the presence of symptoms more nearly approximating severe recurrent subluxation or lateral instability. As noted above, the October 2020 examination report specifically indicates slight subluxation and moderate instability. There are no treatment records showing severe recurrent subluxation or lateral instability for this time period. Under the amended criteria, the August 2021 examination shows that the Veteran had recurrent subluxation or persistent instability, and an incomplete/partial ligament tear. He did not require a prescription by a medical provider for any ambulatory aids. The Veteran also had not had surgical repair of the knee for patellar instability. Therefore, a rating in excess of 20 percent under the amended Diagnostic Code 5257 is not warranted. The Board has also considered the other Diagnostic Codes pertaining to the knee and leg. Other disability ratings may be assigned only if the symptomatology for a disability is not duplicative or overlapping with the symptomatology of any other disability. See Esteban, 6 Vet. App. at 261-62; Lyles, 29 Vet. App. 107. The October 2020 and August 2021 examinations do not show ankylosis warranting a separate rating under Diagnostic Code 5256. However, the Board concludes that a separate 20 percent under Diagnostic Code 5258 from August 7, 2021, is warranted. The October 2020 examination shows that the Veteran's meniscal conditions included a meniscal tear, but he did not have frequent episodes of joint "locking," joint pain or joint effusion. The Veteran reported daily pain, but effusion was only reported to occur three to four times a year. He also reported that his knees "sometimes" will lock up when first getting out of a chair. The August 7, 2021, examination shows that he had a meniscal tear with frequent episodes of joint "locking," joint pain, and joint effusion. The Veteran reported his knees gave out when he tried to walk, and swelled up in the morning. Consequently, the Board finds that an additional separate 20 percent rating from August 7, 2021, but no earlier, is warranted. Additionally, neither examination reports showed symptomatic removal of semilunar cartilage warranting a separate rating under Diagnostic Code 5259. The October 2020 examination shows flexion to 110 degrees and extension to 5 degrees with functional loss of limitation in walking and standing; needing to use a walker, knee braces, and a cane; the inability to squat and kneel; and needing assistance with certain activities of daily living. There was pain on motion. There was no change in motion following repetition. With repeated use over time and during flare-ups, pain and weakness would limit flexion to 105 degrees and extension to 5 degrees. The Veteran had additional factors contributing to disability of swelling, deformity, instability of station, interference with sitting, and interference with standing. The August 2021 examination shows flexion to 70 degrees, both before and after repetition with no evidence of pain, but with evidence of crepitus. The examiner reported that evidence did not suggest pain, fatigability, weakness, lack of endurance, or functional loss would significantly limit functional ability with repeated use over time or with flare-ups. The Veteran denied flare-ups. Even considering these limitations, the evidence does not support a finding of range of motion more nearly approximating limitation of flexion to 60 degrees warranting a separate rating under Diagnostic Code 5260. As noted above, the Veteran is already in receipt of a separate 20 percent rating for limitation of extension. In conclusion, the Board finds that the preponderance of the evidence supports a 30 percent rating prior to October 19, 2020, and a 20 percent rating thereafter under Diagnostic Code 5257. The preponderance of the evidence also supports a separate 20 percent rating under Diagnostic Code 5258 from August 7, 2021. 4. Entitlement to a rating in excess of 10 percent for right knee osteoarthritis from June 9, 2010, to December 20, 2017 The Veteran contends that he is entitled to a higher rating because of his symptomatology. The Veteran's right knee osteoarthritis is rated under 38 C.F.R. § 4.71a, Diagnostic Code 5260, for limitation of flexion of the leg. The criteria for Diagnostic Code 5260, are discussed above and will not be repeated. After a review of all the evidence of record, and resolving reasonable doubt in favor of the Veteran, the Board finds that, for the period from June 9, 2010, to December 20, 2017, the right knee osteoarthritis disability has more nearly approximated dislocated semilunar cartilage with frequent episodes of "locking," pain, and effusion warranting a 20 percent rating under Diagnostic Code 5258. A September 2010 VA examination shows that the Veteran reported knee stiffness, swelling with walking, locking, popping, and his knee giving out. A January 2015 VA examination reveals that the Veteran had a meniscal tear with frequent episodes of joint "locking," joint pain and joint effusion. The only rating available under Diagnostic Code 5258 is 20 percent. 38 C.F.R. § 4.71a, Diagnostic Code 5258. Since the Board is granting a 20 percent rating under Diagnostic Code 5258, the 10 percent rating under Diagnostic Code 5260 will be discontinued because assigning separate ratings under both Diagnostic Codes 5260 and 5258 would constitute pyramiding. The Diagnostic Codes overlap in symptoms, or findings of pain and locking as forms of limitation of motion, such that assigning separate ratings under both codes would violate the prohibition against pyramiding because it would compensate the Veteran twice for the same symptomatology. In finding that a 20 percent rating is warranted under Diagnostic Code 5258, the Board has also considered whether the criteria for a 30 percent rating instead under Diagnostic Code 5260 were met. The symptoms and ranges of motion for the left knee in the September 2010 and January 2015 VA examinations discussed above also apply to the right knee. Consequently, as the objective medical evidence of record does not show limitation of flexion approximating flexion limited to 15 degrees, the Board is unable to conclude that a rating in excess of 20 percent under Diagnostic Code 5260 is warranted for the period from June 9, 2010, to December 20, 2017. With regards to other diagnostic codes used to rate the knee, again, the findings of the September 2010 and January 2015 examination are the same for the right knee as for the left. Therefore, separate ratings under Diagnostic Codes 5256, 5257, 5259, 5262, and 5263 are not warranted. Further, as the same with the left knee, in August 2020, the Board assigned an earlier effective date of December 20, 2017. The Veteran did not appeal that part of the Board's decision assigning an effective date of December 20, 2017, and no earlier. In conclusion, the Board finds that the preponderance of the evidence supports a 20 percent rating under Diagnostic Code 5258 for this period. To this extent, the Veteran's appeal for a rating in excess of 10 percent for right knee osteoarthritis for the period from June 9, 2010, to December 20, 2017, is granted. 5. Entitlement to a rating in excess of 20 percent for right knee osteoarthritis from December 20, 2017, to October 22, 2019 The Veteran contends that he is entitled to a higher rating because of the severity of his symptomatology. The Veteran's right knee osteoarthritis is rated under 38 C.F.R. § 4.71a, Diagnostic Code 5257, which evaluates other impairment of the knee, for this period. See December 2019 rating codesheet. The criteria under Diagnostic Code 5257 are discussed above and will not be repeated. The Board finds that the preponderance of the evidence is against a rating in excess of 20 percent for right knee osteoarthritis for this period. The Board has carefully considered the Veteran's reports about subluxation and instability. English, 30 Vet. App. 347, 352-53. However, overall, the lay and medical evidence indicates that the subluxation symptoms do not more nearly approximate severe recurrent subluxation or lateral instability. The December 2017 VA examination shows that the Veteran had moderate recurrent subluxation, and no lateral instability. He reported that his knee popped and caught, and felt weak. Instability testing was all normal, expect for 1+ (0-5 millimeters) for medial instability. The most severe instability in testing is 3+ (10-15 millimeters). The examination findings do not suggest that the Veteran experienced severe recurrent subluxation or lateral instability for this time period. The Board has also considered the other Diagnostic Codes pertaining to the knee and leg. Other disability ratings may be assigned only if the symptomatology for a disability is not duplicative or overlapping with the symptomatology of any other disability. See Esteban, 6 Vet. App. at 261-62; Lyles, 29 Vet. App. 107. The December 2017 VA examination findings for the left knee are discussed above as they relate to ankylosis and his meniscal condition are the same for the right knee and will not be discussed again. With no ankylosis and no symptoms related to the meniscal condition, separate ratings under Diagnostic Codes 5256, 5258, and 5259 are not warranted. The evidence also does not show that a separate rating for limitation of flexion is warranted. The December 2017 examination shows that the Veteran had flexion to 125 degrees with pain. Following repetition, he had flexion to 110 degrees with pain. He had functional loss due to pain and weakness. The examiner reported that with repeated use over time, the Veteran's functional ability was limited due to pain, fatigue, weakness, lack of endurance and incoordination. With flare-ups, the Veteran's functional ability was limited due to pain and incoordination. The Veteran was unable to quantitate his limitation of motion both with repeated use over time and during flare-ups. A noncompensable rating is warranted for flexion limited to 60 degrees under Diagnostic Code 5260. Therefore, a separate rating under Diagnostic Code 5260 is not warranted. The Board already assigned a separate 20 percent rating for limitation of extension under Diagnostic Code 5261 effective December 20, 2017, in August 2020. The Veteran did not appeal that part of the Board's decision. Lastly, the evidence does not reflect impairment of tibia and fibula or genu recurvatum such that ratings under Diagnostic Codes 5262 and 5263 are warranted. In conclusion, the Board finds that the preponderance of the evidence is against the Veteran's claim for a rating in excess of 20 percent for right knee osteoarthritis for the period from December 20, 2017 to October 22, 2019. In denying such a rating, the Board finds the benefit of the doubt doctrine is not applicable. 38 U.S.C. § 5107; 38 C.F.R. §§ 4.3, 4.7. 6. Entitlement to a rating in excess of 10 percent for right knee osteoarthritis from October 22, 2019 The Veteran contends that he is entitled to a higher rating because of the severity of his symptomatology. The Veteran's right knee osteoarthritis for this period is rated under 38 C.F.R. § 4.71a, Diagnostic Code 5260, for limitation of flexion of the leg. The criteria for Diagnostic Code 5260, are addressed above. Effective February 7, 2021, VA amended the rating criteria for disabilities of the knee and leg; however, Diagnostic Code 5260 was unchanged. The Veteran's disability also shows symptomatology considered under 38 C.F.R. § 4.71a, Diagnostic Code 5257, for other impairment of the knee; the criteria for this code both before and after February 7, 2021, are also discussed above. After a review of all the evidence of record, and resolving reasonable doubt in favor of the Veteran, the Board finds that, for the period from October 22, 2019, to October 19, 2020, the right knee osteoarthritis disability more nearly approximated moderate recurrent subluxation or lateral instability warranting a 20 percent rating under Diagnostic Code 5257. As discussed in the May 2021 JMR, the October 2019 examination is not adequate for rating purposes as the examination report shows that the Veteran had not ever had a meniscal condition, despite evidence to the contrary. The December 2019 rating decision awarding a 20 percent rating from December 20, 2017, to October 22, 2019, also assigned a 10 percent rating from October 22, 2019, based on the results of the examination that same day. In light of the inadequacy of that examination, the Board concludes that the 20 percent rating continued to be warranted as the medical evidence does not show symptomatology contrary to moderate recurrent subluxation or lateral instability. However, adequate examinations considering all of the Veteran's symptomatology, including his meniscal conditions, were provided to him on October 19, 2020, and in August 2021. For the period beginning October 19, 2020, the Board concludes that the preponderance of the evidence shows that the right knee osteoarthritis is manifest by slight recurrent lateral instability warranting a 10 percent rating under the pre-February 7, 2021, Diagnostic Code 5257. The October 2020 VA examination shows that the Veteran had slight recurrent subluxation, and slight lateral instability. As such, a 10 percent rating is warranted. An even higher rating from October 19, 2020, is not warranted. Under Diagnostic Code 5257, the Board finds that the preponderance of the evidence is against a rating in excess of 10 percent. The Board has carefully considered the Veteran's reports about subluxation. English, 30 Vet. App. at 352-53. However, overall, the lay and medical evidence indicates that the subluxation/instability symptoms do not suggest the presence of symptoms more nearly approximating moderate recurrent subluxation or lateral instability. As noted above, the October 2020 examination report specifically indicates slight subluxation and slight instability. There are no treatment records showing moderate recurrent subluxation or lateral instability for this time period. Under the amended criteria, the August 2021 examination shows that the Veteran had recurrent subluxation or persistent instability, and an incomplete/partial ligament tear. He did not require a prescription by a medical provider for any ambulatory aids. The Veteran also had not had surgical repair of the knee for patellar instability. Therefore, a rating in excess of 10 percent under the amended Diagnostic Code 5257 is not warranted. The Board has also considered the other Diagnostic Codes pertaining to the knee and leg. Other disability ratings may be assigned only if the symptomatology for a disability is not duplicative or overlapping with the symptomatology of any other disability. See Esteban, 6 Vet. App. at 261-62; Lyles, 29 Vet. App. 107. The October 2020 and August 2021 examinations do not show ankylosis warranting a separate rating under Diagnostic Code 5256. However, the Board concludes that a separate 20 percent under Diagnostic Code 5258 from August 7, 2021, is warranted. The October 2020 and August 7, 2021, VA examination findings for the right knee are the same as for the left knee discussed above. Consequently, the Board finds that an additional separate 20 percent rating from August 7, 2021, but no earlier, is warranted. Additionally, neither examination reports showed symptomatic removal of semilunar cartilage warranting a separate rating under Diagnostic Code 5259. The October 2020 examination shows flexion to 120 degrees and extension to 5 degrees with functional loss of limitation in walking and standing; needing to use a walker, knee braces, and a cane; the inability to squat and kneel; and needing assistance with certain activities of daily living. There was pain on motion. There was no change in motion following repetition. With repeated use over time, pain and weakness would limit flexion to 115 degrees and extension to 5 degrees. During flare-ups, flexion would be limited to 110 degrees and extension to 5 degrees due to pain and weakness. The Veteran had additional factors contributing to disability of swelling, instability of station, disturbance of locomotion, and interference with standing. The August 2021 examination shows flexion to 70 degrees, both before and after repetition with no evidence of pain, but with evidence of crepitus. The examiner reported that evidence did not suggest pain, fatigability, weakness, lack of endurance, or functional loss would significantly limit functional ability with repeated use over time or with flare-ups. The Veteran denied flare-ups. Even considering these limitations, the evidence does not support a finding of range of motion more nearly approximating limitation of flexion to 60 degrees warranting a separate rating under Diagnostic Code 5260. As noted above, the Veteran is already in receipt of a separate 20 percent rating for limitation of extension. In conclusion, the Board finds that the preponderance of the evidence supports a 20 percent rating prior to October 19, 2020, and a 10 percent rating thereafter under Diagnostic Code 5257. The preponderance of the evidence also supports a separate 20 percent rating under Diagnostic Code 5258 from August 7, 2021. As a final note, the related claim for a total disability rating based upon individual unemployability is being developed on remand at the RO and will be addressed in a separate and forthcoming decision. 7. Entitlement to SMP based on the need for aid and attendance prior to September 10, 2019 SMP at the aid and attendance rate is payable when a veteran is helpless or so nearly helpless that he or she requires the regular aid and attendance of another person. 38 U.S.C. §§ 1502, 1521. To establish a need for regular aid and attendance, a veteran must (1) be blind or so nearly blind as to have corrected visual acuity of 5/200 or less, in both eyes, or concentric contraction of the visual field to 5 degrees or less; (2) be a patient in a nursing home because of mental or physical incapacity; or (3) show a factual need for aid and attendance. 38 U.S.C. § 1502(b); 38 C.F.R. § 3.351. The following will be accorded consideration in determining the need for regular aid and attendance: inability of a claimant to dress or undress himself, or to keep himself ordinarily clean and presentable; frequent need of adjustment of any special prosthetic or orthopedic appliances which by reason of the particular disability cannot be done without aid; inability to feed himself through the loss of coordination of upper extremities or through extreme weakness; inability to attend to the wants of nature; or incapacity, physical or mental, which requires care or assistance on a regular basis to protect him from hazards or dangers incident to his daily environment. It is not required that all of the above disabling conditions be found to exist before a favorable rating may be made. The particular personal functions that a veteran is unable to perform should be considered in connection with his condition as a whole. It is only necessary that the evidence establish that a veteran is so helpless as to need regular aid and attendance, not that there is a constant need. Determinations that a veteran is so helpless as to be in need of regular aid and attendance will not be based solely upon an opinion that his condition is such as would require him to be in bed. They must be based on the actual requirement of personal assistance from others. See 38 C.F.R. § 3.352(a). The Veteran claims that he is entitled to SMP based on the need for the aid and attendance of another person prior to September 10, 2019. The Board agrees and finds that the preponderance of the evidence shows that he required assistance in accomplishing the activities of daily living. As discussed in the May 2021 JMPR, evidence prior to September 10, 2019, shows that the Veteran had a need for aid and attendance. A July 2010 VA examination reveals that the Veteran needed assistance in bathing and tending to other hygiene needs. He also did not have the ability to manage his own financial affairs. He was unable to walk long distances or perform heavy lifting. A February 2011 VA examination again shows that he needed assistance in bathing and other hygiene needs, and was limited in walking and lifting. With respect to his ability to manage his financial affairs, it was noted that the Veteran reported periodic episodes of confusion/disorientation related to his mood disorder and paranoia. An April 2011 VA treatment record shows that the Veteran did have the capacity for making financial decisions. A December 2015 VA examination reveals that the Veteran could not prepare his own meals, needed assistance in bathing and tending to other hygiene needs, and required medication management. He was unable to tolerate prolonged standing, and had decreased range of motion of the spine. An August 2016 VA examination again show that the Veteran could not prepare his own meals, needed assistance in bathing and tending to other hygiene needs, and required medication management. He had had a spinal fusion, with difficulty moving his back and increased pain. Another August 2016 VA examination reveals that the Veteran also needed nursing home care for activities of daily living and personal functioning. In this case, the 2010, 2011, 2015, and 2016 VA examinations reflect that the Veteran needed regular aid and attendance. As noted above, in order for aid and attendance to be warranted, the evidence must show that it is regularly needed, not constantly needed. Further, not every disabling condition listed above needs be found in order for aid and attendance to be granted. Considering the Veteran's need for assistance in bathing and tending to hygiene needs, his limited ability to walk and lift, his need for medication management, and the fact that he cannot prepare his own meals since 2015, the Board concludes that SMP based on the need for aid and attendance prior to September 10, 2019, is warranted. REASONS FOR REMAND 1. Entitlement to service connection for an acquired psychiatric disorder is remanded. The Board cannot make a fully-informed decision on the issue of service connection for an acquired psychiatric disorder because no adequate examination has been provided to the Veteran. The Veteran was afforded a VA posttraumatic stress disorder (PTSD) examination in December 2017, and was not diagnosed with any disorder. However, VA treatment records during this appeal show diagnoses of depression, not otherwise specified (NOS) and a mood disorder. See September 2011 and January 2017 records. A new examination should be provided to the Veteran, with a medical opinion regarding the etiology of the psychiatric diagnoses shown during this appeal. 2. Entitlement to SMC and SMP at the household rate are remanded. The issue of service connection for an acquired psychiatric disorder could have an impact on the issues of entitlement to SMC and SMP at the housebound rate, both raised by the record per the noted JMR. Therefore, they must also be remanded. The matters are REMANDED for the following action: Schedule the Veteran for a VA examination by an appropriate clinician to determine the etiology of any diagnosed acquired psychiatric disorder. The most up-to-date Disability Benefits Questionnaire should be utilized. For any acquired psychiatric disorder diagnosed, the examiner is requested to review the record and offer an opinion as to whether it is at least as likely as not (at least an approximate balance of positive and negative evidence) that any diagnoses are related to the Veteran's active service. If no psychiatric disorder is diagnosed, the examiner should opine as to whether it is at least as likely as not that the diagnoses of depression, NOS and a mood disorder during this appeal are related to the Veteran's active service. A complete rationale should be given for all opinions and conclusions expressed. A. C. MACKENZIE Veterans Law Judge Board of Veterans' Appeals Attorney for the Board L. Barstow, 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.