Citation Nr: 21005724 Decision Date: 02/02/21 Archive Date: 02/02/21 DOCKET NO. 12-35 336 DATE: February 2, 2021 ORDER Entitlement to service connection for obstructive sleep apnea (OSA) is denied. Entitlement to an initial disability rating in excess of 20 percent for cervical disc degeneration is denied. Entitlement to a disability rating in excess of 10 percent for right carpal tunnel syndrome is denied. FINDINGS OF FACT 1. The Veteran’s sleep apnea was not manifest in his first or second periods of service and has not otherwise been shown to be related to those periods of service. Clear and unmistakable evidence demonstrates that sleep apnea preexisted his third period of active duty service and clear and unmistakable evidence demonstrates that disability was not aggravated beyond its natural progression by service. 2. The Veteran’s cervical spine disability is not shown to have been manifested by limitation of cervical spine forward flexion to 15 degrees or less, or favorable ankylosis of the entire cervical spine; additional separately ratable neurological symptoms are not shown, in addition to those the Veteran is already service-connected for; incapacitating episodes of cervical disc disease having a duration of at least 4 weeks but less than 6 weeks in a 12 month period are not shown or alleged. 3. The Veteran’s right carpal tunnel syndrome has been manifested by symptomatology more nearly approximating mild incomplete paralysis of the median nerve, but is not shown to have been manifested by symptomatology more nearly approximating moderate, or greater, incomplete paralysis or complete paralysis. CONCLUSIONS OF LAW 1. The Veteran’s sleep apnea was not incurred in or aggravated by his first or second periods of service. 38 U.S.C. §§ 1110, 1131, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304 (2019). 2. The Veteran’s sleep apnea clearly and unmistakably preexisted the third period of service and clearly and unmistakably was not aggravated therein. The presumption of soundness at entry is rebutted. 38 U.S.C. §§ 1110, 1111, 1131 (2012); 38 C.F.R. §§ 3.303, 3.304, 3.306 (2019). 3. The criteria for an initial disability rating in excess of 20 percent for cervical disc degeneration have not been met. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.1, 4.7, 4.21, 4.40, 4.45, 4.71a, Code 5243. 4. The criteria for a disability rating in excess of 10 percent for right carpal tunnel syndrome have not been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1-4.7, 4.124a, Diagnostic Code 8599-8515 (2019). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the United States Marine Corps from February 1972 to January 1976 and in the United States Army from May 2004 to September 2005 and from April 2008 to June 2009. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from July and December 2011 rating decisions issued by the Department of Veterans Affairs (VA) Regional Office (RO). These matters were previously before the Board in May 2018, when they were remanded for addendum VA examinations. In compliance with the remand directives, VA examinations and VA treatment records were associated with the claims file. The directives have been substantially complied with, and the matter again is before the Board. D’Aries v. Peake, 22 Vet. App. 97, 105 (2008); Stegall v. West, 11 Vet. App. 268, 271 (1998). In addition to the issues currently on appeal, the Veteran had also perfected an appeal for service connection for coronary heart disease. See December 2012 VA Form 9; see also May 2018 Board Remand. In a May 2020 rating decision, the Regional Office (RO) granted service connection for coronary heart disease, stable angina. Because there is no remaining case of controversy pertaining to this claim, it will not be addressed further. 38 U.S.C. § 7105; 38 C.F.R. § 20.202. 1. Entitlement to service connection for sleep apnea The Veteran asserts entitlement to service connection for sleep apnea. Specifically, the Veteran argues that he is entitled based on his diagnosis of sleep apnea within a year of his Gulf War service. See March 2018 Informal Hearing Presentation. Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. § 3.303. The three-element test for service connection requires evidence of: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the current disability and the in-service disease or injury. Shedden v. Principi, 381 F.3d 1163, 1166 -67 (Fed. Cir. 2004). “Active military, naval, or air service” includes active duty and any period of ACDUTRA during which the individual concerned was disabled or died from a disease or injury incurred or aggravated in the line of duty; or any period of inactive duty training (INACDUTRA) in which the individual concerned was disabled or died from an injury, though not also disease, incurred or aggravated in the line of duty or from an acute myocardial infarction, a cardiac arrest, or a cerebrovascular accident occurring during such training. 38 U.S.C. § 101 (24); 38 C.F.R. § 3.6 (a). Service connection may be granted for claims related to service during the Persian Gulf War may if there is (1) an undiagnosed illness, and (2) evidence of a chronic disability. Gutierrez v. Principi, 19 Vet. App. 1 (2004). The chronic disability must not be attributed to any known clinical diagnosis and must result from an illness or combination of illnesses manifested by one or more signs and symptoms that (1) became manifest during active service in the Southwest Asia theater of operations during the Persian Gulf War, or (2) manifested to a degree of 10 percent or more not later than December 31, 2021. 38 U.S.C. § 1117; 38 C.F.R. § 3.317 (a)(1)(i)-(ii). Disabilities that have existed for 6 months or more and disabilities that exhibit intermittent episodes of improvement and worsening over a 6-month period will be considered chronic. The 6-month period of chronicity will be measured from the earliest date on which the pertinent evidence establishes that the signs or symptoms of the disability first became manifest. 38 C.F.R. § 3.317 (a)(3). Qualifying chronic disabilities include medically unexplained chronic multi-symptom illnesses-such as chronic fatigue syndrome, fibromyalgia, and irritable bowel syndrome-that are defined by a cluster of signs or symptoms. 38 U.S.C. § 1117 (a). Signs and symptoms include: (1) fatigue; (2) unexplained rashes or other dermatological signs or symptoms; (3) headache; (4) muscle pain; (5) joint pain; (6) neurological signs or symptoms; (7) neuropsychological signs or symptoms; (8) upper or lower respiratory system signs or symptoms; (9) sleep disturbances; (10) gastrointestinal signs or symptoms; (11) cardiovascular signs or symptoms; (12) abnormal weight loss; and (13) menstrual disorders. 38 U.S.C. § 1117 (g). Manifestations of undiagnosed illness may be presumptively service connected unless there is affirmative evidence that an undiagnosed illness (1) was not incurred in service or (2) was caused by a supervening condition. 38 C.F.R. § 3.317 (a)(7). In addition, service connection may be granted for any disease that is initially diagnosed after service when all of the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303. By way of history, the Veteran was denied entitlement to service connection for sleep apnea in an August 2007 rating decision. The Veteran was notified of the decision and his appellate rights in August 2007. The Veteran submitted a notice of disagreement in September 2007 and a January 2008 statement of the case (SOC) denied the Veteran’s claim. In a March 2008 statement, the Veteran requested that the claims process be stopped until he returned from mobilization. Therefore, the August 2007 decision became final. 38 U.S.C. §§ 7104, 7105; 38 C.F.R. §§ 20.302, 20.1103 (2019). The Veteran requested to reopen his claim of entitlement to service connection for sleep apnea in July 2010. A July 2011 rating decision reopened the Veteran’s claim of entitlement to service connection for sleep apnea but denied entitlement on the merits. Because VA subsequently received official relevant service department records that were not associated with the claims file at the time of the final decision, the May 2018 Board decision reconsidered the Veteran’s claim of entitlement to service connection for sleep apnea. 38 C.F.R. § 3.156(c). The Board remanded the Veteran’s claim to obtain an adequate VA medical opinion, assessing whether or not the Veteran’s sleep apnea had its onset during his first or second periods of service or was aggravated during the Veteran’s third period of service. Following a VA examination in October 2019, a May 2020 supplemental statement of the case (SSOC) denied entitlement to service connection for sleep apnea. The Veteran appealed this decision to the Board. A review of the Veteran’s service treatment records (STRs) shows no symptoms nor diagnosis of sleep apnea for his first or second periods of service, from February 1972 to January 1976 and from May 2004 to September 2005. A March 1996 STR from the Veteran’s service in the United States Army Reserve shows a denial of frequent trouble sleeping. In a January 2001 Health Risk Appraisal, the Veteran reported sleeping six to eight hours a night. A January 2001 Report of Medical History shows the Veteran’s denial of frequent trouble sleeping. A July 2005 Post Deployment Health Assessment shows the Veteran denied still feeling tired after sleeping. A December 2006 VA treatment record shows possible sleep apnea. The physician noted a plan to consult with pneumology to rule out sleep apnea. The Board notes that this record is more than one year after the Veteran’s separation from his second period of service. A March 2007 VA treatment record shows a diagnosis of sleep apnea following a polysomnography. The Veteran reported loud snoring with choking episodes at night as well as daytime sleepiness and poor performance at work. Following the sleep study, the physician diagnosed the Veteran with severe obstructive sleep apnea. The physician recommended use of a CPAP machine with a pressure of 14 cm H2O. A March 2009 STR shows the Veteran received counseling on the need for weight loss. The physician noted that weight loss would improve the Veteran’s sleep apnea. A September 2011 VA treatment record shows the Veteran’s CPAP setting at 14 cm H2O while sleeping. The Veteran was afforded a VA examination in September 2011. The VA examiner confirmed a diagnosis of sleep apnea. The Veteran reported severe snoring and choking while sleeping since 2004, worsening until 2007 when he was diagnosed with sleep apnea. The VA examiner opined that the Veteran’s sleep apnea is less likely than not incurred in or experienced by the Veteran during his service in Southwest Asia. In support of this opinion, the VA examiner reasoned that sleep apnea has a clear and specific etiology and diagnosis and the Veteran was diagnosed in 2007, prior to his Gulf War active duty. A September 2012 VA treatment record shows that the Veteran reported using his CPAP machine with good compliance and clinical response. The physician reported that the Veteran is to receive CPAP at 14 cm H20. In accordance with the May 2018 Board remand, the Veteran was afforded a VA examination in November 2019. The VA examiner noted a diagnosis of obstructive sleep apnea in 2007. The Veteran reported first noticing sleep problems on deployment in Afghanistan in 2004 or 2005, described as difficulty sleeping, attributed to long hours of work and very little time for sleep. He further reported taking his CPAP machine with him on deployment to Iraq in 2011. The Veteran endorsed persistent daytime hypersomnolence. The VA examiner reported a positive sleep study in March 2007, showing severe obstructive sleep apnea. For the Veteran’s first and second periods of service, the VA examiner opined that the Veteran’s sleep apnea appears less likely than not incurred in or caused by the sleep apnea syndromes during service. The VA examiner noted there is no evidence of sleep apnea in the Veteran’s service treatment records (STRs) nor in the year immediately following separation. The VA examiner reasoned that the Veteran’s obesity, unrelated to service, is the most probable cause of the Veteran’s current obstructive sleep apnea. Regarding the Veteran’s second period of service, the VA examiner opined that it is less likely than not that the Veteran’s pre-existing sleep apnea underwent an increase in severity during his third period of service. The VA examiner noted the Veteran’s diagnosis of sleep apnea in 2007 as his established baseline and stated the Veteran’s condition did not increase in severity during or because of his third period of service. The VA examiner reasoned that the Veteran’s CPAP device was initiated at 14cm H20 in May 2007 and was set at the same level in September 2012, more than three years after separation. Regarding the Veteran’s tobacco use during service, the VA examiner reported that tobacco use played no part in the Veteran’s development of sleep apnea. The VA examiner noted that there was no evidence of a 30-year smoking history, based on the Veteran’s report that he stopped smoking in multiple medical records. Thus, a causal relationship between the Veteran’s remote history of cigarette smoking and diagnosis of sleep apnea in 2007 is not found. Having reviewed the record, the Board concludes that entitlement to service connection for sleep apnea is not warranted. As to the Veteran’s first and second periods of active service, there is no lay or medical evidence to suggest that sleep apnea was incurred in or is otherwise related to that period of service. There is no evidence of sleep apnea symptoms or diagnosis in the Veteran’s STRs. Furthermore, the September 2011 and November 2019 VA examiners opined that the Veteran’s sleep apnea is less likely than not incurred in or caused by service. The Board notes that the Veteran has argued that he is entitled to presumptive service connection for his sleep apnea based on his Gulf War service. See March 2018 Informal Hearing Presentation. However, sleep apnea is a known clinical diagnosis and does not qualify an undiagnosed illness which may be presumed to be the result of the Veteran’s position in the Persian Gulf War. Furthermore, the first mention of sleep apnea was in December 2006, more than a year after separation from the Veteran’s second period of service. See December 2006 VA Treatment Record. As such, service connection for sleep apnea cannot be established on a presumptive basis. While the Veteran may sincerely believe that his sleep apnea is due to an undiagnosed illness or in-service exposures during the Persian Gulf War, he is not competent to provide such a diagnosis. The issue is medically complex and requires specialized knowledge and experience with several areas of medical expertise, including somnology and interpretation of scientific tests and studies. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). There is no evidence that the Veteran has the necessary training and experience in those areas; and therefore, the Board finds that the medical evidence has greater probative value. Since there is no evidence that the Veteran’s sleep apnea was incurred in service or manifest to a compensable degree due to his Gulf War service in Southwest Asia, service connection for sleep apnea is not warranted for the Veteran’s first and second periods of service. As to the Veteran’s third period of service, every Veteran shall be taken to have been in sound condition when examined, accepted, and enrolled for service, except as to defects, infirmities, or disorders noted at the time of the examination, acceptance, and enrollment, or where clear and unmistakable evidence demonstrates that the injury or disease existed before acceptance and enrollment and was not aggravated by such service. 38 U.S.C. § 1111 (2012). In order to rebut the presumption of soundness at service entry, there must be clear and unmistakable evidence showing that the disorder preexisted service and there must be clear and unmistakable evidence that the disorder was not aggravated by service. The Veteran is not required to show that the disease or injury increased in severity during service before VA’s duty under the second prong of this rebuttal standard attaches. VAOPGPREC 3-2003 (July 16, 2003); Jordan v. Principi, 17 Vet. App. 261 (2003); Wagner v. Principi, 370 F.3d 1089 (Fed. Cir. 2004). However, where a preexisting disease or injury is noted on the entrance examination, section 1153 of the statute provides that “[a] preexisting injury or disease will be considered to have been aggravated by active military, naval, or air service, where there is an increase in disability during such service, unless there is a specific finding that the increase in disability is due to the natural progress of the disease.” 38 U.S.C. § 1153 (West 2014); 38 C.F.R. § 3.306 (a) (2016). For Veterans who served during a period of war or after December 31, 1946, clear and unmistakable evidence is required to rebut the presumption of aggravation where the pre-service disability underwent an increase in severity during service, and clear and unmistakable evidence includes medical facts and principles which may be considered to determine whether the increase is due to the natural progress of the condition. 38 C.F.R. § 3.306 (b). Temporary or intermittent flare-ups of a preexisting injury or disease are not sufficient to be considered “aggravation in service” unless the underlying condition itself, as contrasted with mere symptoms, has worsened. See Jensen v. Brown, 4 Vet. App. 304, 306-07 (1993); Green v. Derwinski, 1 Vet. App. 320, 323 (1991); Hunt v. Derwinski, 1 Vet. App. 292, 297 (1991). After a review of all of the evidence, the Board finds that sleep apnea existed prior to the Veteran’s third period of service and was not aggravated by service. Here, the evidence of record clearly and unmistakably shows that sleep apnea preexisted the Veteran’s third period of service. The Veteran’s March 2007 VA treatment record shows a diagnosis of sleep apnea, confirmed by a polysomnography, and the Veteran’s STRs show a history of sleep apnea since 2007. As such, the presumption of soundness does not attach with respect to the Veteran’s sleep apnea. Therefore, under the analytical framework set forth in Wagner, the burden is on the VA to demonstrate by clear and unmistakable evidence that the Veteran’s preexisting sleep apnea was not aggravated by service. In this regard, the most credible in-service and post-service medical evidence of record clearly and unmistakably supports the conclusion that the Veteran’s preexisting sleep apnea was not permanently aggravated by his third period of service. Significantly, the Veteran’s CPAP setting was consistently reported as 14 cm H20 before and after service. See March 2007, September 2011, and September 2012 VA Treatment Records. Furthermore, the November 2019 VA examiner opined that the Veteran’s pre-existing sleep apnea was not aggravated by his third period of service. Because the presumption of soundness does not attach, there must be evidence demonstrating a chronic worsening of the condition during service for there to be a presumption of aggravation. There is no medical opinion that purports to establish a permanent worsening of the Veteran’s sleep apnea. The only evidence in favor of the necessary service connection elements comes from the Veteran’s lay statements. Generally, lay evidence is competent with regard to identification of a disease with unique and readily identifiable features which are capable of lay observation. See Barr v. Nicholson, 21 Vet. App. 303, 308-09 (2007). A lay person may speak to etiology in some limited circumstances in which nexus is obvious merely through observation, such as sustaining a fall leading to a broken leg. See Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009); Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). Lay persons may also provide competent evidence regarding a contemporaneous medical diagnosis or a description of symptoms in service which supports a later diagnosis by a medical professional. However, a lay person is not competent to provide evidence as to more complex medical questions, i.e., those which are not capable of lay observation. Lay statements are not competent evidence regarding diagnosis or etiology in such cases. See Woehlaert v. Nicholson, 21 Vet. App. 456, 462 (2007) (concerning rheumatic fever); Jandreau, at 1377, n. 4 (‘sometimes the layperson will be competent to identify the condition where the condition is simple, for example a broken leg, and sometimes not, for example, a form of cancer’); 38 C.F.R. § 3.159 (a)(2). The Board finds that establishing the natural progress of the Veteran’s sleep apnea, and relating post-service sleep apnea symptomatology to remote events of service is not the equivalent of relating a broken bone to a concurrent injury to the same body part (Jandreau, at 1377). Such an opinion requires specialized medical knowledge, and is not capable of lay observation. Accordingly, the Veteran’s lay statements are not competent evidence of an etiologic relationship between incurrence or aggravation of his sleep apnea and service. In sum, the Board finds that sleep apnea predated the Veteran’s third period of service and was not aggravated by service. In light of these findings, the Board concludes that service connection for sleep apnea is not warranted. In reaching this conclusion, the Board has considered the applicability of the benefit-of-the-doubt doctrine. However, as the preponderance of the evidence is against the claim, that doctrine is not applicable. See 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102; Gilbert, 1 Vet. App. at 53-56. Increased Rating Disability ratings are determined by applying the criteria set forth in VA’s Schedule for Rating Disabilities, which is based on the average impairment of earning capacity. Individual disabilities are assigned separate diagnostic codes. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. Where there is a question as to which of two evaluations shall be applied, the higher 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. 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 importance. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). However, separate ratings may be assigned for separate periods of time based on the facts found. This practice is known as “staged” ratings.” Hart v. Mansfield, 21 Vet. App. 505 (2007). The relevant temporal focus for adjudicating an increased rating claim is on the evidence concerning the state of the disability for the time period beginning one year before the claim was filed until VA makes a final decision on the claim. Id. When evaluating a service-connected disability based on limitation of motion, the Board must take into consideration functional loss due to pain under 38 C.F.R. § 4.40 and functional loss due to weakness, fatigability, incoordination or pain on movement of a joint under 38 C.F.R. § 4.45. See DeLuca v. Brown, 8 Vet. App. 202 (1995); see Johnson v. Brown, 9 Vet. App. 7 (1996). A finding of functional loss due to pain must be supported by adequate pathology and evidenced by the visible behavior of the Veteran. 38 C.F.R. § 4.40; Johnston v. Brown, 10 Vet. App. 80, 85 (1997). Nonetheless, a rating higher than the minimum compensable rating is not assignable under any diagnostic code relating to range of motion where pain does not cause a compensable functional loss. Rather, the “pain must affect some aspect of ‘the normal working movements of the body’ such as ‘excursion, strength, speed, coordination, and endurance,’” as defined in 38 C.F.R. § 4.40, before a higher rating may be assigned. See Mitchell v. Shinseki, 25 Vet. App. 32, 37 (2011). 2. Entitlement to an initial disability rating in excess of 20 percent for cervical disc degeneration The Veteran was granted entitlement to service connection for cervical disc degeneration at C5-C6 level in a July 2011 rating decision, rated as 20 percent disabling effective July 2010. The Veteran contends that he is entitled to a disability rating in excess of 20 percent. The Veteran’s spine disability is rated under Code 5243 and the General Rating Formula for Diseases and Injuries of the Spine (General Formula). Under the General Formula, a 20 percent rating is warranted when forward flexion of the thoracolumbar spine is greater than 30 degrees but not greater than 60 degrees; or, with combined range of motion of the thoracolumbar spine not greater than 120 degrees; or, with muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. A 40 percent rating is warranted when forward flexion of the thoracolumbar spine is limited to 30 degrees or less; or with favorable ankylosis of the entire thoracolumbar spine. A 50 percent rating is warranted for unfavorable ankylosis of the entire thoracolumbar spine. A 100 percent rating is warranted for unfavorable ankylosis of the entire spine. Note (1) to the General Formula specifies that any associated objective neurologic abnormalities, including, but not limited to, bowel or bladder impairment, should be separately evaluated under an appropriate diagnostic code. 38 C.F.R. § 4.71a. If the service-connected spine disability includes intervertebral disc syndrome (IVDS) it may alternatively be rated under the Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes. A 20 percent rating is warranted with incapacitating episodes having a total duration of at least 2 weeks but less than 4 weeks during a 12-month period. A 40 percent rating is warranted with incapacitating episodes having a total duration of at least 4 weeks but less than 6 weeks during a 12-month period. A 60 percent rating is warranted with incapacitating episodes having a total duration of at least 6 weeks during a 12-month period. A December 2010 VA treatment record shows the Veteran’s report of cervical pain and morning stiffness. The Veteran’s gait was normal with no antalgic or limp. Range of motion was reported as limited bilaterally. A February 2011 VA treatment record shows the Veteran’s report of cervical neck pain, rated as an eight out of ten. Range of motion was decreased bilaterally upon active movement and full in all planes upon passive movement. Muscle spasms were noted at thoracolumbar paraspinals. A March 2011 VA treatment record shows the Veteran’s report of cervical neck pain that interferes with sleep and general activity level. Range of motion was noted as decreased bilaterally on active movement and full on passive movement. Upon evaluation there were no signs of neuro deficit or radicular symptoms. The Veteran was afforded a VA examination in June 2011. The VA examiner noted a diagnosis of degenerative disc disease at C5-C6 with posterior osteophyte and right lateral disc herniation. The Veteran reported cervical pain beginning during service and progressively worsening. The Veteran denied fatigue, decreased motion, stiffness, weakness, and spasm. The VA examiner noted no incapacitating episodes of spine disease. Pain with motion and tenderness were endorsed. The VA examiner reported guarding resulting in an antalgic gait. Range of motion testing revealed flexion from 0 to 55 degrees, extension from 0 to 20 degrees, left lateral flexion from 0 to 20 degrees, right lateral flexion from 0 to 20 degrees, left lateral rotation from 0 to 65 degrees, and right lateral rotation from 0 to 65 degrees, with objective evidence of pain on movement. There was further evidence of pain following repetitive motion but there were no additional limitations after three repetitions. The VA examiner noted decreased vibration, pain/pinprick, and light touch of the bilateral hands. The Board notes that the Veteran is service-connected for bilateral carpal tunnel syndrome. An October 2012 VA treatment record shows that the Veteran denied cervical pain, numbness, paresthesias, or weakness with Valsalva maneuvers. A May 2019 VA treatment record shows the Veteran had full range of motion in his neck. In accordance with the May 2018 Board remand, the Veteran was afforded a VA examination in October 2019. The VA examiner noted a diagnosis of cervical disc degeneration at C5-C6 level in 2011. The Veteran reported that his condition is slightly worse, with frequent neck stiffness, soreness, and pain aggravated by repeated or sustained gazing over the shoulders as well as upward and downward movement. The Veteran’s symptoms are mitigated by rest and activity modification. The Veteran endorsed flare-ups, described as stiffness, soreness, and less range of motion, and functional loss, described as an inability to move his head all the way. Range of motion testing revealed forward flexion from 0 to 25 degrees, extension from 0 to 40 degrees, right lateral flexion from 0 to 20 degrees, left lateral flexion from 0 to 20 degrees, right lateral rotation from 0 to 70 degrees, and left lateral rotation from 0 to 60 degrees, with no pain noted on examination. There was mild localized tenderness or pain on palpation noted. The Veteran was able to perform repetitive-use testing with no additional loss of function or range of motion after three repetitions. Pain, fatigue, weakness, lack of endurance, or incoordination did not cause functional loss. However, pain and fatigue limit functional ability with flare-ups and repeated use over a period of time. No guarding or muscle spasm was reported. Muscle strength was 5/5 with no atrophy present. There was no evidence of radiculopathy nor ankylosis. The VA examiner reported that the Veteran’s cervical spine disability impacts his ability to work, limiting his capacity to perform duties that require twisting or rotation of the head/neck or any axial loading such as wearing a helmet. As to Correia criteria, there was no objective evidence of pain on non-weight bearing and passive range of motion could not be performed or was not medically appropriate. An April 2020 VA treatment note shows that the Veteran had no neck pain or stiffness. After a review of the evidence, the Board finds that a disability rating in excess of 20 percent for cervical disc degeneration at C5-C6 level is not warranted. It is not shown that at any time during the period for consideration forward flexion of the cervical spine was limited to 15 degrees (or approximating such limitation). At worse, the evidence shows that the Veteran’s forward flexion is limited to 25 degrees. See May 2018 VA examination. Likewise, it has never been noted that the cervical spine was ankylosed (not permitting flexion/extension motion). It is also not shown that the Veteran’s cervical spine disability resulted in incapacitating episodes having a total duration of at least 4 weeks but less than 6 weeks during a 12-month period. As the symptoms and associated impairment of function of the Veteran’s cervical spine disability fall squarely within the parameters of the criteria for the 20 percent rating assigned, and never meet (or approximate) the criteria for the next higher rating under the General Formula, even when taking pain and functional loss into consideration, an increased rating under the General Formula criteria is clearly not warranted. Neurological manifestations may be separately rated under an appropriate Code. Here, the medical evidence does not show neurological manifestations of the cervical spine disability in addition to those for which service connection is already established. Therefore, a separate (additional) rating for neurological manifestations is not warranted. The preponderance of the evidence is against the claim of entitlement to a disability rating in excess of 20 percent for cervical disc degeneration at C5-C6 level, and the appeal in the matter is denied. 3. Entitlement to a disability rating in excess of 10 percent for right carpal tunnel syndrome The Veteran was granted entitlement to service connection for right carpal tunnel condition in a July 2011 rating decision, rated as 10 percent disabling effective July 2010. The Veteran contends that he is entitled to a disability rating in excess of 10 percent. The Veteran’s right carpal tunnel syndrome is currently rated as 10 percent disabling under the hyphenated Diagnostic Code 8599-8515. Carpal tunnel syndrome is not specifically listed in the Rating Schedule; therefore, the Veteran’s disability must be rated by analogy. When an unlisted disease, injury, or residual condition is encountered, requiring rating by analogy, the diagnostic code number will be “built-up” by using the first two digits of the diagnostic code for the most closely analogous disability, followed by the terminal digits “99” connoting an unlisted condition. See 38 C.F.R. § 4.27. Carpal tunnel syndrome “result[s] from compression of the median nerve.” Dorland’s Illustrated Medical Dictionary 1824 (32nd ed. 2012) (“Dorland’s”); see Wilson v. Brown, 7 Vet. App. 542, 544 (1995). Diagnostic Code 8515 contemplates paralysis of the median nerve, and therefore, is an appropriate diagnostic code under which to rate the Veteran’s disability. Diagnostic Codes 8510-8719 address ratings for paralysis, neuritis, and neuralgia of the peripheral nerves affecting the upper extremities, and provide different disability ratings for the major (dominant) and minor (non-dominant) side. Diagnostic Codes 8515, 8615, and 8715 provide ratings for paralysis, neuritis, and neuralgia, respectively, of the median nerve. As relevant to the major arm, as is the case here, Diagnostic Code 8515 provides a 70 percent disability rating for complete paralysis of the median nerve, demonstrated by the hand inclined to the ulnar side, the index and middle fingers more extended than normal, considerable atrophy of the muscles of the thenar eminence, the thumb in the plane of the hand; pronation incomplete and defective, absence of flexion of the index finger and feeble flexion of the middle finger, inability to make a fist with index and middle fingers remaining extended; inability to flex the distal phalanx of the thumb, defective opposition and abduction of the thumb; weakened wrist flexion; and pain with trophic disturbances. Lower disability ratings are provided for incomplete paralysis, defined by the Rating Schedule as “a degree of lost or impaired function substantially less than the type picture for complete paralysis given.” A 50 percent disability rating is assigned for severe incomplete paralysis. A 30 percent disability rating is assigned for moderate incomplete paralysis. A 10 percent disability rating is assigned for mild incomplete paralysis. 38 C.F.R. § 4.124a, Diagnostic Code 8515. Neuritis and neuralgia are to be rated as incomplete paralysis. Neuritis, “characterized by loss of reflexes, muscle atrophy, sensory disturbances, and constant pain, at times excruciating,” shall not be rated higher than severe, incomplete paralysis. 38 C.F.R. § 4.123. The maximum rating which may be assigned for “neuritis not characterized by organic changes referred to in this section” is moderate, or with sciatic nerve involvement, moderately-severe incomplete paralysis. Id. Neuralgia, “characterized usually by a dull and intermittent pain, of typical distribution so as to identify the nerve,” shall not be rated higher than moderate incomplete paralysis. 38 C.F.R. § 4.124. The Rating Schedule further clarifies that “when the [neural] involvement is wholly sensory, the rating should be for mild, or at most, moderate” incomplete paralysis. 38 C.F.R. § 4.124a. The words “mild,” “moderate,” and “severe” are not defined in the Rating Schedule. Rather than applying a mechanical formula, the Board must evaluate all of the evidence to the end that its decisions are “equitable and just.” 38 C.F.R. § 4.6. It should also be noted that use of terminology such as “mild” and “moderate” by VA examiners or other physicians, although an element of evidence to be considered by the Board, is not dispositive of an issue. All evidence must be evaluated in arriving at a decision regarding an increased rating. 38 C.F.R. §§ 4.2, 4.6. The Veteran was afforded a VA examination in June 2011. The VA examiner noted diagnoses of bilateral carpal tunnel syndrome. The Veteran reported that, during service, he developed bilateral hand numbness with mild loss of strength. The VA examiner reported decreased vibration, pain/pinprick, and light touch. The VA examiner found no dysesthesias. The VA examiner reported that the Veteran’s carpal tunnel syndrome impacts the Veteran’s occupational activities, creating problems with lifting and carrying as well as resulting in decreased strength and pain. An April 2012 VA treatment note shows the Veteran underwent a right median nerve entrapment release procedure with no complications. In accordance with the May 2018 Board remand, the Veteran was afforded a VA examination in October 2019. The VA examiner noted diagnoses of bilateral carpal tunnel syndrome and carpal tunnel release, with scar. The Veteran stated that he has loss of strength and difficulty manipulating small objects as well as numbness, with his right hand worse than this left, and pain with repetitive motion. The Veteran reported that his condition has stayed the same since its onset. The Veteran is right hand dominant. The VA examiner noted mild intermittent pain, paresthesias and/or dysesthesias, and numbness. Muscle strength was 5/5 with no atrophy. Reflexes and sensation testing were normal. The VA examiner reported mild incomplete paralysis of the median nerve. The VA examiner noted a carpal tunnel surgery scar, stable and non-tender, measuring 2 centimeters (cm) by 0.1 cm. The VA examiner reported that the Veteran’s right carpal tunnel syndrome impacts his ability to work, limiting his capacity to perform duties that require repetitive motion about the wrists and hands or use of vibrating hand tools or equipment. After having carefully reviewed the evidence of record, the Board finds that the weight of the evidence is against a disability rating in excess of 10 percent for right carpal tunnel syndrome for the entire appeal period. The 10 percent rating was assigned because the Veteran exhibited mild incomplete paralysis of the right hand. The evidence of record demonstrates that Veteran continually reports of pain, numbness, and loss of strength, which supports the current disability ratings. There is no medical evidence showing moderate incomplete paralysis of the right hand. The Board has considered the Veteran’s statements that his right carpal tunnel syndrome causes pain resulting in limited functional ability. However, the medical evidence outlined above is afforded greater weight in the determination as to whether the criteria for a higher rating are met. This is because the rating assigned for carpal tunnel syndrome is based on findings from specific neurological testing that is not altogether capable of lay observation. In this case, the Board finds that the Veteran’s complaints of pain, numbness, and functional impairment are contemplated by the ratings currently assigned. (Continued on the next page)   For these reasons, the weight of the evidence is against the assignment of disability ratings in excess of 10 percent for the service-connected right carpal tunnel syndrome, throughout the increased rating period on appeal. The preponderance of the evidence is against a finding of entitlement to an increased disability rating at any point during the appeal period. The Veteran’s dominant right arm has not demonstrated symptoms indicating moderate or severe incomplete paralysis of the median nerve. A 10 percent disability rating for the Veteran’s right carpal tunnel syndrome is appropriate, and a higher rating is not warranted. The benefit-of-the-doubt doctrine does not apply. See 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 55. KRISTI L. GUNN Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board A. C. Slaughter 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.