Citation Nr: 21005732 Decision Date: 02/02/21 Archive Date: 02/02/21 DOCKET NO. 15-30 255 DATE: February 2, 2021 ORDER Entitlement to service connection for right trochanteric pain syndrome with bursitis (right hip disability) to include as secondary to back disability is denied. Entitlement to service connection for left trochanteric pain syndrome with bursitis (left hip disability) to include as secondary to back disability is denied. Entitlement to an initial rating higher than 10 percent for lumbar strain intervertebral disc syndrome (IVDS) is denied. Entitlement to an initial rating higher than 20 percent for right lower extremity radiculopathy is denied. Entitlement to an initial rating higher than 20 percent for left lower extremity radiculopathy is denied. Entitlement to an initial rating higher than 30 percent for posttraumatic stress disorder (PTSD) prior to April 16, 2019, is denied. REMANDED Entitlement to service connection for a dental condition is remanded. Entitlement to service connection for hemorrhoids is remanded. Entitlement to service connection for human papillomavirus (HPV) is remanded. Entitlement to a total disability rating based on individual unemployability (TDIU) is remanded. FINDINGS OF FACT 1. The competent lay and medical evidence is against a finding that bilateral hip trochanteric pain syndrome with bursitis is related to the Veteran’s military service or secondary to service connected lumbar spine disability. 2. The Veteran’s lumbar spine disability manifested range of motion on forward flexion greater than 0 to 80 degrees. 3. The Veteran’s radiculopathy of the right lower extremity was not productive of more than moderate impairment of the sciatic nerve. 4. The Veteran’s radiculopathy of the left lower extremity was not productive of more than moderate impairment of the sciatic nerve. 5. At no time, prior to April 16, 2019, has the Veteran’s psychiatric disorder caused more than mild depressed mood, sleep impairment, irritability, and mild memory loss; it has not been shown that her depression causes circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; or impaired abstract thinking). CONCLUSIONS OF LAW 1. The criteria for service connection for bilateral hip bursitis are not met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.303, 3.310. 2. The criteria for a rating in excess of 20 percent for radiculopathy of the right lower extremity have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. § 4.124, Diagnostic Code 8520. 3. The criteria for a rating in excess of 20 percent for radiculopathy of the left lower extremity have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. § 4.124, Diagnostic Code 8520. 4. For the initial period at issue prior to April 16, 2019, the criteria are not met for a higher 30 percent rating for the adjustment disorder with mixed emotional features/PTSD. 38 U.S.C. §§ 1155; 38 C.F.R. §§ 4.7, 4.130, Diagnostic Codes 9411, 9440. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from June 2006 to June 2011. This case came to the Board of Veterans’ Appeals (Board) on appeal from February and August 2014 rating decisions by the Department of Veterans Affairs (VA) Regional Office (RO). In November 2018, the RO remanded the issues listed on the title page, and in relevant part, denied the claims for service connection for bilateral hip disabilities secondary to service-connected lumbar strain, and an initial compensable rating for migraines. (Although several other issues were adjudicated by the Board, the Veteran did not appeal those decisions). The Veteran appealed the Board denial of those issues to the United States Court of Appeals for Veterans Claims (Court). In September 2019, the Court, pursuant to a Joint Motion for Remand (Joint Motion), vacated the November 2018 decision and remanded the case to the Board for compliance with the directives specified by the Joint Motion. The Board remanded the claims in April 2020 for VA examination and opinion. In a September 2020 rating action, the RO granted a 50 percent rating (the highest rating of under the Schedule) for migraine headaches since the date of service connection. The Board finds this a complete grant of the benefit sought under the facts of this case. In a September 2020 supplemental statement of the case, the RO denied service connection for bilateral hip disabilities. 1. Entitlement to service connection for right hip disability 2. Entitlement to service connection for left hip disability In general, service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active military service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303 (a). To establish entitlement to direct service connection for the claimed disability, there must be: (1) medical evidence of current disability; (2) medical, or in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and (3) medical evidence of a nexus or link between the claimed in-service disease or injury and the current disability. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004), citing Hansen v. Principi, 16 Vet. App. 110, 111 (2002). Service connection is permissible, as well, on a secondary basis for disability that is proximately due to, the result of, or chronically aggravated by a service-connected condition. See 38 C.F.R. § 3.310 (a) and (b). See also Allen v. Brown, 7 Vet. App. 439, 448 (1995). To establish entitlement to service connection on this secondary basis, there must be (1) evidence of a current disability; (2) evidence of a service-connected disability; and (3) medical evidence establishing a nexus (i.e., link) between the service-connected disability and the current disability. Wallin v. West, 11 Vet. App. 509, 512 (1998). The Board has reviewed all of the evidence in the Veteran’s claims file. Although the Board has an obligation to provide adequate reasons and bases supporting this decision, there is no requirement that the evidence submitted by a Veteran or obtained on her behalf be discussed in detail. Rather, the Board’s analysis below will focus specifically on what evidence is needed to substantiate the claims and what the evidence in the claims file shows, or fails to show, with respect to the claims. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000); Timberlake v. Gober, 14 Vet. App. 122, 128-30 (2000). The Veteran meets the first requirement of any service-connection claim, which is that she has the claimed disability. Boyer v. West, 210 F.3d 1351, 1351 (Fed. Cir. 2000); Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). She has received diagnoses of bilateral hip trochanteric pain syndrome with bursitis. (See August 2020 VA examination report.) She also meets the first and second requirements for secondary service connection as she is service connected for a lumbar spine disability. The question becomes whether the Veteran’s claimed bilateral hip disability is a result of her military service, including her lumbar spine disability. See Watson v. Brown, 4 Vet. App. 309, 314 (1993). However, the preponderance of the evidence as to the nexus element is against the claim, and service connection is not warranted on either a direct or secondary basis. See Szemraj v. Principi, 357 F.3d 1370, 1371 (Fed. Cir. 2004) (when determining service connection, all theories of entitlement must be considered-direct, presumptive and secondary). Reviewing the service treatment records, there are no complaints, findings or diagnoses regarding a hip disorder. On periodic examinations for variously unrelated disorders throughout service, there were no hip problems noted when examining the musculoskeletal systems. Moreover, the lower extremities were considered normal at the examination conducted prior to separation in June 2011. So, these records provide evidence against in-service incurrence of this condition. See Struck v. Brown, 9 Vet. App. 145 (1996). The first complaints of hip problems are in 2014 when she filed for VA benefits. This was nearly 3 years after service discharge, which is far removed from any military duties. There also is no competent and credible evidence otherwise linking or relating her bilateral hip disability directly to her military service. The only medical evidence, of record, is against such a theory. As to whether the bilateral hip disability is secondary to her service-connected lumbar spine disability, the preponderance of the evidence is also against the claim. In August 2020, the VA physician assistant concluded that it is less likely than not that bilateral hip disability is related to lumbar spine disability. She stated: The Veteran is service connected for her back. Hip conditions can be seen in the setting of alteration of gait. Usually the hip condition involves DJD pathology when it is due to the back. She has no alterations in gait due to her back. Her hip X-rays are normal. Her hip condition is associated with a bursitis. While she claims that her hips are due to her back, there is insufficient clinical evidence that this has occurred as her gait is normal. Thus, it is less likely than not that the claimed bilateral hips were aggravated beyond natural progression by the service connected lumbar strain. After considering the evidence both for and against the claim, the Board finds the statements of the VA examiners to be persuasive in light of the overall record. The examiner’s opinions are supported by the clinical evidence of record. There also is no medical opinion in the file refuting the VA examiners’ unfavorable opinions, and the Veteran’s lay statements are insufficient to rebut the opinions. The Veteran’s attorney has recently raised new theories of entitlement. In January 2021, the attorney submitted argument that service-connected disability, to include orthopedic disabilities and PTSD, lead to weight gain that then led to the hip disabilities. The Board acknowledges that the Court and General Counsel opinions have provided that weight gain can be an intermediary step in a disease process. The Board finds however that the record lacks competent evidence that indicates that this is true in this case. Review of the examiner’s opinion and report reveals consideration of the facts of this case and the examiner did not find that weight can was part of this disease process. The attorney has not provided competent evidence specific to the facts of this case. After careful consideration, the Board finds that these new contentions do not provide a basis for granting the benefit or remanding the appeal for further medical opinion. For these reasons and bases, the evidence is not in relative equipoise, meaning not about evenly balanced for and against the claim for service connection bilateral hip disability. Instead, the preponderance of the evidence is unfavorable, and the claim must be denied. Increased Rating The Veteran contends that her service-connected lumbar spine disability, radiculopathy of the lower extremities, and PTSD, warrant higher ratings. Disability evaluations are determined by the application of a schedule of ratings that is based on the average impairment of earning capacity after a review of the entire history. Separate diagnostic codes (DCs) identify the various disabilities. 38 U.S.C. § 1155; 38 C.F.R., Part 4; Schafrath v. Derwinski, 1 Vet. App. 589 (1995). Where there is a question as to which of two disability evaluations shall be applied, the higher evaluation is to be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating is to be assigned. 38 C.F.R. § 4.7. Where the evidence contains factual findings that demonstrate distinct time periods in which the service-connected disability exhibits symptoms that would warrant different evaluations during the course of the appeal, the assignment of staged ratings is appropriate. Fenderson v. West, 12 Vet. App. 119, 126-127 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). Any reasonable doubt remaining is resolved in favor of the Veteran. 38 C.F.R. § 4.3. In considering the severity of a disability, it is essential to trace the medical history of the veteran. 38 C.F.R. §§ 4.1, 4.2, 4.41. Consideration of the whole-recorded history is necessary so that a rating may accurately reflect the elements of any disability present. 38 C.F.R. § 4.2; Peyton v. Derwinski, 1 Vet. App. 282 (1991). Although the regulations do not give past medical reports precedence over current findings, the Board is to consider the veteran’s medical history in determining the applicability of a higher rating for the entire period in which the appeal has been pending. Powell v. West, 13 Vet. App. 31, 34 (1999). 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. Francisco v. Brown, 7 Vet. App. 55 (1994). 3. Entitlement to a disability rating higher than 10 percent for lumbar strain The Veteran maintains that a rating higher than 10 percent is warranted for her lumbar strain with intervertebral disc syndrome. The RO granted service connection for lumbar strain a February 2014 rating action, assigning a 10 percent evaluation, effective June 26, 2011. The RO recharacterized the disability to include intervertebral disc syndrome in an April 2020 rating action. Diagnostic codes that pertain to disabilities Under the DC 5243, intervertebral disc syndrome (IVDS) is rated either on the total duration of incapacitating episodes over the past 12 months or by combining separate evaluations of the chronic orthopedic and neurologic manifestations, whichever method results in the higher rating. See Bierman v. Brown, 6 Vet. App. 125 (1994). However, assigning separate ratings for combination may not be permitted to result in pyramiding under 38 C.F.R. § 4.14 - which prohibits “[t]he evaluation of the same disability under various diagnoses”. See Brady v. Brown, 4 Vet. App. 203, 206 (1993). See, too, Esteban v. Brown, 6 Vet. App. 259, 262 (1994) (the critical element is if symptoms of one condition are duplicative of or overlapping of another). Thus, a rating for IVDS may not be assigned while at the same time assigning separate ratings for the orthopedic and the neurologic components of IVDS. As to incapacitating episodes, if there are incapacitating episodes having a total duration of at least two weeks but less than four weeks during the past 12 months, a 20 percent rating is warranted. If there are incapacitating episodes having a total duration of at least four weeks but less than six weeks during the past 12 months, a 40 percent rating is warranted. If there are incapacitating episodes having a total duration of at least six weeks during the past 12 months, a maximum 60 percent rating is warranted. The IVDS rating criteria do not provide for an evaluation in excess of 60 percent on the basis of the total duration of incapacitating episodes. Note 1 to the revised DC 5293 defines an incapacitating episode as a period of acute signs and symptoms that requires bed rest prescribed by and treatment by a physician. Supplementary Information in the published final regulations states that treatment by a physician would not require a visit to a physician’s office or hospital but would include telephone consultation with a physician. If there are no records of the need for bed rest and treatment, by regulation, there are no incapacitating episodes. 67 Fed. Reg. 54345, 54347 (August 22, 2002). As for rating the orthopedic manifestations, the General Rating Formula for Diseases and Injuries of the Spine (General Rating Formula) is used and encompasses symptoms such as pain (radiating or not), stiffness, and aching but does not require that there be such symptoms for any particular rating. 68 Fed. Reg. at 51454 - 51455 (August 27, 2003). The General Rating Formula provides ratings based on limited spinal motion in either forward flexion or the combined ranges of motion of a spinal segment, or for either favorable or unfavorable ankylosis, or with respect to the entire spine a loss of more than 50 percent vertebral body height due to vertebral fracture or muscle spasm and guarding. Note 2 to the General Rating Formula sets forth normal ranges of motion of the spinal segments, which under Note 4 are measured to the nearest five (5) degrees, although a lesser degree of motion may be considered normal under the circumstances set forth in Note 3. Note 2 to the General Rating Formula provides that normal forward flexion of the thoracolumbar spine is zero to 90 degrees, extension is zero to 30 degrees, left and right lateral flexion are zero to 30 degrees, and left and right lateral rotation are zero to 30 degrees. The sum of these is the combined range of motion, which for the thoracolumbar spine is 240 degrees. Fixation of a spinal segment in neutral position (zero degrees) always represents favorable ankylosis. Note 5 of the General Rating Formula. A 10 percent rating is warranted for limited thoracolumbar motion when forward flexion is greater than 65 degrees but not greater than 85 degrees; or the combined range of motion of the thoracolumbar spine is greater than 120 degrees but not greater than 234 degrees; or, there is muscle spasm, guarding or localized tenderness not resulting in abnormal gait or abnormal spinal contour; or, vertebral body fracture with loss of 50 percent of more of the vertebral height. A 20 percent rating is warranted for limited thoracolumbar motion when forward flexion is greater than 30 degrees but not greater than 60 degrees; or the combined range of motion is not greater than 120 degrees (the maximum combined range of motion being 240 degrees); or if there is either (1) muscle spasm or (2) guarding severe enough to result in abnormal gait or abnormal spinal contour, e.g., scoliosis, reversed lordosis, or abnormal kyphosis. A 40 percent rating is warranted for limited thoracolumbar motion when forward flexion is to 30 degrees or less; or, there is favorable ankylosis of the entire thoracolumbar spine. A 50 percent rating is warranted for unfavorable ankylosis of the entire thoracolumbar spine; and 100 percent for unfavorable ankylosis of the entire spine. Ratings for a joint based on limitation of motion require consideration of 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. In other words, ratings based on limited motion do not ipso facto include or subsume the other rating factors in §§ 4.40 and 4.45, e.g., pain, functional loss, fatigability, and weakness. Thus, a higher rating may be assigned if there is additional limitation of motion from pain or limited motion on repeated use of the joint. See DeLuca v. Brown, 8 Vet. App. 202 (1995). Also, with any form of arthritis, painful motion is factor to be considered. Painful motion of a joint with periarticular pathology is to be at rated at least at the minimum compensable rating for the joint. 38 C.F.R. § 4.59. See DeLuca v. Brown, 8 Vet. App. 202 (1995); Johnston v. Brown, 10 Vet. App. 80, 84-5 (1997); Mitchell v. Shinseki, 25 Vet. App. 32 (2011); and Burton v. Shinseki, 25 Vet. App. 1, 5-6 (2011). The holding in Mitchell v. Shinseki, 25 Vet. App. 32, 40-41 (2011) that painful motion without functional loss did not constitute compensable limited motion, was premised on 38 C.F.R. §§ 4.40 and 4.45, but in Burton v. Shinseki, 25 Vet. App. 1, 5-6 (2011) it was held that painful motion without functional loss did warrant a minimum compensable evaluation under 38 C.F.R. § 4.59. With respect to conducting a rating examination relative to joint dysfunction, a VA examination of the joints should, when possible, include the results of the range of motion testing described in the final sentence of § 4.59 which are tests as to pain on active and passive motion, including weight-bearing and non-weight-bearing and, if possible, with range of the opposite undamaged joint. Correia v. McDonald, 28 Vet. App. 158 (2016). Based on the complete evidence of record, the Board finds that the criteria for a disability rating in excess of 10 percent for lumbar strain with IVDS under 38 C.F.R. § 4.71a DC 5243 were not met. During November 2013 VA examination, the Veteran reported that she originally injured her back when she felled downstairs from a guard tower. She also hurt her back in a rollover drill and again when hit by a door of a Humvee. On examination, she had normal range of motion in all planes with no evidence of pain. She was able to do repetitive motion with no loss of motion or function. However, there was pain. There were no muscle spasms, guarding, muscle atrophy, or loss of muscle strength. Sensory examination was normal and straight leg raising was negative. X-ray study was normal. At VA examination in June 2016, radiculopathy of the lower extremities was confirmed. The RO granted separate 20 percent ratings for radiculopathy of the left and right lower extremities. VA examination was conducted in April 2019. The Veteran reported increased symptoms that included daily back pain on lifting and bending. She also reported radiating pain along with numbness and tenderness in the lower extremities. In reporting functional impairment, she is able to do household chores and lift her 3 year old, but with pain on lifting. She is unable to run as she did in the past. On flareups, the pain is increased with shooting pains down her legs with tingling. The Veteran was able to perform all range of motions, which was considered normal. However, pain was noted on forward flexion at 80 degrees; extension at 20 degrees; lateral flexion at 20 degrees, bilaterally; and at 30 degrees on lateral rotation, bilaterally. There were no muscle spasms, guarding, muscle atrophy, or loss of muscle strength. She was able to perform repetitive motion 3 times with no loss of function. There was no pain on palpation. Straight leg raising was negative. There was decreased sensation to the toes on the sensory examination. There was mild intermittent pain, numbness, paresthesia and/or dysesthesias. The examiner stated that the Veteran had IVDS. The examiner noted that MRI revealed bulging disc at L4-5. The VA examiner found no evidence of pain on weightbearing. The examiner commented that the Veteran is limited to light work. As demonstrated by the VA examination reports, there is no probative evidence showing that the Veteran’s lumbar spine disorder has been manifested by forward flexion of the thoracolumbar spine limited to no more than 80 degrees (before pain begins); or combined range of motion of the thoracolumbar spine no greater than 120 degrees; or muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour. In addition, there is no evidence that the Veteran’s disability of the lumbar spine resulted in any incapacitating episodes, requiring bed rest prescribed by a physician and treatment prescribed by a physician. The Board has assessed the weight to be given to the Veteran’s complaints of pain and functional impairment. Taking into consideration the Veteran’s statements regarding pain, in statements to medical examiners, she reported recurrent pain in the back. Her reports were accounted for in the examinations. Pain did not additionally limit the Veteran’s lumbar spine function beyond the functional loss already accounted for by the assigned rating. The RO granted a 10 percent rating based on her complaints of pain according to DeLuca. The Board does not find that she should be granted a higher rating based on any other functional impairment. She did not identify any functional limitation, which would warrant a higher rating under any applicable rating criteria. Accordingly, an increased rating in excess of 10 percent is not warranted for lumbar strain with IVDS. 4. Entitlement to an initial disability rating higher than 20 percent for radiculopathy, right lower extremity 5. Entitlement to an initial disability rating higher than 20 percent for radiculopathy, left lower extremity The RO granted service connection for radiculopathy of the right and left lower extremities in an August 2016 rating action, assigning separate 20 percent ratings, under Diagnostic Code 8520, based on sensory changes and decreased reflexes. The Appellant’s neurological symptoms are rated separately. Under 38 C.F.R. § 4.124a, the schedules for rating diseases of the cranial and peripheral nerves include alternate diagnostic codes for paralysis, neuritis, and neuralgia of each nerve. See 38 C.F.R. § 4.124a, DCs 8205 to 8730. The DCs for paralysis of a nerve allow for multiple levels of incomplete paralysis, as well as complete paralysis. However, the ratings available for neuritis and neuralgia of the same nerves can be limited to less than the maximum ratings available for paralysis. In rating peripheral neuropathy attention is given to sensory or motor impairment as well as trophic changes (described at 38 C.F.R. § 4.104, Diagnostic Code 7115”). Peripheral neuropathy which is wholly sensory is mild or, at most, moderate. With dull and intermittent pain in a typical nerve distribution, it is at most moderate. With no organic changes it is moderate or, if of the sciatic nerve, moderately severe. 38 C.F.R. § 4.20. Neuralgia of a peripheral nerve of a lower extremity can receive a maximum rating of moderate incomplete paralysis. 38 C.F.R. § 4.124. Neuritis characterized by loss of reflexes, muscle atrophy, sensory disturbances, and constant pain, at times excruciating, can receive a maximum rating of severe, incomplete paralysis. 38 C.F.R. § 4.123. ‘Sciatic’ refers to the sciatic nerve; sciatica is used to refer to ‘a syndrome characterized by pain radiating from the back into the buttock and into the lower extremity along its posterior or lateral aspect, and most commonly caused by prolapse of the intervertebral disk’ the term is also used to refer to pain anywhere along the course of the sciatic nerve’.” Ferraro v. Derwinski, 1 Vet. App. 326, 329-30 (1991). Sciatic neurological manifestations are rated under DC 8520, 8620, or 8720 as, respectively, paralysis, neuritis or neuralgia of the sciatic nerve. The criterion for a 10 percent rating is mild incomplete paralysis. The criterion for a 20 percent is moderate incomplete paralysis and 40 percent when moderately severe. When severe with marked muscular atrophy, 60 percent is warranted and 80 percent is warranted for complete paralysis (with foot drop, no active movement possible below the knee, and weakened or, very rarely, lost knee flexion). See also 38 C.F.R. § 4.124a, DCs 8620, 8720 (for sciatic neuritis and neuralgia). Moderate is also the maximum evaluation that can be assigned for neuritis not characterized by organic changes referred to in 38 C.F.R. § 4.123, neuralgia characterized usually by a dull and intermittent pain in the distribution of a nerve, under 38 C.F.R. § 4.124. Moderately severe incomplete paralysis is only applicable for involvement of the sciatic nerve and is the maximum rating for sciatic nerve neuritis not characterized by the organic changes specified in 38 C.F.R. § 4.123. Motor and/or reflex impairment (for example, weakness or diminished or hyperactive reflexes) at a grade reflecting a high level of limitation or disability is expected. Atrophy may be present. However, for marked muscular atrophy see the criteria for a severe evaluation under 38 C.F.R. § 4.124, DC 8520. With severe incomplete paralysis, in general, expect motor and/or reflex impairment (for example, atrophy, weakness, or diminished or hyperactive reflexes) at a grade reflecting a very high level of limitation or disability. Trophic changes may be seen in severe longstanding neuropathy cases. For the sciatic nerve, under 38 C.F.R. § 4.124a, DC 8520, marked muscular atrophy is expected. Even though severe incomplete paralysis cases should show findings substantially less than representative findings for complete impairment of the nerve; the disability picture for severe incomplete paralysis may contain signs/symptoms resembling some of those expected in cases of complete paralysis of the nerve. Neuritis characterized by loss of reflexes, muscle atrophy, sensory disturbances, and constant pain should be rated as high as severe incomplete paralysis of the nerve, under 38 C.F.R. § 4.123. Based on the complete evidence of record, the Board finds that the criteria for a disability rating in excess of 20 percent for peripheral radiculopathy of the lower extremities under DC 8520 were not met. At the June 2016 VA examination, the Veteran reported daily radicular symptoms to the lower extremities to include shooting pain, paresthesias, and numbness to foot level of the left leg. She experienced right leg radicular symptoms 2-3 times a week. The examiner noted that on examination the left leg was weaker than the right. The Veteran endorsed mild intermittent pain, mild paresthesias, and mild numbness in the right leg. There was moderate intermittent pain, moderate paresthesias, and mild numbness in the right leg. On deep tendon reflexes testing, the right ankle was considered hypoactive. Deep tendon reflexes of the left knee and left ankle were considered hypoactive. There is no doubt, the Veteran experiences significant symptoms associated with her peripheral neuropathy. However, at the VA examination, she had normal strength on knee extension and flexion; ankle plantar flexion; and ankle dorsiflexion. There was no muscle atrophy or tropic changes. Her gait was normal. On deep tendon reflexes testing, the right knee was normal. The Board finds that given the absence of significantly decreased strength, muscle atrophy, trophic or organic changes, the Veteran does not have the combination of symptoms and findings demonstrating moderately severe incomplete paralysis, neuritis or neuralgia of the peripheral nerves of the right lower extremity which would warrant a finding of moderately severe neurological impairment. Accordingly, ratings in excess of 20 percent is not warranted for mild to moderate neurological impairment of the sciatic nerve of the right and left lower extremities. 6. Entitlement to an initial rating higher than 30 percent for posttraumatic stress disorder (PTSD) (formerly diagnosed as adjustment disorder w/mixed emotional features) The Veteran maintains that a rating higher than 30 percent is warranted for PTSD prior to April 16, 2019. In addition, the Veteran’s attorney maintains that a 100 percent rating should have been granted at the time of the initial diagnosis of PTSD. In July 2012 rating action, the RO granted service connection for adjustment disorder with mixed emotional features. A 30 percent rating was granted effective June 26, 2011, under Diagnostic Code 9440. In August 2014, the RO recharacterized the disability to reflect a diagnosis of PTSD, under Diagnostic Code 9411. A 100 percent evaluation was granted in an April 2020 rating action, effective April 16, 2019. In regard to the attorney’s argument that a 100 percent should be granted on the date of the diagnosis of PTSD. As noted above, a claimant may experience multiple distinct degrees of disability that might result in different levels of compensation from the time the increased rating claim was filed until a final decision is made. And when this occurs, the rating must be “staged” to reflect this change in severity of the condition. See Fenderson v. West, 12 Vet. App. 119 (1999) (mandating this consideration and practice when the Veteran timely appeals the rating initially assigned for a disability following the granting of service connection). Here, the Veteran has what amounts to a “staged” rating since her psychiatric disability was initially rated as 30-percent disabling until the increase to 100 percent as of April 16, 2019. Granting a 100 percent rating based simply on the initial diagnosis of PTSD would be speculative and, therefore, not a basis for assigning earlier effective dates for the increased staged ratings. See Swain v. McDonald, 27 Vet. App. 219, 224 (2015); Young v. McDonald, 766 F.3d 1348 (Fed. Cir. 2014). The Board shall consider whether a higher rating is warranted prior to the grant of the 100 percent rating on April 16, 2019, based on review of the relevant medical and lay evidence of record. The General Rating Formula for Mental Disorders provides a 100 percent rating for total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. A 70 percent rating is assigned for occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a worklike setting); inability to establish and maintain effective relationships. A 50 percent rating is assigned for occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships. In addition, when evaluating a mental disorder, the rating agency shall consider the frequency, severity, and duration of psychiatric symptoms, the lengths of remissions, and the Veteran’s capacity for adjustment during periods of remission. 38 C.F.R. § 4.126 (a). The rating agency shall assign an evaluation based on all evidence of record that bears on occupational and social impairment rather than solely on the examiner’s assessment of the level of disability at the moment of the examination. Id. However, when evaluating the level of disability from a mental disorder, the rating agency will consider the extent of social impairment, but shall not assign an evaluation on the basis of social impairment. 38 C.F.R. § 4.126 (b). Use of the term “such symptoms as” in § 4.130 indicates that the list of symptoms that follows is “non-exhaustive,” meaning that VA is not required to find the presence of all, most, or even some of the enumerated symptoms to assign a particular evaluation. Vazquez-Claudio v. Shinseki, 713 F.3d 112, 115 (Fed. Cir. 2013); see Sellers v. Principi, 372 F.3d 1318, 1326-27 (Fed. Cir.2004); Mauerhan v. Principi, 16 Vet. App. 436, 442 (2002). However, because “[a]ll nonzero disability levels [in § 4.130] are also associated with objectively observable symptomatology,” and because the plain language of the regulation makes clear that “the veteran’s impairment must be ‘due to’ those symptoms,” a veteran “may only qualify for a given disability rating under § 4.130 by demonstrating the particular symptoms associated with that percentage, or others of similar severity, frequency, and duration.” Vazquez-Claudio, 713 F.3d at 116-17. Based on the complete evidence of record, the Board finds that the criteria for a disability rating in excess of 30 percent for PTSD under Diagnostic Code 9411 were not met. At QTC examination in December 2011, the Veteran reported symptoms of depression in 2006 after the loss of a child and divorce issues. Additional symptoms included moodiness, irritability, flashes of anger, and insomnia. These symptoms caused tension in her marriage. She denied a history of violent behavior or suicide attempts. She was not receiving treatment. On examination, she was oriented. Her behavior, appearance and hygiene were appropriate. Her affect and mood showed mild depression. Her communication and speech were within normal limits. She showed impaired attention and focus. She reported panic attacks that occurred less than once a week. There were no delusions, hallucinations, or compulsive behavior. Her thought processes were appropriate. She was able to understand directions. There was mild memory impairment, forgetting names, directions, and recent events. The diagnoses were adjustment disorder; depression. VA outpatient records including a February 2012 mental disorders disability benefits questionnaire shows that the Veteran reported continuing symptoms of sleep impairment, panic attacks, mild memory loss, and disturbance of motivation and mood. VA neuropsychiatric assessment was conducted in April 2014. In noting her current status, the Veteran was enrolled in cosmetology and would graduate in October. She maintained an “A” average. She was also taking college level classes at 2 other institutions maintaining a “B” average at each. The testing revealed an average intellectual/cognitive functioning. Her testing was not consistent with a neurological impairment. However, it was noted that she had a relative weakness on coding which may be reflective of her service-connected adjustment disorder. In August 2014, the RO recharacterized the disability to reflect a diagnosis of PTSD and continued the 30 percent rating. VA examination was conducted in July 2015. The examiner found that the previously diagnosed chronic adjustment disorder was as likely as not PTSD. The examiner found that the Veteran had occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational task, although generally functioning satisfactorily with normal routine behavior, self-care and conversations. Her judgment, orientation, motor activity, social interaction, communication and consciousness were normal. She reported sleep impairment, irritability, and increasing social isolation. The examiner indicated that she fulfilled all the criteria for PTSD. At VA examination in May 2016, the Veteran reported her marital and social history indicating her marriage since 2010 with 4 children. She socialized with her family and extended family. She had not worked since November 2014 where she worked as salon receptionist. She spent her time taking care of her children. She reported continuing problems with going to sleep and staying asleep. The Veteran described her mood as anxious, tense, irritable, exhausted, and numb. On mental status examination, she was oriented in all spheres. Her attention, concentration, judgement, and insight were intact. Her memory for remote, recent, and immediate events were intact. The examiner concluded that the Veteran had occupational and social impairment due to mild or transient symptoms with decrease work efficiency and ability to perform occupational tasks only during periods of significant stress or symptoms controlled by medication. Pursuant to the Board remand, VA examination was conducted in April 2019 to review her PTSD symptoms. This examiner reflected increased symptoms and manifestations of the service-connected PTSD. The RO granted a 100 percent rating effective, April 16, 2019, the date of the VA examination. In reviewing the findings and history elicited at VA examination, the Board concludes that the veteran’s disability picture attributable to her PTSD most nearly approximated the manifestations for a 30 percent evaluation, prior to April 16, 2019. Thus, the higher rating is not warranted. 38 C.F.R. § 4.7. At examinations during the relevant period, the Veteran reported that she was unable to sleep well. She experiences depression of motivation and mood. However, for the most part, it appears that the she was generally functioning independently, appropriately, and effectively. She was not socially isolated. Her conversation was normal, not circumstantial, circumlocutory, stereotyped, illogical, obscure, or irrelevant. Her memory was not limited to retention of only highly learned tasks, much less marked by memory loss for close relatives, or her own occupation or name. As noted, she functioned at a high level in her educational pursuits. Hers judgment was not considered inadequate. She did not report problems involving routine behavior, self-care, or conversation, nor did she neglect her personal appearance or hygiene. At examinations her personal hygiene was considered more than adequate. There was no evidence of delusions. She was well oriented, rather than disoriented. She did not report any obsessional rituals. In reviewing the findings and history elicited at VA examination, the Board concludes that the Veteran’s disability picture attributable to her PTSD most nearly approximated the manifestations for a 30 percent evaluation, prior to April 16, 2019. Thus, the higher rating is not warranted. 38 C.F.R. § 4.7. REASONS FOR REMAND 1. Entitlement to service connection for hemorrhoids. In regard to the claim for service connection for hemorrhoids, a VA examiner in April 2019 provided an unfavorable opinion. The examiner noted the Veteran’s reports of inservice symptoms when providing her medical history, but in providing the rationale the examiner did not refer to the Veteran’s statements regarding her inservice and post service symptoms and manifestations. In Dalton v. Nicholson, 21 Vet. App. 23 (2007), the United States Court of Appeals for Veterans Claims (Court) determined a VA compensation examination and opinion were inadequate where the examiner did not comment on the Veteran’s report of in-service injury and, instead, relied on the absence of evidence in the Veteran’s STRs to provide a negative opinion. Therefore, the case must be remanded to obtain complete medical opinions that take into considerations the Veteran’s statements regarding her symptoms. 2. Entitlement to service connection for a dental condition is remanded. In the Remand, the Board requested a medical opinion regarding whether the Veteran has dental bone loss due to trauma or disease that is not periodontal. The remand requested that the examiner review clinical notes to include one dated August 26, 2007. However, this is an incorrect date. The correct date is April 26, 2007. The examiner was unable to locate this record or any other reference to teeth #19 and provided an unfavorable opinion. The Board notes that there are at least two clinical references to teeth #19. See dental records dated on October 5, 2006 and April 26, 2007. Although the examiner ultimately concluded that there were no symptoms associated with the missing teeth, an adequate medical opinion must be made on an accurate review of the medical history. A supplemental opinion is needed. 3. Entitlement to service connection for human papillomavirus (HPV) is remanded. In the Remand, the Board requested a medical nexus opinion regarding HPV. The examiner provided an unfavorable opinion indicating that the Veteran’s pap smears have been negative for HPV, therefore it has resolved. However, during the appeal period there is a positive test for HPV. See VA outpatient record dated January 25, 2017. As an adequate medical opinion must be made on an accurate review of the medical history, a supplemental opinion is needed. 4. Entitlement to a total disability rating based on individual unemployability (TDIU) is remanded The RO denied a TDIU, in part because the Veteran is self-employed. A TDIU presupposes a veteran is not capable of gainful employment. It is not clear from the record that the Veteran is engaged in gainful employment. To verify her income and show it has been marginal in nature during the appeal period, she should submit earnings information since 2011. The matters are REMANDED for the following action: 1. Ask the Veteran to submit documents verifying her income for each year from 2011 to the present. 2. Obtain and associate with the e file all outstanding VA and private treatment records with any needed assistance from the Veteran. 3. After completion of directive #2, the RO should return the e-file to the VA examiner who provided the April 2019 hemorrhoids opinion, or if unavailable, another appropriate examiner, and request an opinion as to whether it is at least as likely as not that her hemorrhoids are etiologically related to the Veteran’s military service? Because the Veteran is competent to report symptoms of difficulties, the examiner must specifically address the Veteran’s report of any manifestation during her active service and since in determining whether any disability is related to military service. 4. After completion of directive #2, the RO should return the e-file to the VA examiner who provided the April 2019 dental opinion, or if unavailable, another appropriate examiner, and request an opinion regarding whether the Veteran has bone loss due to trauma or disease that is not periodontal? If so, is it at least as likely as not (a 50 percent or greater probability) etiologically related to the Veteran’s active military service? The examiner is asked to consider and comment on the Veteran’s dental service treatment records that reflect teeth extraction in February 2007, April 2007, and July 2009.   5. After completion of directive #2, the RO should return the e-file to the VA examiner who provided the April 2019 HPV opinion, or if unavailable, another appropriate examiner, and request an opinion regarding whether the Veteran has HPV and if so, whether it is etiologically related to the Veteran’s active military service? The examiner should note the past positive HPV test. Nathaniel Doan Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board A.D. Jackson, 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.