Citation Nr: 21007520 Decision Date: 02/09/21 Archive Date: 02/09/21 DOCKET NO. 16-01 725 DATE: February 9, 2021 ORDER Entitlement to a greater rating in excess of 10 percent prior to April 4, 2013, for cervical degenerative joint disease, is denied. Entitlement to a greater rating in excess of 30 percent From April 4, 2013, for cervical degenerative joint disease, is denied. Entitlement to an initial rating in excess of 30 percent for neuropathy of the left upper extremity, associated with cervical degenerative joint disease is denied. Entitlement to an initial rating in excess of 20 percent for neuropathy of the right upper extremity, associated with cervical degenerative joint disease is denied. Entitlement to a compensable rating for hypertension is denied. Entitlement to service connection for a hysterectomy is denied. FINDINGS OF FACT 1. Prior to April 4, 2014, the Veteran's cervical spine disability manifested with functional loss due to painful motion; forward flexion and the combined range of motion was within normal limits. 2. From April 4, 2013, the Veteran's cervical spine disability was manifested by forward flexion of the cervical spine at 15 degrees or less, but without unfavorable ankylosis of the entire cervical spine. 3. The Veteran's left upper extremity neuropathy associated with cervical degenerative joint disease manifests in no more than mild incomplete paralysis 4. The Veteran's right upper extremity neuropathy associated with cervical degenerative joint disease manifests in no more than mild incomplete paralysis. 5. The weight of competent and credible evidence is that the Veteran does not have a history of diastolic pressure predominantly 100 or more, or; systolic pressure predominantly 160 or more, or; a history of diastolic pressure predominantly 100 or more and requires continuous medication. 6. A hysterectomy did not manifest in active duty service and is not otherwise attributable to active duty service CONCLUSIONS OF LAW 1. The criteria for entitlement to a rating in excess of 10 percent prior to April 4, 2013, for cervical degenerative joint disease have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.321, 4.1, 4.2, 4.3, 4.7, 4.40, 4.45, 4.71a, DC 5237-5242 (2019). 2. The criteria for entitlement to a rating in excess of 30 percent from April 4, 2013, for cervical degenerative joint disease have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.321, 4.1, 4.2, 4.3, 4.7, 4.40, 4.45, 4.71a, DC 5237-5242 (2019). 3. The criteria for entitlement to a rating in excess of 30 percent for the Veteran's left upper extremity neuropathy associated with cervical degenerative joint disease have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.123, 4.124, 4.124a, Diagnostic Code 8511. 4. The criteria for entitlement to a rating in excess of 20 percent for the Veteran's right upper extremity neuropathy associated with cervical degenerative joint disease have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.123, 4.124, 4.124a, Diagnostic Code 8511. 5. The criteria for an initial compensable rating for hypertension have not been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 4.31, 4.104, Diagnostic Code 7101. 6. The criteria for entitlement to service connection for a hysterectomy have not been met. 38 U.S.C. §§ 1110, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303 (2019). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty for training in the U.S. Army Reserve from November 1987 to March 1988, and on active duty in the U.S. Army from November 1988 to June 2001. This matter comes to the Board of Veterans’ Appeals (Board) on appeal from February 2014 and April 2014 rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in Winston-Salem, North Carolina. In an April 2017 rating decision, the RO granted an increased disability rating for cervical degenerative joint disease to 30 percent, effective October 28, 2016, and granted service connection for neuropathy of the left upper extremity with a disability rating of 30 percent, effective October 28, 2016. In September 2020, the RO assigned earlier effective date of April 4, 2013 for a 30 percent rating for the cervical spine and for service connection and 30 and 20 percent ratings for the left and right upper extremity neuropathy. Although the RO has granted higher disability ratings, the claims remain in controversy because the Veteran is not in receipt of the maximum benefit allowable. See A.B. v. Brown, 6 Vet. App. 35 (1993). The Board remanded the appeal for additional development in October 2018. Since the October 2018 Board remand the remand requirements has been substantially complied. Stegall v. West, 11 Vet. App. 268, 271 (1998). Service Connection The Veteran contend that the symptoms requiring a post-service hysterectomy were incurred in, aggravated by, or otherwise attributable to, active duty service. Competent medical evidence is evidence provided by a person who is qualified through education, training, or experience to offer medical diagnoses, statements, or opinions. Competent medical evidence may also include statements conveying sound medical principles found in medical treatises. It also includes statements contained in authoritative writings, such as medical and scientific articles and research reports or analyses. 38 C.F.R. § 3.159(a)(1). Competent lay evidence is any evidence not requiring that the proponent have specialized education, training, or experience. Lay evidence is competent if it is provided by a person who has knowledge of facts or circumstances and conveys matters that can be observed and described by a lay person. 38 C.F.R. § 3.159(a)(2). This may include some medical matters, such as describing symptoms or relating a contemporaneous medical diagnosis. Jandreau v. Nicholson, 492 F. 3d 1372 (Fed. Cir. 2007); Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011). If the evidence is competent, the Board must then determine if the evidence is credible. Barr v. Nicholson, 21 Vet. App. 303, 308 (2007). After determining the competency and credibility of evidence, the Board must then weigh its probative value. In this regard, the Board may properly consider internal inconsistency, facial plausibility, and consistency with other evidence submitted on behalf of the claimant. Caluza v. Brown, 7 Vet. App. 498, 511 (1995). In determining whether service connection is warranted for a disability, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the veteran prevailing in either event, or whether a preponderance of the evidence is against the claim, in which case the claim is denied. 38 U.S.C. § 5107; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination, the benefit of the doubt is afforded the claimant. In order to establish service connection on a direct basis, the record must contain competent evidence of: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303; Shedden v. Principi, 381 F. 3d 1163, 1167 (Fed. Cir. 2004). Disorders diagnosed after discharge will still be service connected if all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d); see also Combee v. Brown, 34 F. 3d 1039, 1043 (Fed. Cir. 1994). Hysterectomy In January 1989, service treatment records (STRs) showed that the Veteran reported severe cramps and vaginal bleeding and that the Veteran's pregnancy was complicated by severe hyperemesis. See May 2001 STR-Medical, p.35. In July 1990, a clinician indicated that the Veteran was 20 weeks pregnant. See May 2001 STR-Medical, p.20. In a February 1991 report of medical periodic examination, the Veteran reported a history of excessive bleeding. See May 2001 STR-Medical, p.62. In July 1996, the Veteran had a laparoscopic tubal sterilization procedure. See May 2001 STR-Medical, p.65. In a November 1998 STR, a clinician noted that the Veteran had a tubal litigation in July 1997. The Veteran was examined for abnormal vaginal bleeding. See May 2001 STR-Medical, p.75. In a December 1997, a clinician noted the Veteran had irregular menses. See May 2001 STR-Medical, p.78. In May 2000, the Veteran had cytology testing, which noted benign cellular changes associated with the predominance of coccobacilli consistent with a shift in vaginal flora. See May 2001 STR-Medical, p.11. In an October 2000 physical examination, the Veteran reported that she was treated for a gynecological disorder and had a change in menstrual pattern. See May 2001 STR-Medical, p.5. In a March 2001 pre-discharge VA examination report, the examiner indicated that the Veteran underwent uterine surgery one year earlier due to an abnormal pap smear; no complications were noted. The report further referenced a 1996 tubal ligation, which also "went well" without complication. See March 2001 VA Examination, p.2. In addition, the examiner noted that the Veteran had been on medication for hypertension for one year. She endorsed symptoms of lightheadedness, blurred vision, muscle cramps, and constipation, which she noted may be related to her prescribed Verapamil. See March 2001 VA Examination, p.3. In February 2004, the Veteran underwent a transabdominal pelvic ultrasound that showed a "question" of early fibroid formation of the uterus. See August 2013 Medical Treatment Record-Government Facility, p.1. In an August 2005 ultrasound identified a possible small fibroid. See August 2013 Medical Treatment Record-Government Facility, p.2. In an August 2005 VA treatment note, a radiologist noted that a fibroid was noted on a February 2004 ultrasound and the Veteran had a family history of ovarian cancer. The radiologist found that the endometrium was thickened, which was likely related to an overdue menstrual cycle. See Capri, p.53. In February 2007, the Veteran endorsed a history of irregular menses since the age of 21. See August 2013 Medical Treatment Record-Government Facility, p.2. A May 2008 pelvic echogram showed a small fundal fibroid and right ovarian follicular cyst. See August 2013 Medical Treatment Record-Government Facility, p.4. A September 2010 endovaginal ultrasound identified a uterine fibroid. The diagnostic report indicated that the fibroid was in a submucosal and "probably" contributed to the abnormal bleeding history. See August 2013 Medical Treatment Record-Government Facility, p.12. In September 2010, the clinician noted the Veteran had a history of dysmenorrhea and fibroids. The clinician stated that on a 2008 exam there was a small fundal fibroid, right ovarian follicular cyst. The fibroid was 5 centimeters. The clinician indicated that the Veteran had a uterine fibroid and that her ovaries were difficult to evaluate on the ultrasound. The clinician also noted that the fibroid probably contributed to her the abnormal bleeding history. See September 2020 Capri, p.48. In June 2011, the Veteran underwent endometrial ablation. See August 2013 Medical Treatment Record-Government Facility, p.22. In April 2012, the Veteran had a total vaginal hysterectomy and cystoscopy. The physician indicated that prior to surgery and after surgery the Veteran had a diagnosis of menorrhagia after endometrial ablation. The physician also indicated that the Veteran’s ovaries appeared normal and the cystoscopy at end of the procedure revealed bilateral ureteral spill with no evidence of bladder injury. See September 2020 Capri, p.11. In March 2014, the evidence of record reflects the Veteran was afforded a VA gynecological examination. The examination report referenced the Veteran’s reports of fibroids, excessive bleeding, and hysterectomy in 2012. The VA examiner reported, however, that the Veteran did not have any current symptoms related to a gynecological condition. The Board notes that the VA examiner reported that the Veteran underwent natural menopause. Although the VA examiner noted that the Veteran did not have any current symptoms, the examination report indicated that the Veteran had urinary incontinence and leakage due to her hysterectomy. The VA examiner further reported that the Veteran was diagnosed with endometriosis, but did not have any current findings, signs, or symptoms due to the condition. The VA examiner opined that the Veteran’s hysterectomy is less likely than not incurred in or caused by the claimed in-service injury, event, or illness. The VA examiner noted that the hysterectomy was due to uterine fibroid treatment, which reportedly occurred after separation from service in 2001. In April 2014, an addendum VA opinion was obtained. The VA examiner agreed with the March 2014 VA examiner and opined that the Veteran’s hysterectomy was less likely as not due to a condition (including abdominal and pelvic pain, abnormal vaginal bleeding, irregular menses, and frequent urination) that had its onset in service. The April 2014 VA examiner noted that the Veteran had abdominal and pelvic pain, abnormal vaginal bleeding, irregular menses, and frequent urination in service in 1989. The VA examiner further indicated that she had no diagnosis of ovarian fibroid. Post-service, the VA examiner indicated that the Veteran developed a fibroid in 2004, and was diagnosed with a fibroid on her ovary in 2008, and thereafter underwent a hysterectomy for fibroid in 2012. The VA examiner indicated that the Veteran’s fibroid did not develop until 2004 after separation from service, and that the abdominal and pelvic pain, abnormal vaginal bleeding, irregular menses, and frequent urination did not cause the hysterectomy, but rather the cause for the hysterectomy was an ovarian fibroid. In November 2019, the Veteran was afforded a gynecological conditions VA examination. The examiner reviewed the claims file; considered the Veteran’s reports, and conducted an evaluation. The examiner noted that the Veteran had a diagnosis of status post hysterectomy from 2012. The examiner indicated that there was an unknown etiology for the abnormal vaginal bleeding. The Veteran was diagnosed before her hysterectomy with menorrhagia and after endometrial ablation. The Veteran reported that her monthly cycles got heavier after her last child in November 1990; she had severe abdominal cramping and her cycles lasted up to 10-11 days. The examiner found that it was less likely than not the hysterectomy was caused or aggravated by service. The rationale was that due to the Veteran’s records being silent regarding abnormal vaginal/ uterine bleeding from 1998 to 2003 a nexus could not be established to prove that the issue was chronic at time. In a March 2020 Women’s Health exam, the Veteran reported that her maternal aunt had ovarian cancer. The Veteran also noted that she gave birth to two children, with her first pregnancy at the age of 20; and had no abortions or miscarriages. See September 2020 Capri, p. 92. The Veteran and her lay informants contend that the residuals of a hysterectomy and a bladder disorder were incurred in, aggravated by, or otherwise attributable to, service. However, as lay persons, these parties lack the specialized medical training and expertise in the fields of podiatry, gynecology, and/or urology to render diagnoses, etiological opinions, or theories of medical proximate causation. See Jandreau, supra. Therefore, this lay evidence warrants less probative weight. The Board assigns significant probative to the VA examination and opinion, as discussed above. The physician reviewed the claims file; considered the Veteran's reports and conducted an evaluation. Moreover, the respective examiner rendered an opinion based in evidence and medical information. The Board recognizes that some clinical comments suggested that fibroids contributed to the bleeding problems, but these comments did not indicate that the fibroids were present in service. The earliest clinical indication of fibroids was in 2004. The Board assigns probative weight to the November 2019 VA examination. As to the respective etiology of hysterectomy, the examiner provided a negative nexus opinion as to direct service connection. The Board also places weight on the VA clinical records that show symptoms and treatment for early fibroids and heavy bleeding, before the hysterectomy. The Veteran is competent to report that a physician told her that the gynecological disorders and causes of the hysterectomy. The report of this opinion warrants less weight because the basis for it other than a general report of lifting associated with military duties is not of record. Here, the Veteran sincerely believes that that the need for her hysterectomy was incurred in, aggravated by, or otherwise attributable to, service. However, the weight of competent evidence fails to support the Veteran's beliefs. The preponderance of the evidence is against the Veteran's service connection claims; there are no doubts to be resolved. See 38 U.S.C. § 5107(b); Gilbert, supra. Increased Ratings Disability evaluations are determined by the application of a schedule of ratings that is based on average impairment of earning capacity. 38 U.S.C. § 1155. Percentage evaluations are determined by comparing the manifestations of a particular disorder with the requirements contained in the VA's Schedule for Rating Disabilities (Rating Schedule), 38 C.F.R. Part 4. The percentage ratings contained in the Rating Schedule represent, as far as can practically be determined, the average impairment in earning capacity resulting from such disease or injury and their residual conditions in civilian occupations. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. VA has a duty to acknowledge and consider all regulations which are potentially applicable through the assertions and issues raised in the record, and to explain the reasons and bases for its conclusion. The Veteran's entire history is reviewed when making a disability determination. See 38 C.F.R. § 4.1. VA must consider whether the Veteran is entitled to "staged" ratings to compensate when his or her disability may have been more severe than at other times during the course of his or her appeal. The evaluation of the same disability under various diagnoses, known as pyramiding, is generally to be avoided. 38 C.F.R. § 4.14. The critical element in permitting the assignment of several ratings under various DCs is that none of the symptomatology for any one of the disabilities is duplicative or overlapping with the symptomatology of the other disability. See Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994). If there is a question as to which evaluation to apply to the Veteran's disability, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. 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). Cervical Degenerative Joint Disease (Neck) The General Rating Formula for Diseases and Injuries of the Spine provides a 10 percent disability rating for forward flexion of the cervical spine greater than 30 degrees but not greater than 40 degrees; or, combined range of motion of the cervical spine greater than 170 degrees but not greater than 335 degrees; or, muscle spasm, guarding, or localized tenderness not resulting in abnormal gait or abnormal spinal contour; or, vertebral body fracture with loss of 50 percent or more of the height. A 20 percent disability rating is assigned for forward flexion of the cervical spine greater than 15 degrees but not greater than 30 degrees; or, the combined range of motion of the cervical spine not greater than 170 degrees; or, muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. A 30 percent disability rating is assigned for forward flexion of the cervical spine 15 degrees or less; or, favorable ankylosis of the entire cervical spine. A 40 percent disability rating is assigned for unfavorable ankylosis of the entire cervical spine. A 100 percent disability rating is assigned for unfavorable ankylosis of entire spine. 38 C.F.R. § 4.71a. The Notes following the General Rating Formula for Diseases and Injuries of the Spine provide further guidance in rating diseases or injuries of the spine. Note (1) provides that any associated objective neurologic abnormalities, including, but not limited to, bowel or bladder impairment, should be rated separately under an appropriate DC. Note (2) provides that, for VA compensation purposes, normal forward flexion of the cervical spine is zero to 45 degrees, extension is zero to 45 degrees, left and right lateral flexion are zero to 45 degrees, and left and right lateral rotation are zero to 80 degrees. The combined range of motion refers to the sum of the range of forward flexion, extension, left and right lateral flexion, and left and right rotation. The normal combined range of motion of the cervical spine is 340 degrees. The normal ranges of motion for each component of spinal motion provided in this note are the maximum that can be used for calculation of the combined range of motion. See also Plate V, 38 C.F.R. § 4.71a. 38 C.F.R. § 4.71a. Spine conditions can also be rated under the criteria for intervertebral disc syndrome, DC 5243. DC 5243 provides a 10 percent disability rating for intervertebral disc syndrome with incapacitating episodes having a total duration of at least one week but less than 2 weeks during the past 12 months; a 20 percent disability rating for intervertebral disc syndrome where incapacitating episodes have a total duration of at least 2 weeks but less than 4 weeks during the past 12 months. A 40 percent rating is warranted where incapacitating episodes have a total duration of at least 4 weeks but less than 6 weeks during the past 12 months. "Incapacitating episodes" is defined in Note (1) as a period of acute signs and symptoms due to intervertebral disc syndrome that requires bed rest prescribed by a physician and treatment by a physician. Note (2) also allows the Veteran to be rated separately for musculoskeletal and neurological manifestations under appropriate DCs if it would result in a higher combined evaluation for the disability. Evidence The Veteran contends that she is entitled to a higher rating for her cervical degenerative joint disease. The Veteran's neck disability is rated 10 percent disabling prior to April 4, 2013, and as 30 percent disabling from that date. The Veteran’s neck disability is rated under DC 5242. She contends that her neck disability is more severe than currently rated. In a June 2005 physical therapy note, the Veteran was seen for left cervical area pain. The Veteran stated the pain had been present for several years with stiffness and rated her neck pain a 6/10. However, the Veteran denied any numbness. The physical therapist found moderate muscle spasm in left upper trapezius and the range of motion in the neck was within normal limits. See December 2015 Capri, p.296. In March 2014, the Veteran was afforded a VA neck (cervical spine) examination. The examiner did not review the Veteran’s claims file. The examiner noted the Veteran had a diagnosis of cervical degenerative joint disease. The Veteran reported that the pain had gotten worse with turning her head to the left and there was numbness and tingling in her hands and fingers. The Veteran reported flareups. She indicated that she was unable to grasp tightly. The initial range of motion testing revealed forward flexion of 45 degrees or greater but there was no objective evidence of painful motion. The examiner was able to perform repetitive use testing, but there was no additional loss of function. There was no evidence of pain on weight bearing or localized tenderness or pain on palpation. Muscle strength testing was normal. There was no muscle atrophy, sensory exam was normal; there was no signs of radicular pain and no other abnormalities. There was no IVDS of the cervical spine, and the Veteran did not use any assistive devices. The condition did not impact the Veteran’s ability to work. The examiner indicated that he was unable to tell that pain, weakness, fatigability or incoordination significantly limited functional ability with repeated use over a period of time; without mere speculation as all the measurements were the same on the examination. In a July 2014 VA treatment note, there was full range of motion of the neck was noted on physical examination. See October 2015 Capri, p.65. In August 2014, the Veteran endorsed chronic radicular pain in her neck to her right upper extremity. She described it as a recurrent, "electricity type" sensation shooting from her posterior neck down her right arm to her right hand and with associated cramping and tingling sensations of her right thumb and right second digit. See October 2015 Capri, p.55. In September 2014, the Veteran reported neck pain radiating down her right arm. See October 2015 Capri, p.45. Upon physical examination in January 2016, the Veteran displayed reproducible moderate pain over the contralateral sternocleidomastoid (SCM) muscle upon lateral rotation to either side with restricted range of motion due to pain, and reproducible mild to moderate pain with forward flexion but not with extension. See December 2016 Capri, p.115. A March 2016 magnetic resonance imaging testing (MRI) of the cervical spine showed multilevel degenerative disc disease with disc and osteophyte complex posterolaterally at C5 to C6, posterolateral hypertrophy at C6 to C7, minimal disc bulge at C4 to C5, tiny left paracentral protrusion at C3 to C4, and multilevel foraminal narrowing. See December 2016 Capri, p.85. A July 2016 physical examination noted reduced range of motion with lateral rotation to right and associated right neck pain, and mild trigger point tenderness to palpation over the right trapezius muscle. See December 2016 Capri, p.69. In August 2016, the Veteran reported constant neck pain radiating to the left arm, constant tingling and numbness in the left hand and all fingertips. See December 2016 Capri, p.50. An October 2016 physical examination noted full range of motion of the neck. See December 2016 Capri, p.22. In December 2016, the Veteran endorsed constant neck pain radiating to the bilateral shoulder and the left arm. Upon physical examination, the Veteran exhibited poor effort for the strength examination due to pain. Tenderness was also observed in the left shoulder trapezius muscle. The Veteran was assessed with deep cervical neuropathy and cervicalgia. See January 2017 Capri, p.1. In April 2017, the Veteran was afforded a VA neck (cervical spine) examination. The examiner did not review the Veteran’s claims file. The examiner noted the Veteran had a diagnosis of cervical degenerative joint disease and radiculopathy. The Veteran reported flareups of the cervical spine. She indicated that she had chronic neck pain and stiffness, that occurred more in the morning. The Veteran described the pain as a pricking sensation and burning feeling down the left arm. She also stated that there was weakness in the left hand, right shoulder swelling and a numb feeling that radiated down her right arm to small finger. The initial range of motion testing revealed forward flexion of 10 degrees; extension to 5 degrees; right lateral flexion to 10 degrees; left lateral flexion to 15 degrees; right lateral rotation to 5 degrees and left lateral rotation to 10 degrees. The examiner noted that range of motion contributed to functional loss, when she is pushing, pulling, carrying and driving. There was evidence of pain on weight bearing and moderate evidence of localized tenderness or pain on palpation. Pain noted on the examination caused functional loss. The examiner was able to perform repetitive use testing and there was no additional loss of function after three repetitions. The examiner indicated that he was unable to tell that pain, weakness, fatigability or incoordination significantly limited functional ability with repeated use over a period of time; without mere speculation as all the measurements were the same on the examination. Muscle strength testing was a 5/5 at all vectors. The Veteran did not have muscle atrophy but there was radicular pain or any other symptoms due to radiculopathy. The examiner noted that there was moderate intermittent pain of the left upper extremity and moderate paresthesias and/ or dysesthesias of the of the left upper extremity. Overall radiculopathy was mild and located on the left side. There was no ankylosis of the spine or IVDS. The Veteran reported using a brace regularly as assistive devices. The condition also impacted her ability to work when pushing, pulling, lifting, driving or carrying things. The VA examiner noted objective evidence of pain on passive range of motion testing of the neck, and objective evidence of pain on non-weight bearing testing of the neck. In February 2018, the Veteran underwent a magnetic resonance imaging study (MRI). The examiner determined that there was no acute fracture or listhesis; unchanged moderate multilevel degenerative disc disease; unchanged mild articular pillar degenerative osseous overgrowth and unchanged mild bilateral C6-C7 neural foraminal narrowing. See November 2018 Capri, p.30. In May 2019, the Veteran underwent an MRI of the spine. The physician found that the cervical spine demonstrated straightening of the normal cervical lordosis. There was no fracture or swelling but there was mild facet arthropathy at C7-T1. The physician further stated that there were mild degenerative changes throughout the spine. See September 2020 Capri, p.7. In a July 2019 private examination, a clinician noted the cervical spine motion was normal. See July 2019 Medical Treatment Record-Non-Government Facility, p.12. Prior to April 4, 2013 The Board finds that the weight of competent and credible evidence is against a rating in excess of 10 percent for the cervical spine disability for the period prior to April 4, 2013. The Board acknowledges the Veteran's lay reports of symptoms and that there was functional loss. However, even considering the Veteran's lay reports of symptoms and noted functional loss, the degree of limitation would not result in limitation of motion more nearly approximating forward flexion of the cervical spine to 30 degrees or less; or combined range of motion of the cervical spine not greater than 170 degrees. The Veteran's functional loss was considered, as the various VA medical records shows that the Veteran has reported ongoing chronic neck pain. 38 C.F.R. §§ 4.40, 4.45. However, various VA clinicians took limitation caused by pain into account in the findings of range of motion. Thus, the degree of limitation caused by pain is already contemplated in the disability rating currently assigned. There was no evidence in the medical records of further functional loss due to lack of endurance, fatigability, incoordination, or repetition. There is otherwise no evidence of impairment of motor skills, muscle function, or strength. Consequently, the Board finds that a higher rating based on functional loss is not warranted. The Board notes DC 5003 provides for ratings for degenerative disc disease or arthritis. DC 5003 is used where there is evidence of arthritis and some limitation of motion, but not enough limitation of motion to be compensable under the appropriate DC. As discussed above, the Veteran's disability rating under DC 5237-5242 has been based on limitation of motion and a separate rating under DC 5003 would be for the same symptomatology. As separate ratings may not be assigned for the same symptomatology, a separate 10 percent rating under DC 5003 for the Veteran's limitation of motion is not warranted in this case. Regarding neurological impairment, the lay and medical evidence of record is against a finding that the Veteran has any other neurological abnormality associated with his spine disability. For the foregoing reasons, the weight of competent and credible evidence is against the Veteran's claim for a rating in excess of 10 percent for the Veteran's cervical spine disability for the period prior to April 4, 2013. Furthermore, the Board concludes that this rating is warranted for the entire appellate time period prior to April 4, 2013, and, as such, further staged ratings are not warranted. 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. From April 4, 2013 The Board finds that the weight of competent and credible evidence is against a rating in excess of 30 percent for the cervical spine disability from April 4, 2014. The Board acknowledges the Veteran's lay reports of symptoms and that there was functional loss. However, even considering the Veteran's lay reports of symptoms and noted functional loss, the degree of additional limitation does not result in unfavorable ankylosis of the entire spine. According to the April 2017 VA examination, at most forward flexion of the cervical spine was 10 degrees (15 degrees or less). The examiner also noted painful motion on examination, which is already contemplated in the rating currently assigned. The Veteran's functional loss was considered, as the medical evidence shows that the Veteran has reported ongoing chronic neck pain. 38 C.F.R. §§ 4.40, 4.45. However, the examiner took limitation caused by pain into account in the findings of range of motion. Thus, the degree of additional limitation caused by pain is already contemplated in the disability rating currently assigned. The examiner found no evidence of further functional loss due to lack of endurance, fatigability, incoordination, or repetition. There is otherwise no evidence of impairment of motor skills, muscle function, or strength. Consequently, the Board finds that a higher compensable rating based on functional loss is not warranted. As discussed above, the Veteran's disability rating under DC 5242 has been based on limitation of motion and a separate rating under DC 5003 would be for the same symptomatology. As separate ratings may not be assigned for the same symptomatology, a separate 10 percent rating under DC 5003 for the Veteran's limitation of motion is not warranted in this case. Regarding neurological impairment, the lay and medical evidence of record is against a finding that the Veteran has any other neurological abnormality associated with his spine disability. For the foregoing reasons, the preponderance of the evidence is against the Veteran's claim for a rating in excess of 30 percent for the Veteran's cervical spine disability. Furthermore, the Board concludes that this rating is warranted for the entire appellate time period from April 4, 2013, and, as such, further staged ratings are not warranted. 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. Right and Left Upper Extremity Neuropathy The Veteran contends that she is entitled to a higher rating for her bilateral upper extremity neuropathy. The Veteran has been assigned a 20 percent rating under Code 8511 for the right upper extremity neuropathy and 30 percent for left upper extremity neuropathy. For such nerve impairment, a 70 percent rating (for major, 60 percent for minor) is warranted for complete paralysis (all intrinsic muscles of hand, and some or all of flexors of wrist and fingers, paralyzed (substantial loss of use of hand); a 50 percent rating (for major, 40 percent for minor) is warranted for severe incomplete paralysis; a 40 percent rating (for major, 30 percent for minor) is warranted when incomplete paralysis is moderate; and a 20 percent rating is warranted when it is mild. 38 C.F.R. § 4.124a, Code 8511. In February 2017, the Veteran was afforded a peripheral nerve conditions VA examination. The examiner noted the Veteran’s report that there was constant pain in the right upper extremity that was severe and moderate constant pain in the left upper extremity. The examiner also noted the Veteran’s report that there was moderate paresthesias and/ or dysesthesias in the right upper extremity and mild in the left upper extremity. However, on examination, muscle strength, reflexes, and sensory response of both upper extremities was normal. Overall, the examiner found mild incomplete paralysis of the right upper extremity (median nerve) and mild incomplete paralysis of the left upper extremity (median nerve). In December 2019, the Veteran was afforded another peripheral nerve condition examination. However, the examination focused on the lower extremities and the examiner found the upper extremity nerves and radicular groups to be normal at all vectors bilaterally. Although the Veteran reported moderate to severe pain and dysfunction of the upper extremities, the examiner’s findings and assessments are less severe. The VA examination report and treatment records do not show symptoms of, or impairment due to, left upper or right upper extremity neuropathy were of greater severity than that consistent with mild incomplete paralysis of the nerve. Resolving any doubt in the Veteran’s favor, the current ratings are preserved but the level of dysfunction does not warrant a rating in excess of 20 percent of the right upper extremity and 30 percent for the left upper extremity. The February 2017 examiner indicated that upper extremity peripheral neuropathy testing showed mild incomplete paralysis bilaterally. Therefore, symptoms or impairment characteristic of moderate incomplete paralysis of upper extremity radicular group nerve were not shown, and a schedular rating in excess of 20 percent for the right upper extremity and 30 percent for the left upper extremity is not warranted. Hypertension The Veteran contends she is entitled to a compensable rating for hypertension. The Veteran's service-connected hypertension is currently rated as noncompensable under 38 C.F.R. § 4.104, Diagnostic Code 7101. All references to blood pressure measurements are systolic divided by diastolic systolic pressure in millimeters of mercury (mmHg). Under 38 C.F.R. § 4.104, Diagnostic Code 7101, for hypertensive vascular disease (hypertension and isolated systolic hypertension), the criteria for a compensable (10 percent) rating are diastolic pressure is predominantly is 100 or more, or systolic pressure is predominantly 160 or more, or there is a history of diastolic pressure predominantly 100 or more requiring continuous medication for control. A 20 percent rating is assigned when diastolic pressure is predominantly 110 or more, or systolic pressure is predominantly 200 or more. A 40 percent evaluation is provided with diastolic pressure predominantly 120 or more. A maximum scheduler evaluation of 60 percent is provided when there is diastolic pressure predominantly 130 or more. In every instance where the schedule does not provide a zero percent evaluation for a diagnostic code, a zero percent evaluation shall be assigned when the requirements for a compensable evaluation are not met. 38 C.F.R. § 4.31. In the current rating decision on appeal (April 2016), the RO granted service connection for hypertension, assigning a noncompensable rating, effective December 08, 2015. In considering pertinent records and applying the criteria to the facts of the case, the Board finds that the evidence does not show that the Veteran's hypertension approximates the criteria for a 10 percent rating for the period considered in this appeal. She is not shown to have a condition in which systolic pressure is predominantly 160 or more, diastolic pressure was predominantly 100 or more, or that he had a history of diastolic pressure that was predominantly 100 or more for which he needed continuous medication to control it. The pertinent medical records, consisting of service treatment records and VA records, show that the Veteran has consistently taken medication for control of high blood pressure. However, his diastolic pressure during the period considered in this appeal was not predominantly 100 or more. On isolated occasions it was over 100, but the predominant number of readings reflect diastolic pressure less than 100, and sometimes far below 100. Moreover, systolic pressure, while on isolated occasions it was over 160, still remained below or well below 160 on most occasions during the period considered in this appeal. In a July 2003 VA treatment record, the Veteran’s blood pressure was 115/78. See February 2014 Capri, p.25. In a October 2003 VA treatment record, the Veteran’s blood pressure was 126/80. See February 2014 Capri, p.27. In a September 2010 VA treatment record, the Veteran’s blood pressure was 130/62. See February 2014 Capri, p.24 VA outpatient treatment records document the Veteran's blood pressure at 123/75 in June 2012, 182/92 in December 2012, 179/112, 174/101, and 166/102 in October 2013, and 166/92, 152/92, and 148/90 in February 2014. See April 2014 Medical Treatment Record-Government Facility, p.2. In an October 2013 VA treatment record, the Veteran was seen for blood pressure concerns. The Veteran was given three readings: 179/112; 174/101 and 166/102. See April 2014 Medical Treatment Record-Government Facility, p.5. In December 2013, the Veteran was afforded a VA hypertension examination. The examiner noted that the Veteran had a diagnosis of hypertension, which was diagnosed in 2013. The Veteran’s treatment plan included taking continuous medication for hypertension; the examiner noted that the Veteran did not have a history of diastolic blood pressure elevation to predominantly 100 or more. At the time of the examination, the Veteran underwent three blood pressure readings: 138/88; 138/88; and 138/90. The Veteran’s hypertension did not impact the Veteran’s ability to work. Accordingly, while the record notes a history of some diastolic readings of 100 or above, the readings are predominantly below 100, and while at times his systolic pressure was over 160, the majority of the time it was below or well below 160. Therefore, the Board concludes that entitlement to a compensable rating for the Veteran's hypertension is not warranted. As the preponderance of the evidence is against assigning a higher rating, the benefit of the doubt rule is not for application. In this case, the Veteran has not contended, and the evidence does not suggest, that she has experienced symptoms outside of those listed in the schedular criteria. See Doucette v. Shulkin, 28 Vet. App. 366 (2017) (the Board is not obligated to analyze whether remand for referral for extraschedular consideration is warranted if 38 C.F.R. § 3.321 (b)(1) is neither specifically sought by the claimant nor reasonably raised by the facts found by the Board). J.W. FRANCIS Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board E. Long-Ellis, 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.