Citation Nr: 21007806 Decision Date: 02/10/21 Archive Date: 02/10/21 DOCKET NO. 16-35 976 DATE: February 10, 2021 ORDER For the appellate period prior to January 9, 2020, a 20 percent rating, but no higher, for the left upper extremity weakness with reduced hand dexterity/coordination due to a cerebral vascular accident (CVA) is granted. Beginning January 9, 2020, a rating higher than 20 percent for left upper extremity weakness with reduced hand dexterity/coordination due to a CVA is denied. For the appellate period prior to January 9, 2020, a 20 percent rating, but no higher, for left lower extremity weakness is granted. Beginning January 9, 2020, a 20 percent rating, but no higher, for left lower extremity weakness is granted. REMANDED Entitlement to a separate rating for bladder symptoms, to include urinary incontinence, overactive bladder, and nocturia, as a residual of the service-connected CVA, is remanded. Entitlement to a separate rating for erectile dysfunction and/or orchalgia, as residuals of the service-connected CVA, is remanded. Entitlement to a separate rating for right leg Venus insufficiency as a residual of the service-connected CVA is remanded. Entitlement to a separate rating for obstructive sleep apnea with use of CPAP, as a residual of the CVA, is remanded. Entitlement to a rating higher than 50 percent for the psychiatric disabilities as residuals of the CVA is remanded. Entitlement to a total disability rating due to individual unemployability (TDIU) is remanded. FINDINGS OF FACT 1. During the entire appellate period, the left upper extremity CVA residuals included weakness, difficulty with hand dexterity/coordination, and left side neglect. 2. Prior to January 9, 2020, the left upper extremity CVA residuals were wholly sensory and more nearly approximated mild incomplete paralysis of the middle radicular group; these symptoms did not more nearly approximate moderate incomplete paralysis. 3. Beginning January 9, 2020, the left upper extremity CVA residuals did not more nearly approximate moderate incomplete paralysis of the middle radicular group. 4. During the entire appellate period, the left lower extremity CVA residuals included left leg weakness, left foot dragging, left side neglect, and a mildly antalgic gait; however, symptoms of left leg tingling and numbness are not shown to be CVA residuals. 5. Prior to January 9, 2020, the left lower extremity CVA residuals more nearly approximated moderate incomplete paralysis of the sciatic nerve; these symptoms did not more nearly approximate moderately severe incomplete paralysis. 6. Beginning January 9, 2020, the left lower extremity CVA residuals more nearly approximated moderate incomplete paralysis of the sciatic nerve but did not more nearly approximate moderately severe incomplete paralysis. CONCLUSIONS OF LAW 1. For the appellate period prior to January 9, 2020, the criteria for a 20 percent rating, but no higher, for the left upper extremity CVA residuals are met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.3, 4.7, 4.71a, DCs 8008-8511. 2. Beginning January 9, 2020, the criteria for a rating higher than 20 percent for left upper extremity CVA residuals have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.3, 4.7, 4.71a, DCs 8008-8511. 3. For the appellate period prior to January 9, 2020, the criteria for a rating of 20 percent, but no higher, for left lower extremity CVA residuals have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.3, 4.7, 4.71a, DCs 8008-8520. 4. Beginning January 9, 2020, the criteria for a 20 percent rating, but no higher, for left lower extremity CVA residuals have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.3, 4.7, 4.71a, DCs 8008-8520. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from February 1970 to July 1991. This matter comes on appeal before the Board of Veteran’s Appeals (Board) from a December 2014 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO). In April 2019, the Veteran testified before the undersigned Veterans Law Judge (VLJ). A copy of the transcript is of record and has been reviewed. This matter was previously before the Board in August 2019. While on remand, the RO replaced a single 10 percent rating under Diagnostic Code 8008 with several separate ratings for each CVA residual. The claim has now been returned to the Board for further appellate consideration. Preliminary Matters The Board has limited the discussion below to the relevant evidence required to support its finding of fact and conclusion of law, as well as to the specific contentions regarding the case as raised directly by the Veteran and those reasonably raised by the record. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015); Robinson v. Peake, 21 Vet. App. 545, 552 (2008); Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016). Increased Rating Claims Disability ratings are determined by evaluating the extent to which the Veteran’s service-connected disability adversely affects his ability to function under the ordinary conditions of daily life, including employment, by comparing his symptomatology with the criteria set forth in the Schedule for Rating Disabilities (Rating Schedule). 38 U.S.C. § 1155; 38 C.F.R. §§ 4.1. Each service-connected disability is rated based on specific criteria identified by Diagnostic Codes (DCs). 38 C.F.R. § 4.27. The Veteran’s entire history is to be considered when making disability evaluations. 38 C.F.R. § 4.1; Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Where entitlement to compensation already has been established and an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. Francisco v. Brown, 7 Vet. App. 55 (1994). Staged ratings are appropriate for an increased rating claim when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. Hart v. Mansfield, 21 Vet. App. 505, 509 (2007). The analysis in the following decision is therefore undertaken with consideration of the possibility that different ratings may be warranted for different time periods. If two evaluations are potentially applicable, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that evaluation; otherwise, the lower evaluation will be assigned. 38 C.F.R. § 4.7. When there is an approximate balance of positive and negative evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each such issue shall be given to the claimant. 38 U.S.C. § 5107(b); 38 C.F.R. §§ 3.102, 4.3. 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 diagnostic codes 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). In rendering a decision on appeal, the Board must analyze the credibility and probative value of the evidence, account for the evidence which it finds to be persuasive or unpersuasive and provide the reasons for its rejection of any material favorable to the claimant. Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994); Gilbert v. Derwinski, 1 Vet. App. 49, 57 (1990). A veteran is competent to report symptoms because this requires only personal knowledge, not medical expertise, as it comes through the senses. See Layno v. Brown, 6 Vet. App. 465, 470 (1994). Lay testimony is competent to establish the presence of observable symptomatology, where the determination is not medical in nature and is capable of lay observation. Barr v. Nicholson, 21 Vet. App. 303 (2007). Lay evidence may establish a diagnosis of a simple medical condition, a contemporaneous medical diagnosis, or symptoms that later support a diagnosis by a medical professional. Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). When all the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with a veteran prevailing in either event, or whether a preponderance of the evidence is against a claim, in which case, the claim is denied. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. The Veteran in this case asserts that his CVA residuals are worse than currently rated. See April 2016 hearing transcript. Hyphenated diagnostic codes are used when a rating under one diagnostic code requires use of an additional diagnostic code to identify the basis for the rating assigned. 38 C.F.R. § 4.27. Organic diseases of the central nervous system are rated pursuant to a General Rating Formula for neurological conditions and convulsive disorders. Organic diseases of the central nervous system are rated from 10 to 100 percent. 38 C.F.R. § 4.124a. DC 8008 applies to thrombosis of the brain vessels. DC 8008 provides for a disability rating of 100 percent for six months for a vascular condition. A minimum 10 percent rating is assigned thereafter for residuals. 38 C.F.R. § 4.124a, DC 8008. Prior to January 9, 2020, the left upper extremity CVA residuals were rated as a minimum 10 percent disabling under Diagnostic Code 8008 (paralysis of the middle radicular group) and 20 percent thereafter under Diagnostic Code 8008-8511. Under DC 8511, a 20 percent disability rating is warranted when the condition is mild, regardless if the afflicted hand is his dominant or non-dominant side. If the condition is “moderate,” a 40 percent disability rating is provided for the dominant hand and a 30 percent disability rating is provided for the non-dominant hand. If the condition is “severe,” a 50 percent disability rating is provided for the dominant hand, and a 40 percent rating is provided for the non-dominant hand. Complete paralysis warrants a 70 percent rating for dominant hand and 60 percent for the non-dominant hand. The Veteran’s left lower extremity CVA residuals are currently rated as 10 percent disabling under DC 8520 (paralysis of the sciatic nerve), effective January 9, 2020. No rating was assigned prior to January 9, 2020 for the left lower extremity. Under DC 8520, a 10 percent rating is assigned for mild incomplete paralysis of the sciatic nerve; 20 percent rating is assigned for moderate incomplete paralysis; a 40 percent rating is assigned for moderately severe incomplete paralysis; a 60 percent rating is assigned for severe incomplete paralysis, with marked muscular atrophy; and an 80 percent rating is assigned for complete paralysis of the sciatic nerve, where the foot dangles and drops, and there is no active movement possible of muscles below the knee, flexion of knee weakened, or (very rarely), lost. Id. Neither the Rating Schedule nor the regulations provide definitions for descriptive words such as “mild,” “moderate,” “moderately severe,” and “severe.” Sellers v. Wilkie, 30 Vet. App. 157 (2018). Rather than applying a mechanical formula, the Board must instead evaluate all the evidence to the end that its decisions are “equitable and just.” 38 C.F.R. § 4.6. The term “incomplete paralysis,” with peripheral nerve injuries, indicates a degree of lost or impaired function substantially less than the type pictured for complete paralysis given with each nerve, whether due to varied level of the nerve lesion or to the partial regeneration. When the involvement is wholly sensory, the rating should be for the mild, or at most, the moderate degree. See 38 C.F.R. § 4.124a, DCs 8510-8730. The Court held in Miller v. Shulkin that, “[a]lthough the note preceding § 4.124a directs the claims adjudicator to award no more than a 20 percent disability rating for incomplete paralysis of a peripheral nerve where the condition is productive of wholly sensory manifestations, it does not logically follow that any claimant who also exhibits non-sensory manifestations must necessarily be rated at a higher level.” 28 Vet. App. 376, 380 (2017). Here, the Veteran contends that he has had residuals affecting the left upper and lower extremities since the 2009 CVA. Turning to the evidence, a February 2014 VA treatment record noted the Veteran had normal strength (5/5) in the left upper extremity. He was slightly weaker in the left lower extremity than the right lower extremity, which the Veteran attributed to a residual deficit from the 2009 CVA. The Veteran was afforded a VA examination in January 2014. The Veteran reported that he had mild left-sided weakness in the arm and leg and difficulty with coordination. He also had left side neglect in the entire left side of his body. He was able to drive himself to the VA examination. The examiner, a physician, indicated that the Veteran’s stroke residuals had improved over time since 2009. He was currently on Plavix daily. The examiner indicated the Veteran had unrelated prostate enlargement resulting in night waking to urinate. The Veteran was right hand dominant. The Veteran reported muscle weakness in the upper and lower extremities. He also had sleep apnea that required the use of a CPAP machine. He had voiding dysfunction with urinary frequency, which consisted of daytime voiding intervals between one and two hours and nighttime awakening to void three to four times per night. He had voiding dysfunction that caused obstructed voiding, including markedly slow or weak stream and markedly decreased force of stream. The Veteran had erectile dysfunction (ED); however, the examiner found it was less likely related to the CVA. Despite this finding, the examiner also noted that the etiology of the ED was unknown. The Veteran did not have pharynx, larynx, swallowing, respiratory, or bowel conditions. He also did not experience voiding dysfunction with urine leakage or the use of an appliance. He did not have a history of recurrent symptomatic urinary tract infections. On neurological examination, the Veteran had normal speech. He had an antalgic gait due to the CVA and joint problems. Strength testing was normal (5/5) in the upper and lower extremities. His deep tendon reflexes were normal (2+) in the upper and lower extremities, and no muscle atrophy attributable to the CVA was found. He did not have benign or malignant neoplasms, metastases, or scars related to the CVA. The examiner noted the Veteran reported left upper and lower extremity weakness. but no significant weakness was found on examination. The examiner indicated the Veteran did not have psychiatric symptoms associated with the CVA. The examiner indicated the symptoms or neurological defects could be differentiated and attributed to each diagnosis. The Veteran used a cane as a normal mode of locomotion, but the examiner indicated the cane was used due to the joint problems. The Veteran’s function impairment of each extremity was not so severe that it would be equally as well served with amputation and prosthesis. A 2012 MRA with contrast study showed no evidence of significant flow-limiting stenosis in the cervical internal carotid arteries. Atherosclerotic changes with underlying multifocal narrowing was noted in the carotid siphon and both MCAs, most notable in the right MCA M1 segment with underlying at least moderate to high-grade multifocal flow limiting stenosis. The imaging study also showed dominant right vertebral artery congenitally hypoplastic right A1 ACA and near fetal origin right PCA. The evaluation of the origins both common arteries and vertebral arteries were limited due to motion. The study also showed chronic watershed type right MCA/ACA territory infarct. PFTs had not been performed, and there were no other significant diagnostic findings. The Veteran’s CVA impacted his ability to work. He had memory loss and decreased concentration. The CVA mildly affected his ability to complete chores, exercise, play sports, participate in recreational activities, and dress himself. The examiner found it did not affect the Veteran’s ability to shop, travel, feed, bathe, toilet, or groom himself. He was medically retired from his job due to the CVA in 2009. A January 2015 VA treatment record reported the Veteran had tingling that started in the left side of the lumbar spine and radiated down the left leg to the ankle. A July 2015 VA treatment record noted the Veteran had a slightly antalgic gait with decreased stance through the left lower extremity. He ambulated with a single point cane. He stood with his weight shifted to the right lower extremity, and his trunk leaned to the right. Manual muscle testing revealed weakness in the left lower extremity, which was noted to be a residual from the previous CVA. An additional July 2015 VA treatment record also noted the Veteran ambulated with a cane in the right hand due to residual left sided weakness after the stroke. See also August 2015 VA treatment records. November 2015 VA treatment records show the Veteran had pain in his feet and toes, pressure, tingling, numbness, and cramps in his legs. A February 2016 anesthesia note indicated the Veteran had left arm and leg weakness, and that he used a cane due to the prior CVA. In June 2016, the Veteran reported burning in his calves, feet, and toes. He had pain when walking, but no weakness was noted. These symptoms were related to peripheral neuropathy. He was afforded a private EMG, but he did not have the results and could not recall what the private physician had told him about the EMG. The Veteran was afforded a June 2016 VA examination for the CVA residuals. The examiner, a physician’s assistant, noted the Veteran had a CVA in June 2009. Since then, the Veteran had been in rehabilitation and recovery programs. He had mild left hand weakness and difficulty with fine motor action. He was right hand dominant. He was able to drive to the examination and typically drove 45 minutes three times per week to the VA for the MOVE program. He was able to complete 30 minutes on a stationary bicycle at the YMCA two to three times per week. He took Plavix daily. He did not have an infectious condition. The Veteran did not have pharynx, larynx, swallowing, respiratory, or bowel conditions. No sleep disturbances were noted. He also did not have a voiding dysfunction that caused urine leakage or required the use of an appliance. He did not have a history of recurrent symptomatic urinary tract infections. He reported having muscle weakness in the upper and lower extremities and a voiding dysfunction with urinary frequency and obstructed voiding, described as nighttime awakening to void three to four times per night and a slow or weak stream that was not marked. On neurological examination, the Veteran had normal speech but an antalgic gait. He ambulated with a walker. He also had orthopedic conditions in the lower extremities that contributed to the abnormal gait. He did not have ataxia, and his gait was slow and steady. Strength testing was normal (5/5) in the upper and lower extremities. Deep tendon reflexes were normal (2+) in the upper and lower extremities. The Veteran did not have muscle atrophy. The examiner indicated there was no muscle weakness in any extremity. He did not have benign or malignant neoplasms, metastases, scars, or any other pertinent physical findings, complications, conditions, signs, or symptoms related to the CVA. He did not have depression, cognitive impairment, dementia, or any other mental health conditions related to the CVA. The Veteran regularly used a cane as his normal mode of locomotion, but the examiner attributed the need for the cane to the hip and knee disabilities. The Veteran’s functioning was not so diminished as to be equally well served by amputation and prosthesis. The examiner noted the findings on the June 2012 MRA with IV contrast. The Veteran underwent a physical therapy evaluation at VA in August 2016. The Veteran had an antalgic gait with decreased stance through the right lower extremity, ambulated with a single point cane, and was independent with modified transfers and ambulation. September 2016 VA treatment records indicate the Veteran used a cane while walking. See also March 2017 and October 2018 VA treatment records. A July 2017 physical therapy consultation noted the Veteran had a 2009 CVA with left side neglect. An October 2017 VA treatment record indicated the Veteran’s 2009 CVA resulted in a gait imbalance which required a cane to ambulate. Residual neurological deficits included the left leg being weaker than the right, and left side neglect with left hand weakness involving difficulty with fine motor activity. The Veteran testified before the Board in April 2019. He had left side neglect. He could not do certain things as easily as he used to, such as tie his shoes, turn off a light switch with his left hand, or fasten buttons. He dragged his left leg when he walked, which worsened when he was tired. He also indicated he had neuropathy which caused increased pain. He was taking Tizanidine for left side neglect, tingling, and for the left leg “go[ing] dead.” A July 2019 anesthesia note indicated the Veteran had left arm and leg weakness, and that he used a cane. An October 2019 VA treatment record noted the Veteran had a mild left facial droop. The impression was that the Veteran had an old stroke with mild left sided weakness that was unchanged. A November 2019 VA treatment record indicated the Veteran had a history of a 2009 CVA. He had extremely limited activity secondary to chronic pain and the CVA. He used a walker. On physical examination, the bilateral upper and lower extremities were normal. The Veteran was afforded a January 2020 VA examination for the CVA residuals. The examiner had a prior CVA in 2009. He had weakness in his lower legs and hands, and he took Plavix. He did not have an infectious condition. He was right hand dominant. He reported muscle weakness in the upper and lower extremities. The Veteran did not have pharynx, larynx, swallowing, respiratory, or bowel conditions. No sleep disturbances were noted. He did not have voiding dysfunction causing urine leakage, urinary frequency, obstructed voiding, use of an appliance, or a history of recurrent symptomatic urinary tract infections. The examiner indicated the Veteran did not have erectile dysfunction. His speech was normal. He had an abnormal gait with left leg weakness. Strength testing was normal (5/5) on the right upper and lower extremities, and less than normal (4/5) in the left upper and lower extremities. Deep tendon reflexes were normal (2+) in the upper and lower extremities. No muscle atrophy was found. Mild left upper and moderate left lower extremity weakness was noted. No right upper or lower extremity weakness was found. The Veteran did not have malignant or benign neoplasms, scars, or other pertinent physical findings attributable to the CVA. The Veteran had depression, cognitive impairments, or other mental health conditions attributable to the CVA, but they did not cause gross impairment of the thought processes. The examiner reported the Veteran did not use assistive devices for normal mode of locomotion. Imaging studies were not conducted. No other significant diagnostic testing was performed. After an examination of the Veteran and a review of the claims file, the examiner concluded that the left lower extremity symptoms of tingling and numbness in the leg and foot were not caused by the CVA, but instead, were symptoms of the low back disability, venous insufficiency, and peripheral vascular conditions. A February 2020 private treatment record indicated the Veteran was using a cane before his most recent fall. Additional February 2020 private treatment records note that the Veteran has had left side neglect since 2009. March 2020 private treatment records show that the Veteran was independent in his activities of daily living, work, and recreation. He had no pain or limitation on ambulation. 1. Prior to January 9, 2020, a 20 percent rating, but no higher, for the left upper extremity weakness due to a CVA is granted. Initially, the Veteran was assigned a 10 percent rating for the left upper extremity weakness under Diagnostic code 8008 prior to January 9, 2020, which is the minimum rating assigned after the first 6 months following a CVA. After a review of the evidence, both lay and medical, the symptoms associated with the Veteran’s left upper extremity more nearly approximated mild incomplete paralysis of the middle radicular group affecting his strength and dexterity/coordination of this left hand. See DC 8008-8511. Although no objective signs of left upper extremity weakness or difficulty with hand dexterity/coordination were noted on examination or in treatment records prior to January 9, 2020, the Veteran as a lay person is competent to report symptoms, such as reduced weakness and difficulty with hand dexterity/coordination. Multiple notations in the VA and private treatment records clearly indicate that the Veteran experienced left side neglect after the 2009 CVA, and these records also lend credibility to the Veteran’s descriptions of his left upper extremity deficits. Thus, the Board assigns great weight to the Veteran’s lay statements. However, the left upper extremity weakness and reduced dexterity/coordination did not more nearly approximate moderate incomplete paralysis to warrant a rating higher than 20 percent. During this period on appeal, the Veteran’s symptoms were wholly sensory. Prior to the January 2020 VA examination, the Veteran’s deep tendon reflexes for the left upper extremity were normal (2+), muscle strength was normal (5/5), and no atrophy was found. Thus, the Veteran’s left upper extremity weakness, left side neglect, and difficulty with hand coordination/dexterity were no worse than mild. After construing any reasonable doubt in the Veteran’s favor, prior to January 9, 2020, the left upper extremity weakness more nearly manifested as mild incomplete paralysis, but no worse, of the middle radicular group under Diagnostic Code 8008-8511, which warrants a 20 percent rating. Finally, the Board notes that neither the Veteran nor his representative have raised any other issues, nor have any other issues been reasonably raised by the record. See Doucette v. Shulkin, 28 Vet. App. 366, 69-70 (2017) (confirming that the Board is not required to address issues unless they are specifically raised by the claimant or reasonably raised by the evidence of record). 2. Beginning January 9, 2020, a rating higher than 20 percent for left upper extremity weakness due to a CVA is denied. Beginning January 9, 2020, the Veteran’s left upper extremity weakness was rated by analogy as incomplete paralysis of the middle radicular group under 38 C.F.R. § 4.124a, DC 8008-8511. After a review of the evidence, both lay and medical, the Board finds that the left upper extremity weakness and difficulty with hand dexterity/coordination did not more nearly manifest as moderate incomplete paralysis of the left upper extremity to warrant a rating higher than 20 percent. For example, during this period on appeal, the Veteran’s deep tendon reflexes for the left upper extremity were normal (2+) and no muscle atrophy was found. Although muscle strength was reduced in the left upper extremity on examination, the weakness was no worse than mild. See January 2020 VA examination. When considering whether a higher than 20 percent rating is warranted, the Board considered that the Veteran had new objective findings of weakness during this period on appeal. As noted above, the Court has held that, although the diagnostic code requires wholly sensory symptoms be rated no worse than moderate, more than wholly sensory symptoms does not make a higher rating mandatory. Miller, 28 Vet. App. at 380. The Veteran’s description of his left upper extremity weakness has remained consistent during the appellate period, and the mild reduction in left upper extremity strength testing does not indicate a rating higher than 20 percent is warranted. As the preponderance of the evidence is against a rating higher than 20 percent for the left upper extremity CVA residuals, the benefit-of-the-doubt doctrine is not for application. 38 U.S.C. § 5107(b); 38 C.F.R. § 4.3. Finally, the Board notes that neither the Veteran nor his representative have raised any other issues, nor have any other issues been reasonably raised by the record. See Doucette v. Shulkin, 28 Vet. App. 366, 69-70 (2017) (confirming that the Board is not required to address issues unless they are specifically raised by the claimant or reasonably raised by the evidence of record). 3. Prior to January 9, 2020, a 20 percent rating, but no higher, for left lower extremity weakness is granted. The Veteran contends that he has experienced left lower extremity weakness and left side neglect causing him to drag his left leg since the June 2009 CVA. The RO did not assign a rating for left lower extremity weakness prior to January 9, 2020. After a review of the evidence, both lay and medical, the Board finds that a 20 percent rating is warranted for the left lower extremity weakness and left side neglect of the lower extremity prior to January 9, 2020 under Diagnostic Code 8008-8520. Although prior to January 9, 2020, the VA examiners did not find objective findings of left lower extremity weakness, the Veteran, as a lay person, is competent to report a reduction in strength in his left lower extremity. In addition, multiple notations in the VA and private treatment records clearly indicate that the Veteran experienced left side neglect after the 2009 CVA, and these records also lend credibility to the Veteran’s descriptions of his left lower extremity weakness. During this period on appeal, VA treatment records also occasionally note the Veteran had left lower extremity weakness when compared to the right lower extremity, although the severity of the left lower extremity weakness was not quantified. Thus, the Board assigns the Veteran’s lay statements high probative weight. VA treatment records also note the Veteran used a cane and a walker for an antalgic gait, and that he leaned to the right due. There is evidence that the use of a cane and walker was due to the CVA residuals, but there is also evidence that the cane and walker were required for the service-connected left knee and hip disabilities. After reviewing the record, the Board finds the evidence is at least in equipoise that the cane and walker were required because of the CVA residuals, to include left side neglect and left lower extremity weakness. Furthermore, it does not appear that the RO rated the left knee or hip disabilities based on the use of assistive devices for ambulation. See, e.g., August 2009 and January 2020 rating decisions. Therefore, including the use of assistive devices in rating the CVA residuals does not violate the rule against pyramiding. See Esteban, 6 Vet. App. at 261-62. The Board also considered the Veteran’s testimony that he had tingling and numbness in the left lower extremity related to the CVA. However, the January 2020 VA examiner, after reviewing the claims file and a physical examination of the Veteran, found that these symptoms were not attributable to the CVA. Instead, these symptoms were due to the Veteran’s low back, venous insufficiency, and peripheral vascular conditions. The VA treatment records are also consistent with the VA medical opinion. Therefore, the Board finds the January 2020 VA medical opinion to be adequate in this regard. Thus, the Board finds that the tingling and numbness are less likely than not residuals of the service-connected CVA. Based on the above and after construing all reasonable doubt in favor of the Veteran, the Board finds that the left lower extremity weakness more nearly approximated moderate incomplete paralysis of the sciatic nerve, which warrants a 20 percent rating prior to January 9, 2020. However, prior to January 9, 2020, the left lower extremity weakness does not more nearly approximate a rating higher than 20 percent. During this period on appeal, the Veteran’s symptoms were predominantly wholly sensory. Prior to the January 2020 VA examination, the Veteran’s deep tendon reflexes for the left upper extremity were normal (2+), muscle strength was normal (5/5), and no atrophy was found. He was able to ambulate with the use of assistive devices and drive himself to his VA appointments at last three times per week. There is no evidence he was not independent in his activities of daily living due the left lower extremity CVA residuals. Thus, the left lower extremity weakness and left side neglect was no worse than moderate prior to January 9, 2020. In summary, a 20 percent rating, but no higher, is assigned for the left lower extremity weakness prior to January 9, 2020 under Diagnostic Code 8088-8520. Finally, the Board notes that neither the Veteran nor his representative have raised any other issues, nor have any other issues been reasonably raised by the record. See Doucette v. Shulkin, 28 Vet. App. 366, 69-70 (2017) (confirming that the Board is not required to address issues unless they are specifically raised by the claimant or reasonably raised by the evidence of record). 4. Beginning January 9, 2020, a 20 percent rating, but no higher, for the left lower extremity weakness is granted. Beginning January 9, 2020, the Veteran’s left lower extremity was assigned a 10 percent rating for symptoms for mild incomplete paralysis of the sciatic nerve under Diagnostic Code 8520. After a review of the evidence, both lay and medical, the Board finds that the Veteran’s left lower extremity weakness more nearly approximated moderate incomplete paralysis of the sciatic nerve under Diagnostic Code 8008-8520 but did not more nearly approximate moderately severe incomplete paralysis. As discussed above, the Board determined that the Veteran’s left lower extremity tingling and numbness are not residuals of the service-connected CVA but have attributed his use of a cane and walker for ambulation to the CVA. During this period on appeal, muscle strength was found to be reduced in the left lower extremity on physical examination. See January 2020 VA examination. The examiner characterized the left lower extremity weakness as moderate. The left lower extremity deep tendon reflexes were normal, and no muscle atrophy was found. Thus, the Veteran’s left lower extremity weakness and left side neglect were moderate, but no worse, during this period on appeal. Although the Veteran had more than wholly sensory findings of weakness, the Court has held that more than sensory symptoms does not make a rating higher than 20 percent mandatory. Miller, 28 Vet. App. at 380. In this case, the evidence does not indicate that the left lower extremity weakness was worse than moderate. In summary, a 20 percent rating, but no higher, is assigned for the left lower extremity CVA residuals beginning January 9, 2020. Finally, the Board notes that neither the Veteran nor his representative have raised any other issues, nor have any other issues been reasonably raised by the record. See Doucette v. Shulkin, 28 Vet. App. 366, 69-70 (2017) (confirming that the Board is not required to address issues unless they are specifically raised by the claimant or reasonably raised by the evidence of record). REASONS FOR REMAND 1. Entitlement to a separate rating for bladder symptoms, to include urinary incontinence, overactive bladder, and nocturia, as residuals of the service-connected CVA, is remanded. VA treatment records from the Veteran’s treating urologist indicated that the Veteran has had urinary incontinence and overactive bladder since the 2009 CVA. See July 2015, January 2016, April 2016, May 2017, August 2017, February 2018, June 2018, December 2018, April 2019, and December 2019 VA treatment records. In December 2020, a VA urologist physician’s assistant indicated the Veteran may have “oab, possible neurogenic from stroke…” Nevertheless, the Veteran has also been diagnosed with benign prostatic hyperplasia (BPH) during the appellate period, which has similar urinary symptoms. The January 2014 and June 2016 VA examiners identified that the Veteran has urinary symptoms, including voiding dysfunction which caused urinary frequency and obstructed voiding but not leakage. However, the VA examiners did not indicate if these symptoms were residuals of the CVA and did not discuss the BPH diagnosis. Despite the extensive notations of urinary symptoms in the VA treatment records and the identification of urinary symptoms in the January 2014 and June 2016 VA examination reports, the January 2020 VA examiner did not identify urinary symptoms as residuals of the CVA or evaluate the severity of those symptoms. Because there has been no adequate VA examination for these symptoms, a rating cannot yet be assigned by the Board as it is unclear as to which symptoms are attributable to the service-connected CVA and the non-service connected BPH. As such, the January 2020 VA examination report is inadequate to decide the claim, and it also failed to comply with the Board’s previous remand directives. Barr v. Nicholson, 21 Vet. App. 303, 311 (2007); Stegall v. West, 11 Vet. App. 268, 271 (1998). On remand, the examiner should evaluate the Veteran’s urinary symptoms and determine whether they are related to the Veteran’s service-connected CVA or non-service connected BPH. If the symptoms cannot be differentiated, then they should be rated as a residual of the CVA. See Mittleider v. West, 11 Vet. App. 181 (1998). 2. Entitlement to a separate rating for ED and/or orchalgia, as residuals of the service-connected CVA, is remanded. A June 2018 VA urology treatment record indicated the Veteran has orchalgia with a history of CVA. This symptom has not been identified or evaluated on any VA examination. On remand, an addendum opinion should be obtained to determine if this is a residual symptom of the CVA and, if so, to evaluate its severity. In addition, the January 2014 VA examination report indicated the Veteran had ED but that it was less likely than not attributable to the CVA; however, the examiner also noted that the etiology of the ED was unknown. No further explanation was provided. The June 2016 VA examination did not address ED, and the January 2020 VA examination indicated the Veteran was not diagnosed with ED, despite the VA treatment records showing otherwise. December 2020 VA urology records note the Veteran was post-CVA with ED, giving some indication that the ED may be related to the CVA. On remand, an addendum opinion should be obtained to determine whether the ED is a residual of the CVA, and if so, the nature and severity of this symptom. 3. Entitlement to a separate rating for right leg Venus insufficiency as a residual of the service-connected CVA is remanded. The Veteran contends that the right leg venous insufficiency is related to the service-connected CVA. Per the Board’s remand instructions, a VA medical opinion was obtained in January 2020. The examiner concluded the right leg venous insufficiency was due to peripheral vascular causes. However, no supporting rationale was provided for this conclusion. On remand, an addendum opinion should be obtained to explain why the right leg venous insufficiency is not a residual of the service-connected CVA. 4. Entitlement to a separate rating for obstructive sleep apnea with use of CPAP as a residual of the CVA is remanded. Per the Board’s August 2019 remand directive, a January 2020 VA medical opinion as to the nature and etiology of the obstructive sleep apnea was obtained. The examiner concluded that, after a review of the records, it was less likely than not that the Veteran’s sleep disturbances were residuals of the CVA. The examiner noted the Veteran had the CVA in 2009, but the Veteran did not complain of sleep disturbances until the January 2014 VA examination. He was not diagnosed with obstructive sleep apnea until 2017 by a sleep study and was prescribed a CPAP machine. The examiner concluded that the CPAP was prescribed for the sleep apnea and the sleep disturbances were in no way related to the CVA. On review, the January 2020 VA medical opinion is inadequate as it is not factually consistent with the VA treatment records. The Veteran had symptoms of daytime sleepiness and sleep disturbances prior to the January 2014 VA examination report. See, e.g., January 2011 VA treatment record. Therefore, the VA opinion is based on a faulty factual premise. In addition, although the January 2020 VA medical opinion was fully supported by a rationale as to the conclusion that the CPAP was prescribed for the obstructive sleep apnea, a rationale that the sleep apnea was not attributable to the CVA was not provided. On remand, an addendum opinion should be obtained to adequately explain whether the sleep apnea was a residual of the service-connected CVA. 5. Entitlement to a rating higher than 50 percent for the service-connected depressive disorder as a residual of the CVA is remanded. The Veteran was granted service connection for the depressive disorder in a March 2014 rating decision as a residual of the service-connected CVA and assigned a 50 percent rating effective April 8, 2013. This award was confirmed and continued in the December 2014 rating decision on appeal. The Veteran expressed disagreement as to the rating assigned to the CVA and its residuals in February 2015, which included a disagreement as to the initial rating assigned to the psychiatric disability as a residual of the CVA. Furthermore, the Veteran’s testimony at the Board hearing focused primarily on his cognitive and other psychiatric symptoms. Nevertheless, the RO did not address the severity of the service-connected psychiatric disability, to include cognitive symptoms, depression, and anxiety, in either the June 2016 statement of the case or the July 2020 supplemental statement of the case. Accordingly, a Statement of the Case must be issued and provided to the Veteran on these issues before the claim can be adjudicated by the Board. See Manlincon v. West, 12 Vet. App. 238 (1999). 6. Entitlement to a total disability rating due to individual unemployability (TDIU) is remanded. Considering the above, the issue of a TDIU is inextricably intertwined with the increased rating claims being remanded. Adjudication of TDIU must be deferred pending the proposed development. See Harris v. Derwinski, 1 Vet. App. 180, 183 (1991). The matters are REMANDED for the following action: 1. Obtain any outstanding pertinent VA treatment records and associate them with the claims file. 2. Obtain addendum opinions as to the nature and severity of the Veteran’s CVA residuals. Whether an additional physical examination is necessary is left to the discretion of the examiner. After a thorough review of the claims file, the examiner should address the following: a) Identify each CVA residual during the appellate period, whether seen on physical examination or identified in the VA or private treatment records. b) Provide an opinion, with a complete rationale, as to whether the following symptoms are residuals of the service-connected CVA. i) Urinary symptoms, to include urinary incontinence with use of pads and liners, overactive bladder, nocturia, and urgency. If possible, differentiate the urinary symptoms attributable to the service-connected CVA and the non-service connected BPH. See July 2015, January 2016, April 2016, May 2017, August 2017, February 2018, June 2018, December 2018, April 2019, December 2019, and December 2020 VA treatment records; ii) Erectile dysfunction and orchalgia. See January 2014 VA examination report and June 2018 and December 2020 VA urology treatment records; iii) Obstructive sleep apnea with CPAP; iv) Left side facial droop; and v) right leg venous insufficiency. *A complete rationale must be provided for each conclusion given. d) For each residual that is attributed to the CVA, evaluate the nature and severity under the appropriate diagnostic code (except for the left upper and lower extremity weakness which has already been adjudicated herein). (Continued on the next page)   3. Issue a statement of the case as to whether a rating higher than 50 percent is warranted for the service-connected psychiatric disability as a CVA residual. 4. Readjudicate the claims on appeal, to include whether the Veteran is entitled to a TDIU. S. B. MAYS Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board T. Harper, 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.