Citation Nr: 21007881 Decision Date: 02/11/21 Archive Date: 02/11/21 DOCKET NO. 15-01 272 DATE: February 11, 2021 ORDER Entitlement to an initial disability evaluation in excess of 30 percent prior to March 26, 2019 and an increased evaluation in excess of 50 percent thereafter for major depressive disorder, with anxiety and insomnia, is denied. REMANDED Entitlement to an initial disability evaluation in excess of 20 percent for lumbar intervertebral disc syndrome (IVDS) is remanded. Entitlement to an initial disability evaluation in excess of 20 percent for right-lower-extremity radiculopathy is remanded. Entitlement to an initial disability evaluation in excess of 20 percent for left-lower-extremity radiculopathy is remanded. Entitlement to an initial compensable disability evaluation prior to March 26, 2019 and an increased evaluation in excess of 10 percent thereafter for right-ankle sprain is remanded. Entitlement to an initial compensable disability evaluation prior to March 26, 2019 and an increased evaluation in excess of 10 percent thereafter for left-ankle sprain is remanded. Entitlement to total disability evaluation based on individual unemployability, due to service-connected disabilities (TDIU), is remanded. FINDING OF FACT The objective medical evidence shows that prior to March 26, 2019 the frequency, severity and duration of the Veteran’s symptoms of major depressive disorder, with anxiety and insomnia, more closely approximate occupational and social impairment, with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to associated symptoms. Thereafter, symptoms more closely approximate occupational and social impairment, with reduced reliability and productivity, due to associated symptoms, without spatial disorientation, or other more severe symptoms. CONCLUSION OF LAW The criteria for entitlement to an initial disability evaluation in excess of 30 percent prior to March 26, 2019 and an increased evaluation in excess of 50 percent thereafter for major depressive disorder, with anxiety and insomnia, are not met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.102, 4.1, 4.3, 4.6, 4.130, Diagnostic Code 9434 (2019). REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran had active service in the United States Air Force from May 2004 to June 2013.   Increased Schedular Ratings Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (rating schedule), found in 38 C.F.R. Part 4. When a reasonable doubt arises regarding the degree of disability, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating. 38 C.F.R. § 4.7. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107; see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). Additionally, it is possible for a veteran to be awarded separate percentage evaluations for separate periods (staged ratings), based on the facts. See Fenderson v. West, 12 Vet. App. 119, 126–27 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). The rating schedule is primarily a guide in the evaluation of disability resulting from all types of diseases and injuries encountered as a result of, or incident to, military service. The ratings are intended to compensate, as far as can practicably be determined, the average impairment of earning capacity resulting from such diseases and injuries and their residual conditions in civilian occupations. 38 U.S.C. § 1155 (2012); 38 C.F.R. § 4.1 (2018). 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; Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Consideration of the whole-recorded history is necessary so that a rating may accurately reflect the elements of disability present. 38 C.F.R. § 4.2; Peyton v. Derwinski, 1 Vet. App. 282 (1991). Where an increase in the disability rating is at issue, the present level of the veteran’s disability is the primary concern. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). Entitlement to an initial disability evaluation in excess of 30 percent prior to March 26, 2019 and an increased evaluation in excess of 50 percent thereafter for major depressive disorder, with anxiety and insomnia. The Veteran filed a Notice of Disagreement (NOD) with the July 2013 rating decision granting the above claim with an initial rating of 30 percent. VA received the NOD on June 18, 2014, by which appeal period commenced. Although the Board generally will consider evidence of record in the period of approximately one year prior to that date, the Board has also reviewed the December 2012 VA psychiatric examination report, as it is one of only two such VA examinations in the record. The Veteran’s psychiatric disorder is currently evaluated under Diagnostic Code 9434, but most psychiatric disorders, including major depressive disorder and anxiety, are evaluated under the General Rating Formula for Mental Disorders (General Rating Formula), which provides a 30 percent rating for occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, mild memory loss (such as forgetting names, directions, recent events). 38 C.F.R. § 4.130. A 50 percent evaluation requires demonstrated evidence of occupational and social impairment, with reduced reliability and productivity due to such symptoms as: a 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; and/or difficulty in establishing and maintaining effective work and social relationships. Id. A 70 percent disability rating is warranted 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 work-like setting); inability to establish and maintain effective relationships. Id. A 100 percent disability rating will be assigned 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. Id. The symptoms listed in the General Rating Formula are not intended to constitute an exhaustive list, but rather serve as examples of the type and degree of symptoms, or their effects, that would justify a rating. Mauerhan v. Principi, 16 Vet. App. 436 (2002). If the evidence demonstrates that the claimant’s psychiatric disorder produces symptoms and resulting occupational and social impairment equivalent to that set forth in the criteria for a given rating, then that rating will be assigned. Mauerhan, 16 Vet. App. at 443. Because some of the Veteran’s earlier treatment notes in the period relevant to this appeal assign a Global Assessment of Function (GAF) score under the American Psychiatric Association’s DIAGNOSTIC AND STATISTICAL MANUAL OF MENTAL DISORDERS, 4th Edition (DSM-IV), it is important to note that the GAF score is a scale reflecting the “psychological, social, and occupational functioning on a hypothetical continuum of mental health-illness.” Richard v. Brown, 9 Vet. App. 266, 267 (1996) (citing the DSM-IV). A score of 31 to 40 is assigned where there is some impairment in reality testing or communication (e.g., speech is at times illogical, obscure, or irrelevant) or major impairment in several areas, such as work or school, family relations, judgment, thinking or mood (e.g., depressed man avoids friends, neglects family, and is unable to work; a child frequently beats up younger children, is defiant at home, and is failing at school). A score of 41-50 is assigned where there are serious symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent shoplifting) or any serious impairment in social, occupational, or school functioning (e.g., no friends, unable to keep a job). A score of 51-60 is assigned where there are moderate symptoms (e.g., flat affect and circumstantial speech, occasional panic attacks) or moderate difficulty in social, occupational, or school functioning (e.g., few friends, conflict with peers or coworkers). A score of 61-70 is indicated where there are some mild symptoms (e.g., depressed mood and mild insomnia or some difficulty in social, occupational, or school functioning (e.g., occasional truancy, or theft within the household), but generally functioning pretty well and has some meaningful interpersonal relations. Turning to the record, the December 2012 VA psychiatric examination shows the Veteran, still in active service at this time, reported poor sleep patterns beginning in 2005 and resulting in depression, anxiety and chronic worry, each reported as constant at a moderate level of severity and affecting total daily functioning, resulting in daytime tiredness, trouble concentrating, worrying thoughts, poor interpersonal relations, irritability, forgetfulness, and difficulty falling asleep and maintaining sleep. He also reported in the year prior to this examination social function changes of feelings of detachment, feelings of apathy and isolation behavior, but his relationships with his supervisor and co-workers remained good. He further reported no history of violent behavior or suicide attempts. Mental status examination findings were the following: Orientation within normal limits. Appearance and hygiene are appropriate. Behavior is appropriate. Good eye contact during the examination. Affect and mood showed a disturbance of motivation and mood, mood swings, anxiety, and depressed mood. The Veteran “noted worry thoughts,” nervousness and sad moods. Communication was within normal limits. Speech was within normal limits. The Veteran showed impaired attention and/or focus. He was forgetful and needs to be concentrating. No panic attacks. No suspiciousness. No report of a history of delusions. At the time of the examination, there was no delusion observed. No report of a history of hallucinations. At the time of the examination, there was no hallucination observed. No obsessive-compulsive behavior. Thought processes were appropriate. He understands directions. No slowness of thought and he did not appear confused. Judgment is not impaired. Abstract thinking was normal. Memory was within normal limits. No suicidal ideation or homicidal ideation. The December 2012 VA examiner diagnosed the Veteran with insomnia and anxiety disorder, NOS (not otherwise specified) and depressive disorder, NOS. She noted, “The symptoms of each mental disorder cannot be delineated from each other. There is symptom overlap in poor sleep and emotional dysregulation.” She assigned a GAF score of 64, indicating some mild symptoms, such as depressed mood and mild insomnia or some difficulty in social or, occupational functioning, but generally functioning pretty well and having some meaningful interpersonal relations. In her remarks at the end of the examination report, she stated her findings of associated symptoms of depressed mood, anxiety and chronic sleep impairment. The December 2012 VA examiner’s further remarks include the Veteran, mentally, occasionally has some interference in performing activities of daily living because he has chronic sleep issues and mood reactions, but currently, he is able to establish and maintain effective work/school and social relationships. She concluded his symptoms cause occupational and social impairment, with occasional decrease in work efficiency and intermittent inability to perform occupational tasks, although generally functioning satisfactorily, with routine behavior, self-care and normal conversation. In what appears to be a private treatment psychiatric note by Dr. J.B.A. in December 2013, shows the Veteran reported depression. Mental status examination findings showed appropriate hygiene, movements within normal limits, good attitude, the Veteran was cooperative but seemed despondent and never smiled. His speech and language both were within normal limits. He appeared depressed. The Veteran exhibited a restricted affect, sad but coherent thoughts, memory within normal limits, adequate insight, and average intellect. He diagnosed major depressive disorder, moderate, recurring, and anxiety disorder, NOS. Dr. J.B.A. noted the Beck depression score was in the severe range. He assigned a GAF score of 55, indicating moderate symptoms (e.g., flat affect and circumstantial speech, occasional panic attacks) or moderate difficulty in social, occupational, or school functioning (e.g., few friends, conflict with peers or coworkers). In January 2014, now approximately 6 months since separation from active service, the Veteran visited the military medical group at which he received treatment for other disorders and reported his past treatment for anxiety and a desire to resume treatment. He appeared normal, oriented to time, place and person, with a euthymic mood and an abnormal affect, which was less reactive. He reported it is very difficult doing work, home tasks and getting along with others. His depression screening was positive. The treatment provider assessed the Veteran with depression. The Veteran’s records for his application for Social Security disability benefits include a March 2014 “Psychiatric Review Technique,” in which the examiner found the Veteran had affective disorders and anxiety-related disorder. However, both were characterized as medically determinable impairments, which did “not precisely satisfy the diagnostic criteria.” The examiner found restriction of activities of daily living was mild, difficulties in maintaining social functioning were mild, difficulties in maintaining concentration, persistence or pace were moderate, and there were no episodes of decompensation, each of an extended duration. The examiner further noted that, although the Veteran reportedly has severe mental impairments, the record of treatment up to that time showed mental status examinations generally within normal limits and the severity alleged was not supported by the evidence in the file, thereby making the Veteran only partially credible to the examiner. In the period of July 2014 through April 2015 for the Veteran’s visits to VA for mental health treatment, depression screenings, although indicating severe depression once, also showed several negative scores for depression. In an August 2014 visit to a private family clinic, the Veteran reported worsening psychiatric symptoms of insomnia, crying, as well as problems regarding mood, motivation, concentration, memory, anger, anxiety, and dreaming. However, the Social Security Office of Disability Review issued an unfavorable decision in October 2014, finding that, although having among his severe impairments was depression, the Veteran does not have an impairment or combination of impairments meeting the regulatory requirements for disability. In VA mental health notes between May and December 2015, the Veteran reported his depression was due to childhood memories, but also reported it “all has to do with my back and pain.” VA treatment notes show the Veteran’s report of feeling depressed, anxious, angry, irritable, overwhelmed, as well as experiencing poor energy, crying spells, anhedonia, and poor sleep. However, he denied any psychotic symptom or suicidal or homicidal ideations, thoughts or plans at the time of the exam, and he exhibited future-oriented thinking. Moreover, observations of his mental status and behavior showed overall normal findings. Mental status examination findings in this period showed the following: Alert, oriented to time, place, person, and situation. No abnormal movements noted. Was dressed appropriately for the climate. Speech at a normal rate, tone and rhythm. Mood: “Upset.” Affect: Dysphoric and irritable with limited range. Thought processes: Logical and linear. The Veteran denied suicidal ideation and homicidal ideation. No audio/visual hallucinations. No delusions observed. Insight was fair. Judgment was fair. Cognition appeared intact at the time of the examination. The Veteran had the ability to determine right from wrong and can anticipate the potential consequences of his actions. The treatment provider diagnosed mood disorder, secondary to chronic pain and sleep apnea. In December 2015, the treatment provider diagnosed depression, chronic depressed mood, not controlled. Between December 2015 and June 2019, depression screening test results varied between negative and moderate findings. A VA primary care note in June 2016 noted the Veteran’s depression was stable, the Veteran reported it is “a little better” and he was currently taking mirtazapine, venlafaxine and sertraline. In June 2018, the Veteran reported he thought his irritability was better than the previous year. In this period, the Veteran consistently denied suicidal ideation. In a March 2019 VA examination for mental disorders, the VA examiner diagnosed major depressive disorder, recurrent, moderate, with anxious distress and insomnia. She later noted that insomnia and anxiety are part of the Veteran’s depression and are not separate diagnoses. She found occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking and/or mood. She further found associated symptoms of depressed mood, anxiety, chronic sleep impairment, disturbances of motivation and mood, difficulty in establishing and maintaining effective work and social relationships, and difficulty in adapting to stressful circumstances, including work or a work-like setting. The March 2019 VA examiner behavioral observations were the following: “The claimant was cooperative and arrived to the exam in appropriate clothing. His speech prosody, rate and rhythm were within normal limits. He engaged appropriately with the examiner and made appropriate eye contact. He was oriented on all spheres. He indicated his mood as ‘worn out.’ His affect was tearful. No evidence of psychotic thinking was noted. His thought content and thought processing were intact. His insight and judgment were fair.” Based on the foregoing record as a whole, the December 2019 rating decision increased the rating for the Veteran’s psychiatric disorder to 50 percent. The Board notes, as did the rating decision, that the March 2019 found occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking and/or mood. Although this would indicate a 70 percent rating, the December 2019 rating decision stated the Veteran did not exhibit “a preponderance of the evidence of symptoms associated with the requirements for that evaluation.” As already stated above, the symptoms listed in the General Rating Formula are not intended to constitute an exhaustive list, but rather serve as examples of the type and degree of symptoms, of their effects or of an occupational and social impairment equivalent which would justify a higher rating. Therefore, the Board will consider when necessary whether some symptoms may be reasonably similar or analogous to the criteria associated with the higher ratings of the General Rating Formula. However, in looking to 38 C.F.R. § 4.126 (a), the Board notes that it “shall consider frequency, severity, and duration of psychiatric symptoms….” The Board understands that regulation, in its use of the phrase “shall consider,” to require consideration of such factors. See also Vasquez-Claudio v. Shinseki, 713 F.3d 112 116-17 (“Reading §§ 4.126 and 4.130 together, it is evident that the “frequency, severity, and duration” of a veteran’s symptoms must play an important role in determining his disability level”) (Fed. Cir. 2013). Consequently, in following this directive, the Board will consider the factual context regarding symptoms, that is to say, by their temporal significance and their intensity. In considering the summary of the record above and looking to those symptoms found during treatment or on examination in the period prior to March 26, 2019, as a factual determination for the purposes of adjudication, the Board does not discern symptoms, either directly or by way of analogy, indicating an occupational and social impairment at a 50 percent rating or higher. For example, although anxiety forms part of the Veteran’s diagnosis, the Veteran has never specifically reported panic attacks. Although he reported in the December 2012 VA examination that he felt detachment from others and was self-isolating, he added he worked well with both his supervisor and co-workers in the military. Subsequent treatment notes through 2019 show no further reports suggesting difficulty in establishing and maintaining effective relationships, with members of his family or otherwise. From this, it does not appear to have been an issue for the Veteran. There is no indication of impaired thought processes. Although there were some findings earlier in the appeal period of impaired concentration and focus, the record does not indicate any frequency or severity in those symptoms. The record indicates rather that the Veteran’s behavioral and mental status findings in the period were overall normal, with findings showing logical and linear thought processes. Moreover, the December 2012 VA examiner specifically found abstract thinking is normal and the Veteran can understand directions. Looking to what is reasonably suggested by or similar to the criteria for higher ratings, the strongest indicator of severity in symptomatology, and therefore justification for the highest ratings under the General Rating Formula, is suicidal ideation. The record above during the appeal period between December 2012 and March 2019 shows consistently the absence of suicidal ideation in the Veteran’s own reports and in mental status examination findings. Other criteria in ratings for 70 percent and 100 percent speak to severely impaired thought processes and communication abilities. As already stated, the record consistently contains findings showing logical and linear thought processes. The Veteran’s communication and speech abilities were consistently within normal limits. The record shows frequent reports and findings of irritability, but no instances of impaired impulse control rising to a level of severity of violence. The more severe symptoms of total occupational and social impairment are symptoms of total disability, effectively precluding independent functioning, suggested by or similar to criteria such as “gross impairment” in thought processes, communication and behavior, as well as disorientation and persistent delusions or hallucinations. Such symptoms or similar are simply not present in the record. Looking to the period from March 26, 2019, the record offers no further evidence of treatment and examination with findings to warrant a rating higher than 50 percent. For the same reasons just stated for the prior period, the record does not show reports or findings of impaired thought processes, diminished communication abilities, panic attacks, irritability culminating in violence, or suicidal or homicide ideation. There is no basis to assign a higher disability evaluation suggested by rating criteria which are not reasonably applicable to the reports and findings in treatment and on examination. For these reasons and based on the objective medical evidence, the Board finds the preponderance of the evidence does not support a disability evaluation in excess of 30 percent prior to March 26, 2019 and in excess of 50 percent thereafter. The Board has considered the benefit-of-the-doubt doctrine; however, the Board does not perceive an approximate balance of positive and negative evidence. As the preponderance of the evidence is against the claim, the doctrine is not applicable and the claim must be denied. 38 U.S.C. § 5107 (b); 38 C.F.R. § 4.3. REASONS FOR REMAND 1. Entitlement to an initial disability evaluation in excess of 20 percent for lumbar IVDS. 2. Entitlement to an initial disability evaluation in excess of 20 percent for right-lower-extremity radiculopathy. 3. Entitlement to an initial disability evaluation in excess of 20 percent for left-lower-extremity radiculopathy. 4. Entitlement to an initial compensable disability evaluation prior to March 26, 2019 and an increased evaluation in excess of 10 percent thereafter for right-ankle sprain. 5. Entitlement to an initial compensable disability evaluation prior to March 26, 2019 and an increased evaluation in excess of 10 percent thereafter for left-ankle sprain. 6. Entitlement to TDIU. The Board remanded these claims in August 2018 for new VA examinations, as the only VA examinations had been conducted in December 2012 and current findings were now necessary. However, the VA examinations for thoracolumbar spine and for ankle conditions conducted in March 2019 are inadequate for adjudication and rating purposes. The VA examiner in both examinations responded to the examination questions of whether pain, weakness, fatigability, or incoordination significantly limit functional ability with (1) flare-ups and (2) repeated use over a period of time by stating she was unable to say without “mere speculation,” explaining there is no conceptual or empirical basis on which to estimate loss of range of motion without observing function during flare-ups or during repeated use over time. Such responses have been deemed insufficient under Sharp v. Shulkin, 29 Vet. App. 26 (2017) and VA examiners must elicit from a veteran descriptions and reports from which loss of range of motion can then be estimated in actual degrees. As the December 2012 VA examinations are otherwise the sole examinations in the medical evidence of record for these claims, the Veteran must be afforded the best opportunity for the success of his claim. Additionally, a new thoracolumbar spine VA examination will also include new and current findings for radiculopathy and thereby possibly provide the Veteran with a more favorable outcome and opportunity to maximize benefits. As any decision with respect to the claims for increased disability evaluations may significantly affect a decision on the issue of entitlement to a TDIU, the issues are inextricably intertwined. A remand of the claim for entitlement to a TDIU is therefore also required and the Board will defer appellate adjudication pending further development. See Harris v. Derwinski, 1 Vet. App. 180, 183 (1991) (two issues are “inextricably intertwined” when they are so closely tied together that a final decision on one issue cannot be rendered until a decision on the other issue has been rendered). The matters are REMANDED for the following action: 1. Contact the Veteran and/or his representative for information pertaining to any current treatment for lumbar-spine disorder, to include lumbar disorder and intervertebral disc syndrome (IVDS), for right-lower-extremity radiculopathy, for left-lower-extremity radiculopathy, for right-ankle sprain, and for left-ankle sprain at any VA facility and by any private treatment provider. Obtain any records of the above treatments not yet associated with the claims file and associate them with the claims file. The assistance of the Veteran and/or his representative should be requested in obtaining any records of recent treatment as indicated. All attempts to obtain records should be documented in the claims file. 2. After all additional records have been obtained and associated with the claims file, but whether or not records are obtained, arrange for an examination conducted by a VA examiner(s), other than the March 2019 VA examiner and the April 2019 addendum VA examiner, with appropriate specialties for producing findings for lumbar-spine disorder, IVDS, lower-extremity radiculopathy, and ankle disorders. The complete electronic claims file must be made available to the examiner(s) in conjunction with the examination. The examiner(s) should detail all findings. The examiner(s) is requested to provide findings and diagnoses as to the nature, extent and current severity of service-connected lumbar-spine disorder and lumbar IVDS, service-connected right-lower-extremity radiculopathy and left-lower-extremity radiculopathy, and service-connected right and left-ankle sprains. The examiner(s) is reminded to make findings showing testing for pain, active and passive motion, in weight-bearing and non-weight-bearing maneuvers and in comparison to the opposite joint (where appropriate). If the foregoing testing is impracticable, induces discomfort or pain or is medically inappropriate, the examiner should provide an explanation as to why. The examiner(s) is specifically requested to produce findings reflecting the extent of impairment of function due to repeated use over time and due to flare-ups. If it is found that pain, weakness, fatigability, or incoordination significantly limit functional ability with repeated use over a period of time or during a flare-up, it will be insufficient for the examiner to fail to make any findings on the basis that to do so “would be mere speculation” or “there is no conceptual or empirical basis for making such a determination without directly observing function under these conditions” or similar statements. Even if flare-ups or pain on repeated use over time are neither reported nor exhibited during the examination, once again, it will be insufficient for the examiner to make entries such as “not applicable,” “would be mere speculation” or similar statements or fail make any findings whatsoever. The examiner must elicit from the Veteran details as to the actual effects, or what might be the effects, on function from repeated use over a period of time or from flare-ups when pain, weakness, fatigability, or incoordination significantly limit functional ability. After doing so, the examiner is requested for VA rating purposes to estimate the loss of range of motion and function in terms of actual degrees, using his or her professional medical training, knowledge and experience. Any opinion rendered by the examiner must be accompanied by a rationale, by which conclusions are supported by references to and discussion of findings on examination, to clinical findings in the medical evidence of record and/or to accepted medical literature. The examiner is requested to comment on all relevant opinions in the record. The examiner is further requested to acknowledge, address, consider, and discuss all lay evidence of the Veteran, as well as the Veteran’s reports to treatment providers, as they appear throughout the record, and all lay evidence of other persons, as it pertains to lumbar-spine, IVDS, radiculopathy, and ankle disorders. The Board urges the examiner to note that findings or opinions rendered without addressing and discussing any lay evidence of the Veteran and others will be deemed insufficient for purposes of VA adjudication. MICHAEL D. LYON Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board P. Franke, 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.