Citation Nr: 21008353 Decision Date: 02/16/21 Archive Date: 02/16/21 DOCKET NO. 18-15 528 DATE: February 16, 2021 ORDER Entitlement to special monthly compensation (SMC) based on housebound criteria from August 1, 2009 is dismissed as moot. For the period prior to May 9, 2012, entitlement to an initial rating for gastroesophageal reflux disorder (GERD) in excess of 10 percent is granted. For the period from May 9, 2012, entitlement to an initial rating for intestinal bowel syndrome (IBS) with gastroesophageal reflux disorder (GERD) in excess of 30 percent is denied. Entitlement an initial rating in excess of 50 percent disabling for Parkinson’s disease with severe right upper extremity tremors and mild muscle rigidity and stiffness is denied. Entitlement to an initial rating in excess of 10 percent for left upper extremity tremors with mild muscle rigidity prior to September 26, 2019 is denied. Entitlement to an initial rating in excess of 30 percent for left upper extremity tremors with mild muscle rigidity from September 26, 2019 is denied. Entitlement to an initial rating in excess of 10 percent for mild balance impairment is granted. Entitlement to an initial rating in excess of 40 percent for urinary problems is denied. Entitlement to an initial rating in excess of 30 percent for difficulty chewing and swallowing on the left side is denied. Entitlement to an initial rating in excess of 30 percent for difficulty chewing and swallowing on the right side is denied. Entitlement to an initial rating in excess of 30 percent for speech changes is denied. Entitlement to an initial rating in excess of 20 percent for right lower extremity bradykinesia with tremor and muscle rigidity and stiffness is denied. Entitlement to an initial rating in excess of 10 percent for left lower extremity bradykinesia with tremor and muscle rigidity and stiffness is denied. Entitlement to an initial rating in excess of 10 percent for right side loss of automatic movements is denied. Entitlement to an initial rating in excess of 10 percent for left side loss of automatic movements is denied. Entitlement to an initial rating in excess of 10 percent for left side stooped posture is denied. Entitlement to an initial rating in excess of 10 percent for right side stooped posture is denied. Entitlement to an initial rating in excess of 0 percent for loss of sense of smell is denied. FINDINGS OF FACT 1. In an October 2020 rating decision, the RO granted SMC from August 1, 2009. 2. For the period prior to May 9, 2012, the Veteran’s GERD was primarily manifested by persistently recurrent epigastric distress with dysphagia, dyspepsia, reflux, sleep disturbance, nausea, early satiety, bloating, and abdominal gas, accompanied by substernal pain, productive of considerable impairment of health. Material weight loss, and/or hematemesis or melena with moderate anemia or other symptom combinations productive of severe impairment of health have not been demonstrated. 3. For the period from May 9, 2012, the Veteran’s service-connected IBS with GERD was shown to be severe, with alternating diarrhea and constipation with more or less constant abdominal distress. 4. The Veteran’s Parkinson’s disease with severe right upper extremity tremors and mild muscle rigidity and stiffness is manifested with severe incomplete paralysis of the radial nerve. 5. The Veteran’s left upper extremity tremors with mild muscle rigidity and stiffness associated with his Parkinson’s Disease is, for the period prior to September 26, 2019, akin to having mild incomplete paralysis of the left upper extremity movements, and from September 26, 2019, akin to having moderate incomplete paralysis of the left upper extremity movements. 6. The Veteran’s mild balance impairment associated with his Parkinson’s Disease has been manifested by occasional staggering. 7. The Veteran’s urinary problems associated with his Parkinson’s Disease has manifested to no worse than the level of severity requiring the wearing of absorbent materials which must be changed two to four times per day. 8. The Veteran’s difficulty with chewing and swallowing associated with his Parkinson’s Disease does not approximate complete paralysis of the fifth (trigeminal) cranial nerve on the right or left during the period on appeal. 9. The Veteran’s speech changes associated with his Parkinson’s Disease do not approximate the level of disability represented by hoarseness with inflammation of the cords or mucous membranes during the period on appeal. 10. The Veteran’s right lower extremity bradykinesia with tremor and muscle rigidity and stiffness associated with his Parkinson’s Disease manifested to no worse than moderate incomplete paralysis. 11. The Veteran’s left lower extremity bradykinesia with tremor and muscle rigidity and stiffness associated with his Parkinson’s Disease manifested to no worse than mild incomplete paralysis. 12. The Veteran’s bilateral loss of automatic movements associated with his Parkinson’s Disease is equivalent to no more than moderate incomplete paralysis of the seventh cranial nerve warranting the assignment of a noncompensable rating. 13. The Veteran’s bilateral stooped posture associated with his Parkinson’s Disease is equivalent to no more than moderate incomplete paralysis of the eleventh cranial nerve. 14. The Veteran’s loss of sense of smell associated with his Parkinson’s Disease is partial. CONCLUSIONS OF LAW 1. The claim for entitlement to SMC from August 1, 2009 is dismissed as moot. 38 U.S.C. §§ 7104, 7105; 38 C.F.R. § 20.101. 2. For the period prior to May 9, 2012, the criteria for a 30 percent disability rating, but no higher, for GERD, have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.1, 4.3, 4.7, 4.114, Diagnostic Code 7346. 3. For the period from May 9, 2012, the criteria for an initial rating in excess of 30 percent, for IBS with GERD, have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.114, Diagnostic Code 7327-7319. 4. The criteria for a rating in excess of 50 percent for Parkinson’s disease with severe right upper extremity tremors and mild muscle rigidity and stiffness have not been met. 38 U.S.C. § 1155; 38 C.F.R. § 4.124a, DCs 8004-8515. 5. The criteria for an initial rating in excess of 10 percent for left upper extremity tremors with mild muscle rigidity prior to September 26, 2019 and in excess of 30 percent thereafter have not been met. 38 U.S.C. § 1155; 38 C.F.R. § 4.124a, DCs 8599-8513. 6. The criteria for a rating in excess of 10 percent for mild balance impairment has been met. 38 U.S.C. § 1155; 38 C.F.R. § 4.124a, DCs 6922-6204. 7. The criteria for entitlement to a rating in excess of 40 percent for urinary problems have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.3, 4.7, 4.115(a), 4.115(b), Diagnostic Code 7542. 8. The criteria for entitlement to a rating in excess of 30 percent for difficulty chewing and swallowing on the left and right sides have both not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.124a, Diagnostic Code 8004-8205. 9. The criteria for entitlement to an initial rating in excess of 30 percent for speech changes have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.97, Diagnostic Code 6599-6516, 4.124a, Diagnostic Code 8004. 10. The criteria for initial rating in excess of 20 percent for right lower extremity bradykinesia with tremor and muscle rigidity and stiffness have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.7, 4.124a, Diagnostic Code 8599-8520. 11. The criteria for initial rating in excess of 10 percent for left lower extremity bradykinesia with tremor and muscle rigidity and stiffness have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.7, 4.124a, Diagnostic Code 8599-8520. 12. The criteria for initial ratings in excess of 10 percent for right and left side loss of automatic movements, residual of Parkinson’s Disease, have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.7, 4.124a, Diagnostic Code 8299-8207. 13. The criteria for initial ratings in excess of 10 percent for stooped posture of the left and right sides, residual of Parkinson’s Disease, have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.7, 4.124a, Diagnostic Code 8299-8211. 14. The criteria for initial rating in excess of 0 percent for loss of sense of smell have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.7, 4.124a, Diagnostic Code 6275. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the United States Army from March 1960 to February 1961 and in the United States Marine Corps from June 1961 to May 1963. The matters are before the Board of Veterans’ Appeals (Board) from rating decisions dated February 2009, January 2012, March 2017, and September 2017. The claims were remanded by the Board in June 2019. 1. Entitlement to special monthly compensation (SMC) based on housebound criteria from August 1, 2009 is dismissed as moot. In the most recent June 2019 Board remand, the Board remanded the claim for entitlement to SMC from August 1, 2009 for further development due to a Stegall violation. Subsequently, a September 2019 VA examination was obtained. Based on the examination results, in October 2020, the RO granted SMC from August 1, 2009. Specifically, the RO granted a) entitlement to an earlier effective date for SMC based on housebound criteria being met from August 10, 2006 to September 25, 2019, b) entitlement to special monthly compensation based on aid and attendance criteria being met from September 26, 2019, and c) entitlement to additional special monthly compensation based on higher level of aid and attendance criteria from September 26, 2019. As a result of the AOJ’s action of granting SMC from August 1, 2009, there no longer remains a case or controversy with respect to the Veteran’s claim for entitlement to SMC from August 1, 2009. Thus, the Board lacks jurisdiction over this issue because it has been granted and rendered moot on appeal. 38 U.S.C. §§ 7104, 7105 (2012); 38 C.F.R. §§ 19.7, 20.101, 20.200, 20.202 (2017). As such, dismissal of this claim is warranted. Initial Ratings Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities, found in 38 C.F.R., Part 4. 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; 38 C.F.R. § 4.1. Where there is a question as to which of two evaluations shall be applied, 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. All benefit of the doubt will be resolved in the Veteran’s favor. 38 C.F.R. § 4.3. When there is an approximate balance of positive and negative evidence regarding the degree of disability, the benefit of the doubt shall be given to the veteran. See 38 U.S.C. § 5107; 38 C.F.R. § 4.3. GERD with IBS The procedural history of this claim is as follows. First, in an April 2017 rating decision, the RO granted service connection for GERD and assigned an evaluation of 10 percent, under Diagnostic Code 7346, effective August 10, 2006, and a 30 percent evaluation, under Diagnostic Code 7399-7346, effective March 29, 2016. The Veteran timely appealed the rating assignments, and the claim for an initial rating for GERD in excess of 10 percent prior to March 29, 2016, and in excess of 30 percent thereafter was remanded by the Board in June 2019 for a new examination. In the same June 2019 Board decision, the Board additionally granted service connection for irritable bowel syndrome (IBS) as secondary to Parkinson’s Disease. In a July 2020 rating decision, the RO implemented the Board’s grant and assigned a 30 percent disability rating, under Diagnostic Code 7319, effective May 9, 2012. Under 38 C.F.R. § 4.114, ratings under diagnostic codes 7346 and 7319 may not be combined with each other. Instead, a single evaluation will be assigned under the diagnostic code that reflects the predominant disability picture, with elevation to the next higher evaluation where the severity of the overall disability warrants such elevation. Thus, here, pursuant to 38 C.F.R. § 4.114, the original claim for an initial rating for GERD in excess of 10 percent (under Diagnostic Code 7346) prior to March 29, 2016, and in excess of 30 percent (under Diagnostic Code 7399-7346) thereafter, as it was characterized in the June 2019 Board remand, is now characterized as a claim for an initial rating for IBS with GERD in excess of 10 percent (under Diagnostic Code 7346) prior to May 9, 2012 and in excess of 30 percent (under Diagnostic Code 7346-7319) thereafter. The title page and this decision reflects the change in characterization. 2. An initial rating for GERD in excess of 10 percent prior to May 9, 2012 is granted. Turning to the merits of the claim, as stated above, for the period prior to May 9, 2012, the Veteran is in receipt of a 10 percent initial rating for GERD under Diagnostic Code 7346. Under Diagnostic Code 7346, a 10 percent rating is assigned for two or more of the symptoms for the 30 percent evaluation of less severity. A 30 percent rating is assigned for persistently recurrent epigastric distress with dysphagia (difficulty swallowing), pyrosis (heartburn), and regurgitation, accompanied by substernal (chest) pain, productive of considerable impairment of health. A 60 percent rating is warranted for symptoms of pain, vomiting, material weight loss and hematemesis or melena with moderate anemia; or other symptom combinations productive of severe impairment of health. Relevant Evidence An October 2006 private medical treatment from Central Texas Gastroenterology Consultants shows reports of bloating, gas, heartburn (pyrosis), and persistent regurgitation. A March 2007 VA Esophagus and Hiatal Hernia examination confirmed diagnoses of longstanding GERD, Barrett’s esophagus, and hiatal hernia. The report shows a 20+ year history of dysphagia (threat feels constricted and swallowing is sometimes difficult), heartburn (several times a day, 30 minutes after essentially all oral intake), bloating, reflux (at least daily – often waking him up at night), reflux-induced cough, and occasional (3-4 times per month) vomiting. Some weight loss was reported. A September 2007 private medical opinion from Dr. K. R. states that the Veteran has been diagnosed with chronic reflux and is taking medication. The severe reflux symptoms are due to PTSD. A May 2009 VA General Medical Examination report shows confirmation of GERD and IBS. For GERD, the Veteran reported chronic recurrent indigestion, heartburn, reflux, epigastric discomfort, and radiating chest discomfort associated with gastroesophageal reflux. Current treatment consists of daily medication. For IBS, the Veteran reported recurrent bouts of constipation and diarrhea along with dumping syndrome and abdominal cramping. A November 2010 VA Esophagus and Hiatal Hernia examination confirmed diagnoses of Barrett’s esophagus, hiatal hernia, and GERD. The report shows reports of dysphagia (occasional dysphagia for solid foods), chronic indigestion with epigastric pain on a daily basis, reflux without regurgitation on a daily basis, nausea and vomiting occurring on a daily basis with vomiting 1 or 2 times a week. The Veteran is on medication twice a day. The Veteran is retired. He is able to engage in his usual activities of daily living such as operating a motor vehicle, dressing and undressing, and attending to the needs of nature. Nutrition is fair and weight is stable. Legal Analysis and Conclusion From the foregoing, the Board finds that for the period prior to May 9, 2012, the Veteran’s GERD symptoms more nearly approximate the criteria contemplated by a higher 30 percent disability rating under Diagnostic Code 7346. The evidence of record shows that the Veteran’s GERD was manifested by recurrent epigastric distress with dysphagia, dyspepsia, pyrosis, persistent regurgitation, some weight loss, occasional vomiting, reflux, sleep disturbance, nausea, abdominal gas, and substernal pain that has been productive of impairment of health. Accordingly, a higher 30 percent disability rating for GERD for the period prior to May 9, 2012 is warranted. The Board finds that a 60 percent rating under Diagnostic Code 7346 is not warranted because the Veteran’s symptoms were not productive of severe impairment of his general health. His GERD did not impact his ability to work. Although a March 2007 VA Esophagus and Hiatal Hernia examination shows the Veteran had some weight loss, there is no evidence that he had material weight loss. In fact, in a subsequent November 2010 VA Esophagus and Hiatal Hernia examination, the examiner reported that the Veteran’s weight is stable. Moreover, the evidence did not show the Veteran had hematemesis or melena with moderate anemia, or other symptom combinations productive of severe impairment of health. The November 2010 VA Esophagus and Hiatal Hernia examination report states that the Veteran can engage in his usual activities of daily living. The Board has considered the statements submitted by the Veteran, including that he feels incapacitated by his GERD, as it bothers him when he is waking up and while he is sleeping. The Board finds that the Veteran is a lay person and is competent to report observable symptoms he experiences through his senses such pain. Layno v. Brown, 6 Vet. App. 465 (1994). However, the Board finds the medical findings, as provided in the examination reports, are most persuasive and outweighs the Veteran’s statements in support of his claim. The Board further finds that the Veteran was not entitled to additional or higher ratings under any of the other diagnostic codes relating to the digestive symptoms. Specifically, the record reflects that the Veteran has reported difficulty swallowing. Under 38 C.F.R. § 4.114, Diagnostic Code 7203, a 30 percent rating is assigned for moderate stricture of the esophagus, and higher ratings are assigned for more severe stricture of the esophagus. The Board finds that the record reflects that any stricture of the esophagus the Veteran may have did not rise to the level of “moderate” at any time during the relevant rating period. The Veteran reported difficulty swallowing at the March 2007 VA Esophagus and Hiatal Hernia examination, however it was reported that the swallowing is “sometimes” difficult. The Board does not consider this symptom, in terms of frequency and severity, to rise to the level of severe. Therefore, the Board concludes that the Veteran is not entitled to a higher or additional rating under Diagnostic Code 7203. Additionally, as the evidence of record demonstrates that the Veteran’s GERD was not manifested by anemia or weight loss, recurrent hematemesis or melena, or incapacitating episodes occurring at least four times a year with the average duration of 10 days or more, the Veteran’s GERD symptoms do not more nearly approximate the criteria contemplated by the 40 or 60 percent disability ratings under Diagnostic Code 7304. The Board further finds that none of the other diagnostic codes relating to the digestive system are for application in rating the Veteran’s esophageal condition. In summary, resolving all reasonable doubt in favor of the Veteran, for the period prior to May 9, 2012, a 30 percent disability rating, but no higher, for GERD under Diagnostic Code 7346 is granted. 3. An initial rating for IBS with GERD in excess of 30 percent from May 9, 2012 is denied. For the period from May 9, 2012, the Veteran is in receipt of a 30 percent initial rating for IBS with GERD under Diagnostic Code 7346-7319. Under Diagnostic Code 7319, applicable to irritable colon syndrome (spastic colitis, mucous colitis, etc.), a 30 percent rating is warranted for severe disability with diarrhea, or alternating diarrhea and constipation, with more or less constant abdominal distress. A 30 percent evaluation is the maximum schedular rating under this diagnostic code. Relevant Evidence A December 2013 Esophageal Conditions DBQ examination confirms diagnoses of GERD and hiatal hernia. The Veteran reported that his condition between in the 1990s. The Veteran reported heartburn. His treatment plan includes taking continuous medication for the condition. The signs and symptoms include persistently recurrent epigastric distress, pyrosis (heartburn), reflux, regurgitation, sleep (4 or more times per year, for less than 1 day). The Veteran’s esophageal condition does not impact his ability to work. A December 2013 Intestinal Conditions DBQ examination report, confirms a diagnosis of IBS. The Veteran reported that his condition began in the 1990s. He reports stomach cramping, bloating, alternating diarrhea and constipation. The signs and symptoms include alternating diarrhea and constipation. No episodes of bowel disturbance, weight loss, or malnutrition. The Veteran’s IBS does not impact his ability to work. A March 29, 2016 Esophageal Conditions DBQ examination report, confirms diagnoses of GERD, hiatal hernia, and Barrett’s Esophagus. The Veteran’s symptoms are productive of considerable impairment of health to include pyrosis, reflux, regurgitation, substernal pain, sleep disturbances caused by esophageal reflux (for 4 or more times per year for 10 days or more), recurrent nausea (four or more times per year, for 10 days or more), and periodic vomiting (4 or more times per year, for less than 1 day). A March 29, 2016 Intestinal Conditions DBQ examination report, shows a diagnosis of IBS. The symptoms began in the 1980’s, and they include having bowel movements immediately after eating, alternating between diarrhea and constipation, and this condition has stayed the same. Continuous medication is not required. The diarrhea is 10-15 stools 6 out of 7 days per week. The examiner opined that the Veteran’s intestinal condition impacts his ability to work because he must have easy access to the toilet. A June 2017 VA Intestinal Conditions Disability Questionnaire (DBQ) report, shows a 2017 diagnosis of irritable bowel syndrome (IBS). His relevant symptoms include, alternating diarrhea and constipation (up to 3 spells per day, with 1-2 days of constipation per week). He has no episodes of bowel disturbance with abdominal distress or weight loss or malnutrition or tumors. The Veteran’s intestinal condition does not impact his ability to work. In a February 2018 statement, the Veteran reported diarrhea (2-3 times a day or 1-2 times a week), constipation (every morning), abdominal distress (pain in lower part of stomach), fecal incontinence (occasional moderate leakage). A March 2018 VA Intestinal Conditions DBQ report, shows diagnoses of IBS and diverticulitis. The Veteran reported 10 to 15 years after he got out of service, he started to have abdominal cramping, diarrhea, and constipation. Continuous medication is not required, and no surgical treatment has been taken. The Veteran’s symptoms include diarrhea, alternating diarrhea and constipation, abdominal distension, nausea, and vomiting. The Veteran has episodes of bowel disturbance with abdominal distress (frequent episodes), episodes of exacerbations and/or attacks of the intestinal condition (2 or 3 times a month) for 7 or more times in the past 12 months. The Veteran has weight loss attributable to an intestinal condition. No malnutrition or benign or malignant neoplasm. The Veteran’s intestinal condition impacts his ability to work as he has lost 1-2 weeks of work time in the last 12 months due to diarrhea and stomach cramps. A September 2019 VA Esophageal Conditions DBQ report, shows diagnoses of GERD and Barrett’s esophagus. He reported that the regurgitation and acid reflux began in 2006 (GERD). He has a large sliding hiatal hernia on 6/26/2019. Regurgitation of stomach acid began in 2008 and causes him to sleep in an upright position (Barrett’s esophagus). The Veteran takes continuous medication for the condition. The signs and symptoms include persistently recurrent epigastric distress, pyrosis, reflex, regurgitation, substernal pain, sleep disturbance cause by esophageal reflux (4 or more times a year, lasting less than 1 day). The Veteran does not have an esophageal stricture. Legal Analysis and Conclusion As noted above, for the period from May 9, 2012, the Veteran is in receipt of a 30 percent rating under Diagnostic Code 7319, which provides that a maximum 30 percent rating is warranted for severe irritable colon syndrome with diarrhea or alternating diarrhea and constipation, with more or less constant abdominal distress. 38 C.F.R. § 4.114, Code 7319. Because this is the maximum schedular rating for IBS pursuant Diagnostic Code 7319, a higher rating cannot be assigned under that diagnostic code. The Board has also considered whether a higher evaluation would be warranted under Diagnostic Code 7346. However, the Veteran has not been shown to have symptoms of material weight loss and hematemesis or melena with moderate anemia; or other symptom combinations productive of severe impairment of health. Rather, the treatment records reflect that his weight has remained stable, and he has denied hematemesis and melena at his VA examinations. Although he reported periodic vomiting (4 or more times per year), without material weight loss and hematemeses or melena with moderate anemia or other similar symptoms, the Board does not consider this symptom alone to be productive of severe impairment of his general health. As such, the criteria for a 60 percent evaluation under Diagnostic Code 7346 have not been met. The Board has considered the statements submitted by the Veteran in support of the claim, including that there were times he feels incapacitated by his IBS with GERD particularly because of the severe diarrhea. The Veteran, as a lay person, is competent to describe observable symptoms. Moreover, the medical professionals who examined the Veteran, rendered their opinions with consideration of the Veteran’s lay statements. Therefore, the lay statements given by the Veteran are consistent with, and taken into account of, the degree of impairment caused by the disability that has been assessed by the examiners who have the requisite medical expertise to render that opinion. Moreover, as stated above, the Veteran cannot be assigned a separate evaluation under Diagnostic Code 7346. Coexisting diseases of the digestive system do not lend themselves to distinct and separate disability evaluations without violating the fundamental principle relating to pyramiding as outlined in § 4.14. See 38 C.F.R. § 4.113. Ratings under diagnostic codes 7301 to 7329, inclusive, 7331, 7342, and 7345 to 7348 inclusive will not be combined with each other. A single evaluation will be assigned under the diagnostic code which reflects the predominant disability picture, with elevation to the next higher evaluation where the severity of the overall disability warrants such elevation. 38 C.F.R. § 4.114. Based on the foregoing, the Board finds that for the period from May 9, 2012, the weight of the evidence is against a rating higher than 30 percent for IBS with hiatal hernia. As such, the benefit-of-the-doubt rule does not apply, and the claim is denied in this regard. Parkinson’s Disease and Associated Residuals The Veteran is service connected for Parkinson’s Disease with severe right upper extremity tremors and mild muscle rigidity and stiffness, currently rated at 50 percent disabling, effective May 9, 2012, under Diagnostic Code 8004-8515. He is also service-connected for several disabilities associated with his service-connected Parkinson’s disease: left upper extremity tremors with mild muscle rigidity; mild balance impairment; urinary problems; difficulty chewing and swallowing on the left and right sides; speech changes; right lower extremity bradykinesia with tremor and muscle rigidity and stiffness; left lower extremity bradykinesia with tremor and muscle rigidity and stiffness; right and left side loss of automatic movements; stooped posture of the left and right sides; and loss of sense of smell. Notably, in his addendum to the notice of disagreement submitted in October 2017, while only three issues were identified for appeal in the NOD, the Veteran made clear that the scope of his appeal included impairment of the upper extremities as well as his lower extremities. As the Veteran has been awarded separate disability ratings for his various manifestations of Parkinson’s disease, these will be considered in turn. "There can be only one valid NOD as to a particular claim, extending to all subsequent RO and [Board] adjudications on the same claim until a final . . . decision has been rendered in the matter, or the appeal has been withdrawn." Hamilton v. Brown, 4 Vet. App. 528, 538 (1993) (en banc) (emphasis omitted), aff'd, 39 F.3d 1574 (Fed. Cir. 1994). Relevant Facts A February 2017 VA medical record shows the Veteran uses a cane to ambulate due to his Parkinson’s effect on his balance. A June 2017 private medical record confirms a diagnosis of Parkinson’s disease. The treating provider stated that the Veteran still has tremors and that medication works only for three hours at a time. The treating provider reported that he has normal speech and language and independent gait. The Veteran underwent a Parkinson’s Disease Disability Benefits Questionnaire (DBQ) in June 2017. The examiner confirmed a diagnosis of Parkinson’s disease. The Veteran’s dominant hand is the right hand. Motor manifestations due to Parkinson’s Disease or its treatment are mild balance impairment, severe right upper extremity tremor, mild left upper extremity tremor, mild right upper extremity muscle rigidity and stiffness, and mild left upper extremity muscle rigidity and stiffness. The Veteran reported that he was treated for tremors for many years but was not formally diagnosed with Parkinson’s Disease until 2010. The examiner’s Parkinson’s Disease did not impact his ability to work. A January 2018 VA medical record states that due to Parkinson’s Disease, the Veteran has difficulty with walking any distance at all, trouble standing for more than five minutes at a time, difficulty with getting up and down from the toilet and from the shower seat. The Veteran walks with a walking stick and has a slow gait. The Veteran underwent a VA Ear Conditions DBQ in September 2019. The examiner confirmed diagnoses, to include mild balance impairment. The examiner noted the Veteran has vertigo for less than 1 hour, more than weekly. The examiner reported that the Veteran has abnormal gait due to Parkinson’s Disease. The Veteran underwent a VA Parkinson’s Disease DBQ in September 2019. The examiner confirmed a diagnosis of Parkinson’s Disease. The examiner noted motor manifestations due to Parkinson’s Disease to include: moderate stooped posture, severe balance impairment, severe bradykinesia or slowed motion, moderate loss of automatic movements, moderate speech changes, moderate right upper extremity tremor, moderate left upper extremity tremor, moderate right lower extremity, and mild left lower extremity tremor. The examiner also reported moderate right upper extremity muscle rigidity and stiffness, moderate left upper extremity muscle rigidity and stiffness, moderate right lower extremity muscle rigidity and stiffness, and mild left lower extremity muscle rigidity and stiffness. The examiner noted mental manifestations due to Parkinson’s Disease to include: moderate depression, moderate cognitive impairment or dementia. The Veteran has partial loss of sense of smell, severe sleep disturbances, severe difficulty chewing/swallowing, urinary problems that require 2-4 pads/day, severe constipation, and sexual dysfunction. He needs total care, including help him with all daily activities. His disability has gotten worse because he is now on oxygen, must use a scooter to be mobile, has worse tremors, and more dementia. The Veteran’s Parkinson’s Disease impacts his ability to work because he cannot get up and down to do any paperwork that is needed for the muffler shop that he owns, and he has lost 0-1 week work time in the last 12 months. The Veteran underwent a VA Peripheral Nerves Condition DBQ in September 2019. The examiner confirmed a diagnosis of mild left upper extremity tremors with mild muscle rigidity and stiffness (diagnosis 2008), bilateral lower extremity tremors of the peripheral nerve (dx 9/26/2019), right upper extremity tremor and muscle rigidity and stiffness and numbness of the peripheral nerve (diagnosis 2008). The Veteran has symptoms attributable to the peripheral nerve conditions, to include moderate bilateral upper extremity constant pain, moderate bilateral lower extremity constant pain, moderate bilateral upper extremity numbness, moderate bilateral lower extremity numbness. The Veteran has trophic changes attributable to peripheral neuropathy – no hair on legs, skin is shiny. The Veteran’s gait is not normal due to Parkinson’s Disease and could be the peripheral nerve. The nerves affected are as follows: for the radial nerve, there is bilateral mild incomplete paralysis. For the median nerve, there is bilateral mild incomplete paralysis. For the sciatic nerve, there is right moderate incomplete paralysis, left mild incomplete paralysis. The Veteran occasionally uses a walker and regularly uses a scooter. The examiner stated that the walker and scooter are specifically used because of the Parkinson’s Disease. The examiner stated that the diagnoses changed to a new diagnosis of right upper peripheral nerve and left and right lower extremity peripheral nerve due to or related to the service-connected Parkinson’s Disease because it has to do with Agent Orange. An August 2020 VA medical record shows a diagnosis of Parkinson’s Disease and that the Veteran reports difficulty with safe access to his home tub/shower due to difficulty with lifting his legs. The Veteran also reported that his doorways are not wide enough to access his bathroom or bedroom with his scooter or a walker. Veteran reported having difficulty with dressing. 4. Entitlement an initial rating in excess of 50 percent disabling for Parkinson’s Disease with severe right upper extremity tremors and mild muscle rigidity and stiffness is denied. The Veteran is service connected for Parkinson’s Disease with severe right upper extremity tremors and mild muscle rigidity and stiffness and is in receipt of a 50 percent rating, effective May 9, 2012, under Diagnostic Code 8004-8515. The Veteran has appealed the initial rating assigned for the Parkinson’s Disease. In an appeal for a higher initial rating, all evidence submitted in support of a veteran’s claim is to be considered. The Veteran’s right (dominant) upper extremity neurological impairment is rated as 50 percent disabling, and the left upper extremity is rated as 40 percent disabling, under DC 8004-8515, for paralysis of the median nerve. Diagnostic Code 8515 provides a 50 percent rating for severe incomplete paralysis in the major extremity. A higher 70 percent rating is warranted for the major extremity if there is complete paralysis of the median nerve. The factors indicative of complete paralysis consist of the hand inclined to the ulnar side, the index and middle fingers more extended than normally, considerable atrophy of the muscles of the thenar eminence, the thumb in the plane of the hand (ape hand), incomplete and defective pronation, absence of flexion of the index finger and feeble flexion of the middle finger, inability to make a fist, index and middle fingers remain extended, inability to flex the distal phalanx of the thumb, defective opposition and abduction of the thumb, at right angles to the palm, flexion of the wrist weakened, pain with trophic disturbances. The term “incomplete paralysis” as it pertains to peripheral nerve disabilities indicates a degree of lost or impaired function substantially less than the type pictured for complete paralysis given with each nerve. When the involvement is wholly sensory, the rating will be assigned for the mild, or at most, the moderate degree. 38 C.F.R. § 4.124a. The term “incomplete paralysis” indicates a degree of lost or impaired function substantially less than the type of picture for complete paralysis given with each nerve, whether due to varied level of the nerve lesion or to partial regeneration. When the involvement is only sensory, the rating should be for the mild, or at most, the moderate degree. 38 C.F.R. § 4.124a. In rating a peripheral nerve disability, neuritis, characterized by loss of reflexes, muscle atrophy, sensory disturbances, and constant pain, at times excruciating, is to be rated on the scale provided for injury of the nerve involved, with a maximum equal to severe, incomplete paralysis. Based on the evidence of record, the manifestations of Parkinson’s disease involving the Veteran’s right (major) upper extremity is consistent with severe incomplete paralysis of the radial nerve. There is no evidence of complete paralysis of any right upper extremity nerve warranting a higher rating. At the June 2017 VA Parkinson’s Disease Disability Benefits Questionnaire (DBQ), the examiner confirmed that the Veteran’s dominant hand is the right hand. At this examination, the examiner rated the Veteran’s right upper extremity tremors as severe, but the symptom did not impact his ability to work. Notably, the examiner did not find that any right upper extremity nerve was completely paralyzed. Similarly, at the September 2019 VA Parkinson’s Disease DBQ, the examiner found moderate right upper extremity tremor, and moderate right upper extremity muscle rigidity and stiffness, but did not find any right upper extremity nerve that was completely paralyzed. In fact, in September 2019, the Veteran underwent a VA Peripheral Nerves Condition DBQ, in which the examiner determined mild incomplete paralysis, as opposed to complete paralysis, for the radial and median nerves. Additionally, the Veteran has not contended or submitted lay statements indicating that he is experiencing complete paralysis of the right upper extremity. In this regard, the evidence is not indicative of complete paralysis of the right upper extremity that is manifested by absence of hands or fingers movement, or marked limitation of movement in the wrists, or any pain with trophic disturbances. Therefore, a rating in excess of 50 percent for the right upper extremity is not warranted. Accordingly, the Board finds that there is no basis for the assignment of an initial rating in excess of 50 percent or any separate rating. Because the preponderance of the evidence is against the claim, the claim must be denied. 38 U.S.C. § 5107 (b) (West 2012); Gilbert, 1 Vet. App. at 49. 5. & 6. The claims for entitlement to an initial rating in excess of 10 percent for left upper extremity tremors with mild muscle rigidity prior to September 26, 2019 and in excess of 30 percent thereafter are denied. As stated above, in association with his Parkinson’s Disease, the Veteran is also service-connected for left upper extremity tremors with mild muscle rigidity and stiffness, and is in receipt of a 10 percent rating, effective May 9, 2012, under Diagnostic Code 8515, and in receipt of a 30 percent rating, effective September 26, 2019, under Diagnostic Code 8599-5513. (While the claim was on appeal, in a July 2020 rating decision, the RO increased the 10 percent to 30 percent, effective September 26, 2019, based on the findings of a VA examination obtained on that date.) In an appeal for a higher initial rating, all evidence submitted in support of a veteran’s claim is to be considered. The Veteran’s left (non-dominant) upper extremity is rated as 40 percent disabling, under DC 8004-8515, for paralysis of the median nerve. DC 8515 provides ratings for the minor arm as 40 percent for severe incomplete paralysis, and 60 percent for complete paralysis. Here, for the period prior to September 26, 2019, the evidence shows the Veteran’s symptoms were akin to having mild incomplete paralysis of the left upper extremity movements. Notably, there was no evidence of, or symptoms akin to, moderate incomplete paralysis of the left upper extremity for this period. The June 2017 VA Parkinson’s Disease DBQ showed mild left upper extremity tremor and mild left upper extremity muscle rigidity and stiffness. The Veteran’s symptoms did not impact his ability to work. Additionally, the Veteran has not contended or submitted lay statements indicating that he was experiencing moderate incomplete paralysis of the left upper extremity for this period. Turning to the period from September 26, 2019, the Veteran’s symptoms were akin to having moderate incomplete paralysis of the left upper extremity movements. Notably, there was no evidence of, or symptoms akin to, severe incomplete paralysis of the left upper extremity movements for this period. The September 2019 VA Parkinson’s Disease DBQ showed moderate left upper extremity tremor and moderate left upper extremity muscle rigidity and stiffness. The Veteran also underwent a September 2019 VA Peripheral Nerves Condition DBQ, in which the examiner found moderate left upper extremity constant pain and moderate left upper extremity numbness. The examiner also found mild incomplete paralysis of the left radial nerve and mild incomplete paralysis for the left median nerve. Additionally, the Veteran has not contended or submitted lay statements indicating that he has been experiencing complete paralysis of the left upper extremity for this period. Accordingly, the Board finds that there is no basis for the assignment of an initial rating in excess of 10 percent for left upper extremity tremors with mild muscle rigidity prior to September 26, 2019 and in excess of 30 percent thereafter. Because the preponderance of the evidence is against the claim, the claim must be denied. 38 U.S.C. § 5107 (b) (West 2012); Gilbert, 1 Vet. App. at 49. 7. Entitlement to an initial rating in excess of 10 percent for mild balance impairment is granted. As stated above, in association with his Parkinson’s Disease, the Veteran is also service connected for mild balance impairment, and is in receipt of a 10 percent rating, effective May 9, 2012, under Diagnostic Code 6922-6204. In an appeal for a higher initial rating, all evidence submitted in support of a veteran’s claim is to be considered. "There can be only one valid NOD as to a particular claim, extending to all subsequent RO and [Board] adjudications on the same claim until a final . . . decision has been rendered in the matter, or the appeal has been withdrawn." Hamilton v. Brown, 4 Vet. App. 528, 538 (1993) (en banc) (emphasis omitted), aff'd, 39 F.3d 1574 (Fed. Cir. 1994). Diagnostic Code 6204 provides a 10 percent rating for occasional dizziness, and a 30 percent rating for dizziness and occasional staggering. The 30 percent rating is the maximum rating available under Diagnostic Code 6204. Here, the Board finds that a 30 percent rating is warranted for the entire period on appeal as the evidence indicates that the Veteran’s imbalance problem included at least occasional staggering for the entire period on appeal. A February 2017 VA medical record shows the Veteran uses a cane to ambulate due to his Parkinson’s Disease’s effect on his balance. A June 2017 private medical record shows the Veteran has an independent gait. The June 2017 VA Parkinson’s Disease DBQ examiner reported a mild balance impairment. A January 2018 VA medical record states the Veteran has difficulty with walking any distance at all, trouble standing for more than five minutes at a time, difficulty with getting up and down from the toilet and from the shower seat. The September 2019 VA Ear Conditions DBQ examiner reported the Veteran has abnormal gait due to Parkinson’s Disease. The September 2019 VA Parkinson’s Disease DBQ examiner reported motor manifestations due to Parkinson’s to include severe balance impairment. Moreover, an August 2020 VA medical record shows a diagnosis of Parkinson’s Disease and that the Veteran reported difficulty with safe access to his home tub/shower due to difficulty with lifting his legs. Accordingly, entitlement to an initial rating of 30 percent for mild balance impairment is granted. A 30 percent disability rating for the entire rating period represents the maximum schedular rating available under the schedular criteria of Diagnostic Code 6204. 38 C.F.R. § 4.87. Additionally, the Board finds no other applicable diagnostic codes that would afford the Veteran a higher disability rating. 8. Entitlement to an initial rating in excess of 40 percent for urinary problems is denied. As stated above, in association with his Parkinson’s Disease, the Veteran is also service connected for urinary problems, and is in receipt of a 40 percent rating, effective September 26, 2019, under Diagnostic Code 7542. In an appeal for a higher initial rating, all evidence submitted in support of a veteran’s claim is to be considered. "There can be only one valid NOD as to a particular claim, extending to all subsequent RO and [Board] adjudications on the same claim until a final . . . decision has been rendered in the matter, or the appeal has been withdrawn." Hamilton v. Brown, 4 Vet. App. 528, 538 (1993) (en banc) (emphasis omitted), aff'd, 39 F.3d 1574 (Fed. Cir. 1994). 38 C.F.R. § 4.115 (b), DC 7542 instructs that neurogenic bladder should be rated as voiding dysfunction under 38 C.F.R. § 4.115 (a). Under voiding dysfunction, a 40 percent evaluation is warranted where the evidence shows required wearing of absorbent materials which must be changed two to four times per day. A 60 percent evaluation is warranted where the evidence shows required use of an appliance or the wearing of absorbent materials which must be changed more than four times per day. The Board finds that the evidence does not support the allowance for a rating higher than 40 percent for the period on appeal. Absent evidence of the use of an appliance or absorbent materials more than four times per day, there is no basis for a rating in excess of 40 percent for overactive bladder. The Board has considered other facts which may be considered for a higher rating such as waking up at night to void five or more times per day, obstructed bladder, and urethral infections. However, none have been reflected in the medical evidence of record. Additionally, the Veteran has not asserted any specific contention that the medical evidence does not accurately reflect his disability’s level of impairment. In addition, there are no other medical opinions included in the record to contradict these findings. The September 2019 VA Parkinson’s Disease DBQ specifically states the Veteran has urinary problems that require 2-4 pads/day. Accordingly, the Board finds that there is no basis for the assignment of an initial rating in excess of 40 percent or any separate rating. Because the preponderance of the evidence is against the claim, the claim must be denied. 38 U.S.C. § 5107 (b) (West 2012); Gilbert, 1 Vet. App. at 49. 9. & 10. The claims for entitlement to an initial rating in excess of 30 percent for difficulty chewing and swallowing on the left side and in excess of 30 percent for difficulty chewing and swallowing on the right sides are denied. As stated above, in association with his Parkinson’s Disease, the Veteran is also service connected for difficulty and chewing and swallowing on the left and right sides, each with a 10 percent rating, effective September 26, 2019, under Diagnostic Code 8299-8205. In an appeal for a higher initial rating, all evidence submitted in support of a veteran’s claim is to be considered. "There can be only one valid NOD as to a particular claim, extending to all subsequent RO and [Board] adjudications on the same claim until a final . . . decision has been rendered in the matter, or the appeal has been withdrawn." Hamilton v. Brown, 4 Vet. App. 528, 538 (1993) (en banc) (emphasis omitted), aff'd, 39 F.3d 1574 (Fed. Cir. 1994). Under Diagnostic Code 8205, a 10 percent rating is warranted for moderate incomplete paralysis of the nerve; a 30 percent rating is warranted for severe incomplete paralysis of the nerve; and a 50 percent rating is warranted for complete paralysis of the nerve. The rating is dependent on relative degree of sensory manifestation or motor loss. See 38 C.F.R. § 4.124a, Diagnostic Code 8205. After review of the competent and probative evidence, the Board finds that the Veteran’s left side and right-side difficulties with chewing and swallowing most nearly approximate a 30 percent disabling rating, each. The Veteran’s September 2019 VA Parkinson’s Disease DBQ shows, for the first time, severe difficulty chewing/swallowing. However, there is no medical evidence of complete paralysis of the nerve regarding difficulty chewing/swallowing. Additionally, the Veteran has not asserted any specific contention that the medical evidence does not accurately reflect his disability’s level of impairment. Accordingly, the Board finds that there is no basis for the assignment of an initial rating in excess of 30 percent or any separate rating. Because the preponderance of the evidence is against the claim, the claim must be denied. 38 U.S.C. § 5107 (b) (West 2012); Gilbert, 1 Vet. App. at 49. 11. Entitlement to an initial rating in excess of 30 percent for speech changes is denied. As stated above, in association with his Parkinson’s Disease, the Veteran is also service connected for speech changes with a 30 percent rating, effective September 26, 2019, under Diagnostic Code 6599-6516. In an appeal for a higher initial rating, all evidence submitted in support of a veteran’s claim is to be considered. Under Diagnostic Code 6516, a maximum 30 percent rating is assigned when there is hoarseness with thickening or nodules of cords, polyps, submucous infiltration, or pre-malignant changes on biopsy. 38 C.F.R. § 4.97, Diagnostic Code 6516. Here, the Veteran is in receipt of the maximum schedular rating available under the schedular criteria of Diagnostic Code 6204. 38 C.F.R. § 4.87. Additionally, the Board finds no other applicable diagnostic codes that would afford the Veteran a higher disability rating. Accordingly, the Board finds that there is no basis for the assignment of an initial rating in excess of 30 percent or any separate rating. Because the preponderance of the evidence is against the claim, the claim must be denied. 38 U.S.C. § 5107 (b) (West 2012); Gilbert, 1 Vet. App. at 49. 12. Entitlement to an initial rating in excess of 20 percent for right lower extremity bradykinesia with tremor and muscle rigidity and stiffness is denied. As stated above, in association with his Parkinson’s Disease, the Veteran is also service connected for right lower extremity bradykinesia with tremor and muscle rigidity and stiffness with a 20 percent rating, effective September 26, 2019, under Diagnostic Code 8599-8520. In an appeal for a higher initial rating, all evidence submitted in support of a veteran’s claim is to be considered. "There can be only one valid NOD as to a particular claim, extending to all subsequent RO and [Board] adjudications on the same claim until a final . . . decision has been rendered in the matter, or the appeal has been withdrawn." Hamilton v. Brown, 4 Vet. App. 528, 538 (1993) (en banc) (emphasis omitted), aff'd, 39 F.3d 1574 (Fed. Cir. 1994). Under Diagnostic Code 8520, moderate incomplete paralysis warrants a 20 percent disability evaluation; moderately severe incomplete paralysis warrants a 40 percent evaluation; and, severe, with marked muscular atrophy, incomplete paralysis warrants a 60 percent disability evaluation. An 80 percent evaluation is warranted for complete paralysis where the foot dangles and drops, with no active movement possible of muscles below the knee, with flexion of knee weakened or (very rarely) lost. 38 C.F.R. § 4.124a, Diagnostic Code 8520. As the Veteran’s symptoms show no worse than moderate incomplete paralysis, an increased rating is not warranted. The September 2019 VA Peripheral Nerves Condition DBQ shows, for the first time, moderate constant pain in the right lower extremity and moderate numbness in the right lower extremity. There was also moderate incomplete paralysis in the right sciatic nerve. Additionally, the Veteran has not contended or submitted lay statements indicating that he has been experiencing complete paralysis of the right lower extremity for this period. Accordingly, the Board finds that there is no basis for the assignment of an initial rating in excess of 20 percent for right lower extremity bradykinesia with tremor and muscle rigidity and stiffness. Because the preponderance of the evidence is against the claim, the claim must be denied. 38 U.S.C. § 5107 (b) (West 2012); Gilbert, 1 Vet. App. at 49. 13. Entitlement to an initial rating in excess of 10 percent for left lower extremity bradykinesia with tremor and muscle rigidity and stiffness is denied. As stated above, in association with his Parkinson’s Disease, the Veteran is also service connected for left lower extremity bradykinesia with tremor and muscle rigidity and stiffness with a 10 percent rating, effective September 26, 2019, under Diagnostic Code 8599-8520. In an appeal for a higher initial rating, all evidence submitted in support of a veteran’s claim is to be considered. "There can be only one valid NOD as to a particular claim, extending to all subsequent RO and [Board] adjudications on the same claim until a final . . . decision has been rendered in the matter, or the appeal has been withdrawn." Hamilton v. Brown, 4 Vet. App. 528, 538 (1993) (en banc) (emphasis omitted), aff'd, 39 F.3d 1574 (Fed. Cir. 1994). As the Veteran’s symptoms show no worse than mild incomplete paralysis, an increased rating is not warranted. Here, the September 2019 VA Peripheral Nerves Condition DBQ shows, for the first time, mild incomplete paralysis in the right sciatic nerve. Additionally, the Veteran has not contended or submitted lay statements indicating that he has been experiencing complete paralysis of the left lower extremity for this period. Accordingly, the Board finds that there is no basis for the assignment of an initial rating in excess of 10 percent for left lower extremity bradykinesia with tremor and muscle rigidity and stiffness. Because the preponderance of the evidence is against the claim, the claim must be denied. 38 U.S.C. § 5107 (b) (West 2012); Gilbert, 1 Vet. App. at 49. 14. and 15. The claims for entitlement to an initial rating in excess of 10 percent for right side loss of automatic movements and in excess of 10 percent for left side loss of automatic movements are denied. As stated above, in association with his Parkinson’s Disease, the Veteran is also service connected for loss of automatic movements on the left and right sides, each with a 10 percent rating, effective September 26, 2019, under Diagnostic Code 8299-8207. In an appeal for a higher initial rating, all evidence submitted in support of a veteran’s claim is to be considered. "There can be only one valid NOD as to a particular claim, extending to all subsequent RO and [Board] adjudications on the same claim until a final . . . decision has been rendered in the matter, or the appeal has been withdrawn." Hamilton v. Brown, 4 Vet. App. 528, 538 (1993) (en banc) (emphasis omitted), aff'd, 39 F.3d 1574 (Fed. Cir. 1994). The Veteran’s loss of automatic movements have been rated under Diagnostic Code 8207, pertaining to paralysis of the seventh (facial) cranial nerve. Under Diagnostic Code 8207, a 10 percent rating is assigned for moderate incomplete paralysis; a 20 percent rating is assigned for severe incomplete paralysis; and a 30 percent rating is assigned for complete paralysis of the seventh (facial) cranial nerve. 38 C.F.R. § 4.124a, Diagnostic Code 8207. The September 2019 VA Parkinson’s Disease DBQ examiner, for the first time, noted moderate loss of automatic movements such as blinking or leading to fixed gaze. This is equivalent to no more than moderate incomplete paralysis of the seventh cranial nerve warranting the assignment of a noncompensable rating. The evidence does not establish severe incomplete paralysis or complete paralysis such that higher ratings would be warranted. Additionally, the Veteran has not contended or submitted lay statements indicating that he has been experiencing severe loss of automatic movements such as blinking or leading to fixed gaze or complete paralysis for this period. Accordingly, the Board finds that there is no basis for the assignment of an initial rating in excess of 10 percent for loss of automatic movements on the left and right sides, each. Because the preponderance of the evidence is against the claim, the claim must be denied. 38 U.S.C. § 5107 (b) (West 2012); Gilbert, 1 Vet. App. at 49. 16. and 17. The claims for entitlement to an initial rating in excess of 10 percent for left side stooped posture and in excess of 10 percent for right side stooped posture are denied. As stated above, in association with his Parkinson’s Disease, the Veteran is also service connected for side stooped postures on the left and right sides, each with a 10 percent rating, effective September 26, 2019, under Diagnostic Code 8299-8211. In an appeal for a higher initial rating, all evidence submitted in support of a veteran’s claim is to be considered. "There can be only one valid NOD as to a particular claim, extending to all subsequent RO and [Board] adjudications on the same claim until a final . . . decision has been rendered in the matter, or the appeal has been withdrawn." Hamilton v. Brown, 4 Vet. App. 528, 538 (1993) (en banc) (emphasis omitted), aff'd, 39 F.3d 1574 (Fed. Cir. 1994). The Veteran’s side stooped postures on the left and right sides have been rated under Diagnostic Code 8211, pertaining to paralysis of the seventh (facial) cranial nerve. Under Diagnostic Code 8211, a 10 percent rating is warranted for moderate incomplete paralysis of the eleventh cranial nerve (which pertains to functional impairment associated with the sternomastoid and trapezius muscles). A 20 percent rating is warranted for severe incomplete paralysis. A 30 percent rating is warranted for complete paralysis. The September 2019 VA Parkinson’s Disease DBQ examiner noted, for the first time, moderate loss stooped posture. This is equivalent to no more than moderate incomplete paralysis of the eleventh cranial nerve (which pertains to functional impairment associated with the sternomastoid and trapezius muscles) warranting the assignment of a 10 percent rating. The evidence does not establish severe incomplete paralysis or complete paralysis such that higher ratings would be warranted. Additionally, the Veteran has not contended or submitted lay statements indicating that he has been experiencing severe stooped posture for this period. Accordingly, the Board finds that there is no basis for the assignment of an initial rating in excess of 10 percent, each, for side stooped postures on the left and right sides. Because the preponderance of the evidence is against the claim, the claim must be denied. 38 U.S.C. § 5107 (b) (West 2012); Gilbert, 1 Vet. App. at 49. 18. Entitlement to an initial rating in excess of 0 percent for loss of sense of smell is denied. As stated above, in association with his Parkinson’s Disease, the Veteran is also service connected for loss of sense of smell with a 0 percent rating, effective September 26, 2019, under Diagnostic Code 6275. In an appeal for a higher initial rating, all evidence submitted in support of a veteran’s claim is to be considered. Under Diagnostic Code 6275, a 10 percent rating is warranted for the complete loss of the sense of smell. Here, the evidence of record does not demonstrate that an initial compensable rating is warranted under Diagnostic Code 6275 for loss of smell. The probative and competent evidence does not establish the Veteran’s has a complete loss of smell, or that his symptoms more nearly approximate complete loss of smell, at any time during the appeal period. The record does not reflect a subjective complaint or clinical finding of a complete loss of smell. In fact, the September 2019 VA Parkinson’s Disease DBQ shows partial loss of sense of smell, for the first time. Thus, a compensable rating is not warranted. As the Veteran’s symptoms show partial loss of sense of smell, a higher rating is not warranted. Accordingly, the Board finds that there is no basis for the assignment of a compensable initial rating for loss of sense of smell. Because the preponderance of the evidence is against the claim, the claim must be denied. 38 U.S.C. § 5107 (b) (West 2012); Gilbert, 1 Vet. App. at 49. YVETTE R. WHITE Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board C. J. Cho, 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.