Citation Nr: 21012763 Decision Date: 03/05/21 Archive Date: 03/05/21 DOCKET NO. 10-03 257 DATE: March 5, 2021 ORDER Prior to July 22, 2015, an increased evaluation of 20 percent, but no higher, for a lower back disability including include spinal stenosis and mechanical low back pain with degenerative disc disease (DDD) and degenerative joint disease (DJD) is granted. Effective July 22, 2015, an increased evaluation of 40 percent, but no higher, for a lower back disability including spinal stenosis and mechanical low back pain with DDD and DJD, is granted. Effective July 17, 2017 until August 8, 2018, entitlement to a disability rating of 10 percent for radiculopathy of the left lower extremity is granted. Effective August 8, 2018, a disability rating of 20 percent for radiculopathy of the left lower extremity is granted. Effective February 14, 2019, a disability rating of 20 percent for radiculopathy of the right lower extremity is granted. Effective October 19, 2019, entitlement to special monthly compensation (SMC) based on statutory housebound status is granted. REMANDED Entitlement to a temporary total rating under 38 C.F.R. § 4.30 is remanded. FINDING OF FACT 1. Prior to July 22, 2015, the Veteran's lower back disability, to include DDD and DJD, was manifested by symptoms most closely approximating forward flexion of the spine greater than 30 degrees but not greater than 60 degrees. 2. Since July 22, 2015, the Veteran's lower back disability has manifested with symptoms most closely approximating forward flexion of the spine of 30 degrees or less and favorable ankylosis of the thoracolumbar spine. 3. Effective July 17, 2017 until August 8, 2018, radiculopathy of the left lower extremity has manifested as no more than mild incomplete paralysis of the sciatic nerve. 4. Since August 18, 2018, radiculopathy of the left lower extremity has manifested as no more than moderate incomplete paralysis of the sciatic nerve. 5. Effective February 14, 2019 and no earlier, radiculopathy of the right lower extremity has manifested as no more than moderate incomplete paralysis of the sciatic nerve. 6. The Veteran has a 100 percent disability rating for posttraumatic stress disorder (PTSD); in addition, he has service-connected disabilities independently ratable as at least 60 percent effective October 19, 2019. CONCLUSION OF LAW 1. From December 25, 2007 until July 22, 2015, the criteria for a 20 percent rating and no higher, for a lower back disability including DDD and DJD, have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5242. 2. Since July 22, 2015, the criteria for a 40 percent rating and no higher, for a lower back disability, including DDD and DJD, have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5242. 3. From July 17, 2017 until August 8, 2018, the criteria for a disability rating of 10 percent and no higher for left lower extremity radiculopathy have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.124a, Diagnostic Code 8520. 4. Since August 8, 2018, the criteria for a disability rating of 20 percent and no higher, for left lower extremity radiculopathy have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.124a, Diagnostic Code 8520. 5. Since February 14, 2019, the criteria for a disability rating of 20 percent and no higher, for right lower extremity radiculopathy have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.124a, Diagnostic Code 8520. 6. The criteria for entitlement to SMC pursuant to 38 U.S.C. § 1114(s) have been met effective October 19, 2019. 38 U.S.C. §§ 1114(s), 5107; 38 C.F.R. § 3.350. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty in the U.S. Air Force from May 1992 to October 1994 and in the U.S. Army from January 2002 to May 2005 with additional National Guard service. He is a decorated combat Veteran whose awards include the Purple Heart. This matter is before the Board of Veterans’ Appeals (Board) on appeal from a June 2008 rating decision issued by a Department of Veterans Affairs (VA) Regional Office (RO). In December 2011, the Veteran testified before a Veterans Law Judge (VLJ) who is no longer employed by the Board. In July 2017, the Veteran was notified of such and offered an opportunity for a new hearing; he did not respond, and hence is presumed to not desire a new hearing. The matter has been remanded three times, most recently in December 2018 when it was remanded to obtain private treatment records and for n new VA examination. A remand by the Board confers upon the Veteran, as a matter of law, the right to compliance with the remand instructions and imposes upon the VA a concomitant duty to ensure compliance with the terms of the remand. Stegall v. West, 1 Vet. App. 268, 271 (1998). Where the remand orders of the Board are not complied with, the Board must ensure compliance. As explained in more detail below, a remand is necessary to obtain private treatment records. Increased Rating The Veteran filed a claim for an increased rating in February 2008. As an increased rating claim, the Board looks at the evidence in the year prior to this date to see the earliest date that it is factually ascertainable that an increase occurred. 38 C.F.R. § 3.400. The VA’s Schedule for Rating Disabilities is used to determine disability ratings once a disability is service connected. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. In the Rating Schedule, Diagnostic Codes are assigned to specific disabilities. These Diagnostic Codes designate percentage ratings based on the average functional impairment of the Veteran due to a service-connected disability. 38 C.F.R. §§ 3.321, 4.10. Where there is a question as to which of two evaluations shall be applied, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that evaluation. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. After careful consideration of the evidence, any reasonable doubt remaining is resolved in favor of the Veteran. 38 C.F.R. § 4.3. Competent medical evidence is evidence provided by a person who is qualified through education, training, or experience to offer medical diagnoses, statements, or opinions. Competent medical evidence may also include statements conveying sound medical principles found in medical treatises. It also includes statements contained in authoritative writings, such as medical and scientific articles and research reports or analyses. 38 C.F.R. § 3.159 (a)(1). Competent lay evidence is any evidence not requiring that the proponent have specialized education, training, or experience. Lay evidence is competent if it is provided by a person who has knowledge of facts or circumstances and conveys matters that can be observed and described by a lay person. 38 C.F.R. § 3.159 (a)(2). This may include some medical matters, such as describing symptoms or relating a contemporaneous medical diagnosis. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). A layperson is generally not capable of opining on matters requiring medical knowledge. Lumbar Spine Stenosis, DDD and DJD The Veteran's lumbar disability, described as spinal stenosis and mechanical low back pain with DDD and DJD, has been evaluated under Diagnostic Code 5242-5243. Hyphenated Diagnostic Codes denote that a condition is diagnosed and service-connected primarily under the first Code, but the criteria of the second are used to assign evaluations based on residuals or predominant manifestations. 38 C.F.R. § 4.27. VA amended the criteria for rating back disabilities effective from February 7, 2021. These new regulations apply to all applications for benefits received by VA or that are pending before the agency of original jurisdiction on or after February 7, 2021. With regard to the low back disability, the substance of the criteria are unchanged; the amendments addressed changes in terminology and diagnosis which have no impact in this case. Diagnostic Code 5242 applies to degenerative arthritis of the spine, and Diagnostic Code 5243 applied to Intervertebral Disc Syndrome (IVDS). The new regulations expanded then applicability of Diagnostic Code 5242 to include degenerative disc disease, which had been part of Diagnostic Code 5243 for IVDS. The new regulations define IVDS under Diagnostic Code 5243 more narrowly, instructing that Diagnostic Code 5243 should only be assigned when there is disc herniation with compression and/or irritation of the adjacent nerve root. The rating criteria, which are based on incapacitating episodes, remain the same under the new regulations. There is no indication that the Veteran suffers, or has suffered for the pendency of this appeal, from incapacitating episodes. As such, the Board will not evaluate the Veteran’s lumbar spine disability under the previous or current Diagnostic Code 5243. Under the General Rating Formula for Diseases and Injuries of the Spine, with or without symptoms such as pain, whether or not it radiates, stiffness, or aching in the area of the spine affected by the residuals of injury or disease, a 10 percent rating is warranted for forward flexion of the thoracolumbar spine greater than 60 degrees but not greater than 85 degrees; or, the combined range of motion of the thoracolumbar spine greater than 120 degrees but not greater than 235 degrees; or, muscle spasm or guarding or localized tenderness not resulting in an abnormal gait or abnormal spinal contour; or vertebral body fracture with loss of 50 percent or more of the height. A 20 percent rating is warranted for forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees; or, the combined range of motion of the thoracolumbar spine not greater than 120 degrees; or, muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. A 40 percent rating is warranted for disability of the thoracolumbar spine when there is forward flexion of the thoracolumbar spine to 30 degrees or less or favorable ankylosis of the entire thoracolumbar spine. Unfavorable ankylosis of the entire thoracolumbar spine is evaluated as 50 percent disabling, and unfavorable ankylosis of the entire spine is evaluated as 100 percent disabling. 38 C.F.R. § 4.71a, General Rating Formula for Diseases and Injuries of the Spine. In addition, the General Rating Formula for Diseases and Injuries of the Spine provides, in pertinent part, the following: Note (1): Evaluate any associated objective neurologic abnormalities, including, but not limited to, bowel or bladder impairment, separately, under an appropriate diagnostic code. Note (5): For VA compensation purposes, unfavorable ankylosis is a condition in which the entire cervical spine, the entire thoracolumbar spine, or the entire spine is fixed in flexion or extension, and the ankylosis results in one or more of the following: difficulty walking because of a limited line of vision; restricted opening of the mouth and chewing; breathing limited to diaphragmatic respiration; gastrointestinal symptoms due to pressure of the costal margin on the abdomen; dyspnea or dysphagia; atlantoaxial or cervical subluxation or dislocation; or neurologic symptoms due to nerve root stretching. Fixation of a spinal segment in neutral position (zero degrees) always represents favorable ankylosis. In evaluating any disability on the basis of limitation of motion, VA must consider the actual degree of functional impairment imposed by pain, incoordination, weakness, fatigue, and lack of endurance with repetitive motion. 38 C.F.R. §§ 4.40, 4.45, 4.59; DeLuca v. Brown, 8 Vet. App. 202 (1995). In DeLuca, it was held that when the pertinent diagnostic criteria provide for a rating on the basis of loss of range of motion, determinations regarding functional losses are to be “‘portray[ed]’ (38 C.F.R. § 4.40 ) in terms of the degree of additional range-of-motion loss due to pain on use or during flare-ups.” In Correia v. McDonald, 28 Vet. App. 158 (2016), the Court held that the final sentence of 38 C.F.R. § 4.59 requires that the examiner record the results of range of motion testing “for pain on both active and passive motion [and] in weight-bearing and non-weight-bearing and, if possible, with range of motion measurements of the opposite undamaged joint.” In Sharp v. Shulkin, 29 Vet. App. 26 (2017), the Court held that VA examiners must obtain information about the severity, frequency, duration, precipitating and alleviating factors, and extent of functional impairment of flares from the veterans themselves, when a flare-up is not observable at the time of examination. The Board notes that the Veteran was provided with VA examinations in June 2008, August 2010, April 2013, October 2015, January 2017 and December 2019. With the exception of the December 2019 examination, all of these examinations concerning range of motion findings are not adequate because they do not comply with Sharp, 29 Vet. App. 26. Therefore, the Board may not rely on the range of motion findings to deny the Veteran’s claim. Even so, the Board will discuss the other findings of the examinations, other than range of motion, relevant to the Veteran’s claim. The Veteran contends that he is entitled to a higher rating for his lower back disability, to include spinal stenosis, DDD and DJD. The Veteran's lower back disability is currently rated as 10 percent disabling from June 1, 2005 to October 2, 2015, under Diagnostic Code 5237. Since October 2, 2015, the Veteran's back has been rated as 20 percent disabling under Diagnostic Code 5237. Since December 9, 2019, the Veteran's back was again rated as 20 percent disabling, but under Diagnostic Code 5242-5243. 1. Prior to July 22, 2015 On January 25, 2008, the Veteran sought treatment for increased back pain that had begun approximately one month prior; a physical examination showed objective evidence of pain on motion although the degree of onset was not noted. Although the June 2008 VA examination documented normal range of motion, the examiner noted pain at the “extreme range of motion” but did not specify a degree of onset. The Veteran reported flare-ups of his back disability provoked by prolonged walking, standing or remaining in one position. Repeated motion failed to increase pain or reduce motion. The examiner concluded that the Veteran’s flare-ups caused no additional functional loss. Moreover, the examiner did not comment on any additional functional limitations with repetitive use over time. This is inconsistent with the evidence of record, including the Veteran and his wife’s competent. Consistent and credible statements about the functional loss from flare ups and after repetitive use over time, as well as reports of changes to spinal curvature, the effects of the Veteran’s back disability more closely approximate a limitation to no more than 60 degrees of forward flexion. Although the Veteran reported some worsening of his symptoms, treatment records and VA examinations in August 2010 and May 2013 documented relatively stable symptoms. For example, in May 2013, the Veteran had a normal range of motion with no objective evidence of pain, but he reported that his constant pain was worsened by sitting for long periods of time to the extent that he left a job. Prior to July 22, 2015, the Veteran’s symptoms did not approximate a limitation of flexion to 30 degrees or less to warrant a rating in excess of 20 percent. Although the Veteran was experiencing significant limitations due to his back disability, he did not report difficulties with personal care activities such as bathing or dressing, which would require bending to more than 30 degrees on a regular basis. Further, measured range of motion was close to 60 degrees, such as in May 2012, and no marked increase in functional impairment was noted from that point; treating doctors did note complaints of mild pain, and avoidance of particularly heavy labor was reported, but there is no indication of limitation to 30 degrees flexion or less. Even resolving all doubt in favor of the Veteran, the evidence does not support assignment of a rating in excess of 20 percent prior to July 22, 2015. There is no evidence of ankylosis or symptoms approximating ankylosis to support a rating in excess of 20 percent from December 25, 2007 until July 22, 2015. 2. Since July 22, 2015 Since July 22, 2015, the Board finds that a 40 percent rating is warranted for the Veteran’s lumbar spine disability, as his symptoms have most closely approximated a limitation of forward flexion to less than 30 degrees and favorable ankylosis of the thoracolumbar spine On September 22, 2015, the Veteran underwent an MRI due to his reports of increased back pain including left hip pain that had started approximately three months prior. At the October 2015 VA examination, which was not conducted during a flare-up, the Veteran’s range of motion was measured at 35 degrees and he was observed with an antalgic gait due to muscle spasm. The Veteran described flare-ups that required him to lay down caused by activities including laughing, walking, driving or bending. Accounting for the Veteran’s statements describing his flare-ups, his symptoms more closely approximate limitation of flexion to 30 degrees or less, warranting a rating of 40 percent. At the January 2017 VA examination, the Veteran described continuing back pain with increased stiffness. He stated he was not able to do much of anything and had left his previous job with the railroad due to his back. On range of motion testing, he had 70 degrees of forward flexion and 10 degrees of extension. Pain was noted, but the degree of onset was not recorded. Physical examination showed widespread tenderness on his back with guarding or muscle spasm of his back. The examiner was unable to say, without speculation, whether pain, weakness, fatigability or incoordination significantly limited the Veteran’s functional ability with repeated use over time. There was no evidence of ankylosis, and the Veteran denied radicular pain. At the VA examination in November 2019, the Veteran described flare-ups occurring three to four times a week of severe back pain radiating to his lower extremities and numbness in his toes. He said that on some days, he was not able to bend over or tie his shoes due to pain. His forward flexion was measured at 80 degrees and pain causing functional loss was noted, although there was no further loss of function on repetitive use testing. The examiner estimated that the Veteran’s range of motion after repetitive use over time and flare ups would be 70 degrees in forward flexion despite the Veteran’s competent and credible report that at times he could not bend over to tie his shoes. This estimate is given no probative weight. Although the Veteran underwent a back surgery in October 2015 that he initially reported relieved his symptoms, by January 2016, his recurrent back pain led him to seek emergency treatment. At the emergency room in January 2016, the Veteran specifically described his pain as similar to his pre-surgical back pain in character and intensity. The Veteran continued to report significant and frequent exacerbations of his back disability that led him to leave jobs and pursue aggressive treatment options, including epidural steroid injections, narcotic pain medication and repeated courses of physical therapy. Although the Veteran reported worsening symptoms, the Veteran’s forward flexion was measured at 45 degrees at the most recent VA examination in December 2019. However, this examination was not conducted during a flare up, and the examiner could not estimate the Veteran's functional loss during flare-ups or after repeated use over times in terms range of motion. The Veteran has reported instances where he cannot bend over at all, or has difficulty tying his shoes, which would approximate favorable as opposed to unfavorable ankylosis of the thoracolumbar spine. The Veteran's symptoms do not more closely approximate unfavorable ankyloses of his entire thoracolumbar spine or unfavorable ankylosis of the entire spine required for the 50 percent and 100 percent ratings, respectively. Although at times, the Veteran is unable to bend over and cannot pick up items off the floor, this is most consistent with favorable ankylosis of the thoracolumbar spine. In sum, the Board finds that the preponderance of the evidence is against a rating in excess of 40 percent for a lower back disability since July 22, 2015. Lower Extremity Radiculopathy Evaluation of the spine also requires assessment of neurological complications, including radiculopathy. Diagnostic Code 8520 provides the rating criteria for paralysis of the sciatic nerve. Mild incomplete paralysis of the sciatic nerve warrants a 10 percent rating. A 20 percent rating requires moderate incomplete paralysis of the sciatic nerve. A 40 percent rating requires moderately severe incomplete paralysis of the sciatic nerve. A 60 percent rating requires severe incomplete paralysis with marked muscular atrophy. An 80 percent rating requires complete paralysis. When there is complete paralysis, the foot dangles and drops, no active movement of the muscles below the knee is possible, and flexion of the knee is weakened or (very rarely) lost. 38 C.F.R. § 4.124a. The term “incomplete paralysis” with peripheral nerve injuries indicates a degree of loss or impaired function substantially less than the type pictured for complete paralysis given with each nerve, whether due to the varied level of the nerve lesion or to partial regeneration. When the involvement is wholly sensory, the rating should be for mild, or at most, the moderate degree. See note at Diseases of the Peripheral Nerves in 38 C.F.R. § 4.124 (a). The words “mild,” “moderate” and “severe” as used in the various diagnostic codes are not defined in the VA Rating Schedule. Rather than applying a mechanical formula, the Board must evaluate all of the evidence, to the end that its decisions are “equitable and just.” 38 C.F.R. § 4.6. Left Lower Extremity Currently, the Veteran’s left lower extremity radiculopathy is rated as 10 percent disabling, effective November 4, 2019. The Veteran contends that he had experienced symptoms of radiculopathy in his left lower extremity since his October 2015 surgery. However, prior to January 17, 2017, he consistently denied radiating pain or other symptoms of radiculopathy, and the records documents no treatment for symptoms of radiculopathy. Specifically, at the June 2008 VA examination, the examiner documented intact sensation, normal reflexes and full muscle strength in his lower extremities. Similarly, at the August 2010, May 2013 and October 2015 VA examinations, the Veteran had intact sensation, a negative Lasègue’s sign, normal muscle strength and normal reflexes. At the May 2013 and October 2015 VA examinations, the Veteran had negative straight leg raise tests bilaterally. Although the Veteran had an abnormal gait at the October 2015 VA examination, the examiner attributed it to muscle spasm in his back. Additionally, the Veteran does not contend that his radiculopathy symptoms began prior to his October 2015 back surgery, which occurred after the VA examination. While the Veteran was not diagnosed with radiculopathy until April 2019, the record shows that the Veteran has complained of neurological symptoms since the January 17, 2017 VA examination, where he denied pain but reported tingling in the back of his left knee and weakness in his legs. However, he denied pain or use of assistive devices and examination showed a normal gait. The Veteran’s providers began treating his left lower extremity radiculopathy with medication in May 2017, although he discontinued it within a few months. By November 2017, the Veteran had re-started medication for radiculopathy. On August 8, 2018, the Veteran complained of increased pain and his radiculopathy medication dosage was increased. By May 2019, the Veteran was describing significant pain, including pinching in his left calf and lateral left foot that he found especially bothersome, despite medication. At the November 2019 VA examination, the Veteran had a positive straight leg raise test on his left, and reported pain radiating down both legs during flare-ups which occurred three to four times per week. At the December 2019 VA examination, numbness and paresthesia were noted on physical examination. Despite these findings, the Veteran’s gait was routinely assessed as normal, he had full strength in his left lower extremity with no muscle atrophy and he denied using assistive devices to help him walk. Overall, the Veteran’s left lower extremity radiculopathy most closely approximately moderate symptoms since August 8, 2018. Based on the above, the Board finds that between January 17, 2017 and August 8, 2018, the Veteran’s left lower extremity radiculopathy was primarily manifested by sensory disturbance and pain. The most probative evidence of record is against a finding that his left lower extremity was manifest by impairment of motor functions, muscle atrophy, loss of reflexes or complete paralysis. Such warrants assignment of a 10 percent evaluation for mild radiculopathy of the left lower extremity, and no higher. The Board has considered whether a compensable rating is warranted prior to January 17, 2017, as this issue is part and parcel of the question of the ratings warranted for this disability throughout the appeal period for the back. The record does not show treatment for, complaints about or diagnosis of left lower extremity radiculopathy involving the sciatic nerve prior to that date. The lay and medical evidence weighs against a finding that this was an associated neurologic abnormality prior to January 17, 2017. Based on the absence of diagnosis, treatment or complaint, a compensable/separate rating is not warranted prior to January 17, 2017. However, the record shows worsening of symptoms on August 8, 2018, when the Veteran's doctor increased his medication to address increased pain. Therefore, the Board finds that the level of impairment for left leg radiculopathy involving the sciatic nerve is most analogous to moderate incomplete paralysis effective August 8, 2018, and a 20 percent rating is warranted from that date forward for the left lower extremity radiculopathy. Right Lower Extremity The Veteran contends that he has had constant back pain radiating to his right groin and thigh, with occasional foot numbness since his October 2015 back surgery. However, prior to February 14, 2019, he consistently denied right sided radiating pain or neurological complaints on his right lower extremity. Specifically, at the June 2008 VA examination, the examiner documented intact sensation, normal reflexes and full muscle strength in his lower extremities. Similarly, at the August 2010 and May 2013 VA examinations, the Veteran had intact sensation, a negative Lasegue’s sign, normal muscle strength and normal reflexes. At the May 2013 VA examination, the Veteran had negative straight leg raise tests bilaterally. At the January 2017 VA examination, the Veteran did not report any right leg neurological symptoms, and the VA examiner did not note any signs or symptoms of radiculopathy, and he again had full muscle strength, intact sensation, normal reflexes and a negative straight leg raise test on his right lower extremity. The evidence of record shows that the Veteran began complaining of right lower extremity neurological symptoms on February 14, 2019 when he sought emergency treatment for increased back pain and occasional right leg numbness although he was not formally diagnosed until April 2019. The February 14, 2019 physical examination showed right leg weakness and decreased right patellar reflex, although his right achilles reflex was normal and he was able to walk without assistance. The Veteran continued to report pain radiating into his legs from his back, and at the November 2019 VA examination described back pain radiating into both legs during flare-ups occurring three to four times a week. However, physical examinations in November and December 2019 showed full muscle strength, intact sensation and a negative right straight leg raise test. Accounting for the Veteran’s statements, and the examination results, the Board finds that since February 14, 2019, right leg radiculopathy has manifested primarily in sensory disturbance and pain. The most probative evidence of record is against a finding that his right lower extremity was manifest by impairment of motor functions, muscle atrophy, loss of reflexes or complete paralysis. Although the Veteran has reported increased neurological symptoms during flare-ups occurring no more than weekly, he has consistently been observed with a normal gait, negative straight leg raise tests on the right, full muscle strength with no atrophy and has not required the use of an assistive device. Overall, the Veteran's right leg radiculopathy symptoms most closely approximate moderate incomplete paralysis since February 14, 2019, warranting a 10 percent evaluation, and no higher. The Board has considered whether a compensable rating is warranted prior to February 14, 2019, as this issue is part and parcel of the ratings warranted for this disability throughout the appeal period for the back. The record does not show treatment for, complaints of, or diagnosis of right lower extremity radiculopathy involving the sciatic nerve prior to that date. The lay and medical evidence weighs against a finding that this was an associated neurologic abnormality prior to February 14, 2019. Based on the absence of diagnosis, treatment or complaint, a compensable/separate rating is not warranted prior to February 14, 2019. Special Monthly Compensation A veteran is presumed to be seeking the maximum benefit allowed by law or regulation, and such a claim remains in controversy, even if partially granted, where less than the maximum benefit available is awarded. AB v. Brown, 6 Vet. App. 35, 38 (1993). Moreover, VA has a duty to fully and sympathetically develop a veteran’s claim to its optimum, which includes determining all potential claims raised by the evidence and applying all relevant laws and regulations. Moody v. Principi, 360 F.3d 1306, 1310 (Fed. Cir. 2004). Relevant to this appeal, a claim for increased disability compensation may include the “inferred issue” of entitlement to SMC even where the veteran has not expressly placed entitlement to SMC at issue. Akles v. Derwinski, 1 Vet. App. 118, 121 (1991). SMC at the housebound rate is payable where a veteran has a single service-connected disability rated as 100 percent and, in addition: (1) has a service-connected disability or disabilities independently ratable at 60 percent, separate and distinct from the 100 percent service-connected disability, and involving different anatomical segments or bodily systems, or (2) is permanently housebound by reason of service-connected disability or disabilities. See 38 U.S.C. § 1114(s); 38 C.F.R. § 3.350(i). The Veteran is rated as 100 percent disabled for post-traumatic stress disorder (PTSD) as of October 19, 2019. Additionally, by August 8, 2018, the Veteran's other service-connected disabilities combined to be ratable at 60 percent, establishing statutory entitlement to housebound benefits as of October 19, 2019. 38 U.S.C. § 1114(s); 38 C.F.R. § 3.350. Although the Veteran has been granted TDIU from May 7, 2011, this grant was based on the combined effect of his service-connected disabilities; therefore, prior to October 19, 2019, the Veteran did not have a single disability rated at 100 percent. Bradley v. Peake, 22 Vet. App. 280 (2008). REASONS FOR REMAND This case was previously remanded to obtain outstanding private treatment records regarding the Veteran's October 2015 back surgery and any periods of convalescence. There are relevant records previously submitted by the Veteran that are not associated with the claims file, and VA has not contacted all of the private treatment providers identified by the Veteran to obtain his medical records. It appears there was some confusion caused by the November 2016 VA Form 21-4142 submitted by the Veteran. The Veteran listed a doctor and two medical facilities where he received treatment in a single space on the form, identifying Dr. BO, the Good Shepherd Medical Center (GSMC) and the Longview Orthopedic Clinic as treatment providers who had treated his back disability. He indicated that he received treatment between December 2015 and November 2016 (the same month the 21-4142 was signed). Documentation of the development efforts shows that the Veteran's treatment records from December 2015 through November 2016 were requested from the Good Shepherd Medical Center, but not the Longview Orthopedic Clinic, which is a separate entity. In December 2016, the medical center indicated that it had no records for the Veteran. The claims file does not indicate that further development was attempted based on the November 2016 VA Form 21-4142. In September 2019, the Veteran was again asked for the names and addresses of private treatment providers and records from his October 2015 back surgery and did not provide new information. However, in that same decision, the Board stated that the physician identified by the Veteran had reported that the Veteran was not a patient. The claims file does not clearly establish this; rather, the evidence shows that the Good Shepherd Medical Center had no treatment records for the Veteran between December 2015 (two months after his back surgery) and November 2016. Given the lack of clarity in the Veteran's November 2016 VA Form 21-4142 and the subsequent development, another remand is warranted to obtain private treatment records pertaining to the Veteran's October 2015 back surgery. The matters are REMANDED for the following action: 1. Associate with the claims file all documents from the VISTA Imaging System, particularly the discharge summary scanned on November 24, 2015. 2. Contact the Veteran and request properly executed releases for any private care providers who have treated him for his lower back condition. Records from Dr. BO and the Longview Orthopedic Clinic should be specifically requested. Upon receipt of such, VA must take appropriate action to contact the identified providers and request complete treatment records related to the Veteran’s October 2015 back surgery and subsequent convalescence. The Veteran should be informed that in the alternative he may obtain and submit the records himself. 3. Then, readjudicate the claim on appeal. If any benefit sought remains denied, issue an appropriate supplemental statement of the case and return the appeal to the Board WILLIAM H. DONNELLY Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Megan-Brady Viccellio 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.