Citation Nr: 21015225 Decision Date: 03/17/21 Archive Date: 03/17/21 DOCKET NO. 13-29 131 DATE: March 17, 2021 ORDER An initial rating in excess of 20 percent for degenerative joint disease (DJD) of the cervical spine (cervical spine disability) is denied. An initial rating in excess of 20 percent for right shoulder/upper clavicular radiculopathy with right upper extremity (RUE) carpal tunnel syndrome (previously rated as carpal tunnel syndrome, right upper extremity, dominant hand) prior to May 2, 2018, and in excess of 40 percent thereafter is denied. An initial rating in excess of 10 percent for left upper extremity (LUE) carpal tunnel syndrome prior to May 2, 2018 is denied. A 20 percent rating, but no higher, for LUE carpal tunnel syndrome, from May 2, 2018 to October 23, 2020 is granted, subject to the laws and regulations governing the payment of monetary awards. A rating in excess of 30 percent for LUE carpal tunnel syndrome as of October 23, 2020 is denied. A rating in excess of 50 percent for obstructive sleep apnea (OSA) with residuals of sarcoid is denied. REMANDED Entitlement to a total disability rating based on individual unemployability due to service-connected disabilities (TDIU) is remanded. FINDINGS OF FACT 1. The Veteran's cervical spine disability is manifested by forward flexion of the cervical spine greater than 30 degrees and combined range of motion (ROM) of the cervical spine greater than 170 degrees, even in contemplation of functional loss due to symptoms such as pain, fatigue, weakness, lack of endurance, or incoordination, or as a result of repetitive motion and/or flare-ups, without muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour, ankylosis, incapacitating episodes of intervertebral disc syndrome (IVDS), or associated objective neurological abnormalities, other than radiculopathy of the bilateral upper extremities. 2. The Veteran is right-handed. 3. Prior to May 2, 2018, the Veteran’s right shoulder/upper clavicular radiculopathy with RUE carpal tunnel syndrome was productive of no more than mild incomplete paralysis of all radicular groups, but such disability is productive of moderate incomplete paralysis of all radicular groups thereafter. 4. Prior to May 2, 2018, the Veteran’s LUE carpal tunnel syndrome was productive of no more than mild incomplete paralysis of the median nerve. 5. From May 2, 2018 to October 23, 2020 the Veteran’s LUE carpal tunnel syndrome was productive of no more than moderate incomplete paralysis of the median nerve. 6. As of October 23, 2020, the Veteran’s LUE carpal tunnel syndrome is productive of no more than moderate incomplete paralysis of all radicular groups. 7. The Veteran’s OSA with residuals of sarcoid requires the use of a breathing assistance device, such as a CPAP machine, but does not result in chronic respiratory failure with carbon dioxide retention or cor pulmonale, or requires a tracheostomy, and does not result in pulmonary involvement requiring systemic high dose (therapeutic) corticosteroids for control. CONCLUSIONS OF LAW 1. The criteria for an initial rating in excess of 20 percent for DJD of the cervical spine have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code (DC) 5242. 2. The criteria for a rating in excess of 20 percent prior to May 2, 2018, and in excess of 40 percent thereafter, for RUE carpal tunnel syndrome have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.124a, DC 8513. 3. The criteria for a rating in excess of 10 percent prior to May 2, 2018, for LUE carpal tunnel syndrome have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.124a, DCs 8515, 8513. 4. From May 2, 2018 to October 23, 2020, the criteria for a 20 percent rating, but no higher, for LUE carpal tunnel syndrome have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.124a, DCs 8515, 8513. 5. As of October 23, 2020, the criteria for a rating in excess of 30 percent for LUE carpal tunnel syndrome have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.124a, DCs 8515, 8513. 6. The criteria for a rating in excess of 50 percent for OSA with residuals of sarcoid are not met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.3, 4.7, 4.97, DCs 6600-6847 (2020). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from June 1997 to June 2009. This matter comes to the Board of Veterans’ Appeals (Board) on appeal from rating decisions issued in March 2010, August 2011, and December 2014 by a Department of Veterans Affairs (VA) Regional Office (RO). During the course of the appeal, the Veteran was represented by a private attorney; however, the Veteran's attorney withdrew from representation in May 2019. During the course of this appeal, in a rating decision dated December 2014, the RO increased the Veteran’s disability rating for degenerative joint disease of the cervical spine, assigning a 20 percent rating effective June 27, 2009. In a rating decision dated 2017, the RO increased the Veteran’s disability rating for right shoulder/upper clavicular radiculopathy with RUE carpal tunnel syndrome, assigning a 20 percent rating effective June 27, 2009, and a December 2019 rating decision assigned a 40 percent rating effective May 2, 2018 for such disability. Additionally, in a November 2018 rating decision, the RO granted service connection for obstructive sleep apnea with residuals of sarcoid and assigned a 50 percent rating effective June 27, 2009. Lastly, in a December 2020 rating decision, the RO increased the Veteran’s disability rating for LUE carpal tunnel syndrome, assigning a 30 percent rating effective October 23, 2020. However, as claimants are generally presumed to be seeking the maximum benefit allowed by law and regulation, the issue of entitlement to higher ratings for such disabilities remains on appeal. AB v. Brown, 6 Vet. App. 35, 38 (1993). The Board notes the Veteran requested a Board hearing in his October 2013 and December 2014 substantive appeals. However, in April 2016, the Veteran submitted a written statement withdrawing his requests for a hearing. Therefore, the Board considers the hearing request withdrawn. See 38 C.F.R. § 20.704 (e) (2017). Further, as the Veteran’s previous representative argues that his service-connected disabilities render him unable to work, the Board has assumed jurisdiction over the issue of entitlement to a TDIU and has included such issue in the title page of this decision. See Rice v. Shinseki, 22 Vet. App. 447 (2009). In October 2017, the case was remanded for additional development and now returns for further appellate review. Increased Rating Claims The Veteran contends his cervical spine disability, right shoulder/upper clavicular radiculopathy with RUE carpal tunnel syndrome (hereafter as RUE carpal tunnel syndrome), LUE carpal tunnel syndrome, and OSA with residuals of sarcoid are more severe than as reflected by the currently assigned ratings. Disability ratings are determined by applying a schedule of ratings that is based on average impairment of earning capacity. Separate diagnostic codes identify the various disabilities. 38 U.S.C. § 1155; 38 C.F.R., Part 4. Each disability must be viewed in relation to its history and the limitation of activity imposed by the disabling condition should be emphasized. 38 C.F.R. § 4.1. Examination reports are to be interpreted in light of the whole recorded history, and each disability must be considered from the point of view of the veteran working or seeking work. 38 C.F.R. § 4.2. All reasonable doubt will be resolved in the claimant’s favor. 38 C.F.R. § 4.3. Where there is a question as to which of two disability evaluations shall be applied, the higher evaluation is to be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating is to be assigned. 38 C.F.R. § 4.7. Separate ratings can be assigned for separate periods based on the facts found - a practice known as “staged” ratings. Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). Staged ratings are appropriate whenever the factual findings show distinct periods where the service-connected disability exhibits symptoms that would warrant different ratings. Id. In general, all disabilities, including those arising from a single disease entity, are rated separately, and all disability ratings are then combined in accordance with 38 C.F.R. § 4.25. Pyramiding, the evaluation of the same disability, or the same manifestation of a disability, under different diagnostic codes, is to be avoided when rating a Veteran’s service-connected disability. 38 C.F.R. § 4.14. It is possible for a Veteran to have separate and distinct manifestations from the same injury which would permit rating under several diagnostic codes, however, the critical element in permitting the assignment of several ratings under various diagnostic codes is that none of the symptomatology for any one of the conditions is duplicative or overlapping with the symptomatology of the other condition. See Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994). The basis of disability evaluation is the ability of the body as a whole, or of the psyche, or of a system or organ of the body to function under the ordinary conditions of daily life including employment. 38 C.F.R. § 4.10. 1. Entitlement to an initial rating in excess of 20 percent for a cervical spine disability. Disability of the musculoskeletal system is primarily the inability, due to damage or infection in parts of the system, to perform the normal working movements of the body with normal excursion, strength, speed, coordination and endurance. Functional loss may be due to the absence or deformity of structures or other pathology, or it may be due to pain, supported by adequate pathology and evidenced by the visible behavior in undertaking the motion. Weakness is as important as limitation of motion, and a part that becomes painful on use must be regarded as seriously disabled. 38 C.F.R. § 4.40. In Mitchell v. Shinseki, 25 Vet. App. 32, 44 (2011), the United States Court of Appeals for Veterans Claims (Court) held that, although pain may cause a functional loss, “pain itself does not rise to the level of functional loss as contemplated by VA regulations applicable to the musculoskeletal system.” Rather, pain may result in functional loss, but only if it limits the ability “to perform the normal working movements of the body with normal excursion, strength, speed, coordination, or endurance.” Id., quoting 38 C.F.R. § 4.40. With respect to joints, in particular, the factors of disability reside in reductions of normal excursion of movements in different planes. Inquiry will be directed to more or less than normal movement, weakened movement, excess fatigability, incoordination, pain on movement, swelling, deformity or atrophy of disuse. 38 C.F.R. § 4.45; DeLuca v. Brown, 8 Vet. App. 202 (1995). The intent of the Rating Schedule is to recognize actually painful, unstable or malaligned joints, due to healed injury, as entitled to at least the minimum compensable rating for the joint, even in the absence of arthritis. 38 C.F.R. § 4.59; Burton v. Shinseki, 25 Vet. App. 1, 5 (2011). In this regard, 38 C.F.R. § 4.59 requires that “[t]he joints involved should be tested for pain on both active and passive motion, in weight-bearing and nonweight-bearing and, if possible, with the range of the opposite undamaged joint.” Correia v. McDonald, 28 Vet. App. 158 (2016). Further, 38 C.F.R. § 4.59 is applicable to the evaluation of musculoskeletal disabilities involving actually painful, unstable or malaligned joints or periarticular regions, regardless of whether the DC under which the disability is evaluated is predicated on range of motion measurements. Southall-Norman v. McDonald, 28 Vet. App. 346 (2016). As of June 27, 2009, commensurate with the date of his discharge from active service, the Veteran’s cervical spine disability was rated under DC 5242, which provides that such is evaluated under either the General Rating Formula for Disease and Injuries of the Spine (General Rating Formula) or the Formula for Rating IVDS Based on Incapacitating Episodes (IVDS Formula). Ratings under the General Rating Formula for Diseases and Injuries of the Spine are made with or without symptoms such as pain (whether or not it radiates), stiffness, or aching in the area of the spine affected by residuals of injury or disease. Such provides for a 20 percent rating where there is 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 forward flexion of the thoracolumbar spine to 30 degrees or less; or favorable ankylosis of the entire thoracolumbar spine. A 50 percent rating is warranted for unfavorable ankylosis of the entire thoracolumbar spine. Finally, a 100 percent rating is warranted for unfavorable ankylosis of the entire spine. 38 C.F.R. § 4.71a. Note (1): Any associated objective neurologic abnormalities, including, but not limited to, bowel or bladder impairment, should be separately evaluated under an appropriate diagnostic code. Note (2): (See also Plate V.) For VA compensation purposes, normal forward flexion of the cervical spine is zero to 45 degrees, extension is zero to 45 degrees, left and right lateral flexion are zero to 45 degrees, and left and right lateral rotation are zero to 80 degrees. Normal forward flexion of the thoracolumbar spine is zero to 90 degrees, extension is zero to 30 degrees, left and right lateral flexion are zero to 30 degrees, and left and right lateral rotation are zero to 30 degrees. The combined range of motion refers to the sum of the range of forward flexion, extension, left and right lateral flexion, and left and right rotation. The normal combined range of motion of the cervical spine is 340 degrees and of the thoracolumbar spine is 240 degrees. The normal ranges of motion for each component of spinal motion provided in this note are the maximum that can be used for calculation of the combined range of motion. Note (3): In exceptional cases, an examiner may state that because of age, body habitus, neurologic disease, or other factors not the result of disease or injury of the spine, the range of motion of the spine in a particular individual should be considered normal for that individual, even though it does not conform to the normal range of motion stated in Note (2). Provided that the examiner supplies an explanation, the examiner’s assessment that the range of motion is normal for that individual will be accepted. Note (4): Round each range of motion measurement to the nearest five degrees. 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. Note (6): Separately evaluate disability of the thoracolumbar and cervical spine segments, except when there is unfavorable ankylosis of both segments, which will be rated as a single disability. Id. As noted above, IVDS may be evaluated under either the General Rating Formula or under the IVDS Formula, whichever method results in the higher evaluation when all disabilities are combined. 38 C.F.R. § 4.25 (combined ratings table). The IVDS Rating Formula provides that a 20 percent evaluation is warranted when there are incapacitating episodes having a total duration of at least 2 weeks but less than 4 weeks during the past 12 months. A 40 percent evaluation is warranted when there are incapacitating episodes having a total duration of at least 4 weeks but less than 6 weeks during the past 12 months. A 60 percent evaluation is warranted when there are incapacitating episodes having a total duration of at least 6 weeks during the past 12 months. Note (1) provides that an incapacitating episode is a period of acute signs and symptoms due to IVDS that requires bed rest prescribed by a physician and treatment by a physician. 38 C.F.R. § 4.71a. As an initial matter, the Board notes that the record does not show, and the Veteran does not contend, that he ever had incapacitating episode of IVDS as defined by VA regulations, i.e., required physician prescribed bed rest. In this regard, a November 2013 VA examination found that the Veteran had IVDS, but such did not result in any incapacitating episodes. Furthermore, VA examinations conducted in May 2018 and November 2020 found the Veteran did not have IVDS of the cervical spine. Therefore, higher ratings under the IVDS Formula are not warranted at any point pertinent to the appeal. Further, the Board finds that a rating in excess of 20 percent is not warranted under the General Rating Formula. In this regard, the record does not reflect that his range of motion was limited to the extent necessary to warrant higher ratings at any point during the period on appeal. Specifically, the next higher rating of 30 percent requires evidence of forward flexion of the cervical spine to 15 degrees or less, or favorable ankylosis of the entire cervical spine. In this regard, the Veteran was afforded a VA examination of his cervical spine in February 2010. At such time he was diagnosed with degenerative arthritis at C4-C7 with posterior osteophytes with an abutment of the ventral cord at C5-6. Range of motion testing (ROM) was not recorded. The Veteran underwent another VA examination of his cervical spine in November 2013 at which time he denied flare-ups. ROM testing revealed forward flexion to 35 degrees and extension to 25 degrees with pain that caused functional loss. Following repetitive use testing, the Veteran’s flexion was further limited to 25 degrees and extension to 15 degrees due to pain on movement, weakened movement, and disturbance of locomotion. The examiner noted the Veteran had localized tenderness or pain to palpation for joints/soft tissue of the cervical spine, and guarding or muscle spasm was present, but did not result in abnormal gait or spinal contour. Muscle strength, reflexes, and sensation was normal in the bilateral upper extremities. Ankylosis was not noted. However, in an October 2017 decision, the Board reviewed the November 2013 VA examination report and concluded that the findings did not meet the requirements of 38 C.F.R. § 4.59 pursuant to Correia, supra. Thus, the case was remanded for another VA examination. In May 2018, the Veteran underwent another VA examination for his cervical spine. At such time, he reported worsening intermittent neck pain with numbness in the upper back that radiates to the left and right shoulder, and at times to the left arm. Initial ROM testing revealed forward flexion to 35 degrees and extension to 25 degrees with pain that caused functional loss; however, there was no pain on weight-bearing. There was no additional functional loss after repetitive use testing. The Veteran denied flare-ups. The examiner noted the Veteran had localized tenderness or pain to palpation for joints/soft tissue of the cervical spine, and muscle spasm was present, but did not result in abnormal gait or spinal contour. Muscle strength was 5/5, with the exception of bilateral wrist dorsiflexion, which was 4/5. There was no muscle atrophy, and reflex testing was normal. Sensation was normal in the bilateral upper extremities, with the exception of the bilateral hand/fingers, where it was decreased. Ankylosis was not present. Radiculopathy of the upper extremities was noted and is discussed further herein. However, there was no other neurologic abnormalities or findings related to the Veteran’s cervical spine disability, to include bowel or bladder problems. Contemporaneous private treatment records reveal the Veteran complained of off and on neck pain, but he reported no change in bladder or bowel function. See April 2016, July 2017, and August 2017 Dr. N.K. records. The Veteran underwent another VA examination in October 2020. At such time, the Veteran reported worsening neck pain, such that a few months prior he had gone to an ER due to symptoms of left arm numbness and chest pain, and stated he was diagnosed with muscle spasm of the upper back. Initial ROM testing revealed forward flexion to 35 degrees and extension to 30 degrees with pain that caused functional loss. There was evidence of pain on weight-bearing. There was no additional limitation of motion with repetitive motion testing and, although not conducted during a flare-up, the examiner noted that the examination was medically consistent with the Veteran's statements describing functional loss duringa flare-up and over time. The examiner noted the Veteran had localized tenderness or pain to palpation for joints/soft tissue of the cervical spine, and guarding was present, and resulted result in abnormal gait or spinal contour due to the Veteran’s antalgic neck position. Muscle strength was 5/5, with the exception of right elbow extension, which was 4/5. There was no muscle atrophy, and reflex testing was normal. Sensation was normal in the bilateral upper extremities, with the exception of the bilateral hand/fingers, where it was decreased. Ankylosis was not present. Although radiculopathy of the upper extremities was noted, there was no other neurologic abnormalities or findings related to the Veteran’s cervical spine disability, to include bowel or bladder problems. Based on the foregoing, the Board finds that, as the Veteran’s neck disability was manifested by forward flexion greater than 35 degrees, even in contemplation of functional loss due to symptoms such as pain, fatigue, weakness, lack of endurance, or incoordination, or as a result of repetitive motion and/or flare-ups, a rating in excess of 20 percent is not warranted under the General Rating Formula. There are no ROM findings during such period that reflect that the Veteran’s neck disability was manifested by a greater limitation of flexion. Thus, a higher rating under the General Rating Formula for such period is not warranted. Furthermore, while he was found to have an antalgic neck position during his October 2020 VA examination, the Veteran’s neck disability is not shown to result in ankylosis, which is defined in general as "immobility and consolidation of a joint due to disease, injury, or surgical procedure." Colayong v. West, 12 Vet. App. 524 (1999) (citing Dorland’s Illustrated Medical Dictionary (28th ed. 1994) at 86). Notably, the evidence of record does not reveal that the Veteran's cervical spine is fixed in position or ankylosed at any point during the appeal period. Thus, a higher rating under the General Rating Formula for such period is not warranted. With regard to Note (1) of the General Rating Formula, the Board observes that the Veteran has been awarded separate ratings for carpal tunnel syndrome of the bilateral upper extremities (BUE) as associated with his neck disability, the propriety of which will be discussed further herein. However, the evidence fails to show that such disability is manifested by any other associated objective neurologic abnormalities, including, but not limited to, bowel or bladder impairment. In this regard, the VA examinations conducted during the appeal period, as well as treatment records, fail to show the presence of any such associated objective neurologic abnormalities. Consequently, separate ratings for associated objective neurologic abnormalities other than carpal tunnel syndrome of the bilateral upper extremities are not warranted. Finally, the Board notes the Veteran has a separate noncompensable rating for his residual scar of the right neck associated with his cervical spine disability pursuant to DC 7800. In this regard, at his October 2020 VA examination, such scar was noted to be 4.0 centimeters (cm) long and 0.2 cm wide, and not painful to palpation or movement. Further, the Veteran’s scar was not raised or unstable, and there was no underlying soft tissue damage. As the Veteran’s scar is not deep, nonlinear, painful, unstable, or covering an area greater than 6 square inches (39 square centimeters), a compensable rating is not warranted. 2. Entitlement to an initial rating in excess of 20 percent for right shoulder/upper clavicular radiculopathy with RUE carpal tunnel syndrome prior to May 2, 2018, and 40 percent thereafter. 3. Entitlement to an initial rating in excess of 10 percent for LUE carpal tunnel syndrome prior to October 23, 2020, and 30 percent thereafter. In rating peripheral nerve injuries and their residuals, attention should be given to the site and character of the injury, the relative impairment and motor function, trophic changes, or sensory disturbances. 38 C.F.R. § 4.120. Under 38 C.F.R. § 4.124a, a disability from neurological disorders is rated from 10 to 100 percent in proportion to the impairment of motor, sensory, or mental function. With partial loss of use of one or more extremities from neurological lesions, rating is to be by comparison with mild, moderate, severe, or complete paralysis of the peripheral nerves. 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. In regards to his RUE carpal tunnel syndrome, the Veteran is currently in receipt of an initial 20 percent rating as of June 27, 2009, commensurate with the date of his discharge from active service, to May 2, 2018, and a 40 percent rating thereafter for such disability pursuant to DC 8513. Specific to his LUE carpal tunnel syndrome, the Veteran is currently in receipt of an initial 10 percent rating as of June 27, 2009, commensurate with the date of his discharge from active service, to October 23, 2020 pursuant to DC 8599-8515, and a 30 percent rating thereafter for such disability pursuant to DC 8513. Under DC 8513, incomplete paralysis of all radicular groups is rated as 20 percent disabling when it is mild. When incomplete paralysis of all radicular groups is moderate, a 30 percent rating is assigned for the minor extremity and a 40 percent rating is assigned for the major extremity. When incomplete paralysis of the median nerve is severe, a 60 percent rating is assigned for the minor extremity and a 70 percent rating is assigned for the major extremity. 38 C.F.R. § 4.124a. The Board notes the Veteran is right hand dominant. Further, as pertinent to his LUE carpal tunnel syndrome, under DC 8515 incomplete paralysis of the median nerve is rated as 10 percent disabling when it is mild. When incomplete paralysis of the median nerve is moderate, a 20 percent rating is assigned for the minor extremity and a 30 percent rating is assigned for the major extremity. When incomplete paralysis of the median nerve is severe, a 40 percent rating is assigned for the minor extremity and a 50 percent rating is assigned for the major extremity. At his February 2010 VA examination, the Veteran reported problems with bilateral carpal tunnel syndrome when doing a lot of computer work or typing. He wears braces when needed, although he reported that they do not provide much relief. His carpal tunnel syndrome primarily effects his thumb, index and long finger, and can be exacerbated or flared by driving for very long, working a keyboard, typing or writing. Upon physical examination, deep tendon reflexes were symmetrical in the upper extremities. Sensorium was symmetrical except for the bilateral thumb, index and long fingers. The Veteran stated feeling "asleep," but monofilament testing was unremarkable. Strength testing was diminished at the right biceps, right triceps and with dorsiflexion and extension of the right wrist. The examiner stated the Veteran’s essentially normal right shoulder examination was suggestive of cervical radiculopathy. Private treatment records dated July 2010 reveal the Veteran had some weakness in his triceps, mostly in his left upper extremity, along with significant paresthesias in his upper extremities. He underwent a cervical fusion at C5-6 and C6-7 in December 2010. A February 2012 private treatment record reflects he did not note any radiating arm symptoms. See Dr. W.J records. At his November 2013 VA examination, the Veteran reported neck pain that radiated to the right shoulder and numbness to the arms, and a tingling sensation to the bilateral shoulder/upper clavicular area. The examiner noted the Veteran had mild intermittent pain, mild paresthesias and/or dysesthesias, and mild numbness of his BUE. As noted previously, the Veteran’s muscle strength sensory tests were normal. The examiner found that the Veteran had mild incomplete radiculopathy of the upper radicular group of his BUE. Private treatment records dated April 2016 and August 2017 reflect neurological examinations were negative for numbness. See Dr. N.K records. The Veteran underwent a VA wrist examination in May 2018. At such time he reported experiencing numbing of the bilateral wrists which worsened with driving, typing, and using a mouse. Additionally, certain wrist movements produced pain. The Veteran denied flare-ups. Physical examination revealed ROM with dorsiflexion to 70 degrees and palmar flexion to 55 degrees of the right hand, and dorsiflexion to 40 degrees and palmar flexion to 80 degrees of the left hand. The examiner noted the Veteran did not experience functional loss, functional impairment, and/or additional limitation of range of motion following repetitive use testing of the bilateral wrists. Strength testing revealed the Veteran had normal flexion strength bilaterally, but extension strength was 4/5 bilaterally. The examiner further noted that the Veteran did not have ankylosis of either wrist, but that the Veteran had coarse tremors. The examiner diagnosed the Veteran with bilateral wrist carpal tunnel syndrome. X-rays taken in conjunction with this examination showed no fracture of dislocation, with visualized joint spaces normally maintained, and no soft tissue abnormality bilaterally. As noted previously, the Veteran also underwent a VA cervical spine examination in May 2018, which was the basis for the assignment of his increased rating of 40 percent for his RUE carpal tunnel syndrome. At such time, the examiner noted that the Veteran had no constant pain, mild intermittent pain, mild paresthesias and/or dysesthesias, and moderate numbness of the BUE. As mentioned previously, muscle strength was 5/5, with the exception of bilateral wrist dorsiflexion, which was 4/5. There was no muscle atrophy, and reflex testing was normal. Sensation was normal in the bilateral upper extremities, with the exception of the bilateral hand/fingers, where it was decreased. The examiner diagnosed the Veteran with moderate BUE radiculopathy. The Veteran was afforded another VA examination in October 2020, which was the basis for the assignment of his increased rating of 30 percent for his carpal tunnel syndrome of the LUE. It does not appear the Veteran’s RUE carpal tunnel syndrome was evaluated at such examination. At such time, the Veteran reported recurring symptoms of left arm numbness. Upon physical examination, the examiner noted that the Veteran had no constant pain, and mild intermittent pain, paresthesias and/or dysesthesias and numbness of the LUE. Muscle strength was 5/5, with the exception of left wrist flexion, which was 4/5. There was no muscle atrophy, and reflex testing was normal. The Veteran had decreased sensation in the left shoulder area (C5) and hand/fingers (C6-8.) The examiner noted that the Veteran had moderate incomplete paralysis of the median and ulnar nerves. Therefore, based on the foregoing, the Board finds that prior to May 2, 2018, an initial rating in excess of 10 percent for the Veteran’s LUE carpal tunnel syndrome, and 20 percent for right shoulder/upper clavicular radiculopathy with RUE carpal tunnel syndrome are not warranted. Specifically, prior to May 2, 2018, the severity of the Veteran’s BUE carpal tunnel syndrome has been characterized by no more than mild incomplete paralysis. Furthermore, April 2016 and August 2017 VA private treatment records reflect he denied numbness in the extremities, at his November 2013 VA examination muscle testing was normal, and sensory testing was normal. Furthermore, as of May 2, 2018, a rating in excess of 40 percent for the Veteran’s RUE carpal tunnel syndrome is not warranted. In this regard, such disability is manifested by no more than moderate incomplete paralysis of all radicular groups. The May 2018 examiner found that the Veteran had mild intermittent pain, mild paresthesias and/or dysesthesias, and moderate numbness in the right upper extremity. Muscle strength testing was reduced at 4/5 in right elbow extension and wrist dorsiflexion. Thus, the examiner assessed the Veteran’s RUE carpal tunnel syndrome as moderate incomplete paralysis of all radicular groups. Consequently, the Board finds that an initial rating in excess of 20 percent for right shoulder/upper clavicular radiculopathy with RUE carpal tunnel syndrome prior to May 2, 2018, and 40 percent thereafter is not warranted. However, as of May 2, 2018, the Board finds the Veteran’s LUE carpal tunnel syndrome is manifested by moderate incomplete paralysis of the median nerve, and thus a 20 percent rating under DC 8515 is warranted. As noted above, the May 2018 examiner diagnosed the Veteran with moderate BUE radiculopathy. Therefore, based on the foregoing, the Board resolves all doubt in favor of the Veteran and finds that, from May 2, 2018 to October 23, 2020, his LUE carpal tunnel syndrome is manifested by moderate incomplete paralysis of the median nerve. Thus, a 20 percent rating for such disability is warranted. The Board observes that, as of October 23, 2020, the Veteran’s LUE carpal tunnel syndrome involved impairment of the ulnar nerve group as well as the median nerve group. However, as the Veteran is already in receipt of a rating that contemplates impairment in all radicular groups, separate ratings for such disability under Diagnostic Codes 8510, 8514, 8515, and 8516, based on the same neurological symptoms would constitute prohibited pyramiding. 38 C.F.R. § 4.14; Esteban, supra. Further, as discussed above, his LUE carpal tunnel syndrome was found to be moderate in nature. The highest rating warranted for moderate incomplete paralysis of all radicular groups of the minor hand, is 30 percent. Thus, the Veteran is already in receipt of the highest rating possible, and a rating in excess of 30 percent is not warranted. 4. Entitlement to a rating in excess of 50 percent for OSA with residuals of sarcoid. The Veteran is currently in receipt of an initial 50 percent rating as of June 27, 2009, commensurate with the date of his discharge from active service, for his OSA with residuals of sarcoid under hyphenated DC 6600-6847. 38 C.F.R. § 4.97. Hyphenated diagnostic codes are used when a rating under one code requires use of an additional diagnostic code to identify the basis for the rating. 38 C.F.R. § 4.27. Here, the hyphenated diagnostic codes indicate that the Veteran’s respiratory disabilities are rated under the criteria for sarcoidosis (DC 6846) and sleep apnea (DC 6847). Under 38 C.F.R. § 4.97, a single rating is assigned for coexisting respiratory conditions that reflect the predominant disability. Obstructive sleep apnea is rated in accordance with 38 C.F.R. § 4.97, DC 6847. A 50 percent rating is warranted when the use of a breathing assistance device such as a CPAP machine is required. A 100 percent rating is warranted when there is chronic respiratory failure with carbon dioxide retention or cor pulmonale or if a tracheostomy is required. Under DC 6846, sarcoidosis with pulmonary involvement with persistent symptoms requiring chronic low dose (maintenance) or intermittent corticosteroids is rated 30 percent disabling. Sarcoidosis with pulmonary involvement requiring systemic high dose (therapeutic) corticosteroids for control is rated 60 percent disabling. Sarcoidosis with cor pulmonale, or; cardiac involvement with congestive heart failure, or; progressive pulmonary disease with fever, night sweats, and weight loss despite treatment, is rated 100 percent disabling. 38 C.F.R. § 4.97. Alternatively, sarcoidosis may be rated pursuant to DC 6600 under the rating criteria for chronic bronchitis. 38 C.F.R. § 4.97, DC 6846 (“or rate active disease or residuals as chronic bronchitis (DC 6600) and extra-pulmonary involvement under specific body system involved”). DC 6600 provides ratings for chronic bronchitis based on the results of pulmonary function tests (PFTs). FEV-1 of 56- to 70-percent predicted, or; FEV-1/FVC of 56- to 70-percent predicted or; DLCO (SB) of 56- to 65-percent predicted, is rated 30 percent disabling. FEV-1 of 40- to 55-percent predicted, or; FEV-1/FVC of 40- to 55-percent, or; DLCO (SB) of 40- to 55-percent predicted, or; maximum oxygen consumption of 15 to 20 ml/kg/min (with cardiorespiratory limit), is rated 60 percent disabling. FEV-1 less than 40 percent of predicted value, or; FEV-1/FVC less than 40 percent predicted, or; DLCO (SB) less than 40 percent predicted, or; maximum exercise capacity less than 15 ml/kg/min oxygen consumption (with cardiac or respiratory limitation), or; cor pulmonale (right heart failure), or; right ventricular hypertrophy, or; pulmonary hypertension (shown by Echo or cardiac catheterization), or; episode(s) of acute respiratory failure, or; requires outpatient oxygen therapy is rated 100 percent disabling. 38 C.F.R. § 4.97. In this regard, PFTs are required to rate respiratory conditions except in certain situations, such as when the PFTs are inconsistent with the other clinical evidence of record and the examiner states why they are not a valid indication of respiratory functional impairment in a particular case. 38 C.F.R. § 4.96(d)(3). Further, post-bronchodilator PFT studies are required except when the results of pre-bronchodilator tests are normal or when the examiner determines that post-bronchodilator studies should not be done and states why. 38 C.F.R. § 4.96(d)(4). When evaluating a disability based on PFTs, post-bronchodilator results should be used unless such results are poorer than the pre-bronchodilator results, in which case the latter should be applied. 38 C.F.R. § 4.96(d)(5). When there is a disparity between the results of different PFTs (FEV-1, FVC, etc.) so that the level of evaluation would differ depending on which test result is used, use the test result that the examiner states most accurately reflects the level of disability. 38 C.F.R. § 4.96(d)(6). Turning to the evidence of record, PFTs done in conjunction with the Veteran’s February 2010 VA examination reveal the Veteran had FEV-1 pre-bronchodilator 2.66 and post-bronchodilator was 3.06 percent. The Veteran had FVC pre-bronchodilator of 3.48 and 3.90 post-bronchodilator. DLCO was 3.03. The examiner indicated these results showed minimal lung defects. Airway obstruction is confirmed by a decrease in flow rate at peak flow and flow at 50 percent and 75 percent of the flow volume curve. The examiner stated it appeared the Veteran had a good response to the bronchodilator. No complications of cor pulmonale, right ventricular hypertrophy, pulmonary hypertension, or chronic respiratory failure with carbon dioxide retention were noted. Private treatment records reflect that, on June 3, 2010, within one year of discharge from service, the Veteran was diagnosed with sleep apnea by a sleep study. Further, on November 30, 2010 he was prescribed a CPAP machine for treatment of his sleep apnea. Subsequent private treatment records reflect the ongoing prescription and use of a CPAP machine. However, such records do not reflect the presence of chronic respiratory failure with carbon dioxide retention or cor pulmonale, or the necessitation of a tracheostomy. X-rays taken in May 2012 reveal a clinical indication of sarcoidosis. In this regard, the x-rays revealed both lungs were well-expanded, there was no consolidation, no effusion, and calcified granuloma of the left lower lung measuring 5 mm was noted. See Dr. R.M. records. Private treatment records dated April 2016 reflect the Veteran’s sarcoidosis was asymptomatic. See Dr. N.K. records. In May 2018 the Veteran underwent a VA respiratory examination in connection with his claim for service connection for his OSA with residuals of sarcoid. At such time, he reported a history of snoring, and that his sarcoidosis had been asymptomatic for the past 18 months. He reported only two past flare-ups, once while still in military service, and the second in 2012. The Veteran stated he was prescribed prednisone both times. The examiner noted the Veteran’s sarcoidosis was asymptomatic, and the Veteran does not require use of oral or parenteral corticosteroid medications, or inhaled medications, or oral bronchodilators. The Board notes PFT testing was completed that same month, but such results were deemed not valid for rating purposes as pre and post-tests results showed session quality D and a caution note stated there was only one acceptable maneuver, and the results were to be interpreted with care. Further, the examiner found that such disability did not impact the Veteran’s ability to work. Following a review of the record, the Board finds that a rating in excess of 50 percent under DC 6847 for the Veteran’s OSA with residuals of sarcoid is not warranted at any time during the appeal period as there is no evidence that such disability results in chronic respiratory failure with carbon dioxide retention or cor pulmonale, or requires a tracheostomy. Further, with regard to DC 6846, the Veteran’s sarcoidosis was noted to be asymptomatic and there is no evidence of use of oral or parenteral corticosteroid medications or inhaled medications, or oral bronchodilator at any time during the appeal period. Thus, a higher rating under 6846 is not warranted. Other Considerations In reaching the foregoing determinations, the Board acknowledges the Veteran’s sincerely held belief that the symptoms associated with his right cervical spine disability, BUE carpal tunnel syndrome disabilities, and OSA with residuals of sarcoid disability, are more severe than as reflected by the currently assigned ratings. In this regard, the Board must consider the entire evidence of record when analyzing the criteria laid out in the rating schedule. While the Board recognizes that the Veteran is competent to describe his symptomatology and resulting functional difficulties, he is not competent to provide an opinion regarding the severity of his symptomatology in accordance with the rating criteria. See Woehlaert v. Nicholson, 21 Vet. App. 456 (2007). Ultimately, the Board finds the medical evidence in which professionals with specialized expertise examined the Veteran, acknowledged his reported symptoms, and described the manifestations of such disabilities in light of the rating criteria to be more persuasive than his own reports regarding the severity of his disabilities. The Board has also considered whether additional staged ratings under Fenderson, supra, or Hart, supra, are appropriate for the Veteran’s cervical spine disability, BUE carpal tunnel syndrome disabilities, and OSA with residuals of sarcoid disability; however, the Board finds that his symptomatology has been stable throughout each period on appeal. Therefore, assigning additional staged ratings for such disabilities is not warranted. Further, neither the Veteran nor his representative have raised any other issues, nor have any other issues been reasonably raised by the record, in regard to the initial and increased rating claims adjudicated herein. Doucette v. Shulkin, 28 Vet. App. 366 (2017). In reaching such decision, the Board has applied the benefit of the doubt doctrine and resolved all doubt in the Veteran’s favor, which has resulted in the partial award of an increased rating of 20 percent for his LUE carpal tunnel syndrome from May 2, 2018 to October 23, 2020. However, insofar as the Board has denied higher or separate ratings, the preponderance of the evidence is against such aspects of the Veteran’s claims. Therefore, the benefit of the doubt doctrine is not applicable in such regard and the Veteran’s initial and increased rating claims must otherwise be denied. 38 U.S.C. § 5107; 38 C.F.R. §§ 4.3, 4.7. REASONS FOR REMAND 5. Entitlement to a TDIU. As noted previously, the claim for a TDIU has been raised in connection with the Veteran's claims for increased ratings for his cervical spine disability, BUE carpal tunnel syndrome disabilities, and OSA with residuals of sarcoid disability pursuant to Rice, supra. At his October 2020 VA examination, the examiner stated recurrent episodes of neck and left shoulder pain, and left hand [disability] made it difficult for the Veteran to maintain any job. However, the record is unclear as to the Veteran’s current employment status. In this regard, the Board notes that at his May 2018 VA examination he reported that he was working as a project manager, and private treatment records dated August 2017 reflect he was working full time. Thus, on remand, the Veteran should be requested to complete and return a VA Form 21-8940, Veteran's Application for Increased Compensation Based on Unemployability. Thereafter, all indicated development should be conducted and his claim for a TDIU should be adjudicated. The matter is REMANDED for the following action: Request that the Veteran complete and return VA Form 21-8940, Veteran's Application for Increased Compensation based on Unemployability. Thereafter, conduct all indicated development and adjudicate his claim for a TDIU. K. R. LAFFITTE Acting Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board J. M. Kelly, 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.