Citation Nr: 21020956 Decision Date: 04/08/21 Archive Date: 04/08/21 DOCKET NO. 15-01 374 DATE: April 8, 2021 ORDER Entitlement to a rating in excess of 30 percent for depression prior to January 20, 2020 is denied. Entitlement to a rating in excess of 50 percent for depression from January 20, 2020 is denied. Entitlement to a rating in excess of 20 percent for thoracic spine degenerative joint disease (low back disorder) is denied. Entitlement to a rating in excess of 20 percent for right shoulder bursitis with right partial-thickness rotator cuff tear and impingement (right shoulder disorder) other than during a period of convalescence from July 11, 2017 through August 31, 2017 is denied. Entitlement to special monthly compensation (SMC) on the basis of the need for aid and attendance for the Veteran’s spouse is denied. FINDINGS OF FACT 1. For the period prior to January 20, 2020, the Veteran’s depression symptoms resulted in occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks. Symptoms of occupational and social impairment with reduced reliability and productivity were not demonstrated. 2. For the period after January 20, 2020, the Veteran’s depression symptoms have resulted in occupational and social impairment with reduced reliability and productivity. Symptoms of occupational and social impairment in most areas have not been demonstrated. 3. Throughout the period on appeal, the competent and credible evidence demonstrates that the Veteran’s low back disorder has not been manifested by limitation of forward flexion to 30 degrees or less; favorable ankylosis of the entire thoracolumbar spine; incapacitating episodes, or an associated neurological disability for which a separate rating has not been previously awarded. 4. Throughout the period on appeal (excluding a period for convalescence), and even with consideration of his complaints of pain, pain on motion and functional loss, the Veteran’s right shoulder disorder did not manifest as limitation of motion for his right arm at midway between his side and shoulder level or to 25 degrees from his side. 5. The preponderance of the evidence does not demonstrate that the Veteran’s spouse requires the regular aid and attendance of another person to perform the routine activities of daily living. CONCLUSIONS OF LAW 1. The criteria for entitlement to a rating in excess of 30 percent for depression prior to January 20, 2020 have not been met. U.S.C. §§ 1155, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.6, 4.7, 4.132, Diagnostic Code 9435 (2019). 2. The criteria for entitlement to a rating in excess of 50 percent for depression from January 20, 2020 have not been met. U.S.C. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.6, 4.7, 4.132, Diagnostic Code 9435. 3. The criteria for entitlement to a rating in excess of 20 percent for thoracic spine degenerative joint disease (low back disorder) have not been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.2, 4.3, 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5242. 4. The criteria for entitlement to a rating in excess of 20 percent for right shoulder bursitis with right partial-thickness rotator cuff tear and impingement (right shoulder disorder) other than during a period of convalescence from July 11, 2017 through August 31, 2017 have not been met. U.S.C. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.2, 4.3, 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5019-5201 (2019). 5. The criteria for entitlement to special monthly compensation (SMC) on the basis of the need for aid and attendance for the Veteran’s spouse have not been met.38 U.S.C. §§ 1114, 1115, 5107 (2012); 38 C.F.R. §§ 3.102, 3.351, 3.352 (2019). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from September 1989 to May 1999 and from August 1999 to August 2002. In September 2019, the Board remanded the appeal for evidentiary development. During development, and in pertinent part, a September 2020 rating decision increased the Veteran’s depression from 30 percent disabling to 50 percent, effective January 20, 2020 (date VA examination showed worsening of condition). It also increased his low back disorder from 10 percent disabling to 20 percent, effective August 27, 2012 (date VA received claim for benefits). It was noted that a temporary evaluation of 100 percent was assigned for his right shoulder disorder from July 11, 2017 to August 31, 2017 based on surgical or other treatment necessitating convalescence. Entitlement to a total disability rating based on individual unemployability (TDIU) was also awarded, effective August 27, 2012. The remaining issues, as they have been characterized above, have since been returned to the Board for further consideration. Increased 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 percentage ratings are based on the average impairment of earning capacity as a result of a service-connected disability, and separate diagnostic codes identify the various disabilities and the criteria for specific ratings. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. If two disability evaluations are potentially applicable, 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 reasonable doubt as to the degree of disability will be resolved in favor of the claimant. 38 C.F.R. § 4.3. While it is necessary to consider the complete medical history of the Veteran’s condition in order to evaluate the level of disability and any changes in condition, where an increase in the level of a service-connected disability is at issue, the primary concern is the present level of disability. Schafrath v. Derwinski, 1 Vet. App. 589, 594 (1991); Francisco v. Brown, 7 Vet. App. 55 (1994). In deciding the Veteran’s increased evaluation claim, the Board has considered the determinations in Fenderson v. West, 12 Vet. App. 119 (1999) and Hart v. Mansfield, 21 Vet. App. 505 (2007), and whether the Veteran is entitled to an increased evaluation for separate periods based on the facts found during the appeal period. Disability of the musculoskeletal system is primarily the inability, due to damage or inflammation in parts of the system, to perform normal working movements of the body with normal excursion, strength, speed, coordination, and endurance. The functional loss may be due to absence of part or all of the necessary bones, joints and muscles, or associated structures, or to deformity, adhesions, defective innervation, or other pathology, or may be due to pain, supported by adequate pathology and evidenced by visible behavior of the claimant undertaking the motion. Weakness is as important as limitation of motion, and a part which becomes painful on use must be regarded as disabled. See 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. 38 C.F.R. § 4.59. In addition, when assessing the severity of a musculoskeletal disability that, as here, is at least partly rated on the basis of limitation of motion, VA must also consider the extent to which the Veteran may have additional functional impairment above and beyond the limitation of motion objectively demonstrated, such as during times when his symptoms are most prevalent (“flare-ups”) due to symptoms such as pain. See also 38 C.F.R. §§ 4.40, 4.45. 1. Entitlement to a rating in excess of 30 percent for depression prior to January 20, 2020 2. Entitlement to a rating in excess of 50 percent for depression from January 20, 2020 As discussed above, a September 2020 rating decision increased the Veteran’s depression from 30 percent to 50 percent disabling, effective January 20, 2020 (date of VA examination). The Veteran seeks entitlement to a rating more than 30 percent prior to January 20, 2020 and in excess of 50 percent thereafter. The Veteran’s depression is evaluated under the provisions of 38 C.F.R. § 4.130, Diagnostic Code 9435, and is subject to the criteria of the General Rating Formula for Mental Disorders that provide for the following: A 30 percent rating is where there is occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, mild memory loss (such as forgetting names, directions, recent events). Id. A 50 percent rating is warranted for occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; and difficulty in establishing and maintaining effective work and social relationships. Id. A 70 percent rating is warranted for occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work-like setting); inability to establish and maintain effective relationships. Id. A 100 percent evaluation is warranted for total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. 38 C.F.R. § 4.130, Diagnostic Code 9434. When determining the appropriate disability evaluation to assign, the Board’s primary consideration is a Veteran’s symptoms, but it must also make findings as to how those symptoms impact a Veteran’s occupational and social impairment. Vazquez-Claudio v. Shinseki, 713 F.3d 112, 118 (Fed. Cir. 2013). Because the use of the term “such as” in the rating criteria demonstrates that the symptoms after that phrase are not intended to constitute an exhaustive list, the Board need not find the presence of all, most, or even some, of the enumerated symptoms to award a specific rating. See Sellers v. Principi, 372 F.3d 1318, 1326-27 (Fed. Cir. 2004). Nevertheless, all ratings in the general rating formula are also associated with objectively observable symptomatology and the plain language of the regulation makes it clear that the veteran’s impairment must be “due to” those symptoms, a Veteran may only qualify for a given disability by demonstrating the particular symptoms associated with that percentage, or others of similar severity, frequency, and duration. Vazquez-Claudio, 713 F.3d at 118. Based on the evidence presented, the Board finds that a rating more than 30 percent for depression prior to January 20, 2020 is not warranted. A review of the record discloses that the Veteran’s symptoms during the earlier period were more characteristic of a disability picture that is contemplated by a 30 percent rating rather than that contemplated by a 50 percent rating or higher under Diagnostic Code 9435. Few of the type of criteria contemplated for a 50 percent rating or higher have been demonstrated. Similarly, the Board also finds that a rating in excess of 50 percent for depression after January 20, 2020 is not warranted. Further discussion follows. The Veteran received a VA examination in March 2013, wherein he was diagnosed with depression. The Veteran reported that he has been married to his second wife for 14 years and they have two teenage sons. He stated that his current family life was good, but he rarely talks to his ex-wife and son from his previous marriage. He claimed to enjoy fishing, camping, bowling, and golfing. It was indicated that he does not take his medication prescribed to treat his depression and that he no longer engages in therapy either. The examiner provided the following remarks: [The Veteran] was oriented to person, place, time, and situation, dressed casually and adequately groomed. Manner was cooperative; eye contact was good; speech volume, rate, and tone were within normal limits. Mood was dysphoric; affect was mildly constricted. Thought process was logical and non-tangential; thought content was responsive without delusions, paranoia, or symptoms of psychosis. No suicidal/homicidal ideations were present. The examiner noted that the Veteran’s depression includes symptoms of depressed mood and chronic sleep impairment. The examiner found that the Veteran’s depression causes occupational and social impairment due to mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress, or symptoms controlled by medication. The Veteran’s VA treatment records during the period on appeal do not show that the Veteran receives any therapy or mental health counseling. Additionally, his psychiatric condition was has been generally described as normal with no homicidal or suicidal ideations present. Pursuant to the Board’s September 2019 remand, the Veteran received another VA psychiatric examination on January 20, 2020, wherein a diagnosis of depression was confirmed. The Veteran stated that he still has a good family life with no problems in his current marriage. He also stated that he has close friends that he goes fishing with and enjoys reading, watching TV, and woodworking. He claimed that he did not enjoy mental health therapy so does not attend anymore, but tends to takes his prescription medication. He denied any suicidal or homicidal ideations but is easily angered and feels down all the time. He also denied any obsessions, compulsions, or panic attacks but feels anxious often. He also has difficulty sleeping. According to the examiner, the Veteran was adequately groomed, alert/oriented, and cooperative. His thought processes were linear and he had fair judgment and insight with an appropriate mood. The examiner noted that the Veteran’s depression includes symptoms of depressed mood, anxiety, chronic sleep impairment, mild memory loss, disturbances of motivation and mood, and neglect of personal appearance and hygiene. The examiner found that the Veteran’s depression causes occupational and social impairment with reduced reliability and productivity. The Board acknowledges that this examination resulted in an increased 50 percent rating for depression, effective January 20, 2020 (date of VA examination). The above findings justify no more than a 30 percent rating for the period prior to January 20, 2020. The Board finds such symptoms did not rise to the level of occupational and social impairment with reduced reliability and productivity. As such, the Veteran did not display any symptoms that mirrored flattened affect, speech disturbances, memory impairment, difficulty understanding complex commands, impaired judgment, impaired abstract thinking, or difficulty in establishing and maintaining effective relationships. The March 2013 VA examination revealed that the Veteran’s orientation, appearance, personal hygiene, behavior, communication, speech, judgment, and abstract thinking were all within normal limits. The Board notes that while the Veteran reported having a depressed mood and sleep impairment, he also denied any suicidal or homicidal ideation and any audio/visual hallucinations. The Veteran also reported that he enjoys activities such as camping, golfing, and bowling and has a normal relationship with his wife and children living with him. Although the VA examiner had the opportunity to do so, the examiner did not conclude that the Veteran’s depression caused occupational and social impairment with reduced reliability and productivity. Finally, the VA treatment reports discussed above show that his symptoms were stable during this time period and often well-controlled with medication. For the reasons stated above and given the absence of symptoms prior to January 20, 2020 such as flattened affect; circumstantial, circumlocutory or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment or abstract thinking; disturbances of motivation and mood; and difficulty in establishing and maintaining effective work and social relationships, the Board finds against a 50 percent rating or higher for the period prior to January 20, 2020. Given its review of the medical evidence of record, the Board also finds that for the period after January 20, 2020, the Veteran’s service-connected depression is shown to be essentially productive of occupational and social impairment with reduced reliability and productivity and difficulty in establishing and maintaining effective work and social relationships. In this regard, the Board notes that the January 20, 2020 VA examiner remarked that the Veteran’s depression causes occupational and social impairment with reduced reliability and productivity. Moreover, the examiner noted that the Veteran experiences depression symptoms such as anxiety, irritability, and chronic sleep impairment. He also maintains contact with his children, has a normal relationship with his wife, and occasionally goes fishing with his close friends. For the reasons stated above and given the absence of symptoms such as obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; spatial disorientation; neglect of personal appearance and hygiene; and given the absence of an inability to establish and maintain effective relationships, the Board finds against a rating of 70 percent rating or higher for the period after January 20, 2020. The Board finds that the Veteran has been competent and credible when reporting his symptoms. The medical and lay evidence, however, establish that at best, there has been occupational and social impairment with reduced reliability and productivity, but occupational and social impairment with deficiencies in most areas has not been shown. Although the Veteran reports some social and impairment, problems with sleep disturbance, and anxiety, such symptoms do not warrant a 70 percent evaluation or higher when all the other manifestations are considered. See Mauerhan v. Principi, 16 Vet. App. 436 (2002). In sum, the Veteran’s depression for the period prior to January 20, 2020 was more characteristic of a disability picture that is contemplated by a 30 percent rating and more characteristic of a 50 percent rating thereafter. Neither the lay nor credible medical evidence shows his symptoms met the level required for a 50 percent evaluation prior to January 20, 2020, nor do they suggest a rating in excess of 50 percent for the period thereafter. In reaching this decision the Board considered the benefit of the doubt doctrine; however, as the preponderance of the evidence is against the claim the doctrine is not for application. 38 U.S.C. § 5107. 3. Entitlement to a rating in excess of 20 percent for thoracic spine degenerative joint disease (low back disorder) As discussed previously, a September 2020 rating decision increased the Veteran’s low back disorder from 10 percent disabling to 20 percent, effective August 27, 2012 (date VA received claim for benefits). The Veteran’s low back disorder is rated under 38 C.F.R. § 4.71a, Diagnostic Code 5242. Under the General Rating Formula for Diseases and Injuries of the Spine (General Rating Formula), 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, unfavorable ankylosis of the entire spine warrants a 100 percent rating. Unfavorable ankylosis of the entire thoracolumbar spine warrants a 50 percent rating. Forward flexion of the thoracolumbar spine 30 degrees or less; or, favorable ankylosis of the entire thoracolumbar spine, warrants a 40 percent rating. 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 spine contour such as scoliosis, reversed lordosis, or abnormal kyphosis warrants a 20 percent rating. Forward flexion of the thoracolumbar spine greater than 60 degrees but not greater than 85 degrees, or combined range of motion of greater than 120 degrees but not greater than 235 degrees, or muscle spasm, guarding, or localized tenderness not resulting in abnormal gait or abnormal spinal contour; or vertebral body fracture with loss of 50 percent or more of the height warrants a 10 percent rating. Note (1): Evaluate any associated objective neurological abnormalities, including, but not limited to, bowel or bladder impairment, separately, under an appropriate diagnostic code. The Board acknowledges that separate ratings have been assigned for neurological impairment of the bilateral lower extremities. Those ratings are not at issue in this appeal. Note (2): (See also Plate V.) For VA compensation purposes, normal forward flexion of the thoracolumbar spine is zero to 90 degrees, extension is 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 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 (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. Additionally, Diagnostic Code 5243, pertains to intervertebral disc syndrome. Under the Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes, a 20 percent evaluation is warranted with 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 assigned for incapacitating episodes having a total duration of at least 4 weeks but less than 6 weeks during the past 12 months; and a 60 percent evaluation is assigned for incapacitating episodes having a total duration of at least 6 weeks during the past 12 months. See 38 C.F.R. § 4.71a, Diagnostic Code 5243. The Board observes that the Veteran has received some VA treatment for his low back disorder, including prescription medication. The majority of this treatment includes complaints of pain, but range of motion testing is mostly absent. The Veteran underwent a VA examination in June March 2013. Range of motion testing showed 40 degrees flexion with no objective evidence of painful motion, 10 degrees extension with no objective evidence of painful motion, right lateral flexion to 10 degrees with no objective evidence of painful motion, left lateral flexion to 20 degrees with no objective evidence of painful motion, and right/left lateral rotation to 30 degrees with no objective evidence of painful motion. Repetitive use testing yielded similar results. The examiner stated that the Veteran has no functional impairment and was self-limiting during the examination. It was noted that the Veteran complained of back pain when standing or sitting too long but is still able to bowl and play golf. No tenderness or guarding was reported. Muscle strength testing, reflex exam, and sensory exam were all normal. No radiculopathy or other neurological abnormalities were found, and intervertebral disc syndrome was not present. X-ray findings revealed an impression of “minimal DJD of the lumbar spine … which is no worse than what would be expected for age.” Pursuant to the Board’s May 2019 remand, the Veteran underwent another VA back examination in January 2020. The examiner diagnosed the Veteran with degenerative joint disease of the thoracic spine, to include low back pain. The Veteran reported additional back pain with spasms and he indicated that he receives injections to ease the pain. Flare-ups were reported every 3-4 months to every 6-7 months, usually lasting several days. Difficulty moving was reported as to any functional loss or impairment. The range of motion for his lumbar spine was reported as: 70 degrees of forward flexion, 20 degrees of extension, 30 degrees of right lateral flexion, 30 degrees of left lateral flexion, 30 degrees of right lateral rotation, and 30 degrees of left lateral rotation, with additional pain that causes functional loss. The examiner stated this this examination was being conducted during a flare-up. Repetitive motion testing yielded similar results. No guarding or muscle spasms were reported. Muscle strength testing was 4/5 with reflex and sensory examinations also normal. Straight leg testing was negative and no radiculopathy was found in the lower extremities. The examiner noted that the Veteran did not have intervertebral disc syndrome. No atrophy, ankylosis, or other neurologic abnormalities were reported. The examiner stated that there is objective evidence of pain on non-weight bearing and that passive range of motion testing was the same as active range of motion testing. The Board notes that this examination resulted in an increased 20 percent rating for his low back disorder, effective August 27, 2012 (date VA received a claim for increase). In order for a higher evaluation to be warranted for the Veteran’s service-connected low back disorder, the evidence must show forward flexion of the thoracolumbar spine 30 degrees or less; or, favorable ankylosis of the entire thoracolumbar spine; or incapacitating episodes having a total duration of at least 4 weeks during a twelve-month period. Considering the evidence of record, the Board finds that the manifestations of the Veteran’s low back disorder have not approached the severity contemplated for an evaluation higher than 20 percent. Even considering limited motion due to pain and on repetitive testing, forward flexion was greater than 30 degrees. Additionally, there has not been objective evidence of ankylosis or intervertebral disc syndrome. Finally, there is otherwise no additional diagnostic code that could apply to the Veteran’s low back disorder. See Diagnostic Codes 5235-5243. The Board has considered the lay statements regarding the extent of the Veteran’s back pain and finds them to be probative. However, the objective findings of the medical professionals as to his ranges of motion are more probative in assigning ratings under the Schedule. In sum, the Board finds that the preponderance of the evidence is against a rating in excess of 20 percent for his low back disorder. In reaching this conclusion, the Board has considered the applicability of the benefit of the doubt doctrine; however, as the preponderance of the evidence is against assignment of higher ratings, that doctrine is not applicable. See 38 U.S.C. § 5107. 4. Entitlement to a rating in excess of 20 percent for right shoulder bursitis with right partial-thickness rotator cuff tear and impingement (right shoulder disorder) other than during a period of convalescence from July 11, 2017 through August 31, 2017 The Veteran seeks entitlement to an evaluation more than 20 percent for a right shoulder disorder other than for a period of convalescence. The Board acknowledges that during the course of the appeal, his right should disorder was temporarily rated as 100 percent disabling from July 11, 2017 through August 31, 2017 because he underwent surgery and required a period of convalescence after the procedure and this period is not on appeal. The Veteran’s right shoulder disorder is rated under Diagnostic Codes 5019-5201 (for bursitis with limitation of motion of the arm). Normal range of motion for the shoulder is from 0 to 180 degrees flexion and abduction, and 0 to 90 degrees of external and internal rotation. 38 C.F.R. § 4.71, Plate I. Upper extremity ratings depend on whether the disabled extremity is the major or minor extremity. The major extremity is the one predominantly used by the veteran. Only one extremity may be considered to be major. 38 C.F.R. § 4.69. Here, the evidence demonstrates that the Veteran’s right arm is his dominant upper extremity. Diagnostic Code 5201 provides a 20 percent rating for a major or minor extremity where range of motion is limited to lifting an arm to shoulder level. Where limitation of the arm is limited to midway between a veteran’s side and shoulder level, Diagnostic Code 5201 provides a 30 percent evaluation for a major extremity. Where limitation of the arm is limited to 25 degrees from the side, Diagnostic Code 5201 affords a 40 percent rating for a major extremity. Diagnostic Code 5201 does not provide separate ratings for limitations on flexion, extension, abduction, and rotation, but rather permits only a single rating for limitation of motion of an arm. Yonek v. Shinseki, 722 F.3d 1355, 1359. Initially, the Board observes that the Veteran has received some VA treatment for several conditions, including complaints of shoulder pain. The Veteran received a VA examination in March 2013. The examiner diagnosed the Veteran with right shoulder bursitis. The examiner noted that the Veteran is right hand dominant. The examiner stated that the Veteran experiences flare-ups that impact the function of his shoulder and arm. Right shoulder flexion was 0 to 100 degrees, with no objective evidence of painful motion and right shoulder abduction was 0 to 90 degrees, with no objective evidence of painful motion. Repetitive motion testing yielded similar results. No pain, guarding, or functional loss were noted. Muscle strength testing was normal and no ankylosis was reported. Rotator cuff testing were all negative and there was no instability or history of surgery indicated. Pursuant to the Board’s September 2019 remand, the Veteran had another VA examination in January 2020, wherein his previous diagnosis was confirmed. The Veteran reported moderate to severe shoulder flare-ups that last several days, resulting in difficulty with repetitive arm movement. Right shoulder flexion was 0 to 135 degrees, abduction was 0 to 120 degrees, external rotation was 0 to 90 degrees, and internal rotation was 0 to 90 degrees. Pain was noted on examination (during flexion and abduction) that causes functional loss, including difficulty getting dressed. Repetitive use testing yielded similar results and it was noted that this examination was being conducted during a flare-up. Right shoulder muscle strength testing was 4/5 and no ankylosis was reported. Rotator cuff testing were all negative except for a positive lift-off subscapularis test. Right shoulder instability and mechanical symptoms were reported. A history of right shoulder surgery was noted, which resulted in pain and decreased range of motion. The examiner found that there is objective evidence of pain on passive range of motion testing of the right shoulder and objective evidence of pain on non-weight bearing testing of the right shoulder. Here, the Board finds that the medical evidence of record demonstrates that a rating more than 20 percent is not warranted. Specifically, the evidence indicates findings of arm motion limited at shoulder level, with right shoulder flexion of at least 0 to 100 degrees. Thus, the evaluation of 20 percent disabling more closely approximated the Veteran’s symptomatology than a rating of 30 percent, for which the Veteran’s range of motion would have needed to have been limited to between side and shoulder level. Accordingly, a rating more than 20 percent disabling is not warranted. The Board has considered the Veteran’s reports of pain and functional loss in his right shoulder. As summarized above, the examinations of record took into account his complaints of pain when measuring and assessing his range motion. The fact that he may have had pain in all range of motion testing does not warrant a higher evaluation. See Mitchell v. Shinseki, 25 Vet. App. 32, 43 (2011) (discounting the notion that the highest disability ratings are warranted where pain is merely evident as it would lead to potentially absurd results). In sum, the evidence shows limitation of motion of the right arm as described above more closely approximates the evaluation currently assigned rather than the higher evaluation sought by the Veteran. Thus, the next higher schedular disability rating is not warranted. See 38 C.F.R. § 4.71a. In addition, the Veteran’s symptomatology has been adequately contemplated by the evaluations under Diagnostic Code 5201 discussed above. The Board has considered whether higher ratings could be assigned under alternate diagnostic codes. See Butts v. Brown, 5 Vet. App. 532 (1993); see also Pernorio v. Derwinski, 2 Vet. App. 625, 629 (1992) (indicating that any change in Diagnostic Code must be specifically explained). The record on appeal does not support evaluating the Veteran’s right shoulder disorder under alternate diagnostic codes. The VA examinations did not identify ankylosis in the right shoulder; therefore, Diagnostic Code 5200 is not applicable. Diagnostic Code 5202 is not applicable because the record is silent as to any impairment of the Veteran’s humerus, to include flail shoulder, false flail shoulder, fibrous union, or recurrent shoulder dislocations. Likewise, Diagnostic Code 5203 is not applicable because the record does not document dislocation, nonunion, or malunion of the clavicle and scapula. Lastly, Diagnostic Code 5051, which applies to prosthetic shoulder replacements, is not applicable here because the Veteran has not had shoulder replacement surgery. As such, a rating more than 20 percent for a right shoulder disorder is not warranted. In reaching this conclusion, the Board has considered the applicability of the benefit of the doubt doctrine; however, as the preponderance of the evidence is against assignment of a higher rating, that doctrine is not applicable. See 38 U.S.C. § 5107. 5. Entitlement to special monthly compensation (SMC) on the basis of the need for aid and attendance for the Veteran’s spouse The Veteran is seeking entitlement to SMC based on aid and attendance for his spouse, C.B., stating that she needs full-time caregiving. The Board concludes that, although the Veteran’s spouse has some disabilities affecting her ability to attend to the activities of daily living, the preponderance of the evidence is against finding that she requires the regular aid and attendance of another person. 38 C.F.R. §§ 3.351, 3.352. Under 38 C.F.R. § 3.351(a)(2), SMC is payable to a Veteran by reason of the Veteran’s spouse being in need of aid and attendance. 38 U.S.C. §§ 1114, 1115. The need for aid and attendance means helplessness as to require the regular aid and attendance of another person. 38 C.F.R. § 3.351(b). In this regard, the Veteran’s spouse will be considered in need of regular aid and attendance if he or she (1) is blind or so nearly blind as to have corrected visual acuity of 5/200 or less in both eyes, or concentric contraction of the visual field to 5 degrees or less; or (2) is a patient in a nursing home because of mental or physical incapacity; or (3) establishes a factual need for aid and attendance under the criteria set forth in 38 C.F.R. § 3.352(a), 38 C.F.R. § 3.351(c). The Veteran does not allege, and the record does not suggest, that his spouse is vision impaired or blind. Nor does the evidence show that the Veteran’s spouse is a resident of a nursing home. Therefore, the remaining question in this case is whether the Veteran’s spouse requires the regular assistance of another person for most of the activities of daily living and for protection against the hazards or dangers incident to daily life. 38 C.F.R. §§ 3.352(a). The elements considered in making a determination regarding the third basis for establishing entitlement to aid and attendance benefits include the inability to perform such tasks as to dress and undress oneself, to maintain ordinary cleanliness, adjust prostheses, to feed oneself, to attend to the wants of nature, or to have such physical or mental incapacity that the care or assistance on a regular basis of another person to protect against the hazards or dangers incident to the daily environment is necessary. 38 C.F.R. § 3.352(a). A finding that the Veteran’s spouse is “bedridden” provides a proper basis for the determination. Bedridden will be that condition which, through its essential character, actually requires that the Veteran’s spouse remain in bed. The fact that an individual has voluntarily taken to bed or that a physician has prescribed rest in bed for the greater or lesser part of the day to promote convalescence or cure will not suffice. It is not required that all of the disabling conditions enumerated in this paragraph be found to exist before a favorable rating may be made. Id. Pursuant to the Board’s September 2019 remand, the spouse, C.B., underwent a VA examination for housebound status or permanent need for regular aid and attendance in July 2020. The examiner stated that C.B. is not currently hospitalized, able to feed herself, able to prepare her own meals, not legally blind, does not require nursing home care, and does not require medication management. The examiner then provided the following remarks: Patient requires assistance for bathing and tending to hygiene needs due to stability issues from chronic musculoskeletal conditions and obesity. Did not indicate she requires assistance with medication management or managing finances. Pt’s chronic condition cause severe functional limitations including not being able to lift more than 3 pounds without pain. She is not confined to her bed or her house and is able to ambulate with assistive devices. Pt has history of dyspnea/cough/shortness of breath, cervical disc disorder, artificial hip joint bilateral, left knee artificial joint, obesity with BMI of 38, bilateral carpal tunnel syndrome. and bilateral ulnar neuropathy. After careful consideration of the medical and lay evidence of record, the Board finds that aid and attendance for the Veteran’s spouse is not warranted. While the Board acknowledges that the evidence shows that the Veteran’s spouse has significant health problems, she is not shown to meet the criteria for aid and attendance as outlined in 38 C.F.R. § 3.352(a). In this regard, C.B. is capable of leaving the home unassisted. Based on statements given to the medical provider, she is capable of assisting the Veteran when his back flare-ups occur. She is not hospitalized. She is capable of ambulating, self-feeding, and meal preparation. While she has stability issues, this does not prevent self-care. Finally, she is not blind and does not require medication management. The overall evidence does not establish that the Veteran’s spouse is substantially confined to the premises of her home or that she requires regular aid and assistance of another for activities of daily living. The preponderance of the evidence is unfavorable to the claim. There is no reasonable doubt which may be resolved in the Veteran’s favor. 38 U.S.C. § 5017. Therefore, the claim for SMC based on the spouse’s need for regular aid and attendance must be denied. MICHAEL D. LYON Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board M. Miller, 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.