Citation Nr: 21022719 Decision Date: 04/19/21 Archive Date: 04/19/21 DOCKET NO. 17-10 955A DATE: April 19, 2021 ORDER Entitlement to a disability rating in excess of 30 percent for degenerative arthritis of the cervical spine is denied. Entitlement to a disability rating in excess of 40 percent for degenerative arthritis of the thoracolumbar spine is denied. Eligibility for financial assistance in the purchase of one automobile or other conveyance and/or automobile adaptive equipment is denied. REMANDED Entitlement to service connection for an acquired psychiatric disorder is remanded. Entitlement to service connection for a bilateral knee condition is remanded. Entitlement to an increased disability rating for cervical radiculopathy, right upper extremity, currently rated as 40 percent disabling is remanded. Entitlement to an increased disability rating for cervical radiculopathy, left upper extremity, currently rated as 30 percent disabling is remanded. Entitlement to an increased disability rating for lumbar radiculopathy, left lower extremity, currently rated as 20 percent disabling is remanded. Entitlement to an increased disability rating for lumbar radiculopathy, right lower extremity, currently rated as 20 percent disabling is remanded. Entitlement to a disability rating in excess of 10 percent for right foot cold injury residuals is remanded. Entitlement to a disability rating in excess of 10 percent for left foot cold injury residuals is remanded. Entitlement to a total disability rating based upon individual unemployability due to service-connected disability is remanded. Entitlement to special monthly compensation based on the need for regular aid and attendance or at the statutory housebound rate is remanded. FINDINGS OF FACT 1. The Veteran’s degenerative arthritis of the cervical spine is manifest by significant limitation of motion, but not favorable or unfavorable ankylosis of the entire cervical spine. 2. The Veteran’s degenerative arthritis of the thoracolumbar spine is manifest by significant limitation of motion, but not favorable or unfavorable ankylosis of the entire thoracolumbar spine. 3. The Veteran’s service-connected disabilities do not result in the physical loss or permanent loss of use of one or both hands or feet, permanent impairment of vision in both eyes with corrected central visual acuity of 20/200 or less in the better eye or central visual acuity of more than 20/200 with a visual field defect of a degree specified by regulation, severe burn injury, amyotrophic lateral sclerosis, or ankylosis of one or both knees or hips. CONCLUSIONS OF LAW 1. The criteria for a rating in excess of 30 percent for degenerative arthritis of the cervical spine have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, Diagnostic Code 5242. 2. The criteria for a rating in excess of 40 percent for degenerative arthritis of the thoracolumbar spine have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, Diagnostic Code 5242. 3. The criteria for establishing eligibility for financial assistance in the purchase of one automobile or other conveyance and adaptive equipment or automobile adaptive equipment only are not met. 38 U.S.C. §§ 3901, 3902, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.350, 3.808. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the United States Army from March 1986 to February 1989. These matters come before the Board of Veterans’ Appeals (Board) on appeal from a December 2013 rating decision by a Department of Veterans Affairs (VA) Regional Office (RO). In April 2019, the Board remanded these matters for further development. They have since been returned to the Board.   Increased Ratings 1. Entitlement to a disability rating in excess of 30 percent for degenerative arthritis of the cervical spine is denied. The Veteran contends that he is entitled to a disability rating higher than the 30 percent currently assigned for his service-connected degenerative arthritis of the cervical spine. The Board notes that the April 2013 VA examination included a diagnosis of intervertebral disc syndrome, cervical spine. Under 38 C.F.R. § 4.71a, Diagnostic Code 5243, intervertebral disc syndrome (IVDS) is to be rated either under the General Rating Formula for Diseases and Injuries of the Spine or under the Formula for Rating IVDS Based on Incapacitating Episodes, whichever method results in the higher rating when all disabilities are combined under 38 C.F.R. § 4.25. Ratings under DC 5243 are assigned on the basis of total duration of incapacitating episodes, which Note 1 to DC 5243 defines as a period of acute signs and symptoms due to IVDS that requires bed rest prescribed by a physician and treatment by a physician. The Veteran has not asserted, and the evidence of record does not otherwise demonstrate, that he suffered from incapacitating episodes of IVDS requiring bed rest prescribed by a physician. Therefore, consideration under the General Rating Formula for Diseases and Injuries of the Spine is more favorable to the Veteran. The Veteran’s degenerative arthritis of the cervical spine is rated under 38 C.F.R. § 4.71a, Diagnostic Code 5242. Under the General Rating Formula for Diseases and Injuries of the Spine, a 10 percent rating is warranted for forward flexion of the cervical spine greater than 30 degrees but not greater than 40 degrees; or, combined range of motion of the cervical spine greater than 170 degrees but not greater than 335 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. A 20 percent rating is warranted for forward flexion of the cervical spine greater than 15 degrees but not greater than 30 degrees; or, the combined range of motion of the cervical spine not greater than 170 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 30 percent rating is warranted for forward flexion of the cervical spine to 15 degrees or less; or favorable ankylosis of the entire cervical spine. A 40 percent rating is warranted for unfavorable ankylosis of the entire cervical spine. A 100 percent rating is warranted for unfavorable ankylosis of the entire spine. 38 C.F.R. § 4.71a, General Rating Formula for Diseases and Injuries of the Spine. Any associated objective neurological abnormalities, including, but not limited to, bowel or bladder impairment, are to be evaluated separately under an appropriate diagnostic code. Id. at Note 1. Unfavorable ankylosis is defined as “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.” Id. at Note 5. Additionally, fixation of a spinal segment in neutral position (zero degrees) is “always” considered favorable ankylosis. Id. When evaluating musculoskeletal disabilities based on limitation of motion, 38 C.F.R. § 4.40 requires consideration of functional loss caused by pain or other factors listed in that section that could occur during flare-ups or after repeated use and, therefore, not be reflected on range-of-motion testing. 38 C.F.R. § 4.45 requires consideration also be given to less movement than normal, more movement than normal, weakened movement, excess fatigability, incoordination, and pain on movement. See DeLuca v. Brown, 8 Vet. App. 202 (1995); see also Mitchell v. Shinseki, 25 Vet. App. 32, 44 (2011). Nonetheless, even when the background factors listed in § 4.40 or 4.45 are relevant when evaluating a disability, the rating is assigned based on the extent to which motion is limited, pursuant to 38 C.F.R. § 4.71a; a separate or higher rating under § 4.40 or 4.45 itself is not appropriate. See Thompson v. McDonald, 815 F.3d 781, 785 (Fed. Cir. 2016) (“[I]t is clear that the guidance of § 4.40 is intended to be used in understanding the nature of the veteran’s disability, after which a rating is determined based on the § 4.71a criteria.”). Under 38 C.F.R. § 4.59, painful motion is a factor to be considered with any form of arthritis; however, 38 C.F.R. § 4.59 is not limited to disabilities involving arthritis. See Burton v. Shinseki, 25 Vet. App. 1 (2011). 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.” The spine has no opposite 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 finds that the preponderance of the evidence is against a rating in excess of 30 percent for degenerative arthritis of the cervical spine. The Board acknowledges and has considered the Veteran’s lay reports of his symptoms and that there is functional loss due to pain, lack of endurance, and flare-ups. However, even considering the Veteran’s lay reports of symptoms and noted functional loss, the degree of additional functional limitation reflected by his statements to VA examiners do not reflect symptoms more nearly approximating unfavorable ankylosis of the entire cervical spine. In this respect, VA examination in December 2019 and April 2013 demonstrated, at worst, range of motion of the cervical spine limited to 15 degrees of flexion, 15 degrees of extension, left lateral flexion to 15 degrees, right lateral flexion to 15 degrees, right lateral rotation to 40 degrees, and left lateral rotation to 40 degrees, following three repetitions of movement at the December 2019 examination. The Veteran described experiencing moderate flare-ups two or three times per month, lasting less than two hours, precipitated by lifting or holding items. The Veteran reported that he experienced further difficulty with range of motion during flare-ups and with repeated use over time; the examiner found that pain and lack of endurance would limit the veteran’s functional range of motion to 15 degrees of forward flexion, extension, right lateral flexion, and left lateral flexion and 30 degrees of left and right lateral rotation. No ankylosis of the spine was found at either examination, and the Veteran has not asserted that his cervical spine disability resulted in effective fixation of the spine, even during flare-ups of symptoms or with repeated use over time. For the foregoing reasons, the preponderance of the evidence is against the Veteran’s claim for a rating in excess of 30 percent for cervical spine degenerative arthritis. As the weight of the evidence is against the claim, there is no doubt to be resolved in the Veteran’s favor, and the benefit of the doubt doctrine is not applicable. See 38 U.S.C. § 5107; 38 C.F.R. §§ 4.3, 4.7. Regarding associated neurological impairment, the Veteran has already been granted service connection for cervical radiculopathy of the left and right lower extremity, and the lay and medical evidence of record is against a finding that the Veteran has any other neurological abnormality associated with his spine disability. The Veteran’s appeals concerning the ratings assigned for the cervical radiculopathy are addressed in the remand, below. 2. Entitlement to a disability rating in excess of 40 percent for degenerative arthritis of the thoracolumbar spine is denied. The Veteran contends that he is entitled to a disability rating higher than the 40 percent currently assigned for his service-connected degenerative arthritis of the thoracolumbar spine. The Board notes that the April 2013 VA examination included a diagnosis of intervertebral disc syndrome, thoracolumbar spine. While the Veteran reported to a private physician in January 2018 that he must lay down to relieve his back pain several times a day for an hour at a time, he has not asserted, and the evidence of record does not otherwise demonstrate, that he suffered from incapacitating episodes of IVDS requiring bed rest prescribed by a physician. Therefore, consideration under the General Rating Formula for Diseases and Injuries of the Spine is more favorable to the Veteran. See 38 C.F.R. § 4.71a, Diagnostic Code 5243. The Veteran’s degenerative arthritis of the thoracolumbar spine is currently rated under 38 C.F.R. § 4.71a, Diagnostic Code 5242. Under the General Rating Formula for Diseases and Injuries of the Spine, a 10 percent rating is warranted for forward flexion of the thoracolumbar spine greater than 60 degrees but not greater than 85 degrees; or, combined range of motion of the thoracolumbar spine 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. 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 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. A 100 percent evaluation is warranted for unfavorable ankylosis of the entire spine. 38 C.F.R. § 4.71a, General Rating Formula for Diseases and Injuries of the Spine. Any associated objective neurological abnormalities, including, but not limited to, bowel or bladder impairment, are to be evaluated separately under an appropriate diagnostic code. Id. at Note 1. The Board finds that the preponderance of the evidence is against the assignment of a rating in excess of 40 percent for degenerative arthritis of the thoracolumbar spine. Objective range of motion testing conducted at VA examinations in December 2019 and April 2013 demonstrated limited motion of, at worst, forward flexion to 35 degrees, extension to 15 degrees, left and right lateral flexion to 15 degrees, and left and right lateral rotation to 15 degrees, all after three repetitions of motion at the December 2019 examination. The Board acknowledges the Veteran’s lay reports of symptoms of throbbing pain and stiffness and functional loss including difficulty walking and running for long periods of time, difficulty standing or sitting for long periods of time, difficulty with stairs, and occupational functioning limitations including back pain, stiffness, limited range of motion, and difficulty with repeated lifting. However, even considering the Veteran’s lay reports of significant symptoms and noted functional loss, the Board notes that 40 percent evaluation under the General Rating Formula for Diseases and Injuries of the Spine contemplates favorable ankylosis of the entire thoracolumbar spine. The degree of additional limitation reflected by his statements are not found to more nearly approximate unfavorable ankylosis of the entire thoracolumbar spine, where the entire thoracolumbar spine is fixed in flexion or extension and results in one of the additional severe impairments enumerated under Note 5 of the General Formula. For the foregoing reasons, the preponderance of the evidence is against the Veteran’s claim for a rating in excess of 40 percent for degenerative arthritis of the thoracolumbar spine. In denying such a rating, the Board finds the benefit of the doubt doctrine is not applicable. 38 U.S.C. § 5107; 38 C.F.R. §§ 4.3, 4.7. Regarding associated neurological impairment, the Veteran has already been granted service connection for lumbar radiculopathy of the left and right lower extremity and the lay and medical evidence of record is against a finding that the Veteran has any other neurological abnormality associated with his spine disability. The Veteran’s appeals concerning the ratings assigned for the cervical radiculopathy are addressed in the remand, below. Finally, it is noted that a January 2018 private medical opinion report indicates that the Veteran takes several medications for treatment of his pain, which impact his ability to stay focused, make him feel drowsy and dizzy, and cause him to fall asleep. While the General Rating Formula for Disabilities of the Spine does not specifically list such side effects in determining the appropriate rating, pain is listed under 38 C.F.R. § 4.40 and § 4.45 as a consideration when rating musculoskeletal disabilities. It follows that the taking of pain medication, with such resultant side effects, is neither unusual nor extraordinary for such a disability. That the Veteran is currently assigned the highest schedular rating available absent the presence of unfavorable ankylosis for both his degenerative arthritis of the cervical spine and degenerative arthritis of the thoracolumbar spine reflects compensation for significant impairment, and an additional rating or extraschedular referral for the side effects of the pain medication is not found warranted. 3. Eligibility for financial assistance in the purchase of one automobile or other conveyance and/or automobile adaptive equipment is denied. Financial assistance may be provided to an “eligible person” in acquiring an automobile or other conveyance and adaptive equipment, or automobile adaptive equipment only. 38 U.S.C. § 3902(a)(b). Eligibility for financial assistance in the purchase of a vehicle or other conveyance and adaptive equipment is warranted where one of the following exists as the result of injury or disease incurred or aggravated during active service: (1) loss or permanent loss of use of one or both feet; (2) loss or permanent loss of use of one or both hands; (3) permanent impairment of vision of both eyes, meaning central visual acuity of 20/200 or less in the better eye, with corrective glasses, or central visual acuity of more than 20/200 if there is a field defect in which the peripheral field has contracted to such an extent that the widest diameter of visual field subtends an angular distance no greater than 20 degrees in the better eye; (4) severe burn injury precluding effective operation of an automobile; (5) amyotrophic lateral sclerosis; or, (6) for adaptive equipment only, ankylosis of one or both knees or one or both hips. 38 C.F.R. § 3.808. In chapter 39 of title 38 of the U.S. Code, Congress established the program authorizing funding for automobiles and adaptive equipment for veterans with certain service-connected disabilities. 38 U.S.C. §§ 3901-04. Pursuant to the authority established in 38 U.S.C. § 3902, the Secretary promulgated 38 C.F.R. § 3.808, which reiterates the § 3901(a) requirement that entitlement to automobile and adaptive equipment is warranted for "the loss or permanent loss of use” of one or both feet or one or both hands. 38 C.F.R. § 3.808(b)(i), (ii). The regulation does not further define the phrase "loss or permanent loss of use." Under the applicable eligibility criteria for financial assistance in the purchase of an automobile or other conveyance and adaptive equipment, found in statutory § 3901 and regulatory § 3.808, the appellant must show that they lost their foot or hand or permanently lost the use of a foot or hand as a result of service-connected disability. It is noted that "loss of use" is used in several places in the rating schedule. In the context of special monthly compensation under 38 C.F.R. § 3.350(a)(2)(i), loss of use of a hand or a foot will be held to exist when no effective function remains other than that which would be equally well served by an amputation stump at the site of election below elbow or knee with use of a suitable prosthetic appliance. A less restrictive definition is written into 38 U.S.C. § 2101 and 38 C.F.R. § 3.809 regarding specially adapted housing; that regulation specifies that “loss of use” was defined by the adjacent modifier, “such as to preclude locomotion without the aid of braces, crutches, canes, or a wheelchair.” See Jensen v. Shulkin, 29 Vet. App. 66, 78-79 (2017). However, this modifier is noticeably absent from 38 U.S.C. § 3901 and 38 C.F.R. § 3.808, and had Congress or the Secretary of VA wished for such a definition to apply to these sections, it presumably would have been included. As such, loss of use under 38 C.F.R. § 3.808 will be taken to mean actual loss of functional use of the body part(s), with any need of assistive devices being relevant to, but not dispositive of the question of whether the Veteran has permanent loss of use. The Veteran is presently in receipt of VA service connection benefits for the following disabilities: degenerative arthritis of the thoracolumbar spine; degenerative arthritis of the cervical spine; cervical radiculopathy of the right and left upper extremities; lumbar radiculopathy of the right and left lower extremities; ¬¬¬and right and left foot cold injury residuals. The Veteran has not been granted service connection benefits for disabilities involving visual impairment, burn injuries, or amyotrophic lateral sclerosis. While the Veteran does have a pending appeal seeking service connection for bilateral knee disability, he has not asserted, and the evidence of record does not otherwise demonstrate that he has disability resulting in fixation/ankylosis of either knee joint. The Veteran additionally does not have a service-connected hip disability. Eligibility for financial assistance in the purchase of an automobile or other conveyance and/or adaptive equipment is therefore unavailable on these bases. In considering the evidence of record, the Board finds that the Veteran’s service-connected lumbar and cervical radiculopathy do not result in such a severe degree of functional impairment as to approximate “loss of use” of either a hand or foot. The Veteran was most-recently provided with VA examinations in December 2019. At the cold injury residuals examination, the Veteran reported throbbing pain and stiffness; he was not noted to use an assistive device for ambulation. At the thoracolumbar spine examination, the Veteran was found to have moderate neuropathy affecting the sciatic nerve bilaterally, which he described as involving moderate constant pain, paresthesias/dysesthesias, and numbness. He was again noted to not use assistive devices, and the examiner found that there was not functional impairment of such a severity that no function remains other than that the Veteran would be equally well served by an amputation with prosthesis. The Veteran also reported experiencing flare-ups of back pain 3-4 times per month brought on by walking, running, standing, sitting, or using stairs. At the cervical spine examination, the Veteran was found to have moderate bilateral radiculopathy affecting the middle radicular root; the examiner found that functional impairment was not so diminished that the Veteran would be equally well served by amputation with prosthesis. The Board notes that at a November 2020 VA examination for the Veteran’s claimed knee condition, the Veteran reported regular use of a cane. However, even assuming without deciding that the knee conditions are service-connected, the Veteran’s use of a cane, alone, would not reflect such significant impairment as to rise to the level of loss of use of a foot. The Board further acknowledges that a January 2018 private medical opinion recorded the Veteran’s report of significantly worse limitations of functioning from his service-connected disabilities, including standing and walking limited to less than 20-30 minutes at a time, and typing limited to 15-20 minutes or less. Even taking these additional limitations as fact for the purpose of consideration of this claim only, the limited manual dexterity and ambulation difficulties described are not found to rise to the level of loss of use of a foot or hand, as the Veteran still retains functional use of the appendages for activities involving manipulation and balance/propulsion, albeit to a less than full degree. A preponderance of the evidence is found to demonstrate that while the Veteran likely suffers from limitations on his ability to stand and walk and potentially limitations on his manual dexterity over time as a result of his service-connected disabilities, he retains the ability to walk and make functional use of his feet and hands. Therefore, the weight of the evidence is against a finding that the Veteran has permanent loss of use of a foot or hand due to service-connected disability. Eligibility for the benefit sought in this case requires the Veteran to meet at least one of the enumerated criteria under 38 C.F.R. § 3.808. Because the Veteran does not have service-connected disability resulting in the loss or permanent loss of use of one or both hands or feet, does not have ankylosis of his knees or hips, and does not have any of the other physical disabilities listed among the relevant criteria, he does not qualify for eligibility for financial assistance in the purchase of an automobile or other conveyance and/or adaptive equipment under 38 C.F.R. § 3.808. As such, the claim must be denied. REASONS FOR REMAND 1. Entitlement to service connection for an acquired psychiatric disorder is remanded. When the Veteran filed his claim for service connection, he submitted a statement in support of claim in June 2012 asserting that he has not been mentally stable since getting out of the military in 1989, has had trouble keeping a job for very long and has had problems with relationships, which leads him to self-medicate. He also endorsed difficulty focusing and not liking being around people very much since leaving the military. The Veteran’s DD-214 indicates that he had an under honorable conditions discharge, and was separated due to “misconduct- drug abuse.” The Veteran’s full service personnel records (SPRs) are not in the claims file, and may be of assistance to the Board in considering this claim. Additionally, the service treatment records (STRs) in the file appear to be missing the report from the Veteran’s separation examination and report of medical history. On remand, efforts should be made to ensure all STRs and SPRs are associated with the claims file. A January 1996 treatment record documents admission to a polysubstance dependence program, and noted a diagnosis of depression, NOS. At that time, the Veteran reported experiencing depression, remorse, and suicidal ideation after use of cocaine, with symptoms of decreased concentration, social withdrawal, sadness, and decreased interest. He attributed his relationship problems to his drug use. At an October 2013 VA examination, the Veteran was diagnosed with opioid abuse and adjustment disorder with depressed mood. No opinion was provided concerning whether the Veteran’s mental health condition(s) arose during his active service or was proximately caused or aggravated by his service-connected disabilities. The Board finds that remand is needed to provide the Veteran with VA examination and medical opinion concerning his claim for service connection for an acquired psychiatric disorder. It is acknowledged that a private medical opinion was submitted on the Veteran’s behalf in February 2015. That report indicates that the Veteran had depressive disorder secondary to medical condition and social impairment which are emotionally debilitating. It noted that the Veteran reported suffering from symptoms including but not limited to chronic sleep impairment, near-continuous panic or depression affecting his ability to function effectively, difficulty establishing and maintaining relationships, intermittent inability to perform activities of daily living. The examiner concluded that the Veteran’s depressive disorder was caused by his service-connected disabilities, reasoning that medical literature details a connection between medical issues and psychiatric disorders. She noted the physical findings from the April and October 2013 VA examinations as showing permanent and debilitating physical disability, and then concluded that the service-connected disabilities “are more likely than not aggravating his depressive disorder due to another medical condition, with mixed features.” In finding that an additional medical opinion is needed, the Board notes that the rationale provided by the February 2015 examiner describes relationships between medical issues and psychiatric disorders in a general/global sense, rather than addressing how this particular Veteran’s disorders cause or aggravate his depressive disorder. Additionally, the February 2015 report makes no mention of the earlier evidence from 1996 of polysubstance dependence and the Veteran’s reports of mental health/relationship issues related to his drug use. Finally, per 38 C.F.R. § 3.310, VA will not concede that a nonservice-connected disease or injury was aggravated by a service-connected disease or injury unless the baseline level of severity of the nonservice-connected disease or injury is established by medical evidence. The February 2015 opinion is therefore found to provide an inadequate basis for a grant of the benefit sought. On remand, the Veteran should be provided with a VA examination and medical opinion concerning the nature and etiology of his claimed acquired psychiatric disorder(s). 2. Entitlement to service connection for a bilateral knee condition is remanded. As the outstanding service treatment records may provide evidence relevant to the claim for service connection for a bilateral knee condition, remand of this issue is also found warranted. The record also includes an October 2019 VA community care scheduling record noting that an orthopedic consult had been requested for evaluation and treatment. It is unclear whether such consult ever took place. On remand, the AOJ should associate any notes from the Veteran’s community care with the claims file. On remand, a supplemental medical opinion should also be provided. A VA examination and medical opinion was previously provided in November 2020, but the full rationale stated for the conclusion that a current knee condition is less likely than not related to service was that there was no documentation in the service treatment records of any complaint of knee pain. While the examiner noted the Veteran’s lay statements regarding his claimed onset of symptoms during service, it does not appear such statements were considered in rendering the decision. 3. Entitlement to an increased disability rating for cervical radiculopathy, right upper extremity, currently rated as 40 percent disabling is remanded. 4. Entitlement to an increased disability rating for cervical radiculopathy, left upper extremity, currently rated as 30 percent disabling is remanded. The Veteran asserts that the severity of his cervical radiculopathy of the right and left upper extremities warrant higher ratings than those currently assigned. In a January 2018 private medical interview, the Veteran reported that his cervical radiculopathy would not allow him to type for longer than 15-20 minutes, because he would then experience weakness/numbness and shooting pain down his fingers. The evaluating physician opined that the Veteran’s cervical radiculopathy significantly impacts his manual dexterity, including his ability to type or write. Other medical evidence of record, including 2018 and 2019 residual functional capacity evaluations performed in connection with the Veteran’s claim for Social Security Administration disability benefits, indicate that hand or finger limitations were not found. A December 2019 VA examination of the neck and associated cervical radiculopathy made no mention this claimed limitation. On remand, an additional examination and medical opinion should be provided specifically focusing on the severity and manifestations of the Veteran’s bilateral cervical radiculopathy. 5. Entitlement to an increased disability rating for lumbar radiculopathy, left lower extremity, currently rated as 20 percent disabling is remanded. 6. Entitlement to an increased disability rating for lumbar radiculopathy, right lower extremity, currently rated as 20 percent disabling is remanded. Pursuant to the Board’s remand directives, the Veteran was provided with a VA examination of his thoracolumbar spine in December 2019. At that time, neurological evaluation was also performed, and the examiner found that the Veteran had moderate sciatic nerve neuropathy, bilaterally. However, the Board notes that the form only provided the options of “not affected,” “mild,” “moderate,” and “severe,” whereas the rating schedule includes a rating level for “moderately severe” for incomplete paralysis of the sciatic nerve. On remand, an additional examination and medical opinion should be sought concerning the overall severity and manifestations of the Veteran’s bilateral lower extremity lumbar radiculopathy. 7. Entitlement to a disability rating in excess of 10 percent for right foot cold injury residuals is remanded. 8. Entitlement to a disability rating in excess of 10 percent for left foot cold injury residuals is remanded. Pursuant to the Board’s remand directives, the Veteran was provided with a VA examination addressing the current severity of his right and left foot cold injury residuals in December 2019. The examination report documented right and left foot cold injury residuals with calcaneal spurs. In the remarks section, it states that this is a progression of the previous diagnosis. It remains unclear to the Board whether this indicates that the Veteran’s diagnoses of the feet have progressed in general, or whether the calcaneal spurs noted on X-ray are the result of the Veteran’s service-connected cold injury residuals. A clarifying medical opinion should be sought on remand. 9. Entitlement to a total disability rating based upon individual unemployability due to service connected disability is remanded. 10. Entitlement to special monthly compensation at the aid and attendance or housebound rate is remanded. Because a decision on the remanded issues of entitlement to service connection for an acquired psychiatric disorder and entitlement to higher disability ratings for cervical radiculopathy of the right and left upper extremity could significantly impact a decision on the issues of entitlement to a TDIU and entitlement to SMC at the aid and attendance or housebound rate, the issues are inextricably intertwined; remand of the latter issues is therefore needed. The record reflects that after the RO made two requests to obtain employment information from the Veteran’s past employers, the record does not reflect that responses have been received from several of them. On remand, the Veteran must be provided with adequate notice that VA was unable to obtain this information. The matters are REMANDED for the following action: 1. Obtain the Veteran’s complete service personnel records and ensure the complete service treatment records, specifically including any 1989 separation examination and report of medical history, are associated with the claims file. 2. Associate any relevant community care records with the claims file, including orthopedic treatment records following an October 2019 scheduling note indicating that a consult with evaluation and treatment was requested for a duration of up to 180 days. 3. Send the Veteran appropriate notice concerning any nonresponse from his prior employers following the letters requesting information sent in February and March 2021. 4. After completing the aforementioned development, schedule the Veteran for a VA examination for his claimed acquired psychiatric disorder. The examiner must review the claims file. Identify a diagnosis for any psychiatric disorder present at any point during the relevant appeal period (June 2012 to present). If a diagnosis cannot be provided but the Veteran’s condition manifests in symptoms that cause functional impairment, then the examiner should consider them a “disability” for the purpose of providing the requested opinion(s) below. The examiner is asked to provide a response to the following: i. Is it at least as likely as not that the psychiatric disability arose during or is otherwise related to the Veteran’s military service? The examiner’s attention is directed to lay statements submitted by the Veteran that he has not felt mentally stable since service and has had difficulty with his relationships and holding a job for very long, which leads him to self-medicate. In responding to the following two inquiries, the examiner is asked to address the private medical opinion from February 2015. ii. Is the psychiatric disability at least as likely as not proximately due to one or more of the Veteran’s service-connected disabilities? iii. Is the psychiatric disability at least as likely as not aggravated, i.e., worsened beyond its natural progression, by one or more of the service-connected disabilities? If aggravated, is it possible to determine the baseline severity of the psychiatric disability prior to the aggravating effect of the service-connected disability? A clear rationale must be provided for any opinion stated. 5. After associating all records responsive to remand directives #1 and #2 with the claims file, request a supplemental medical opinion from an appropriate medical professional (“clinician”) concerning the nature and etiology of the Veteran’s claimed bilateral knee disability. The clinician must review the claims file. If it is determined that additional examination is required in order to address the below inquiries, such should be scheduled and the Veteran provided with notice. For any left and/or right knee disability present at any time during the relevant appeal period (June 2012 to present), including bilateral patellofemoral pain syndrome, is it at least as likely as not that the disability arose during or is otherwise related to service? The Veteran asserts that his current knee pain and stiffness is related to excessive running as part of in-service physical training. Provide a rationale to support the opinion(s). In providing the requested opinion, consider the Veteran’s description of his in-service injury and symptoms as well as his post-service symptoms. If there is any medical reason to accept or reject the proposition that the Veteran’s reported injury and symptoms in service and thereafter represented the onset of his current disability, this should be noted. Stated another way, do the Veteran’s reports about his knee symptoms align with how the currently diagnosed disability is known to develop or are the Veteran’s reports generally inconsistent with medical knowledge or implausible? 6. After associating all records responsive with remand directives #1 and #2 with the claims file, schedule the Veteran for an examination by an appropriate clinician to determine the current severity of his service-connected left and right upper extremity cervical radiculopathy. The examiner should provide a full description of the disability and report all signs and symptoms necessary for evaluating the Veteran’s disability under the rating criteria. The examiner should provide an opinion regarding the functional limitations resulting from the Veteran’s cervical radiculopathy, to include those affecting occupational functioning (e.g. limitations re grasping, lifting, typing, etc…) The examiner is specifically asked to review the January 2018 private medical opinion of record, and address the likelihood that the Veteran’s cervical radiculopathy manifests in the described weakness/numbness and sharp pain shooting down his fingers with prolonged typing. 7. After associating all records responsive to remand directives #1 and #2 with the claims file, schedule the Veteran for an examination by an appropriate clinician to determine the current severity and manifestations of his service-connected left and right lower extremity lumbar radiculopathy. The examiner should provide a full description of the disability and report all signs and symptoms necessary for evaluating the Veteran’s disability under the rating criteria. For involvement of the sciatic nerve, the examiner must opine as to whether the involvement is mild, moderate, moderately severe, or severe. A clear rationale must be provided for any opinions or conclusions stated. It would be helpful to the Board if the examiner indicated why they chose a particular level of severity, and what would have needed to be shown for the next higher level. 8. Refer the claims file to the examiner who conducted the December 2019 cold injury residuals examination, or if unavailable, to another suitably-qualified medical professional, for a supplemental medical opinion concerning the Veteran’s service-connected cold injury residuals. The clinician should clarify whether the calcaneal spurs noted on X-ray at the December 2019 examination themselves represent a residual of the Veteran’s in-service cold injuries, or are otherwise caused or aggravated beyond their normal progression by the service-connected cold injury residuals. A clear rationale must be provided for any opinion or conclusion stated. 9. After completing the above, and conducting any further development deemed necessary in light of the expanded record, readjudicate the issues remaining on appeal: entitlement to service connection for an acquired psychiatric disorder and bilateral knee disability; entitlement to increased ratings for cervical radiculopathy of the left and right upper extremity, lumbar radiculopathy of the left and right lower extremity, and cold injury residuals of the bilateral feet; entitlement to a TDIU; and entitlement to SMC at the aid and attendance or housebound rate. If any of the benefits are not granted to the Veteran’s satisfaction, issue the Veteran and his representative a supplemental statement of the case and allow them an opportunity to respond before returning the appeal(s) to the Board for further appellate review, if in order. MICHAEL MARTIN Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board A. Solomon, 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.