Citation Nr: 21025747 Decision Date: 04/28/21 Archive Date: 04/28/21 DOCKET NO. 13-31 367A DATE: April 28, 2021 ORDER Entitlement to an initial evaluation of 20 percent from February 24, 2010, to July 22, 2013, for lumbar strain with lumbar intervertebral disc syndrome (IVDS) and erectile dysfunction is granted. Entitlement to an initial evaluation in excess of 20 percent from February 24, 2010, to November 7, 2020, for lumbar strain with lumbar IVDS and erectile dysfunction is denied. Entitlement to an initial evaluation in excess of 40 percent since November 8, 2020, for lumbar strain with lumbar IVDS and erectile dysfunction is denied. REMANDED Entitlement to a total disability evaluation based on individual unemployability due to the service-connected disabilities (TDIU) from February 24, 2010, to February 17, 2011, on an extraschedular basis, is remanded. Entitlement to service connection for a left neurological arm/shoulder/fingers disability, to include as secondary to the service-connected lumbar strain with lumbar strain with lumbar IVDS, is remanded. Entitlement to service connection for a cervical spine disability, to include as secondary to the service-connected lumbar strain with lumbar IVDS, is remanded. Entitlement to service connection for hypertension, to include as secondary to the service-connected lumbar strain with lumbar IVDS, is remanded. FINDINGS OF FACT 1. From February 24, 2010, to July 22, 2013, the Veteran’s lumbar strain with lumbar IVDS and erectile dysfunction was manifest by muscle spasms severe enough to result in an abnormal gait. 2. From February 24, 2010, to November 7, 2020, the Veteran’s lumbar strain with lumbar IVDS and erectile dysfunction was not manifest by forward flexion to 30 degrees; favorable ankylosis of the entire thoracolumbar spine; or, IVDS with incapacitating episodes requiring physician prescribed bedrest for a duration of at least 4 weeks during the prior 12 months. 3. Since November 8, 2020, the Veteran’s lumbar strain with lumbar IVDS and erectile dysfunction has not been manifested by unfavorable ankylosis or incapacitating episodes having a total duration of at least 6 weeks during the past 12 months. 4. Throughout the entire appeal period, the Veteran has experienced erectile dysfunction, but has not demonstrated a penile deformity. CONCLUSIONS OF LAW 1. The criteria for an initial evaluation of 20 percent from February 24, 2010, to July 22, 2013, for lumbar strain with lumbar IVDS and erectile dysfunction have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.40, 4.45, 4.71a, Diagnostic Codes 5237, 5243. 2. The criteria for an initial evaluation in excess of 20 percent from February 24, 2010, to November 7, 2020, for lumbar strain with lumbar IVDS and erectile dysfunction have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.40, 4.45, 4.71a, Diagnostic Codes 5237, 5243. 3. The criteria for an initial evaluation in excess of 40 percent since November 8, 2020, for lumbar strain with lumbar IVDS and erectile dysfunction have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.40, 4.45, 4.71a, Diagnostic Codes 5237, 5243. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active military service from August 1979 to February 1984. These issues are on appeal from October 2010, August 2013, October 2013, and January 2021 rating decisions. In October 2017 and July 2020, the Board of Veterans’ Appeals (Board) remanded these issues for further development. In a May 2019 correspondence, the Veteran withdrew his request for a Board hearing. In his August 2012 claim, the Veteran sought service connection for “numbness and tingling in my left arm. It is not a good feeling from the left shoulder down to my fingers.” The Agency of Original Jurisdiction (AOJ) interpreted this statement as a claim for a left arm disability and adjudicated it as such in the August 2013 rating decision. However, under Clemons v. Shinseki, 23 Vet. App. 1 (2009), the Board finds that the Veteran’s statement encompasses a broader claim for service connection for a left neurological arm/shoulder/fingers disability. The Board has expanded the Veteran’s claim on the title page of this decision. In the January 2021 rating decision, the AOJ granted service connection for a left knee strain and entitlement to basic eligibility to Dependents’ Educational Assistance. In the January 2021 rating decision, the AOJ also granted entitlement to a TDIU, effective February 18, 2011. To date, the Veteran has not filed a Notice of Disagreement with these grants. Thus, these issues are no longer on appeal before the Board. However, on his August 2012 VA Form 21-8940, the Veteran reported that he last worked full-time in May 2005 because of, in pertinent part, his service-connected lumbar strain with lumbar IVDS. His initial rating claims for his lumbar spine disability has been on appeal since February 24, 2010, the effective date of service connection. Thus, the TDIU grant was not for the entire appeal period. Accordingly, the issue of entitlement to a TDIU from February 24, 2010, to February 17, 2011, is raised as part and parcel of the initial rating claims on appeal and has been added to the current appeal. See Rice v. Shinseki, 22 Vet. App. 447 (2009). INCREASED RATINGS The Veteran contends he is entitled to higher ratings because he uses a back brace, a cane, and a heating pad for his disability. See August 2012 statement. He reported gait training and physical training for the treatment of his lumbar spine. Id. The Veteran also stated that the muscle spasms of his lumbar spine caused him to stay in bed for 80 percent of the day. See October 2017 statement. His pain had gotten so bad that it was affecting his sleep. Id. In October 2017, the Veteran’s sister submitted a lay statement, in which she argued that the Veteran wakes up, takes his medicine, and goes back to bed for at least three to four hours, sometimes more. He stays in bed to deal with his back pain. Id. This happens every day. Id. Some days, he stays in bed for up to eight hours after waking because of his back pain. Id. Disability evaluations are determined by the application of a schedule of ratings which is based on the average impairment of earning capacity in civil occupations. Separate diagnostic codes identify the various disabilities. See 38 U.S.C. § 1155; 38 C.F.R. § Part 4. Where a veteran appeals the initial rating assigned for a disability at the time that service connection for that disability is granted, evidence contemporaneous with the claim and with the initial rating decision granting service connection would be most probative of the degree of disability existing at the time that the initial rating was assigned and should be the evidence “used to decide whether an original rating on appeal was erroneous . . . .” Fenderson v. West, 12 Vet. App. 119, 126 (1999). If later evidence indicates that the degree of disability increased or decreased following the assignment of the initial rating, “staged” ratings may be assigned for separate periods of time based on facts found. Id. The Veteran’s lumbar strain with lumbar IVDS and erectile dysfunction is currently rated under 38 C.F.R. § 4.71a, Diagnostic Code 5243. The disability was previously rated under 38 C.F.R. § 4.71a, Diagnostic Code 5237. Diagnostic Code 5243 provides that 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. The Formula for Rating IVDS Based on Incapacitating Episodes provides that a 10 percent rating is warranted for IVDS with incapacitating episodes having a total duration of at least one week but less than 2 weeks during the past 12 months. A 20 percent rating is warranted for IVDS 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 rating is warranted for IVDS with incapacitating episodes having a total duration of at least 4 weeks but less than 6 weeks during the past 12 months. A 60 percent rating is warranted for IVDS with incapacitating episodes having a total duration of at least 6 weeks during the past 12 months. 38 C.F.R. § 4.71a, Formula for Rating IVDS Based on Incapacitating Episodes. Note 1 to Diagnostic Code 5243 provides that, for purposes of ratings under Diagnostic Code 5243, an incapacitating episode is a period of acute signs and symptoms due to intervertebral disc syndrome that requires bed rest prescribed by a physician and treatment by a physician. Id. at Note 1. 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. Ankylosis is defined as “immobility and consolidation of a joint due to disease, injury, or surgical procedure.” Dorland’s Illustrated Medical Dictionary, 94 (32nd ed. 2012). Fixation of a spinal segment in neutral position (zero degrees) always represents favorable ankylosis. Id. at Note 5. 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 U.S. Court of Appeals for Veterans Claims (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. 1. Entitlement to an initial evaluation in excess of 10 percent from February 24, 2010, to July 22, 2013, for lumbar strain with lumbar IVDS and erectile dysfunction. The Board finds that the preponderance of the evidence supports a higher rating of 20 percent from February 24, 2010, to July 22, 2013, for the lumbar strain with lumbar IVDS and erectile dysfunction under the General Rating Criteria. At the August 2010 VA examination, the Veteran reported constant muscle spasms and constant pain of the lumbar spine. The Veteran stated he was “in pain 24/7.” The VA examiner noted the Veteran walked with an antalgic gait and found the Veteran’s abnormal gait was due to his back pain. In an August 2012 statement, the Veteran reported receiving gait training for the treatment of his lumbar spine. The treatment records support the evidence provided at the VA examination. This evidence establishes that the Veteran’s muscle spasms and pain of the lumbar spine were severe enough during this appeal period to result in an abnormal gait, which warrants the 20 percent rating. 38 C.F.R. § 4.71a, Diagnostic Code 5237. For the foregoing reasons, the preponderance of the evidence supports a higher rating of 20 percent from February 24, 2010, to July 22, 2013, for the lumbar strain with lumbar IVDS and erectile dysfunction. The claim is granted. 38 U.S.C. § 5107; 38 C.F.R. §§ 4.3, 4.7. 2. Entitlement to an initial evaluation in excess of 20 percent from February 24, 2010, to November 7, 2020, for lumbar strain with lumbar IVDS and erectile dysfunction. The Board finds that the preponderance of the evidence is against a rating in excess of 20 percent from February 24, 2010, to November 7, 2020, for the lumbar strain with lumbar IVDS and erectile dysfunction based on incapacitating episodes. The evidence of record is against a finding that the Veteran was ever prescribed bed rest by a physician for a duration that meets the criteria for a higher rating. At the August 2010 VA examination, the Veteran denied any incapacitation in the past 12 months as a result of his lumbar strain with lumbar IVDS. At the July 2013 VA examination, the Veteran did not report any incapacitating episodes due to his lumbar strain with lumbar IVDS. The July 2013 VA examiner found the Veteran did not have IVDS of the thoracolumbar spine, and did not provide an opinion regarding incapacitation. In March 2019, while the Veteran was receiving in-patient VA psychological treatment, a psychologist documented that the Veteran was “in bed rest for severe back pain.” The record documented that the bed rest ended 7 hours later. This bed rest does not appear to have been prescribed by a physician, but instead merely documented by a physician. At the January 2020 VA examination, the Veteran reported that he has to lay in bed for 21 hours per day because of a throbbing, burning, and stabbing sensation in his lumbar spine. He stated that movement made his back worse and he has “not found anything that makes it better.” The Veteran did not report any physician prescribed bed rest at the examination. The January 2020 VA examiner found that the Veteran had IVDS, but that he did not have any episodes of acute signs and symptoms due to IVDS that required bed rest prescribed by a physician and treatment by a physician in the past 12 months. In providing this opinion, the January 2020 VA examiner reviewed the Veteran’s claims file. The remaining treatment records dated during this period do not provide any contrary evidence. The Veteran is competent and credible to report having to lie down for up to 21 hours per day due to his back pain. However, the medical evidence of record dated from February 24, 2010, to November 7, 2020, does not show physician-prescribed bed rest (with the possible exception of one day in March 2019), which is the requirement for an incapacitating episode. See 38 C.F.R. § 4.71a, Diagnostic Code 5243, Note 1. The Veteran’s lay statements alone are not sufficient to establish that his lumbar IVDS was manifested by incapacitating episodes having a total duration of at least 4 weeks but less than 6 weeks at any point from February 24, 2010, to November 7, 2020. 38 C.F.R. § 4.71a, Diagnostic Code 5243. Thus, a disability rating in excess of 20 percent during this portion of the appeal period is not warranted for the lumbar strain with lumbar IVDS and erectile dysfunction. Id. The preponderance of the evidence is also against a rating in excess of 20 percent from February 24, 2010, to November 7, 2020, for the lumbar strain with lumbar IVDS and erectile dysfunction under the General Rating Criteria. The Board acknowledges the Veteran’s lay reports of symptoms and that there was functional loss due to pain, muscle spasms, weakened movement, less movement than normal, excess fatigability, incoordination, lack of endurance, pain during flare-ups, and pain during repetitive use over time. However, even considering the Veteran’s lay reports of symptoms and noted functional loss, the degree of additional limitation reflected by the statements that he “cannot stand, sit, walk even short distances, cannot climb stairs, difficulty driving, even laying down and turning in bed is difficult” and that he experiences daily flare-ups that can last all day (see January 2020 VA examination report) would not result in limitation of motion more nearly approximating forward flexion of the thoracolumbar spine to 30 degrees or less; or, favorable ankylosis of the entire thoracolumbar spine. Specifically, at the August 2010 VA examination, the Veteran’s forward flexion of the lumbar spine was to 90 degrees with no objective evidence of painful motion. He did not have any additional degree of limitation following repetitive range of motion. The examiner found that the Veteran’s lumbar spine was not additionally limited by pain, fatigue, weakness, lack of endurance, or incoordination after repetitive use. At the July 2013 VA examination, the Veteran’s forward flexion of the lumbar spine was to 60 degrees with no objective evidence of painful motion. Following repetitive use testing with three repetitions, the Veteran’s forward flexion of the lumbar spine was to 70 degrees. The examiner found that the Veteran had functional loss, functional impairment and/or additional limitation of ranges of motion of the thoracolumbar spine after repetitive use, to include the contributing factor of less movement than normal. At the January 2020 VA examination, the Veteran’s forward flexion of the lumbar spine was to 50 degrees. Pain was noted on forward flexion and caused functional loss. There was evidence of pain on weight-bearing. There was no additional loss of function or range of motion after three repetitions. The examiner estimated that the Veteran’s forward flexion of the lumbar spine would be to 50 degrees following repeated use over time and during a flare-up. The examiner stated that the Veteran presented to the examination with a flare-up of the lumbar spine. Therefore, no additional decreased ranges of motion could be estimated for the Veteran’s ranges of motion following repeated use over time and during a flare-up. The examiner indicated that passive range of motion of the spine was not performed as it was not feasible to do this in a safe and reasonable manner. The non-weight-bearing assessment was not applicable. The opposing joint assessment was not applicable because the spine does not have an opposing joint. Additionally, favorable ankylosis of the lumbar spine was not documented at the August 2010, July 2013, and January 2020 VA examinations or in the treatment records dated during the appeal period. Even when considering the functional limitation during a flare-up, the Veteran’s symptoms do not more nearly approximate fixation of a spinal segment in neutral position (zero degrees). Thus, from February 24, 2010, to November 7, 2020, the Veteran’s lumbar strain with lumbar IVDS and erectile dysfunction was not manifested by forward flexion of the thoracolumbar spine to 30 degrees or less; or, favorable ankylosis of the entire thoracolumbar spine, to warrant a higher 40 percent rating under the General Rating Criteria. 38 C.F.R. § 4.71a, Diagnostic Code 5237. The Board notes that in adjudicating a claim, the competence and credibility of the Veteran must be considered. See Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006); Washington v. Nicholson, 19 Vet. App. 362, 368-69 (2005). The Veteran is competent to give evidence about what he observes or experiences. For example, he is competent to report that he experiences certain symptoms, such as pain, and he is credible in this regard. See, e.g., Layno v. Brown, 6 Vet. App. 465 (1994). The Veteran’s competent and credible belief that his disability is worse than the assigned rating, however, is outweighed by the competent and credible medical examinations that evaluated the true extent of impairment based on objective data coupled with the lay complaints. The VA examiners have the training and expertise necessary to administer the appropriate tests for a determination on the type and degree of the impairment associated with the Veteran's complaints. For these reasons, greater evidentiary weight is placed on the physical examination findings. Also, as stated above, the rating criteria are specific in indicating that some of the criteria must be objectively demonstrated. Furthermore, the Veteran's symptoms do not appear to have changed significantly during this initial rating period so as to warrant a staged rating. Fenderson, 12 Vet. App. at 126. Based on the foregoing, the preponderance of the evidence is against the Veteran’s claim for a rating in excess of 20 percent from February 24, 2010, to November 7, 2020, for the lumbar strain with lumbar IVDS and erectile dysfunction. 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. 3. Entitlement to an initial evaluation in excess of 40 percent since November 8, 2020, for lumbar strain with lumbar IVDS and erectile dysfunction. The Board finds that the preponderance of the evidence is against a rating in excess of 40 percent since November 8, 2020, for the Veteran’s lumbar strain with lumbar IVDS and erectile dysfunction based on incapacitating episodes. The evidence of record is against a finding that the Veteran was ever prescribed bed rest by a physician for a duration that meets the criteria for a higher rating since November 8, 2020. The November 8, 2020, VA examiner determined that the Veteran had episodes of acute signs and symptoms due to IVDS of the thoracolumbar spine that required bed rest prescribed by a physician and treatment by a physician in the past 12 months. Specifically, the examiner stated that the Veteran had episodes of bed rest having a total duration of at least 6 weeks during the past 12 months. The examiner indicated that the “yes” response was documented by the medical history as described by the Veteran only, without documentation. The examiner reported that the Veteran stated that he lays on flat, firm surface at least 18-20 hours per 24-hour period every day. Any additional activity or out of bed meant he would be in debilitating pain and would have to return to a lying position. The treatment records dated since November 8, 2020, do not document any physician-prescribed bed rest for the treatment of the lumbar spine. 38 C.F.R. § 4.71a, Diagnostic Code 5243. The Veteran is competent and credible to report having to lie down for 18-20 hours per day due to his back pain. However, the medical evidence of record dated since November 8, 2020, does not show physician-prescribed bed rest, which is the requirement for an incapacitating episode. See 38 C.F.R. § 4.71a, Diagnostic Code 5243, Note 1. The Veteran’s lay statements alone are not sufficient to establish that his lumbar IVDS was manifested by incapacitating episodes having a total duration of at least 6 weeks at any point since November 8, 2020. 38 C.F.R. § 4.71a, Diagnostic Code 5243. The November 8, 2020’s VA examiner’s medical opinion is not probative as it was based solely on the Veteran’s lay statements of having to lie down for 18-20 hours per day, as opposed to medical documentation of physician-prescribed bed rest. The examiner noted the lack of medical documentation and that the opinion was based solely on the Veteran’s reported medical history. While the Board acknowledges that the Veteran is competent and credible to report having to lie flat, these lay statements are not sufficient under the regulations to warrant a grant of the benefits sought. Thus, a disability rating in excess of 40 percent during this portion of the appeal period is not warranted for the lumbar strain with lumbar IVDS and erectile dysfunction based on incapacitating episodes. Id. The preponderance of the evidence is also against a rating in excess of 40 percent since November 8, 2020, for the Veteran’s lumbar strain with lumbar IVDS and erectile dysfunction under the General Rating Criteria. The Board acknowledges the Veteran’s lay reports of symptoms and that there was functional loss due to pain, weakened movement, excess fatigability, lack of endurance, and pain during repetitive use over time. However, even considering the Veteran’s lay reports of symptoms and noted functional loss, the degree of additional limitation reflected by the fact that the Veteran is unable to perform repetitive-use testing with at least three repetitions would not result in symptoms more nearly approximating unfavorable ankylosis of the entire thoracolumbar spine. Unfavorable ankylosis was not documented at the November 8, 2020, VA examination, or in the treatment records dated during the appeal period. Even when considering the functional limitation during a flare-up or during repeated use over time, the Veteran’s symptoms do not more nearly approximate the entire spine fixed in flexion or extension and one of the additional symptoms set forth in Note 5. Fixation of a spinal segment in neutral position (zero degrees) always represents favorable ankylosis as opposed to unfavorable ankylosis. Thus, the Veteran’s inability to perform observed repetitive use testing is akin to favorable ankylosis (i.e., zero degrees), for which he is receiving his current 40 percent rating. Since November 8, 2020, the Veteran’s lumbar strain with lumbar IVDS and erectile dysfunction has not been manifested by unfavorable ankylosis of the entire thoracolumbar spine to warrant a higher rating under the General Rating Criteria. 38 C.F.R. § 4.71a, Diagnostic Code 5237. The Board notes that in adjudicating a claim, the competence and credibility of the Veteran must be considered. See Buchanan, 451 F.3d at 1331; Washington, 19 Vet. App. at 368-69. The Veteran is competent to give evidence about what he observes or experiences. For example, he is competent to report that he experiences certain symptoms, such as pain, and he is credible in this regard. See, e.g., Layno, 6 Vet. App. at 465. The Veteran’s competent and credible belief that his disability is worse than the assigned rating, however, is outweighed by the competent and credible medical examinations by the VA examiners and the VA physicians who evaluated the true extent of impairment based on objective data coupled with the lay complaints. The VA examiner and VA physicians have the training and expertise necessary to administer the appropriate tests for a determination on the type and degree of the impairment associated with the Veteran's complaints. For these reasons, greater evidentiary weight is placed on the physical examination findings. Also, as stated above, the rating criteria are specific in indicating that some of the criteria must be objectively demonstrated. Furthermore, the Veteran's symptoms do not appear to have changed significantly during this initial rating period so as to warrant a staged rating. Fenderson, 12 Vet. App. at 126. For the foregoing reasons, the preponderance of the evidence is against the Veteran’s claim for a rating in excess of 40 percent since November 8, 2020, for lumbar strain with lumbar IVDS and erectile dysfunction. 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. Erectile Dysfunction and Additional Considerations The Veteran is currently service-connected for erectile dysfunction, secondary to his service-connected lumbar strain with lumbar IVDS. The erectile dysfunction has been rated as noncompensable by the AOJ, and thus combined with his current lumbar spine disability ratings. He is also currently in receipt of special monthly compensation for the loss of a creative organ based on his service-connected erectile dysfunction. Erectile dysfunction is rated under 38 C.F.R. § 4.115b, Diagnostic Code 7522 (penis, deformity, with loss of erectile power). Under Diagnostic Code 7522, for the Veteran to receive a compensable rating for erectile dysfunction, physical deformity of the penis with loss of erectile power is required. Such manifestations would warrant a 20 percent rating. 38 C.F.R. § 4.115b. Simply stated, the condition is not compensable in the absence of penile deformity. Upon a review of the evidence, the Veteran does not meet the criteria for a 20 percent rating for his erectile dysfunction. It is not in dispute that he has loss of erectile power. He was found to have erectile dysfunction at the August 2010 VA examination. He reported that he could not achieve and maintain an erection. His genital examination findings were within normal limits. During the November 2020 VA examination, the Veteran was diagnosed with erectile dysfunction. He could not achieve an erection sufficient for penetration and ejaculation without medication. The Veteran’s penis and testes were not examined per his request, but he reported normal anatomy with no penile or testicular deformity or abnormality. The treatment records do not provide any evidence contrary to these examinations. As such, there is no lay or medical evidence to support a separate compensable disability rating for erectile dysfunction under Diagnostic Code 7522. 38 C.F.R. § 4.115b. There is no evidence of a loss of erectile power with penile deformity to warrant a separate 20 percent evaluation for his erectile dysfunction at any point during the appeal period. 38 C.F.R. § 4.115b, Diagnostic Code 7522. Regarding additional neurological impairment, the Veteran has already been granted service connection for radiculopathy of the bilateral lower extremities. The Veteran has already been granted service connection for major depressive disorder associated with his service-connected lumbar strain with lumbar IVDS and erectile dysfunction. The lay and medical evidence of record is against a finding that the Veteran has any other neurological abnormality associated with his lumbar strain with lumbar IVDS and erectile dysfunction. For instance, at the August 2010 VA examination, the Veteran denied any bowel or bladder dysfunction associated with his lumbar strain with lumbar IVDS and erectile dysfunction. Neither the Veteran nor his representative has raised any other issues, nor have any other issues been reasonably raised by the record. See Yancy v. McDonald, 27 Vet. App. 484, 495 (2016); Doucette v. Shulkin, 38 Vet. App. 366, 369-70 (2017) (confirming that the Board is not required to address issues unless they are specifically raised by the claimant or reasonably raised by the evidence of record). REASONS FOR REMAND 1. Entitlement to a TDIU from February 24, 2010, to February 17, 2011, on an extraschedular basis, is remanded. The Veteran’s service-connected disabilities do not meet the schedular requirements for a TDIU under 38 C.F.R. § 4.16(a) from February 24, 2010, to February 17, 2011. However, on his August 2012 VA Form 21-8940, the Veteran reported that he last worked full-time in May 2005 because of, in pertinent part, his service-connected lumbar strain with lumbar IVDS. Thus, the Veteran’s claim for a TDIU from February 24, 2010, to February 17, 2011, is being remanded and referred to VA’s Director of Compensation Service for extraschedular consideration. Also, upon remand, the AOJ should request the Veteran’s tax returns to confirm his claimed unemployment during this appeal period. 2. Entitlement to service connection for a left neurological arm/shoulder/fingers disability, to include as secondary to the service-connected lumbar strain with lumbar strain with lumbar IVDS, is remanded. The Board cannot make a fully-informed decision on the left neurological arm/shoulder/fingers issue because the January 2020 VA medical opinion focused solely on the Veteran’s left arm, and did not provide an opinion on his left shoulder and fingers. The January 2020 medical opinion also did not address the in-service incurrence or the Veteran’s lay statements. Additionally, the January 2020 VA examiner did not provide a chronic presumptions opinon, after diagnosing the Veteran with radiculopathy of the left upper extremity. The July 2013 VA opinion only addressed the causation element of secondary service connection, and did not address the aggravation element of secondary service connection or provide a direct nexus opinion. Upon remand, an adequate VA medical opinion must be obtained. 3. Entitlement to service connection for a cervical spine disability, to include as secondary to the service-connected lumbar strain with lumbar IVDS, is remanded. Unfortunately, there has not been substantial compliance with the Board’s previous remand directives regarding the cervical spine issue. In July 2020, the Board remanded this issue, in pertinent part, for a VA medical opinion to be obtained. In December 2020, a VA examiner provided a negative nexus medical opinion. However, in providing the secondary service connection opinion, the examiner did not provide any rationale. The examiner merely stated that the lumbar spine does not mechanically cause any effect to the neck, and failed to discuss the Veteran’s lay statements of pain radiating from his low back to his neck. In providing the direct service connection nexus opinion, the examiner did not discuss the in-service incurrences documented in the Veteran’s service treatment records. A chronic presumptions opinion also was not provided. Another remand is required for an adequate VA medical opinion to be obtained. Stegall v. West, 11 Vet. App. 268, 271 (1998). 4. Entitlement to service connection for hypertension, to include as secondary to the service-connected lumbar strain with lumbar IVDS, is remanded. Unfortunately, there has not been substantial compliance with the Board’s previous remand directives regarding the hypertension issue. In July 2020, the Board remanded this issue, in pertinent part, for a VA medical opinion to be obtained. In December 2020, a VA examiner provided a negative nexus medical opinion. However, in providing the causation element of the secondary service connection opinion, the examiner did not address the Veteran’s assertions, to include the cited Web article, that inactivity from his service-connected lumbar strain with lumbar IVDS caused his hypertension. The examiner was asked to specifically address this theory in the Board’s July 2020 remand. The examiner also did not provide a chronic presumptions opinion. In providing the negative aggravation opinion, the examiner stated that there was only one documented incident of bedrest and incapacitation in the record, but did not address the Veteran’s lay statements of inactivity, which is different than incapacitation. Another remand is required for an adequate VA medical opinion to be obtained. Stegall, 11 Vet. App. at 271. The matters are REMANDED for the following actions: 1. Ask the Veteran to provide IRS tax returns from 2010 through 2011, and a statement that the copy is an exact duplicate of the return filed with the IRS. Provide the Veteran with an IRS Form 4506-T “Request for Transcript of Tax Return,” which may also be found at https://www.irs.gov/pub/irs-pdf/f4506t.pdf so that the Veteran may request tax returns from 2010 thru 2011, and submit them to VA. Tell the Veteran that if he does not have copies of his tax returns for the requested years, he may use the IRS form cited to above. 2. Refer the Veteran’s claim for a TDIU from February 24, 2010, to February 17, 2011, to VA’s Director of Compensation Service for extraschedular consideration. 3. Obtain an addendum opinion from an appropriate clinician regarding the Veteran’s currently diagnosed left cervical radiculopathy of the shoulder/arm/fingers. The examiner must review the claims file. The examiner is asked to provide a response to the following: Is the left cervical radiculopathy of the shoulder/arm/fingers at least as likely as not related to service, including the June 1980 treatment for the upper back? Is it at least as likely as not that the left cervical radiculopathy of the shoulder/arm/fingers (1) began during active service, (2) manifested within one year after discharge from service, or (3) was noted during service with continuity of the same symptomatology since service? Is the left cervical radiculopathy of the shoulder/arm/fingers at least as likely as not proximately due to the service-connected lumbar strain with lumbar IVDS? Is the left cervical radiculopathy of the shoulder/arm/fingers at least as likely as not aggravated, i.e., worsened beyond its natural progression, by the service-connected lumbar strain with lumbar IVDS? Provide a rationale to support the opinions. The examiner must address the Veteran’s statement at the August 2010 VA examination that his low back pain travels to his shoulders. 4. Obtain an addendum opinion from an appropriate clinician regarding the Veteran’s currently diagnosed cervical strain and degenerative arthritis of the spine. The examiner is asked to provide a response to the following: Are the cervical strain and degenerative arthritis of the spine at least as likely as not related to service, including the September 1979 treatment for the neck and the June 1980 treatment for the upper back? Is it at least as likely as not that the cervical strain and degenerative arthritis of the spine (1) began during active service, (2) manifested within one year after discharge from service, or (3) were noted during service with continuity of the same symptomatology since service? Are the cervical strain and degenerative arthritis of the spine at least as likely as not proximately due to the service-connected lumbar strain with lumbar IVDS? Are the cervical strain and degenerative arthritis of the spine at least as likely as not aggravated, i.e., worsened beyond its natural progression, by the service-connected lumbar strain with lumbar IVDS? Provide a rationale to support the opinions. The examiner must address the Veteran’s statement at the August 2010 VA examination that his low back pain travels to his neck. 5. Obtain an addendum opinion from an appropriate clinician regarding the Veteran’s currently diagnosed hypertension. The examiner is asked to provide a response to the following: Is the hypertension at least as likely as not related to service? Is it at least as likely as not that the hypertension (1) began during active service, (2) manifested within one year after discharge from service, or (3) were noted during service with continuity of the same symptomatology since service? Is the hypertension at least as likely as not proximately due to the service-connected lumbar strain with lumbar IVDS? Is the hypertension at least as likely as not aggravated, i.e., worsened beyond its natural progression, by the service-connected lumbar strain with lumbar IVDS? Provide a rationale to support the opinions. The examiner must address the Veteran’s argument that a lack of physical activity due to his service-connected lumbar strain with lumbar IVDS caused his hypertension, to include a discussion of the Web article cited by the representative in the October 24, 2017, Third Party Correspondence.   6. After the above development, and any additionally indicated development, has been completed, readjudicate the issues on appeal. If the benefits sought are not granted to the Veteran’s satisfaction, send the Veteran and his representative a Supplemental Statement of the Case and provide an opportunity to respond. If necessary, return the case to the Board for further appellate review. MARJORIE A. AUER Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Shauna M. Watkins, 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.