Citation Nr: 21026395 Decision Date: 05/03/21 Archive Date: 05/03/21 DOCKET NO. 17-59 342 DATE: May 3, 2021 ORDER New and material evidence having been received, the request to reopen a claim for service connection for diabetes mellitus is granted. Entitlement to a higher initial rating for service-connected pes planus, currently with a 30 percent evaluation from October 3, 2011 and a 50 percent evaluation from November 19, 2019, is denied. Entitlement to an initial disability rating in excess of 10 percent for left knee limitation of extension is denied. Entitlement to a separate 10 percent disability rating for left knee limitation of flexion is granted. Entitlement to a separate 20 percent disability rating for left knee meniscal disability from October 6, 2016 is granted. Entitlement to a higher initial disability rating of 30 percent for left knee lateral instability, with subluxation, from October 6, 2016 is granted. Entitlement to a higher initial disability rating for left knee lateral instability, with subluxation in excess of 20 percent prior to October 6, 2016 and in excess of 30 percent thereafter is denied. Entitlement to an initial disability rating in excess of 10 percent for left knee scars. is denied. Entitlement to an initial disability rating in excess of 10 percent for right knee limitation of extension is denied. Entitlement to a separate 10 percent disability rating for right knee limitation of flexion is granted. Entitlement to a separate 10 percent disability rating for post-surgical residuals of right knee meniscectomy is granted. Entitlement to a higher initial disability rating for right knee lateral instability and subluxation, currently with a 20 percent evaluation prior to November 19, 2019 and a 30 percent evaluation thereafter is denied. Eligibility for financial assistance in the purchase of one automobile or other conveyance and automobile adaptive equipment is granted. Eligibility for assistance in acquiring specially adapted housing is granted. REMANDED Entitlement to service connection for diabetes mellitus is remanded. Entitlement to a level of Special Monthly Compensation greater than the intermediate rate between (l) and (m) is remanded. FINDINGS OF FACT 1. In a June 2013 rating decision, the RO denied the Veteran's claim of entitlement to service connection for diabetes mellitus; the Veteran did not submit a Notice of Disagreement (NOD) and new and material evidence was not received by VA within the one-year period following the June 2013 decision. 2. Evidence associated with the claims file since the June 2013 denial is new, relates to unestablished facts necessary to substantiate the claim, and raises a reasonable possibility of substantiating the claim for service connection for diabetes mellitus. 3. Prior to November 19, 2019, the Veteran's bilateral pes planus manifested in completely flattened transverse and longitudinal foot arches with corresponding plantar calluses and cornification of inside of arches, slight adduction of the forefoot, pain accentuated on manipulation and use, and swelling, but not marked pronation, extreme tenderness of plantar surfaces of the feet, marked inward displacement and severe spasms of the tendo Achillis on manipulation; from November 19, 2019, the Veteran's bilateral pes planus is rated as 50 percent disabling, which is the maximum schedular rating permitted for acquired flatfoot. 4. The Veteran's service-connected left knee disability has manifest in, at worst, extension limited to 10 degrees. 5. The Veteran's service-connected left knee disability has manifest in, at worst, flexion limited to 40 degrees. 6. From October 6, 2016, the Veteran's service-connected left knee disability has manifest in a torn meniscus with frequent episodes of pain and effusion. 7. From October 6, 2016, the Veteran's service-connected left knee disability manifest in severe recurrent subluxation or lateral instability. 8. Prior to October 6, 2016, the Veteran's service-connected left knee disability manifest in moderate recurrent subluxation and instability; the Veteran will be in receipt of the maximum evaluation for left knee lateral instability and patellar subluxation from October 6, 2016. 9. The Veteran's post-surgical left knee scar is tender, deep, and covers an area of 32 sq. cm., but is not unstable and does not, itself, cause functional impairment. 10. The Veteran's service-connected right knee disability has manifest in, at worst, extension limited to 10 degrees. 11. The Veteran's service-connected right knee disability has manifest in, at worst, flexion limited to 40 degrees. 12. The Veteran has suffered from symptomatic residuals of a 2008 right knee meniscectomy throughout the relevant appeal period. 13. Prior to November 19, 2019, the Veteran's service-connected right knee disability manifested in moderate recurrent subluxation and instability; from November 19, 2019, the Veteran's right knee disability has manifest in severe recurrent subluxation and instability. 14. For purposes of determining eligibility to financial assistance in the purchase of an automobile and automobile adaptive equipment only, the Veteran's service-connected disabilities result in the effective loss of use of a foot. 15. The Veteran has service-connected disability rated as permanent and total due to the loss of use of both lower extremities, such as to preclude locomotion without the aid of braces, crutches, canes, or a wheelchair. CONCLUSIONS OF LAW 1. The June 2013 rating decision denying the Veteran's claim of entitlement to service connection for diabetes mellitus is final. 38 U.S.C. § 7105(c); 38 C.F.R. §§ 3.104, 20.302, 20.1103. 2. New and material evidence has been received; the issue of entitlement to service connection for diabetes mellitus is reopened. 38 U.S.C. §§ 5108, 7105; 38 C.F.R. § 3.156. 3. The criteria for a rating in excess of 30 percent for bilateral pes planus prior to November 19, 2019 and in excess of 50 percent thereafter have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.59, 4.71a, Diagnostic Code 5276. 4. The criteria for a rating in excess of 10 percent for left knee limitation of extension have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, Diagnostic Code 5261. 5. The criteria for a separate evaluation of 10 percent, but no higher, for left knee limitation of flexion have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, Diagnostic Code 5260. 6. From October 6, 2016, the criteria for a separate evaluation of 20 percent, but no higher, for left knee meniscal disability have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.25, 4.71a, Diagnostic Codes 5258. 7. Resolving all reasonable doubt in the Veteran's favor, from October 6, 2016, the criteria for a higher rating of 30 percent for left knee lateral instability with subluxation have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.25, 4.71a, Diagnostic Codes 5257. 8. The criteria for a rating in excess of 20 percent for left knee lateral instability with subluxation prior to October 6, 2016 and in excess of 30 percent thereafter have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.25, 4.71a, Diagnostic Codes 5257. 9. The criteria for a disability rating in excess of 10 percent for post-surgical left knee scar have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.118, Diagnostic Codes 7801, 7804. 10. The criteria for a rating in excess of 10 percent for right knee limitation of extension have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, Diagnostic Code 5261. 11. The criteria for a separate evaluation of 10 percent, but no higher, for right knee limitation of flexion have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, Diagnostic Code 5260. 12. The criteria for a separate evaluation of 10 percent, but no higher, for residuals of right knee meniscectomy have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.25, 4.68, 4.71a, Diagnostic Codes 5259. 13. The criteria for a rating in excess of 20 percent for right knee lateral instability with subluxation prior to November 19, 2019 and in excess of 30 percent thereafter have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.25, 4.71a, Diagnostic Codes 5257. 14. The criteria for establishing eligibility for financial assistance in the purchase of an automobile or other conveyance and/or automobile adaptive equipment are met. 38 U.S.C. §§ 3901, 3902, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.350, 3.808. 15. The criteria for eligibility for assistance in acquiring specially adapted housing are met. 38 U.S.C. §§ 2101, 5107; 38 C.F.R. §§ 3.102, 3.809. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from June 1981 to December 1990. This matter comes before the Board of Veterans' Appeals (Board) on appeal from rating decisions issued by a Department of Veterans Affairs (VA) Regional Office (RO). In May 2019, the Board remanded the issues of entitlement to disability ratings in excess of 10 percent for left knee limitation of extension, 20 percent for left knee lateral instability with subluxation, 20 percent for right knee instability with subluxation, 10 percent for right knee limitation of extension, and 30 percent for bilateral pes planus, as well as entitlement to special monthly compensation (SMC) at a rate greater than that between 38 U.S.C. § 1114 paragraphs (l) and (m). They have since been returned for further appellate consideration. In an April 2020 rating decision, the Agency of Original Jurisdiction (AOJ) granted increased disability ratings of 30 percent each for left and right knee instability with subluxation and 50 percent for bilateral pes planus, all effective November 19, 2019, and granted service connection and a separate 10 percent disability rating for a painful left knee scar, effective from October 26, 2016. As these awards do not represent a full grant of any of the benefits sought, the issues remain in appellate status. New and Material Evidence 1. New and material evidence having been received, the request to reopen a claim for service connection for diabetes mellitus is granted. Generally, a claim which has been denied in an unappealed RO decision or an unappealed Board decision may not thereafter be reopened and allowed. 38 U.S.C. §§ 7104(b), 7105(c). However, under pertinent legal authority, VA may reopen and review a claim that has been previously denied if new and material evidence is submitted by or on behalf of the Veteran. 38 U.S.C. § 5108; 38 C.F.R. § 3.156(a); see also Hodge v. West, 155 F.3d 1356 (Fed. Cir. 1998). New evidence means existing evidence not previously received by agency decision makers. Material evidence means existing evidence that, by itself or when considered with previous evidence of record, relates to an unestablished fact necessary to substantiate the claim. New and material evidence can be neither cumulative nor redundant of the evidence of record at the time of the last prior final denial of the claim sought to be reopened, and must raise a reasonable possibility of substantiating the claim. 38 C.F.R. § 3.156(a). In a June 2013 rating decision, the AOJ denied the Veteran's claim of entitlement to service connection for diabetes mellitus. The Veteran did not submit a timely NOD pertaining to this issue and new and material evidence was not received prior to the expiration of the one-year period following the denial. Therefore, the June 2013 denial of service connection for diabetes mellitus became final as to the evidence then of record, and is not subject to revision on the same factual basis. 38 U.S.C. § 7105(c); 38 C.F.R. §§ 3.104, 20.302, 20.1103. The June 2013 denial of service connection for diabetes mellitus was based on findings that the evidence did not demonstrate that the Veteran had been clinically diagnosed with diabetes or that there was evidence of complaints, treatment, or diagnosis for the condition during or within one year of separation from service. In support of his petition to reopen the previously-denied claim, the Veteran submitted a September 2014 note from his doctor stating that the Veteran has diabetes mellitus. This evidence is not cumulative or redundant of the evidence previously of record and relates to unestablished facts necessary to substantiate the claim. Therefore, it is found to be new and material, and reopening the issue of entitlement to service connection for diabetes mellitus is warranted. Increased Ratings Ratings are based on a schedule of reductions in earning capacity from specific injuries or combination of injuries. The ratings shall be based, as far as practicable, upon the average impairments of earning capacity resulting from such injuries in civilian occupations. 38 U.S.C. § 1155. Generally, the degrees of disability specified are considered adequate to compensate for considerable loss of working time from exacerbations or illnesses proportionate to the severity of the several grades of disability. 38 C.F.R. § 4.1. Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. Where after careful consideration of all procurable and assembled data, a reasonable doubt arises regarding the degree of disability such doubt will be resolved in favor of the claimant. 38 U.S.C. § 5107(b); 38 C.F.R. §§ 3.102, 4.3. 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). The Board notes that it has thoroughly reviewed the record in conjunction with this case. Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, the extensive evidence submitted by the Veteran or on his behalf. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (the Board must review the entire record but does not have to discuss each piece of evidence). Rather, the Board's analysis below will focus specifically on what the evidence shows, or fails to show, on the claim. See Timberlake v. Gober, 14 Vet. App. 122, 129 (2000) (noting that the Board must analyze the credibility and probative value of the evidence, account for the evidence which it finds to be persuasive or unpersuasive and provide the reasons for its rejection of any material evidence favorable to the claimant). 2. Entitlement to a higher initial rating for service-connected pes planus, currently with a 30 percent evaluation from October 3, 2011 and a 50 percent evaluation from November 19, 2019 is denied. The Veteran contends that he is entitled to a higher rating because his foot condition is not improved with the help of orthoses, and he asserts that his pes planus has been severe throughout the appeal period. The Veteran's service-connected pes planus is rated under 38 C.F.R. § 4.71a, Diagnostic Code 5276, for acquired flatfoot. Under Diagnostic Code 5276, a 30 percent rating is warranted for severe bilateral acquired flat foot; objective evidence of marked deformity (pronation, abduction, etc.), pain on manipulation and use accentuated, indication of swelling on use, characteristic callosities. A 30 percent rating is also warranted for pronounced unilateral acquired flatfoot; marked pronation, extreme tenderness of plantar surfaces of the feet, marked inward displacement and severe spasm of the tendo Achillis on manipulation, not improved by orthopedic shoes or appliances. A maximum 50 percent rating is warranted for bilateral acquired flatfoot; marked pronation, extreme tenderness of plantar surfaces of the feet, marked inward displacement and severe spasm of the tendo Achillis on manipulation, not improved by orthopedic shoes or appliances. 38 C.F.R. § 4.71a, Diagnostic Code 5276. The intent of the Rating Schedule is to recognize actually painful, unstable or malaligned joints, due to healed injury, as entitled to at least the minimum compensable rating for the joint, even in the absence of arthritis, to include in situations where the disability at issue is not evaluated based on range of motion measurements. 38 C.F.R. § 4.59; Burton v. Shinseki, 25 Vet. App. 1, 5 (2011); Southall-Norman v. McDonald, 28 Vet. App. 346 (2016). The Board finds that the preponderance of the evidence is against a rating in excess of 30 percent for bilateral pes planus prior to November 19, 2019. The Board acknowledges the Veteran's lay reports of his symptoms and functional loss due to significant pain both with and without movement interfering with his ability to walk and balance. He has also described flare-ups of shooting pain in his feet that render him unable to move or use them when they occur, but the evidence of record indicates that this is less likely related to the Veteran's pes planus and more likely neurologic in origin. See November 2019 foot and knee examinations and opinions. The Board notes that the Veteran is in receipt of service connection for both left and right lower extremity radiculopathy, and flare-ups of radicular pain and symptoms are contemplated under those ratings. The Veteran was provided with VA examination of his pes planus in June 2013. At that time, the Veteran described increasing pain over the last years of such an extent that the condition "inables [him] to walk." The Veteran had pain on use which was accentuated on use and manipulation of the feet, bilaterally. The Veteran was also noted to have indication of swelling on use, and extreme tenderness of plantar surface of both feet. The symptoms were not relieved by arch supports. He further had decreased longitudinal arch height on weight-bearing. The Veteran's pes planus did not manifest in characteristic callosities, objective evidence of marked deformity of the foot (pronation, abduction, etc...), weight-bearing line falling over or medial to the great toe, inward bowing of the Achilles tendon, or marked inward displacement and severe spasm of the Achilles tendon. A July 2013 private orthopedic treatment record documented findings including completely flattened transverse and longitudinal foot arches with corresponding plantar calluses and cornification of the inside of the arches, slight adduction of the forefoot, and active straightening up well supported by the longitudinal and transverse arches of the foot. The hind foot was noted to have normal position. An additional private orthopedic record from April 2018 also includes findings of completely sunken longitudinal and transverse arches with corresponding plantar callosity and cornification of the medial side of the arches, mild forefoot adduction, and active straightening developing in the longitudinal and transverse arches well. The Veteran was again noted to have normal tarsus positioning. When considering the evidence of record in total prior to November 2019, the Board finds that the severity and manifestations of the Veteran's pes planus do not more-nearly approximates the criteria for a higher 50 percent rating rather than the currently-assigned 30 percent rating. In this regard, the Veteran's documented manifestations of pain on manipulation and use accentuated, swelling on use, and characteristic callosities are all specifically contemplated by the 30 percent rating assigned for pes planus that is "severe." There was additionally evidence of slight/mild adduction of the forefoot, which is less than the "marked deformity" contemplated under the 30 percent criteria. The Board recognizes that the June 2013 VA examination report documents extreme tenderness of the plantar surface of both feet, with symptoms not relieved by arch support; both of which are listed under the 50 percent rating level under DC 5276. However, this particular diagnostic code lists manifestations that, when considered together, combine to describe pes planus that is "pronounced." While it is not necessary that all listed manifestations be present for a veteran to warrant a 50 percent evaluation, it is also not expected that the mere presence of one or more of these manifestations automatically describes pes planus of a pronounced severity. In this case, prior to November 2019, the Veteran's pes planus were not found to manifest in marked pronation, marked inward displacement or severe spasm of the tendo achilles on manipulation, or marked deformity. Taken together, the Board finds the totality of the Veteran's feet symptoms more-closely approximates severe pes planus contemplated by the currently-assigned 30 percent rating, rather than pronounced pes planus warranting a 50 percent rating. The Board has also considered the other Diagnostic Codes pertaining to the foot. Other disability ratings may be assigned only if the symptomatology for a disability is not duplicative or overlapping with the symptomatology of any other disability. See Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994); see also Lyles v. Shulkin, 29 Vet. App. 107 (2017). In Scott v. Wilkie, the Federal Circuit expressly adopted the Court's holding that disabilities specifically listed in the rating schedule may only be rated under Diagnostic Codes which specifically pertain to them. Scott v. Wilkie, 920 F.3d 1375 (Fed. Cir. 2019) (citing Copeland v. McDonald, 27 Vet. App. 333, 336 (2015)). The Federal Circuit also expressly adopted the Court's holding that unlisted conditions may be rated by analogy to Diagnostic Codes that may not describe the unlisted disability but addresses disabilities that may be productive of similar symptoms. Scott, 920 F.3d 1375 (citing Yancy v. McDonald, 27 Vet. App. 484, 493 (2016). Finally, the Federal Circuit concluded that the Board must also consider assigning separate ratings under analogous Diagnostic Codes, when rating an unlisted service-connected foot disability exhibiting distinct manifestations, even when service connection has also been granted for one of the eight conditions listed in the rating schedule. Id. Here, the Veteran's pes planus/flatfoot is specifically listed under the rating schedule and therefore cannot be rated under a different Diagnostic Code. The Veteran has additionally been awarded service connection for left and right lower extremity radiculopathy, as well as metatarsalgia and hallux valgus of the bilateral feet. The Veteran is in receipt of a 10 percent disability rating for bilateral metatarsalgia, which is the highest rating available under DC 5279. A higher disability rating is also not warranted for hallux valgus, as the evidence does not indicate that he has undergone operation with resection of metatarsal head or that the disability is severe and equivalent to amputation of either great toe. The evidence of record does not reflect that the Veteran has any other service-connected foot disabilities that would warrant a separate rating under a different diagnostic code. From November 19, 2019, the Veteran is in receipt of a 50 percent disability rating for his pes planus. As the Veteran is in receipt of the highest schedular rating for acquired flat foot from this point forward, there is no basis to award a higher rating. The Veteran has asserted that his disabilities result in effective loss of use of his feet, and such will be considered as part of the remanded issue of entitlement to a higher level of SMC. In conclusion, the Board finds that the preponderance of the evidence is against a rating in excess of 30 percent for service-connected pes planus prior to November 19, 2019 and in excess of 50 percent thereafter. 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. Knee Ratings The Veteran's right and left knee disabilities are currently rated under 38 C.F.R. § 4.71a, Diagnostic Code 5257 for lateral instability with subluxation and Diagnostic Code 5261 for limited extension of the knee. Disabilities of the same knee joint may be simultaneously rated under multiple diagnostic codes without impermissible pyramiding, so long as individual manifestations are not used under multiple diagnostic codes when assigning the ratings. Therefore, separate compensable ratings are potentially available for limited flexion, limited extension, instability, and impairment involving the meniscus. See VAOPGCPREC 09-04. Effective February 7, 2021, VA amended the regulations governing the rating of musculoskeletal disabilities. 85 Fed. Reg. 76,453 (Nov. 30, 2020) (eff. Feb. 7, 2021). Unless otherwise indicated, in cases where rating criteria are amended during the course of the appeal, the Board must consider both the former and current schedular criteria. If an increased rating is warranted under new, revised criteria, the award may not be made effective before the effective date of change. See Kuzma v. Principi, 341 F.3d 1327, 1328 (Fed. Cir. 2003). DC 5256, used for rating ankylosis of the knee, provides for a 30 percent disability rating for ankylosis at a favorable angle in full extension, or in slight flexion between 0 degrees and 10 degrees. A 40 percent disability rating is assigned for a knee ankylosed in flexion between 10 and 20 degrees. A 50 percent disability rating is assigned for ankylosis in flexion between 20 and 45 degrees. A 60 percent disability rating is assigned for extremely unfavorable ankylosis, where the joint is fixed in flexion at an angle of 45 degrees or more. 38 C.F.R. § 4.71a. Under DC 5260, flexion of the leg limited to 60 degrees is rated as noncompensable (0 percent); flexion of the leg limited to 45 degrees is rated 10 percent; flexion of the leg limited to 30 degrees is rated 20 percent; and flexion of the leg limited to 15 degrees is rated 30 percent. Under DC 5261, extension of the leg limited to 5 degrees is rated noncompensable (0 percent); extension of the leg limited to 10 degrees is rated 10 percent; extension of the leg limited to 15 degrees is rated 20 percent; extension of the leg limited to 20 degrees is rated 30 percent; extension of the leg limited to 30 degrees is rated 40 percent; and extension of the leg limited to 45 degrees is rated 50 percent. 38 C.F.R. § 4.71a. Normal ranges of motion of the knee are to 0 degrees in extension, and to 140 degrees in flexion. 38 C.F.R. § 4.71, Plate II. DC 5257 provides ratings for other impairment of the knee that includes recurrent subluxation or lateral instability. Prior to February 7, 2021, slight recurrent subluxation or lateral instability of the knee is rated 10 percent; moderate recurrent subluxation or lateral instability of the knee is rated 20 percent; and severe recurrent subluxation or lateral instability of the knee is rated 30 percent. 38 C.F.R. § 4.71a (2019). The rating schedule does not define the terms "mild," "moderate," or "severe." Therefore, the Board must evaluate the evidence of record and reach a decision that is equitable and just. 38 C.F.R. § 4.6. Although an element of evidence to be considered by the Board, the use of terminology such as "severe" by VA examiners and others is not dispositive of an issue. All evidence must be evaluated in arriving at a decision regarding an increased rating. 38 C.F.R. §§ 4.2, 4.6. With regard to the knee disability involving the lateral and medial meniscus, also known as "semi-lunar" cartilages, DC 5258 provides for a 20 percent disability rating for cartilage, semilunar, dislocated, with frequent episodes of "locking," pain, and effusion in to the joint, and DC 5259 provides for a 10 percent disability rating for removal of the semilunar cartilage which remains symptomatic. 38 C.F.R. § 4.71a. Other diagnostic codes involving the knee include those for, impairment of the tibia and fibula, and genu recurvatum. 38 C.F.R. § 4.71a, DCs 5262, 5263. Such DCs are inapplicable to the present case, as there is no evidence of either impairment. The February 7, 2021 amendments made significant changes to DC 5257, including laying out criteria for "recurrent subluxation and lateral instability" as well as for "patellar instability." However, as both contemplate disability involving instability of the knee and consider the prescription of assistive devices, the assignment of multiple ratings under DC 5257 would result in impermissible pyramiding. See Esteban v. Brown, 6 Vet. App. 259, 262 (1994); 38 C.F.R. § 4.14. As both of the Veteran's knees are presently in receipt of the maximum schedular rating provided for under both the pre- and post-amendment DC 5257 from February 7, 2021 to present, a full recitation of the amended criteria is unnecessary, as their application could not result in a higher award for the Veteran. 3. Entitlement to an initial disability rating in excess of 10 percent for left knee limitation of extension is denied. 4. Entitlement to a separate 10 percent disability rating for left knee limitation of flexion is granted. The Veteran is currently in receipt of a 10 percent disability rating for limited motion of the left knee, specifically for limited extension under DC 5261. The Veteran was provided with VA examination of his knees in June 2013 and November 2019. At the June 2013 examination, the Veteran described experiencing excruciating pain and an inability to walk longer distances, being forced to stay at home due to pain. Range of motion testing for the left knee demonstrated extension limited to 10 degrees and flexion limited to 85 degrees, with objective evidence of pain beginning at 10 degrees of extension and 40 degrees of flexion. The Veteran was unable to perform three repetitions of motion due to shooting pain in left knee and back after first bending. At the November 2019 examination, the Veteran described continuous knee pain, stating that sometimes he feels like he is paralyzed by pain and has to sit down and cannot move anymore. Range of motion testing for the left knee demonstrated full extension and flexion limited to 40 degrees, with pain throughout both movements. Again, the Veteran was unable to perform repetitive use testing due to pain. In considering the totality of the evidence, including the Veteran's lay statements about the effects of pain and flare-ups of pain further limiting his range of motion of the knee, the Board finds that the Veteran's left knee disability warrants a 10 percent rating for limitation of flexion in addition to the currently assigned 10 percent for limited extension. While range of motion testing at the VA examinations did not show both extension limited to 10 degrees and flexion limited to 45 degrees or less simultaneously, each motion was objectively observed to be limited to this extent at one of the two examinations. When considering the DeLuca factors, 38 C.F.R. § 4.59, and the fact that the June 2013 examination reports documents observed painful motion beginning at 40 degrees of flexion when extension was limited to 10 degrees, the left knee is found to have manifested in flexion effectively limited to at least 45 degrees, but not limited to 30 degrees or less under DC 5260. In so finding, the Board recognizes the Veteran's assertions that his inability to perform repetitive motion testing at either examination and flare-ups of knee pain at times leaving him "paralyzed by pain" and unable to move the joint warrants a maximum rating under DCs 5260, 5261, and 5256 for ankylosis of the knee. As explained in greater detail, above, the Veteran's flare-ups involving "shooting pain" have largely been attributed to his lower extremity radiculopathy/neurological condition. To also grant a higher rating for limited motion or functional ankylosis would be compensating the Veteran under multiple diagnostic codes for the same manifestation of his knee disability, and would constitute impermissible pyramiding. See Esteban v. Brown, 6 Vet. App. 259, 262 (1994); 38 C.F.R. § 4.14. Thus, while the evidence supports an assignment of a separate 10 percent disability rating for the left knee under DC 5260 for limitation of flexion, a preponderance of the evidence is found to weigh against the assignment of a disability rating in excess of 10 percent for left knee limitation of flexion and in excess of 10 percent for left knee limitation of extension. 5. Entitlement to a separate 20 percent disability rating for left knee meniscal disability is granted from October 6, 2016. As explained above, separate ratings may be assigned for distinct disabilities resulting from the same injury so long as symptomatology from one condition is not duplicative of or overlapping with the symptomatology of the other. The claims file contains private treatment records and surgical reports documenting that the Veteran suffered traumatic rupture of his quadriceps tendon with rupture of medial and lateral recess, and rupture of the medial meniscus posterior horn, for which he underwent osseous re-fixation of the quadriceps tendon in October 2016. Thereafter, he evidenced frequent pain and swelling of the joint. The November 2019 VA knee examination report further states that the Veteran suffered a left knee meniscal tear in 2016. Based on this evidence, the Board finds that a separate 20 percent rating for the left knee meniscus disability is warranted from October 6, 2016 under DC 5258. An October 6, 2016 private left knee MRI represents the earliest evidence of the left knee meniscal tear. While the June 2013 VA knee examination notes that the Veteran had frequent episodes of joint pain and effusion bilaterally, only the right knee was noted to have a meniscal tear and to have undergone meniscectomy. Thus, October 6, 2016 represents the earliest date from which entitlement to a separate rating for left knee meniscus rupture with frequent episodes of pain and effusion can be established. 6. Entitlement to a higher initial disability rating of 30 percent for left knee lateral instability, with subluxation, from October 6, 2016 is granted. 7. Entitlement to a higher initial disability rating for left knee lateral instability, with subluxation in excess of 20 percent prior to October 6, 2016 and in excess of 30 percent thereafter is denied. The Veteran is presently in receipt of a 20 percent disability rating prior to November 19, 2019 and a 30 percent disability rating from that date for lateral instability with subluxation of the left knee under DC 5257. The Veteran was also awarded a temporary total evaluation from October 26, 2016 to December 31, 2016 based on surgical treatment necessitating convalescence. Considering the evidence prior to October 6, 2016, the Board finds that the weight of the evidence shows that the Veteran's left knee lateral instability and patellar subluxation had a severity that was closer to moderate rather than severe. In that respect, private treatment records documented ligament instability and hyper-mobile patella in July 2013, and VA examination of the knees in June 2013 documented left knee medial-lateral instability of 1+ (0-5 millimeters), with normal anterior instability and posterior instability. The examiner concluded that the instability demonstrated on testing was best characterized as "moderate." A preponderance of the evidence thus weighs against an award of an evaluation greater than 20 percent for left knee lateral instability and patellar subluxation under DC 5257 prior to October 6, 2016. The evidence of record shows that the Veteran's left knee instability and subluxation disability worsened significantly following trauma to the left knee resulting in rupture of the quadriceps tendon and rupture of medial patellar retinaculum with mild laterization of patella and trochlear dysplasia seen on private MRI on October 6, 2016. The weight of the evidence is found to at least be evenly balanced as to whether the Veteran's left knee instability and subluxation remained severe following the October 2016 surgery. Resolving all reasonable doubt in the Veteran's favor, an award of the higher 30 percent disability rating for severe recurrent subluxation and lateral instability of the knee under DC 5257 is warranted from October 6, 2016. A 30 percent disability rating is the maximum evaluation available under DC 5257. As the Veteran will be in receipt of the highest schedular evaluation available for the disability from October 6, 2016 to the present, there is no basis upon which to grant a higher rating. Thus, the Board finds that a higher 30 percent disability rating for left knee lateral instability and subluxation is warranted from October 6, 2016, but that the weight of the evidence and relevant regulations do not support an award in excess of 20 percent prior to October 6, 2016, or in excess of 30 percent thereafter. 8. Entitlement to an initial disability rating in excess of 10 percent for left knee scar is denied. While the Veteran's appeal seeking a higher initial disability rating for his service-connected left knee disability was in remand status, the RO issued a rating decision in April 2020 granting service connection for a painful left knee scar, and assigned it a 10 percent evaluation under DC 7804 for unstable or painful scar(s), effective from October 26, 2016. See 38 C.F.R. § 4.118. The Board notes that VA amended the criteria for rating skin disabilities effective from August 13, 2018. However, Diagnostic Code 7804 was not changed by the August 13, 2018, amendments. Under Diagnostic Code 7804, one or two scars that are unstable or painful scars warrants a 10 percent rating. Three or four scars that are unstable or painful scars warrants a 20 percent rating. Five or more scars that are unstable or painful warrants a 30 percent rating. 38 C.F.R. § 4.118. Note 1 to Diagnostic Code 7804 instructs that an unstable scar is one where, for any reason, there is frequent loss of covering of skin over the scar. Id. The Board finds that the preponderance of the evidence is against the assignment of a rating in excess of 10 percent under Diagnostic Code 7804 because the Veteran's scar is not manifest by three or four scars that are unstable or painful. The Veteran was provided with a VA scar examination in November 2019. At that time, the examiner documented the presence of one post-surgical scar on the left knee that was extremely tender, but not unstable. The report notes that the scar involved underlying tissue damage, and was 16 centimeters long by 2 centimeters wide, with a total area of approximately 32 sq. centimeters. The scar itself was not found to result in limitation of motion of other functional loss. The Board has considered the other Diagnostic Codes pertaining to scars. In this regard, DC 7801 used for rating scar(s) not of the head, face, or neck that are deep and nonlinear provides for a 10 percent disability rating for such scars covering an area or areas of at least 6 square inches (39 square centimeters) but less than 12 square inches (77 square centimeters), and higher ratings for deep nonlinear scars covering larger areas. While the Veteran's left knee scar was found to have underlying soft tissue damage, and thus is "deep" per Note (1) to DC 7801, it does not cover an area of at least 39 square centimeters. Thus, a separate/higher disability rating is not warranted under this diagnostic code. Finally, the evidence of record shows there are no other disabling effects not considered in a rating provided under Diagnostic Codes 7800-04 as contemplated under both pre- and post-August 13, 2018, Diagnostic Code 7805. In conclusion, the Board finds that the preponderance of the evidence is against the assignment of a disability rating in excess of 10 percent for left knee painful scar. 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. 9. Entitlement to an initial disability rating in excess of 10 percent for right knee limitation of extension is denied. 10. Entitlement to a separate 10 percent disability rating for right knee limitation of flexion is granted. The Veteran is currently in receipt of a 10 percent disability rating for limited motion of the right knee, specifically for limited extension under DC 5261. The Veteran was provided with VA examination of his knees in June 2013 and November 2019. At the June 2013 examination, the Veteran described experiencing excruciating pain and an inability to walk longer distances, being forced to stay at home due to pain. Range of motion testing for the right knee demonstrated extension limited to 10 degrees and flexion limited to 95 degrees, with objective evidence of pain beginning at 10 degrees of extension and 45 degrees of flexion. The Veteran was unable to perform three repetitions of motion due to shooting pain in the knees and back after first bending. At the November 2019 examination, the Veteran described continuous knee pain, stating that sometimes he feels like he is paralyzed by pain and has to sit down and cannot move anymore. Range of motion testing for the right knee demonstrated full extension and flexion limited to 40 degrees, with pain throughout both movements. Again, the Veteran was unable to perform repetitive use testing due to pain. In considering the totality of the evidence, including the Veteran's lay statements about the effects of pain and flare-ups of pain further limiting his range of motion of the knee, the Board finds that the Veteran's right knee disability warrants a 10 percent rating for limitation of flexion in addition to the currently assigned 10 percent for limited extension. While range of motion testing at the VA examinations did not show both extension limited to 10 degrees and flexion limited to 45 degrees or less simultaneously, each motion was objectively observed to be limited to this extent at one of the two examinations. When considering the DeLuca factors, 38 C.F.R. § 4.59, and the fact that the June 2013 examination reports documents observed painful motion beginning at 45 degrees of flexion when extension was limited to 10 degrees, the right knee is found to have manifested in flexion effectively limited to at least 45 degrees, but not limited to 30 degrees or less under DC 5260. In so finding, the Board recognizes the Veteran's assertions that his inability to perform repetitive motion testing at either examination and flare-ups of knee pain at times leaving him "paralyzed by pain" and unable to move the joint warrants a maximum rating under DCs 5260, 5261, and 5256 for ankylosis of the knee. As explained above, the Veteran's flare-ups involving "shooting pain" have largely been attributed to his lower extremity radiculopathy/neurological condition. To also grant a higher rating for limited motion or functional ankylosis would be compensating the Veteran under multiple diagnostic codes for the same manifestation of his knee disability, and would constitute impermissible pyramiding. See Esteban v. Brown, 6 Vet. App. 259, 262 (1994); 38 C.F.R. § 4.14. Thus, while the evidence supports an assignment of a separate 10 percent disability rating for the right knee under DC 5260 for limitation of flexion, a preponderance of the evidence is found to weigh against the assignment of a disability rating in excess of 10 percent for right knee limitation of flexion and in excess of 10 percent for left knee limitation of extension. 11. Entitlement to a separate 10 percent disability rating for post-surgical residuals of right knee meniscectomy is granted. As explained above, separate ratings may be assigned for distinct disabilities resulting from the same injury so long as symptomatology from one condition is not duplicative of or overlapping with the symptomatology of the other. The evidence clearly documents that the Veteran underwent a right knee meniscectomy in 2008. Treatment records and VA examination reports throughout the appeal period document continued right knee effusion and pain, and the November 2019 VA examiner specified that the Veteran continued to experience frequent episodes of joint pain and effusion despite the surgery. As such, a separate rating of 10 percent is found warranted under DC 5259, for continued meniscal symptoms following surgery. As the medical evidence including a private MRI of the right knee from July 2017 does not demonstrate recurrence of dislocated semilunar cartilage during the relevant appeal period, the evidence is found to weigh against an assignment of 20 percent evaluation for the right knee under DC 5258. 12. Entitlement to a higher initial disability rating for right knee lateral instability and subluxation, currently with a 20 percent evaluation prior to November 19, 2019 and a 30 percent evaluation thereafter is denied. The Veteran is presently in receipt of a 20 percent disability rating prior to November 19, 2019 and a 30 percent disability rating from that date for lateral instability with subluxation of the right knee under DC 5257. Considering the evidence prior to November 19, 2019, the Board finds that the weight of the evidence shows that the Veteran's right knee lateral instability and patellar subluxation had a severity that was closer to moderate rather than severe. In that respect, private treatment records documented ligament instability and hyper-mobile patella in July 2013, and VA examination of the knees in June 2013 documented right knee medial-lateral instability of 1+ (0-5 millimeters), with normal anterior instability and posterior instability. The examiner concluded that the instability demonstrated on testing is best characterized as "moderate." It was not until the November 19, 2019 VA examination that joint stability testing demonstrated a clear worsening of the Veteran's right knee joint instability. At that time, objective testing recorded a 3+ for medial and lateral instability. A preponderance of the evidence thus weighs against an award of an evaluation greater than 20 percent for right knee lateral instability and patellar subluxation under DC 5257 prior to November 19, 2019. As the Veteran is in receipt of the highest schedular evaluation available for right knee instability under DC 5257 from November 19, 2019 to the present, there is no basis upon which to grant a higher rating. While the Veteran has asserted that he should be awarded separate compensable disability ratings for lateral instability as well as patellar subluxation, to grant more than one rating under this diagnostic code would be doubly compensating the Veteran for instability of the joint and would constitute impermissible pyramiding. The resulting manifestations of the disability, regardless of whether it is due to patellar subluxation or lateral instability, are fully contemplated by the one rating under DC 5257. Thus, the Board finds that a preponderance of the evidence is against the award of an initial disability rating for the right knee in excess of 20 percent prior to November 19, 2019 and in excess of 30 percent thereafter. As the weight of the evidence is against the claim, there is no reasonable doubt to be resolved in the Veteran's favor. In considering all of the claims for higher initial disability ratings for both knees, the Board recognizes the Veteran's assertions that his service-connected lower extremity disabilities result in effective loss of use of his feet and legs, and renders him helpless. Such contentions will be considered as part of the remanded issue of entitlement to a level of Special Monthly Compensation greater than the intermediate rate between (l) and (m). Finally, the Veteran has been in receipt of a schedular 100 percent disability rating and previously found entitled to SMC at the 38 U.S.C. § 1114(s) level for the entirety of the appeal period. Thus, any consideration of entitlement to a TDIU could not result in a higher benefit for the Veteran, and is therefore moot. See 38 C.F.R. § 4.16(a) (TDIU may be assigned "where the schedular rating is less than total"); Buie v. Shinseki, 24 Vet. App. 242 (2010); Bradley v. Peake, 22 Vet. App. 280 (2008). Other Benefits 13. Eligibility for financial assistance in the purchase of one automobile or other conveyance and automobile adaptive equipment is granted. Financial assistance may be provided to an eligible person in acquiring an automobile or other vehicle conveyance and adaptive equipment, or adaptive equipment only. 38 U.S.C. § 3902(a)(b). Eligibility for assistance to purchase a vehicle 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 U.S.C. § 3901; 38 C.F.R. § 3.808. In relevant part, the Veteran is presently in receipt of service connection benefits for the following disabilities: disabilities of the left and right knee; lumbar spine disc disease and spondylosis with left and right lower extremity radiculopathy; and bilateral pes planus, metatarsalgia, and hallux valgus. The Board finds that when resolving all reasonable doubt in the Veterans favor, solely for the purposes of determining eligibility for automobile adaptive benefits, the evidence demonstrates that these service-connected disabilities result in the effective loss of use of one or both feet. In this regard, the Veteran was provided with VA examinations of his knees and feet in November 2019, at which the examiner stated an opinion that the functioning of his knees and feet were so diminished that he would be equally well-served by amputation with use of suitable prosthesis. The examiner highlighted that the Veteran was unable to perform repetitions of motion of either knee due to severe pain, demonstrated severe instability of both knees, and stated that there was objective evidence of extreme pain with every manipulation for range of motion measurement or instability on examination, and "there is nearly immobilized crucifying painful situation in this veteran accompanied by weakness in both lower extremities." Considering the above, the Board finds that the weight of evidence is at least evenly balanced as to whether the Veterans service-connected disabilities, alone, are of sufficient severity to result in the effective loss of use of one or both feet, solely for the purpose of establishing eligibility for automobile adaptation benefits under 38 C.F.R. § 3.808. Resolving all reasonable doubt in the Veterans favor, a grant of the benefit sought is warranted. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. 14. Eligibility for assistance in acquiring specially adapted housing is granted. Specially adapted housing is available to a veteran who has a permanent and total service-connected disability due to: (1) amyotrophic lateral sclerosis rated as 100 percent disabling under 38 C.F.R. § 4.124a, Diagnostic Code 8017; (2) blindness in both eyes, having only light perception, plus the anatomical loss or loss of use of one lower extremity; (3) full thickness or subdermal burns that have resulted in contractures with limitation of motion of two or more extremities or of at least one extremity and the trunk; or (4) the loss or loss of use of both upper extremities such as to preclude use of the arms at or above the elbows. Specially adapted housing is also available to a veteran with a permanent and total disability that precludes locomotion without the aids of braces, crutches, canes, or a wheelchair due to: (5) the loss, or loss of use, of both lower extremities; (6) the loss or loss of use of one lower extremity, together with residuals of organic disease or injury which so affect the functions of balance and propulsion; or, (7) the loss or loss of use of one lower extremity together with the loss or loss of use of one upper extremity which so affect the functions of balance or propulsion. 38 U.S.C. § 2101(a); 38 C.F.R. § 3.809(a), (b), (d). The phrase "preclude locomotion" is defined as the necessity for regular and constant use of a wheelchair, braces, crutches, or canes as a normal mode of locomotion, although occasional locomotion by other methods may be possible. 38 C.F.R. § 3.809(c). As noted above, the Veteran is presently service-connected for a number of disabilities negatively affecting his ability to use his lower extremities. Following implementation of this decision, the Veteran will also be in receipt of a combined 100 percent evaluation on the basis of these lower extremity disabilities. VA examination in November 2019 also found that the Veteran makes constant use of assistive devices, including braces, crutches, canes, and walker, and requires them due to pain and instability of his knees. The evidence is thus found to demonstrate that the Veteran has a permanent and total service-connected disability due to loss of use of both lower extremities, such as to preclude locomotion without the aid of braces, crutches, canes, or a wheelchair. Eligibility for assistance in acquiring specially adapted housing is therefore warranted. REASONS FOR REMAND 1. Entitlement to service connection for diabetes mellitus is remanded. As the claim for entitlement to service connection for diabetes mellitus has been reopened, remand is warranted before it may be adjudicated on the merits by the Board. Specifically, the April 2018 rating decision and March 2020 statement of the case (SOC) both declined to reopen the issue of entitlement to service connection for a lung disability, finding that new and material evidence had not been submitted. Because the Board reopened the claim, as discussed in greater detail above, the AOJ must adjudicate the reopened claim on the merits in the first instance. See Bernard v. Brown, 4 Vet. App. 384, 394 (1993). The Veteran has not yet been provided with a VA examination concerning his claim for service connection for diabetes mellitus. The Veteran has asserted that his diabetes mellitus resulted from his obesity, which was not a problem until he started having trouble with his service-connected back, knees, and feet disabilities. On remand, the Veteran should be provided with VA examination and medical opinion pertaining to this claim. 2. Entitlement to a level of Special Monthly Compensation greater than the intermediate rate between (l) and (m) is remanded. The Veteran is presently in receipt of SMC under 38 U.S.C. § 1114 at the intermediate rate between (l) and (m), on the basis of being so helpless as to be in need of regular aid and attendance with additional disability, obstructive sleep apnea, independently ratable at 50 percent or more. The Veteran asserts that he is entitled to the maximum SMC, at the 1114(o) level, due to his alleged paraplegia during flare-ups of symptoms. While the evidence does not clearly demonstrate paralysis of both lower extremities together with loss of anal or bladder sphincter control, the Board notes that a higher level of SMC than that currently assigned may be available on the basis of a combination of disabilities. Therefore, on remand, additional examination and medical opinion should be sought concerning whether the Veteran has loss of use of two extremities separate from service-connected disability of a severity sufficient to render him in need of regular aid and attendance. The matters are REMANDED for the following action: 1. Schedule the Veteran for a VA examination for his claimed diabetes mellitus. The examiner must review the claims file. The examiner is asked to address the following: A. Confirm or rule out a diagnosis of diabetes mellitus at any time during the relevant appeal period (September 2014 to present); B. Is it at least as likely as not that diabetes mellitus arose during or within one year of separation from active service, or is otherwise related to service? With regard to the Veteran's assertion that his diabetes mellitus is secondary to obesity caused or aggravated by his service-connected disabilities, the clinician is asked to address the following: C. Is it at least as likely as not that the Veteran's obesity was (i) caused or (ii) aggravated by his service-connected disabilities? i. If the clinician finds that obesity was caused by one or more of the Veteran's service-connected disabilities: a. is it at least as likely as not that obesity was a substantial factor in causing the Veteran's diabetes mellitus; and b. is it at least as likely as not that diabetes mellitus would not have occurred but for the Veteran's obesity? ii. If the clinician finds that obesity was aggravated by one of more of the Veteran's service-connected disabilities: c. is it at least as likely as not that the aggravation of obesity as a result of service-connected disability was a substantial factor in causing diabetes mellitus; and d. is it at least as likely as not that diabetes mellitus would not have occurred but for obesity aggravated by the service-connected disability or disabilities? The clinician must provide a rationale for any opinion expressed/conclusion reached. If the clinician finds that they cannot offer an opinion without resorting to mere speculation, they must state whether the need to speculate is due to a deficiency in the state of general medical knowledge (no one could respond given medical science and the known facts), a deficiency in the record (additional facts are required), or the clinician (does not have the knowledge or training). 2. Schedule the Veteran for a VA examination to presently and retrospectively provide an opinion as to the severity and effect of certain service-connected disabilities on his overall functioning and need for regular aid and attendance. The Veteran has previously been found to have required the regular aid and attendance of another throughout the relevant appeal period. The examiner must be provided with access to the claims file and a list of the Veteran's service-connected disabilities, and should review the evidence of record before responding to the following: The examiner should state an opinion as to whether functional impairment from each of the combination of disabilities, below, would alone be sufficient for the Veteran to require the regular aid and attendance of another person to assist with activities such as dressing/undressing, bathing, clothing, and feeding himself. To the extent possible, the examiner should indicate what functional impairment would result from each combination. If the need was only present for a portion of the relevant appeal period (July 2011 to present), the examiner should so state. A. coronary artery disease; B. coronary artery disease + lumbar spine disc disease and spondylosis; C. any combination of service-connected disabilities EXCEPT those pertaining to the lower extremities; D. service-connected disabilities of the lower extremities. Pertaining to the Veteran's service-connected disabilities affecting the lower extremities, the examiner should elicit detailed information from the Veteran as to the frequency, duration, and severity of his flare-ups of pain throughout the appeal period, which he has described as feeling "paralyzed by pain" and needing to sit down. For any opinion or conclusion stated, the examiner must provide a clear rationale. 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.