Citation Nr: 21030634 Decision Date: 05/19/21 Archive Date: 05/19/21 DOCKET NO. 09-17 878 DATE: May 19, 2021 ORDER The issue as to whether the character of the Veteran's discharge for the period of service from November 21, 1983 to August 1, 1986 is a bar to the receipt of Department of Veterans Affairs (VA) benefits is dismissed. Entitlement to a compensable rating for a service-connected left ear hearing loss disability is denied. A separate disability rating of 10 percent for radiculopathy of the right lower extremity (sciatic nerve) is granted for the entire period on appeal. A separate disability rating of 10 percent for radiculopathy of the left lower extremity (sciatic nerve) is granted for the entire period on appeal. REMANDED Entitlement to service connection for arthritis of the bilateral hands is remanded. Entitlement to service connection for a left ankle disability, to include as secondary to a service-connected disability or disabilities, is remanded. FINDINGS OF FACT 1. In August 2019, the Army Board for Correction of Military Records (ABCMR) upgraded the character of the Veteran's discharge for the period of service from November 21, 1983 to August 1, 1986 from "bad conduct" to "under honorable conditions (general)." 2. The Veteran is service-connected for impaired hearing of the left ear only, and such impairment has not been shown to manifest in a numeric designation of hearing impairment warranting a compensable evaluation at any time during the period on appeal. 3. For the entire period on appeal, the Veteran has demonstrated subjective symptoms of radiculopathy of the right lower extremity (sciatic nerve) associated with his service-connected lumbar strain with degenerative changes. 4. For the entire period on appeal, the Veteran has demonstrated subjective symptoms of radiculopathy of the left lower extremity (sciatic nerve) associated with his service-connected lumbar strain with degenerative changes. CONCLUSIONS OF LAW 1. An August 2019 ABCMR upgrade of the character of the Veteran's discharge for the period of service from November 21, 1983 to August 1, 1986 to "under honorable conditions (general)" removed the bar to the receipt of VA benefits. Accordingly, there is no case or controversy as to whether the character of the Veteran's discharge for this period of service is a bar to the receipt of VA benefits, and the appeal as to this issue is dismissed. 38 U.S.C. § 7105; 38 C.F.R. § 20.104. 2. The criteria for entitlement to a compensable evaluation for a service-connected left ear hearing loss disability have not been met at any time during the period on appeal. 38 U.S.C. § 1155; 38 C.F.R. §§ 4.85, 4.86. 3. For the entire period on appeal, the criteria for entitlement to a separate 10 percent disability rating for radiculopathy of the right lower extremity (sciatic nerve) associated with the Veteran's service-connected lumbar strain with degenerative changes have been met. 38 U.S.C. § 1155, 5107; 38 C.F.R. §§ 3.102, 4.71a, Note (1), 4.124a, Diagnostic Codes 5242-5237, 8520. 4. For the entire period on appeal, the criteria for entitlement to a separate 10 percent disability rating for radiculopathy of the left lower extremity (sciatic nerve) associated with the Veteran's service-connected lumbar strain with degenerative changes have been met. 38 U.S.C. § 1155, 5107; 38 C.F.R. §§ 3.102, 4.71a, Note (1), 4.124a, Diagnostic Codes 5242-5237, 8520. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the United States Army from July 1976 to July 1979, and from January 1980 to August 1986. The issues on appeal were previously remanded by the Board in August 2012, July 2018, and December 2019. The Board finds the agency of original jurisdiction (AOJ) has substantially complied with the remand instructions and the evidence of record is sufficient to proceed with a decision on the merits concerning the issues of: (1) whether the character of the Veteran's discharge for the period of service from November 21, 1983 to August 1, 1986 is a bar to the receipt of VA benefits; (2) entitlement to a compensable rating for a service-connected left ear hearing loss disability; and (3) entitlement to separate disability ratings for radiculopathy of the bilateral lower extremities associated with the Veteran's service-connected lumbar strain with degenerative changes. The Board regrets the additional delay, but for the reasons discussed further below, finds remand is necessary for additional development with respect to the Veteran's claim for entitlement to service connection for arthritis of the bilateral hands, and entitlement to service connection for a left ankle disability. Character of Discharge In a March 2008 VA administrative decision, the Veteran's bad conduct discharge by reason of the sentence of a general court martial, for the period of service from November 21, 1983 to August 1, 1986, was determined to be a bar to the receipt of VA benefits. See 38 U.S.C. § 5303; 38 C.F.R. § 3.12(c)(2). During the pendency of the current appeal, the ABCMR determined the Veteran's discharge for the period of service from November 21, 1983 to August 1, 1986 should be upgraded from "bad conduct" to "under honorable conditions (general)." See August 2019 ABCMR decision. Under 38 C.F.R. § 3.12(e), an honorable discharge or a discharge under honorable conditions issued through a board for correction of records established under 10 U.S.C. § 1552 is final and conclusive on VA. In this case, the action of the ABCMR sets aside any prior bar to benefits imposed under 38 U.S.C. § 5303 or 38 C.F.R. § 3.12(c). In a November 2020 letter, VA notified the Veteran that the character of his discharge for the period of service from November 21, 1983 to August 1, 1986 no longer constitutes a bar to the receipt of VA benefits. Accordingly, the benefit sought on appeal has been grantednamely, that the character of the Veteran's discharge for the period of service from November 21, 1983 to August 1, 1986 is not a bar to the receipt of VA benefits. As such, there remains no case or controversy for the Board to resolve regarding the Veteran's character of discharge, and the issue of whether the character of the Veteran's discharge for the period of service from November 21, 1983 to August 1, 1986 is a bar to the receipt of VA benefits is dismissed. 38 U.S.C. § 7105. Increased Ratings Disability evaluations are determined by evaluating the extent to which a Veteran's service-connected disability adversely affects the ability to function under the ordinary conditions of daily life, including employment, by comparing symptomatology with the criteria set forth in the Schedule for Rating Disabilities (Rating Schedule). 38 U.S.C. § 1155; 38 C.F.R. §§ 4.1, 4.2, 4.10. Left Ear Hearing Loss Disability Ratings for hearing loss range from noncompensable to 100 percent based on organic impairment of hearing acuity as measured by the results of speech discrimination tests combined with the average hearing threshold levels as measured by pure tone audiometry tests in the frequencies 1000, 2000, 3000, and 4000 cycles per second. To rate the degree of disability for service-connected hearing loss, the Rating Schedule has established eleven auditory acuity levels, designated from Level I, for essentially normal acuity, through Level XI, for profound deafness. 38 C.F.R. § 4.85(h), Table VI. In order to establish entitlement to a compensable rating for hearing loss, it must be shown that certain minimum levels of the combination of the percentage of speech discrimination loss and average pure tone decibel loss are met. The assignment of disability ratings for hearing impairment is derived by a mechanical application of the Rating Schedule to the numeric designations assigned after audiometric evaluations are rendered. Lendenman v. Principi, 3 Vet. App. 345 (1992). As set out in the Rating Schedule, the results of controlled speech discrimination tests (Maryland CNC) and pure tone audiometry tests are charted on Table VI, or Table VIA in exceptional cases as described in 38 C.F.R. § 4.86, and Table VII. 38 C.F.R. § 4.85. An exceptional pattern of hearing loss occurs when the pure tone threshold at 1000, 2000, 3000, and 4000 Hertz is 55 decibels or more, or when the pure tone threshold is 30 decibels or less at 1000 Hertz and 70 decibels or more at 2000 Hertz. 38 C.F.R. § 4.86. Specifically, when the pure tone threshold is 30 decibels or less at 1000 Hertz and 70 decibels or more at 2000 Hertz, the Roman numeral designation for hearing impairment is determined from either Table VI or Table VIA, whichever results in the higher numerical. 38 C.F.R. § 4.86(b). That numeral will then be elevated to the next higher Roman numeral, and then each ear will be evaluated separately. Id. The United States Court of Appeals for Veterans Claims (Court) held that in addition to dictating objective test results, a VA audiologist must fully describe the functional effects caused by a hearing disability in his or her final report. Martinak v. Nicholson, 21 Vet. App. 447, 455 (2007). In considering the evidence of record for the period on appeal, the Veteran was afforded a VA hearing loss examination in May 2008. The examiner noted that audiometric evaluations in service treatment records documented progressive high frequency hearing loss in the left ear. The Veteran reported difficulty following group conversations and watching television due to his left ear hearing impairment. On the May 2008 VA audiological evaluation, pure tone thresholds, in decibels, were as follows: HERTZ 500 1000 2000 3000 4000 LEFT 10 15 10 15 45 Speech audiometry revealed speech recognition ability of 100 percent in the left ear. For the Veteran's service-connected left ear hearing loss disability, adding the sum of the Hertz levels from 1000 through 4000 and dividing by four results in an average pure tone threshold of 21. The examiner reported a speech recognition ability of 100 percent in the left ear. Applying the average pure tone threshold and speech recognition ability into Table VI reveals a Roman Numeral designation for hearing impairment of I in the left ear. 38 C.F.R. § 4.85. When impaired hearing is service-connected in only one ear, as is the case here, the nonservice-connected ear will be assigned a numeric designation of Level I. 38 C.F.R. § 4.85(f). Entering the Roman Numeral designation of I for the service-connected left ear and I for the nonservice-connected right ear in Table VII results in a noncompensable evaluation under Diagnostic Code 6100. 38 C.F.R. § 4.85, Table VII. In July 2008, the Veteran requested an increase in the evaluation of his service-connected left ear hearing loss disability, indicating disagreement with the noncompensable evaluation assigned in a June 2008 rating decision. See July 2008 VA Form 21-4138. In September 2009 correspondence, Dr. N.A.O.V. indicated the Veteran watched television and listened to the radio at volumes louder than normal. Dr. N.A.O.V. indicated the Veteran often had difficulty understanding conversation in crowded places, had to look at the person talking in order to understand what was being said, and had to request that people repeat conversation. Pursuant to the August 2012 Board remand, the Veteran was afforded a new VA hearing loss examination in July 2015 to assess the current severity of his service-connected left ear hearing impairment. On the July 2015 VA audiological evaluation, pure tone thresholds, in decibels, were as follows: HERTZ 500 1000 2000 3000 4000 LEFT 30 30 30 45 50 Speech audiometry revealed speech recognition ability of 88 percent in the left ear. For the Veteran's service-connected left ear hearing loss disability, adding the sum of the Hertz levels from 1000 through 4000 and dividing by four results in an average pure tone threshold of 39. The examiner reported a speech recognition ability of 88 percent in the left ear. Applying the average pure tone threshold and speech recognition ability into Table VI reveals a Roman Numeral designation for hearing impairment of II in the left ear. 38 C.F.R. § 4.85. Entering the Roman Numeral designation of II for the service-connected left ear hearing impairment and I for the nonservice-connected right ear in Table VII results in a noncompensable evaluation under Diagnostic Code 6100. 38 C.F.R. § 4.85, Table VII. The Board recognizes that the Veteran underwent a VA audiological evaluation in October 2016. Although the October 2016 audiological evaluation is unclear as to which speech discrimination test was used, even if the Board were to presume that the Maryland CNC test was utilized as required under 38 C.F.R. § 4.85, the Veteran's service-connected left ear hearing impairment does not meet the criteria for a compensable evaluation. As such, the Board finds remand to obtain clarification as to whether the Maryland CNC test was used to test speech recognition would not result in any further benefit to the Veteran, and would cause an unnecessary delay in the adjudication of the case. Soyini v. Derwinski, 1 Vet. App. 540 (1991). In July 2018, the Board remanded the Veteran's claim for entitlement to a compensable rating for his service-connected left ear hearing disability, directing the AOJ to readjudicate this issue. The Veteran was afforded a new VA hearing loss examination in October 2018. On the October 2018 VA audiological evaluation, pure tone thresholds, in decibels, were as follows: HERTZ 500 1000 2000 3000 4000 LEFT 30 30 30 45 50 Speech audiometry revealed speech recognition ability of 24 percent in the left ear. For the Veteran's service-connected left ear hearing loss disability, adding the sum of the Hertz levels from 1000 through 4000 and dividing by four results in an average pure tone threshold of 39. The examiner reported a speech recognition ability of 24 percent in the left ear. The examiner indicated the use of the speech discrimination score was not appropriate because of language difficulties, cognitive problems, inconsistent speech discrimination scores, etc. However, the Board observes utilizing either Table VI, based on pure tone threshold average and speech discrimination, or Table VIA, based only on pure tone threshold average, results in a noncompensable evaluation. Applying the average pure tone threshold (only) into Table VIA reveals a Roman Numeral designation for hearing impairment of I in the left ear. Applying the average pure tone threshold and speech recognition ability into Table VI reveals a Roman Numeral designation for hearing impairment of IX in the left ear. 38 C.F.R. § 4.85. Entering the Roman Numeral designation of I under Table VIA (or IX under Table VI) for the Veteran's service-connected left ear hearing impairment and I for the nonservice-connected right ear in Table VII results in a noncompensable evaluation under Diagnostic Code 6100. 38 C.F.R. § 4.85, Table VII. A February 2019 VA audiological evaluation explicitly noted that the CID W-22 speech discrimination test was utilized and not the Maryland CNC test as required under 38 C.F.R. § 4.85. Therefore, the February 2019 VA audiological evaluation cannot be considered for VA rating purposes. Pursuant to the December 2019 Board remand, the Veteran was afforded a new VA hearing loss examination in January 2021 to assess the current severity of his service-connected left ear hearing disability. On the January 2021 VA audiological evaluation, pure tone thresholds, in decibels, were as follows: HERTZ 500 1000 2000 3000 4000 LEFT 30 30 30 50 50 Speech audiometry revealed speech recognition ability of 94 percent in the left ear. For the Veteran's service-connected left ear hearing loss disability, adding the sum of the Hertz levels from 1000 through 4000 and dividing by four results in an average pure tone threshold of 40. The examiner reported a speech recognition ability of 94 percent in the left ear. Applying the average pure tone threshold and speech recognition ability into Table VI reveals a Roman Numeral designation for hearing impairment of I in the left ear. 38 C.F.R. § 4.85. Entering the Roman Numeral designation of I for the service-connected left ear hearing impairment and I for the nonservice-connected right ear in Table VII results in a noncompensable evaluation under Diagnostic Code 6100. 38 C.F.R. § 4.85, Table VII. In this case, a compensable rating for the Veteran's service-connected left ear hearing loss disability is not warranted at any time during the period on appeal. While the Board in no way calls into question the effects of the Veteran's service-connected left ear hearing impairment on his ability to hear conversations, sounds around him, and frequently requiring repetition of comments, the Court has specifically held that the schedular criteria for rating hearing loss contemplates the functional effects of difficulty hearing and understanding speech, such as those reported by the Veteran. Doucette v. Shulkin, 28 Vet. App. 366, 371 (2017). To the extent that the Veteran contends that his service-connected left ear hearing loss disability is more severe than the noncompensable evaluation assigned over the period on appeal, the Veteran is competent to report symptoms of his left ear hearing loss disability. However, he is not competent to report that his left ear hearing acuity is of sufficient severity to warrant a higher evaluation under VA's tables for rating hearing loss disabilities because such an opinion requires medical expertise (training in evaluating hearing impairment), which he has not been shown to have. Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). As noted above, the assignment of disability ratings for hearing impairment is derived by a mechanical application of the Rating Schedule to the numeric designations assigned after audiometric evaluations are rendered. Lendenman, 3 Vet. App. at 349. In light of the above, a compensable rating for the Veteran's service-connected left ear hearing loss disability is not warranted at any time during the period on appeal, and the claim is denied. Radiculopathy of the Bilateral Lower Extremities The General Rating Formula for Diseases and Injuries of the Spine requires that consideration be given to any associated objective neurologic abnormalities, which are to be evaluated separately under an appropriate diagnostic code. See 38 C.F.R. § 4.71a, Note (1). In this case, the evaluation of the Veteran's service-connected lumbar strain with degenerative changes was decided by the Board in a final December 2019 decision. While the issue of the evaluation of the Veteran's service-connected lumbar strain with degenerative changes is no longer before the Board, the issue of whether a separate evaluation for any associated neurologic abnormalities is warranted has been returned to the Board for consideration following readjudication by the AOJ. In a May 2008 VA spine examination, the Veteran reported pain at the lumbosacral area radiating to the bilateral lower extremities. The examiner reported neurological examination revealed intact sensation to pinprick, muscle strength of 5/5, and no atrophy of the bilateral lower extremities. The Veteran underwent electrodiagnostic testing in December 2008 based on his report of bilateral pins and needle sensation in the lower extremities. See December 2008 VA consult. The provider reported that objective electrodiagnostic testing did not reveal evidence of peripheral neuropathy or lumbar radiculopathy in the muscles tested. In September 2009 correspondence, Dr. N.A.O.V. reported the Veteran's service-connected lumbar strain with degenerative changes resulted in bad posture, loss of correct alignment of the thoracic and lumbar spine, and an imbalance of stress on vertebrae that could result in disc bulging, herniation, and radiculopathy and neuropathy. In a November 2009 VA physical medicine note, the provider reported that the Veteran did not demonstrate clinical evidence of radiculopathy of the bilateral lower extremities associated with low back pain. However, the provider indicated the Veteran's history of symptoms associated with his low back may suggest a possible radicular process. The Veteran was afforded a VA peripheral neuropathy examination in March 2010. The Veteran reported numbness of the bilateral lower extremities. The examiner reported that physical examination of the bilateral lower extremities revealed normal muscle strength, and no motor function impairment. In an April 2011 VA primary care note, the provider reported the Veteran demonstrated radiculopathies due to his back pain. See also June 2016 VA podiatry consult. In a June 2011 evaluation associated with Social Security Administration records, the Veteran reported pain and discomfort in the lumbar region radiating to his legs, with the left lower extremity being most affected. On examination, the provider reported the Veteran demonstrated decreased sensation to pain, heat and vibration of the left lower extremity. Deep tendon reflexes were reported as symmetrical and normal. In a September 2012 VA primary care note, the provider reported the Veteran exacerbated his low back pain, and was positive for lumbar radiculopathy. See also April 2013 VA primary care note. In a February 2014 VA pain consult, the Veteran reported low back pain with electrical pain down the bilateral lower extremities. On physical examination, the provider reported the Veteran's muscle strength was 5/5, and sensory to pinprick, light touch, position sense, and vibration was unremarkable throughout. Imaging revealed L5-S1 disk degeneration with mild disk bulging. The provider's impression was lumbar radicular pain. See also August 2015 VA pain clinic note; see also November 2019 VA podiatry consult. The Veteran was afforded VA thoracolumbar spine examinations in September 2015, February 2018, March 2018, and April 2019. On all examinations, the examiners reported that the Veteran did not demonstrate muscle atrophy, muscle strength testing was 5/5, results for testing of deep tendon reflexes were reported as normal, and results for sensation to light tough testing were reported as normal. With the exception of the March 2018 VA thoracolumbar spine examination, all of the examiners reported that the Veteran did not have radicular pain or any other signs or symptoms due to radiculopathy, or any other neurologic abnormalities. The March 2018 VA thoracolumbar spine examination took a history from the Veteran, in which he reported back pain radiating to the bilateral lower extremities. Contrary to the other examinations, the March 2018 examiner reported the Veteran had radicular pain or other signs or symptoms due to radiculopathy. The examiner reported the Veteran demonstrated mild radiculopathy of the bilateral lower extremities (sciatic nerve). In considering the entire evidence of record, the Board resolves reasonable doubt in favor of the Veteran in finding that a separate 10 percent disability rating for radiculopathy of the right and the left lower extremity, respectively, is warranted for the entire period on appeal. In this regard, the Board places weight on the March 2018 VA thoracolumbar spine examination, which determined the Veteran demonstrated mild radiculopathy of the bilateral lower extremities (sciatic nerve). The examiner's determination was made based on the Veteran's reported history of symptoms of radiculopathy of the bilateral lower extremities, and is supported by VA treatment records documenting a diagnosis of lumbar radiculopathy and/or lumbar radicular pain. Under 38 C.F.R. § 4.124a , Diagnostic Code 8520, a 10 percent disability rating is warranted for mild incomplete paralysis of the sciatic nerve, 20 percent for moderate incomplete paralysis, 40 percent for moderately severe incomplete paralysis, 60 percent for incomplete paralysis that is severe with marked muscular atrophy, and a maximum 80 percent for complete paralysis of the sciatic nerve. The term "incomplete paralysis" indicates a degree of lost or impaired function substantially less than the type picture for complete paralysis given with each nerve, whether due to varied level of the nerve lesion or to partial regeneration. When the involvement is wholly sensory, the rating should be for the mild, or at most, the moderate degree. Words such as "mild," "moderate," and "severe" are not defined in the Rating Schedule. Rather than applying a mechanical formula, the Board must evaluate all of the evidence to the end that its decisions are "equitable and just." 38 C.F.R. § 4.6. In this case, although the Veteran has reported subjective signs and symptoms of radiculopathy of the bilateral lower extremities for the entire period on appeal, electrodiagnostic and other objective testing has not revealed evidence of peripheral neuropathy or lumbar radiculopathy. As indicated on the VA examinations and reported in VA treatment records, the Veteran has consistently demonstrated normal muscle strength, generally intact sensation to light touch of the bilateral lower extremities, normal results for testing of the deep tendon reflexes, and no evidence of muscle atrophy. Based on such evidence, the Board finds that the Veteran's subjective symptoms of radiculopathy of the bilateral lower extremities (sciatic nerve) are manifested by wholly sensory involvement, warranting a separate evaluation of 10 percent for the right and left lower extremity, respectively, but no higher. REASONS FOR REMAND Arthritis of the Bilateral Hands In his August 2007 application for entitlement to service connection for arthritis of the bilateral hands, the Veteran indicated the onset of his current disability was in service. In an April 4, 1979 service treatment record, the Veteran sought treatment for a cut or puncture wound to the palm of his right hand. The provider noted an incidental finding that the Veteran was unable to flex his little finger and had limited range of motion of the 4th and 5th digits with pain. In a follow up appointment on April 6, 1979, the provider indicated the injury was to the Veteran's left hand. However, in a May 2008 VA examination, the Veteran reported that he injured his right hand in 1979. On a May 1979 Report of Medical History, the Veteran reported a history of swollen or painful joints for which he had received treatment in service. In February 1980, the Veteran reported an injury to his left hand. The provider noted the Veteran had decreased sensation and tenderness of his left hand, swelling over the metacarpophalangeal joint, and decreased range of motion secondary to pain. The provider indicated an assessment of soft tissue injury of the left hand. A medical opinion was requested concerning the Veteran's claim for entitlement to service connection for arthritis of the left hand, but not the right hand, and the examiner considered only the February 1980 service treatment record pertaining to the Veteran's left hand. See November 2020 exam scheduling request. Given the Veteran's contentions and evidence of both a right and a left hand injury or disease in service, the Board finds remand is necessary to obtain a medical opinion addressing the nature and etiology of the Veteran's claim for entitlement to service connection for arthritis of the bilateral hands. See Harris v. Derwinski, 1 Vet. App. 180, 183 (1991) (holding that where a decision on one issue may have a "significant impact" upon another, the two claims are inextricably intertwined). Left Ankle Disability The Veteran contends that he has a current left ankle disability related to service. See April 2021 Appellate Brief. In September 2009 correspondence, Dr. N.A.O.V. indicated the Veteran's service-connected lumbar strain with degenerative changes and service-connected right ankle disability cause bad posture and weight bearing problems, which cause or aggravate the Veteran's claimed left ankle disability. See also April 2012 VA physical therapy assessment, and August 2013 podiatry consult; see also November 2017 Dr. C.W. physical therapy records. The Board finds such evidence raises the theory of entitlement to service connection for a left ankle disability as secondary to a service-connected disability or disabilities. The Board finds remand is necessary before an informed decision can be made, as to date, a medical opinion has not been obtained addressing this theory of secondary service connection. The matters are REMANDED for the following action: 1. Obtain a medical opinion assessing the nature and etiology of the Veteran's arthritis of the bilateral hands. Following a review of the record, the medical professional should opine as to whether it is at least as likely as not (50 percent or greater probability) that the Veteran's current diagnosis of arthritis of the bilateral hands had onset in or is otherwise related to his active service, to include the service treatment records documenting treatment for the Veteran's right hand in April 1979 and left hand in February 1980. The need for an examination is left to the discretion of the medical professional. A complete medical rationale for all opinions expressed must be provided. 2. Obtain a medical opinion assessing the nature and etiology of the Veteran's claimed left ankle disability. Following a review of the record, the medical professional should respond to the following: (a.) Identify any left ankle disability or disabilities existing for the period on appeal. The medical professional should note that even if no diagnosis can be rendered, a disability nevertheless exists for VA purposes if symptoms of pain manifest in functional impairment or loss. Saunders v. Wilkie, 886 F.3d 1356, 1368 (Fed. Cir. 2018). (b.) For any left ankle disability identified, is it at least as likely as not (50 percent or greater probability) that such had onset in or is otherwise related to the Veteran's military service? (c.) For any left ankle disability identified, is it at least as likely as not (50 percent or greater probability) that such was caused or aggravated by a service-connected disability or disabilities, to specifically include the Veteran's service-connected lumbar strain with degenerative changes and/or service-connected right ankle disability? The need for an examination is left to the discretion of the medical professional. A complete medical rationale for all opinions expressed must be provided. 3. Readjudicate the issues on appeal. If any of the benefits sought remain denied, issue the Veteran and his representative a supplemental statement of the case and inform the Veteran of his appeal options. V. Chiappetta Veterans Law Judge Board of Veterans' Appeals Attorney for the Board B. Mask, Associate Counsel The Board's decision in this case is binding only with respect to the instant matter decided. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.