Citation Nr: 21030905 Decision Date: 05/19/21 Archive Date: 05/19/21 DOCKET NO. 17-05 672 DATE: May 19, 2021 ORDER A disability rating in excess of 70 percent for generalized anxiety disorder, to include major depressive disorder is denied. A disability rating in excess of 20 percent for osteoarthritis, humero-ulnar joint with deformity status post ununited fracture of the left (minor) ulna (left ulnar joint disability) is denied. Prior to December 27, 2020, a disability rating in excess of 40 percent for status post left ulnar nerve transposition (left ulnar nerve disability) with limitation of elbow flexion is denied. Prior to December 27, 2020, a compensable disability rating for status post ulnar nerve transposition (left ulnar nerve disability) with limitation of elbow extension is denied. As of December 27, 2020, a disability rating of 60 percent, but no more, for status post left ulnar nerve transposition (left ulnar nerve disability), to include limitation of elbow flexion and extension, is granted. FINDINGS OF FACT 1. The severity, frequency, and duration of the Veteran's generalized anxiety disorder, to include major depressive disorder, did not more closely approximate total occupational and social impairment. 2. The Veteran's left ulnar joint disability did not manifest as loss of the left hand (bone fusion) through fixed supination or hyperpronation during the appeal period. 3. Prior to December 27, 2020, the Veteran's left ulnar nerve disability did not manifest as complete paralysis of the left ulnar nerve (Diagnostic Code 8516), and was rated as 40 percent disabling, which is the maximum schedular rating permitted for limitation of elbow extension (Diagnostic Code 5206), and did not manifest as limitation of elbow extension of 45 degrees or more (Diagnostic Code 5207). 4. As of December 27, 2020, the Veteran's left ulnar nerve disability manifested as incomplete severe disability of all radicular nerve groups of the left upper extremity (Diagnostic Code 8513), to include limitation of elbow flexion and extension. CONCLUSIONS OF LAW 1. The criteria for a disability rating in excess of 70 percent for generalized anxiety disorder, to include major depressive disorder, have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.126, 4.130, Diagnostic Code 9400. 2. The criteria for entitlement to an increased disability rating in excess of 20 percent for service-connected left ulnar joint disability have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.321, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5213. 3. Prior to December 27, 2020, the criteria for entitlement to an increased disability rating in excess of 40 percent for service-connected left ulnar nerve disability with limitation of elbow flexion have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.321, 4.14, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 8516, 5206. 4. Prior to December 27, 2020, the criteria for entitlement to a compensable disability rating for service-connected left ulnar nerve disability with limitation of elbow extension have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.321, 4.14, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 8516, 5207. 5. As of December 27, 2020, the criteria for entitlement to a disability rating of 60 percent, but no more, for left ulnar nerve disability manifested by nerve conditions of all radicular groups, to include limitation of elbow flexion and extension, have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.321, 4.14, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 8513. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the United States Navy from March 1981 until his honorable discharge in April 1982. This case comes before the Board of Veterans' Appeals (Board) on appeal from a March 2016 rating decision by the White River Junction, Vermont, Regional Office of the United States Department of Veterans Affairs (VA). In November 2019, the Veteran testified at a Board hearing before the undersigned Veterans Law Judge. In March 2020, the Board remanded the case to the VA Regional Office for further development. Specifically, the Board directed the VA Regional Office to obtain outstanding VA medical records and to obtain updated VA examinations addressing the Veteran's claimed disabilities, each of which the VA Regional Office accomplished. The case now returns to the Board. Evidentiary Standards In deciding claims, it is the Board's responsibility to evaluate the entire record on appeal. VA is required to give due consideration to all pertinent medical and lay evidence when rating disabilities. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, VA shall give the benefit of the doubt to the claimant. 38 C.F.R. § 4.3. To deny a claim on its merits, the preponderance of the evidence must be against the claim. See Alemany v. Brown, 9 Vet. App. 518, 519 (1996). A claim for an increased rating is a new, distinct claim. See Suttman v. Brown, 5 Vet. App. 127, 136 (1993) (a claim for an increase is "based upon facts different from the prior claim"). An increased disability rating is generally assigned based on a showing that a service-connected disability has worsened. The Board is to consider each disability in relation to the Veteran's medical history in determining the applicability of a higher rating for the entire period in which the appeal has been pending. Powell v. West, 13 Vet. App. 31, 34 (1999); 38 C.F.R. § 4.1. The Board must also determine if it is factually ascertainable that the disability worsened within one year preceding the filing of the claim for an increased rating. 38 U.S.C. § 5110(b)(2); 38 C.F.R. § 3.400(o)(2). Separate ratings can be assigned for separate periods of time based on the facts founda practice known as "staged" ratings. Fenderson v. West, 12 Vet. App. 119, 126 (1999). A staged rating is a rating that looks backwards and retroactively assigns specific ratings to discrete periods. See Reizenstein v. Shinseki, 583 F.3d 1331, 1337 (Fed. Cir. 2009). This practice accounts "for the possible dynamic nature of a disability while the claim works its way through the adjudication process." O'Connell v. Nicholson, 21 Vet. App. 89, 93 (2007); see also 38 C.F.R. § 4.1. The effective date for a staged rating is when it is factually ascertainable that a particular rating is warranted. Hart v. Mansfield, 21 Vet. App. 505, 509 (2007). In cases where staged ratings are appropriate, it is necessary to consider all "the evidence of record from the time of the veteran's application." Fenderson, 12 Vet. App. at 127. The law requires the Board address its reasons for rejecting evidence favorable to the Veteran. Timberlake v. Gober, 14 Vet. App. 122, 12829 (2000). The Board must review the entire record but does not have to discuss each piece of evidence. Gonzales v. West, 218 F.3d 1378, 1381 (Fed. Cir. 2000). The analysis below focuses on the most salient and relevant evidence within the period on appeal and on what this evidence shows, or fails to show, on the claims. Increased Ratings Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities found in 38 C.F.R. Part 4. The Schedule is primarily a guide in the evaluation of disability resulting from all types of diseases and injuries encountered as a result of or incident to military service. The ratings are intended to compensate, as far as can practicably be determined, the average impairment of earning capacity resulting from such diseases and injuries and their residual conditions in civilian occupations. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. Diagnostic codes (DC) are assigned to individual disabilities. Diagnostic codes provide rating criteria specific to a particular disability. If two diagnostic codes are applicable to the same disability, the diagnostic code that allows for the higher disability rating applies. 38 C.F.R. § 4.7. When a question arises as to which of two ratings apply under a particular diagnostic code, the higher evaluation is assigned if the disability more closely approximates the criteria for the higher rating. Id. 1. A disability rating in excess of 70 percent for generalized anxiety disorder, to include major depressive disorder. Rating Criteria Psychiatric Disabilities Under the General Formula for Mental Disorders, 38 C.F.R. § 4.130, the Board must conduct a "holistic analysis" that considers all associated symptoms, regardless of whether they are listed as criteria. Bankhead v. Shulkin, 29 Vet. App. 10, 22 (2017). The symptoms listed in the VA's general rating formula for mental disorders are not intended to constitute an exhaustive list, but rather serve as examples of the type and degree of the symptoms, or their effects, which would justify a particular rating. Mauerhan v. Principi, 16 Vet. App. 436 (2002). The Board must determine whether unlisted symptoms are similar in severity, frequency, and duration to the listed symptoms associated with specific disability percentages. Then, the Board must determine whether the associated symptoms, both listed and unlisted, caused the level of impairment required for a higher disability rating. Vazquez-Claudio v. Shinseki, 713 F.3d 112, 11418 (Fed. Cir. 2013). The Veteran's generalized anxiety disorder, to include major depressive disorder, is rated under 38 C.F.R. § 4.130, DC 9400, which provides, in pertinent part: Rating (%) Total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. 100 Occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a worklike setting); inability to establish and maintain effective relationships. 70 38 C.F.R. § 4.130, DC 9400 does provide for ratings lower than 70 percent. In this case, however, the Veteran has a disability rating of 70 percent. Thus, an analysis of the ratings lower than 70 percent is unwarranted, absent legal and factual bases to issue a reduction in the Veteran's current rating. See 38 C.F.R. § 3.344. Considerations in rating a mental disorder include the frequency, severity, and duration of psychiatric symptoms, the length of remissions, and the Veteran's capacity for adjustment during periods of remission. 38 C.F.R. § 4.126(a). The rating must be based on all evidence of record that bears on occupational and social impairment rather than solely on an examiner's assessment of the level of disability at the moment of the examination. Id. Although the extent of social impairment is a consideration in determining the level of disability, the rating may not be assigned solely on the basis of social impairment. 38 C.F.R. § 4.126(b). The United States Court of Appeals for the Federal Circuit held that evaluation under 38 C.F.R. § 4.130 is "symptom-driven," meaning that "symptomatology should be the fact-finder's primary focus when deciding entitlement to a given disability rating." Vazquez-Claudio, 713 F.3d at 11617. Analysis The Veteran electronic claims file contains a significant number of VA mental health treatment that is relevant to the analysis. The Board finds that it would be unduly burdensome to discuss each individual medical record. Instead, the Board finds it most sensible to address the relevant evidence by the year within this case. The Veteran filed his claim for an increased disability rating for his generalized anxiety disorder in January 2016. Thus, the Board will consider relevant evidence approximate to January 2015 with respect to his claim. 38 U.S.C. § 5110(b)(2); 38 C.F.R. § 3.400(o)(2). Beginning with a December 2014 VA psychiatry note, the Veteran reported experiencing nightmares three to four times a year and experiencing intrusive thoughts. He denied experiencing flashbacks, hypervigilance, or hyperarousal. At that time, he was working, which is significant because it indicates he was not "totally" impaired to the point that he was unable to maintain an occupation. Nevertheless, he experienced instances that reminded him of his military service, and he struggled with anxiety due to his work. Due to his service-connected left ulnar joint and nerve disabilities, he experienced negative feelings and thoughts. The VA psychiatrist who examined the Veteran in December 2014 did not record any abnormal behavior, indications of irregular speech/thought/cognition issues, or evidence of auditory/visual issues. Throughout 2015, the Veteran's symptomatology generally mirrored that in December 2014. He had near monthly VA psychiatry visits throughout 2015. He generally reported mood fluctuations, anxiety, relatively less than average sleep, four to five hours a night, low energy, concentration issues sometimes, ongoing low self-esteem, and worsening physical health. He denied any feelings of hopelessness, helplessness, and suicidal or homicidal ideations. He demonstrated sincere compassion for his family throughout his visits. He continued to work throughout 2015, but he still struggled with anxiety due to his work. His strengths included his familial support, housing, employment, therapeutic alliance, and medication compliance. There is no evidence of record that the Veteran demonstrated severe abnormal behavior, had indications of severe irregular speech/thought/cognition issues, or evidence of severe auditory/visual issues. Throughout 2016, the Veteran continued to have near monthly VA psychiatry visits. Significantly, the Veteran requested to retire early from his employment according to a February 2016 VA psychiatry note. This was due to his ongoing physical disabilities involving his service-connected left ulnar joint and nerve, which limited his ability to do physical work. It did not have to do with his psychiatric disabilities. Throughout the first part of 2016, he generally reported a better mood disposition but still suffered from anxiety and relatively less than average sleep. A March 2016 VA psychiatrist documented the Veteran experienced difficulty sustaining attention in tasks, he avoided tasks that required mental effort, he was easily distracted by extraneous stimuli, fidgeted with his feet, blurted out answers before a question had been completed, and often had difficulty waiting his turn. In March 2016, the Veteran appeared for a VA examination to address the severity of his psychiatric disability. The examiner opined that the Veteran's service-connected generalized anxiety disorder caused occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although generally functioning satisfactorily, with normal routine behavior, self-care and conversation. Notably, this is the criteria associated with a 30 percent disability rating. 38 C.F.R. § 4.130, DC 9400. He reported symptoms including daily anxiety, depression, less than average sleep, and trouble concentrating, focusing, and comprehending information. He denied any suicidal or homicidal ideations. The examiner recorded that the Veteran demonstrated no abnormal behavior, indications of irregular speech/thought/cognition issues, or evidence of auditory/visual issues. In June 2016, the Veteran began experiencing more problematic psychiatric symptoms. He reported increased depression, loss of sleep (sleeping only two to three hours a night), low energy, poor concentration, weight loss due to lack of appetite, and increased stress generally. He denied any suicidal or homicidal ideations. He continued to experience physical problems with his left arm. The psychiatrist documented circumstantial speech, but his speech was linear when redirected. Otherwise, there were no documented behavioral issues, to include visual, auditory, cognitive, or physical. For the rest of 2016, the Veteran's psychiatric symptoms mirrored those in June 2016. Of note is an October 2016 VA psychiatry note that recorded much of the Veteran's psychiatric anxiety was due to his own loss of ability to work and contribute to his family's well-being. This is important because it indicates the Veteran's occupational impairment primarily stemmed from his physical disability as previously discussed, not his psychiatric disability. There is no evidence of record that the Veteran demonstrated severe abnormal behavior, had indications of severe irregular speech/thought/cognition issues, or evidence of severe auditory/visual issues. Throughout 2017, the Veteran began biweekly psychology visits, which focused on coping mechanisms, to include mindfulness techniques. His psychiatric symptoms did not worsen as compared to past symptomatology, although he did express increased anxiety and depression at times, which his treating VA psychologists documented. But he also expressed absence of such symptoms on occasion. He routinely denied suicidal and homicidal ideations, demonstrating fair judgment and though processes. There is no evidence of record that the Veteran demonstrated severe abnormal behavior, had indications of severe irregular speech/thought/cognition issues, or evidence of severe auditory/visual issues throughout 2017. Throughout 2018, the Veteran's symptoms continued to mirror those in 2017. He reported increased sleep of five to six hours a night. He reported social anxiety about meeting new people but denied a specific phobia. He denied paranoid thoughts but reported occasional suspicious thoughts of landscapers and mechanics purposely not doing their best work. There is no evidence of record that the Veteran demonstrated severe abnormal behavior, had indications of severe irregular speech/thought/cognition issues, or evidence of severe auditory/visual issues throughout 2018. During the Veteran's November 2019 Board hearing, he reported experiencing communication issues. November 2019 Board Hearing Transcript, at 4. He testified that he "cut," which the board interprets as physical harm to himself. Id. He reported social isolation, yet he also testified he went out the prior weekend for dinner with another couple. Id. at 6. He testified experiencing panic attacks "once a week," then "a couple of times a month," then "sometimes more, sometimes less." Id. at 78. He testified to sleeping four to five hours a night. Id. at 8. The Veteran's VA mental health records from 2019 through the present, however, do not align with his testimony. In no VA medical record has the Veteran ever reported cutting himself and no VA medical professional has made any such observations. In addition, the 2019 treating VA mental health professionals did not document any reports of social isolation. Rather, the Veteran reported feeling less social than in recent years, which is different than the commonly understood meaning of "isolation." See May 2019 VA Psychiatry Outpatient Note. Even the Veteran's own testimony reflects he had social interactions, perhaps not frequently. Furthermore, the Board notes that a January 2020 VA psychology note recorded that the Veteran reported that he joined a gym and found it helped improve his fitness and social interactions. Finally, the Veteran's report of frequent panic attacks is partially at odds with his medical records. The Veteran denied experiencing panic attacks prior to his Board testimony. See, e.g., October 2018 VA Psychiatry Outpatient Note; September 2019 VA Psychiatry Outpatient Note. It appears the first time the Veteran reported panic attacks to a medical professional was during the March 2020 VA examination, as discussed later. He then mentioned experiencing a panic attack six weeks prior to an August 2020 VA psychiatry visit. Overall, the Board finds the Veteran's testimony is not entirely credible in light of the record as a whole, and other evidence of record is more probative. First, the Board finds the lack of "cutting" in any medical records, where such actions would be documented due to the serious nature of the assertion, is the most credible and probative evidence on the subject, thus indicating that cutting did not occur. See AZ v. Shinseki, 731 F.3d 1303 (Fed. Cir. 2013) (recognizing the widely held view that the absence of an entry in a record may be considered evidence that the fact did not occur if it appears that the fact would have been recorded if present). Second, the Veteran's general characterization that he was socially "isolated" is not the best characterization of his actual circumstances. The Board finds he had reduced social interactions, but he was not isolated; he continued to experience social and familial interactions. Finally, the Veteran's report of panic attacks is credible only to the extent that he had them "occasionally" (such as monthly as of March 2020) rather than weekly. The lack of medical documentation is the most credible and probative evidence on this subject because such frequent panic attacks, as described by the Veteran, would reasonably be reported by him to his treating medical professionals and documented in his medical records, just like all of his other reported symptoms, and they were not. See id. Otherwise there is no evidence of record that the Veteran demonstrated severe abnormal behavior, had indications of severe irregular speech/thought/cognition issues, or evidence of severe auditory/visual issues throughout 2019. From 2020 to the present, the Veteran's psychiatric symptomatology worsened. He generally reported continued anxiety, depression, decreased concentration, and sleep disturbances. In March 2020, the Veteran was provided with a VA examination to assess the severity of his psychiatric disability. The examiner opined that the Veteran's symptomatology represented occupational and social impairment with reduced reliability and productivity, which is consistent with the 50 percent rating criteria. 38 C.F.R. § 4.130, DC 9400. He reported his symptoms to include depression, anxiety, near continuous panic attacks, chronic sleep impairment, mild memory loss, flattened affect, mood issues, difficulty in establishing and maintain effective work and social relationships, difficulty in adapting to stressful circumstances, suicidal ideation, and neglect of appearance and hygiene. He reported social withdrawal and low motivation and energy. As to his occupational impairment, the examiner opined that his current symptoms rendered him a moderate-significant reliability risk and mild-moderate safety risk in the occupational environment. The examiner also recorded symptoms of poor concentration, anhedonia, irritability, somatic complaints, and low self-esteem. During an August 2020 VA psychiatry visit, he reported that he had panic attacks "occasionally," with the most recent being six weeks prior. He routinely denied any suicidal or homicidal ideations. He continued to experience physical problems with his left arm. He continued to demonstrate circumstantial speech, but his speech was linear when redirected. Otherwise, there were no documented severe behavioral issues, to include visual, auditory, cognitive, or physical. A November 2020 VA psychiatry note also documented similar symptoms but included a report of recent passive suicidal ideation and increased depression. In December 2020, he denied any suicidal or homicidal ideations. He also experienced marital tension at the end of 2020, resulting in him moving out for a brief period of time. Thus, there was a worsening of some symptoms toward the end of 2020. In 2021, the Veteran's symptoms became less severe. A March 2021 VA psychology note documented that the Veteran reported less anxiety, less pain, but martial tension continued to exist. He denied depression and suicidal and homicidal ideations at that time and he had moved back into the marital home. Throughout the appeal period, the Veteran has routinely had appropriate grooming practices, cooperative and pleasant behaviors, good judgment, clear speech, and normal thought processes. To the extent his speech had been circumstantial at moments, it has not affected his ability to work nor has it affected his social relationships. The same is true of isolated instances of increased anxiety and depression. While he endorsed isolated instances of passive suicidal ideations, these symptoms are properly encompassed within with 70 percent rating because there is a lack of evidence that they rendered him totally unable to work or unable form social relationships. The Veteran never endorsed delusions or hallucinations, never demonstrated grossly inappropriate behavior, did not exhibit intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene), disorientation to time or place, or memory loss for names of close relatives, own occupation, or own name. The Board finds the VA examiner's medical opinions (neither of which endorsed criteria consistent with a rating of 100 percent) are more probative as to the issue of occupational and social impairment due to the Veteran's psychiatric symptoms than the Veteran's lay testimony and beliefs. The Board finds that, based on the Veteran's entire symptomatology during the appeal period, there is a lack of evidence of deficiencies in functioning such that the Veteran's symptomatology most closely approximated total occupational and social impairment. In this regard, the Board notes that the 70 percent rating assigned is recognition of occupational and social impairment with deficiencies in most (not all) areas. In sum, the Board finds an absence of evidence that the Veteran's symptomatology most closely resembled total occupational and social impairment. 38 C.F.R. § 4.130, DC 9400 (100 percent rating criteria). 2. A disability rating in excess of 20 percent for osteoarthritis, humero-ulnar joint with deformity status post ununited fracture of the left (minor) ulna Rating Criteria Ulnar Joint The Veteran's osteoarthritis, humero-ulnar joint with deformity status post ununited fracture of the left (minor) ulna (ulnar joint disability) is currently rated at 20 percent disabling under 38 C.F.R. § 4.71a, DC 5213, based on limitation of pronation: motion lost beyond the middle of the arc. Diagnostic Code 5213 provides: Rating (%) Major Minor Supination and pronation, impairment of: Loss of (bone fusion): The hand fixed in supination or hyperpronation 40 30 The hand fixed in full pronation 30 20 The hand fixed near the middle of the arc or moderate pronation 20 20 Limitation of pronation: Motion lost beyond middle of arc 30 20 Motion lost beyond last quarter of arc, the hand does not approach full pronation 20 20 Limitation of supination: To 30° or less 10 10 Full forearm pronation is to 80 degrees. 38 C.F.R. § 4.71, Plate I. "Middle of arc" of pronation is 40 degrees. Full forearm supination is to 85 degrees. Id. The terms "major" and "minor" refer to a veteran's "dominant" and "non-dominant" side, respectively. See Yonek v. Shinseki, 722 F.3d 1355, 1357 (Fed. Cir. 2013); 38 C.F.R. § 4.69. In addition, when VA evaluates musculoskeletal disabilities under the Rating Schedule, it must determine whether or not the factors listed in 38 C.F.R. §§ 4.40, 4.45, and 4.59 are properly accounted for within the applicable diagnostic criteria. Under section 4.40, VA must consider whether there is evidence of functional loss due to pain on movement and diminished excursion, strength, speed, coordination, and endurance, to include during flare-ups or after repetitive use. 38 C.F.R. § 4.40; Mitchell v. Shinseki, 25 Vet. App. 32, 43 (2001). Pain on movement, standing alone, is not sufficient to warrant a higher rating under section 4.40. Id. (reaffirming that pain must affect some aspect of "the normal working movements of the body . . . in order to constitute functional loss"). Section 4.45 expands upon the concept of functional loss, noting six factors that VA must consider when evaluating a disability, namely: (1) less or (2) more movement than is normal; (3) weakened movement; (4) excess fatigability; (5) incoordination; and (6) pain on movement (as well as swelling, deformity, and atrophy) that affects stability, standing, and weight-bearing, to include during flare-ups or after repetitive use. 38 C.F.R. § 4.45. Noticeably, the aspects of functional loss listed in section 4.40 closely parallel the factors listed in section 4.45. Section 4.45 applies to muscles, nerves, as well as the entire musculoskeletal system. DeLuca v. Brown, 8 Vet. App. 202, 207 (1995). Under section 4.59, a veteran may be awarded the minimum compensable evaluation available under a given musculoskeletal diagnostic code, even if application of that code would not support a compensable evaluation, where there is evidence of "actually painful, unstable, or malaligned joints." 38 C.F.R. § 4.59; Petitti v. McDonald, 27 Vet. App. 415, 427 (2015). Section 4.59 does not require medical evidence; it may be satisfied with lay and other non-medical evidence. Id. at 428. Thus, pain alone is compensable under section 4.59 for joint disabilities in general. Burton v. Shinseki, 25 Vet. App. 1, 5 (2011). Analysis The Veteran has been afforded two VA examinations in connection with his January 2016 claim for an increased disability rating for his left ulnar joint disability. The Board observes the Veteran is right-hand dominant; thus, his disability rating is analyzed under the "minor" column listed above. In March 2016, a VA examiner documented the following ranges of motion as to the Veteran's left forearm/elbow: Flexion (0 to 145): 0 to 30 degrees Extension (145 to 0): 30 to 0 degrees Forearm supination (0 to 85): 0 to 45 degrees Forearm pronation (0 to 80): 0 to 45 degrees Pain was noted during each range of motion, but the examiner found that the pain did not result in additional functional loss. Following repetitive-use testing, no additional functional loss was observed. The examiner also opined that the Veteran's left ulnar joint disability displayed moderate pronation (20 percent rating criteria). The examiner recorded that the Veteran reported daily pain with increased flare-ups of pain four to five times per week. He reported pain and decreased range of motion. The examiner opined that the Veteran's ranges of motion were neither medically consistent nor inconsistent with the Veteran's statements as to flare-ups and following repetitive use over time. The examiner was unable to offer an estimated effect on the Veteran's ranges of motion in such circumstances because, according to the examiner, "[t]here is insufficient evidence or objective exam findings that would provide a reliable prediction of decreased functional ability[.]" "Based on the available evidence and exam findings, it is not possible, without resorting to speculation, to predict within a reasonable degree of medical certainty, a potential loss of range of motion manifested as a consequence of a flare or exacerbation [or repetitive use over a period of time] outside the clinical setting." Examiners may, at times, express reluctance to opine on a matter for fear of speculating. In those situations, it is true that the Board must not accept the opinion if "it is not clear whether the examiner lacks the expertise to render such an opinion, or whether some additional testing or information is needed." Jones v. Shinseki, 23 Vet. App. 382, 390 (2010). Here, after the examiner "obtained and considered all relevant and available information," he nevertheless was "unable to furnish the requested opinion." Id. Such a finding "is a medical conclusion just as much as a firm diagnosis or a conclusive opinion," and an examiner is not required "to render an opinion beyond what may reasonably be concluded from the procurable medical evidence." Id. at 39091. The Veteran's VA medical records indicate his left elbow flexion was 40 degrees, with lessened muscle strength, and his left forearm pronation was 60 degrees on June 13, 2018. On July 11, 2018, his left elbow flexion was 44 degrees with lessened muscle strength, and his left forearm pronation was 60 degrees. On July 18, 2018, his left elbow flexion was 15 degrees, with lessened muscle strength, and his left forearm pronation was 60 degrees. His left elbow extension was within normal functional limits during each testing. VA obtained a December 2020 examination from a VA-contracted examiner who documented the following ranges of motion as to the Veteran's left forearm/elbow: Flexion (0 to 145): 0 to 30 degrees Extension (145 to 0): 30 to 0 degrees Forearm supination (0 to 85): 0 to 25 degrees Forearm pronation (0 to 80): 0 to 20 degrees Pain was noted during each range of motion, and the examiner found that the pain resulted in functional loss. Following repetitive-use testing, no additional functional loss was observed. The examiner recorded that the Veteran reported flare-ups, which he described as follows: "it grinds even more, feels like someone is squeezing, twisting and grabbing my arm, pain shoots up from a 10 out of 10 to a 20 in matter of seconds." The examiner opined that the Veteran's ranges of motion were medically consistent with his statements describing functional loss with repetitive use over time and during flare-ups. As such, the examiner opined that Veteran did not suffer additional loss of ranges of motion during such events. Absent evidence to the contrary, the Board finds the above-mentioned medical professionals were competent to exam the Veteran and offer their respective medical opinions. Cox, 20 Vet. App. at 569. The Board finds the medical professionals' respective examinations, medical findings, and medical opinions are credible and probative. The medical professionals conducted thorough examinations, relied on accurate facts, considered the Veteran's relevant medical records, medical history, and lay statements, and provided well-reasoned medical judgments. Applying the rating criteria of DC 5213, the only available rating higher than 20 percent for the Veteran's ulnar joint disability (his non-dominant hand, i.e., "minor") is a 30 percent rating. To be entitled to that rating the evidence must demonstrate his left hand is fixed in supination or hyperpronation due to his ulnar joint disability. The VA examinations and medical records each indicate that that the Veteran has some range of motion as to supination and pronation, to include during flare-ups and after repetitive use over time. The Board has also reviewed the Veteran's other medical records associated with his file. There is no evidence that his left hand was fixed in supination or hyperpronation during the appeal period. The Board also finds that the factors found within sections 4.40, 4.45, and 4.59 are appropriately accounted for within the 20 percent disability rating criteria under DC 5213. Accordingly, the weight of the evidence is against awarding the Veteran a higher disability rating for his ulnar joint disability under DC 5213. The Board has considered whether any other diagnostic code is appliable to the Veteran's ulnar joint disability during the appeal period. First, no evidence of record indicates, or reasonably suggests, the Veteran had ankylosis of the elbow, or the functional equivalent of ankylosis. Therefore, DC 5205, which deals with elbow ankylosis, is not applicable. Second, the Veteran has not exhibited forearm/elbow flexion limited to 100 degrees and extension to 45 degrees during the appeal period, thus making DC 5208 inapplicable (both limitations must be present). Third, there is no evidence of record that the Veteran exhibited impairment of the flail joint (DC 5209), nonunion of the radius and ulna with flail false joint (DC 5210), or impairment of the radius (DC 5212). Previously the Veteran's ulnar joint disability was rated under DC 5211 ("impairment of ulna"). In 2014, the VA Regional Office applied DC 5213 instead because it more closely resembled the Veteran's disability. The Board agrees with the VA Regional Office and finds that DC 5211 is no longer the appropriate diagnostic code under which to rate the Veteran's ulnar joint disability as it does not exhibit nonunion in the upper half with false movement. The Board has also considered whether the Veteran is entitled to a separate rating under DC 5003 or DC 5010 (arthritis) for his left ulnar joint osteoarthritis. The Board finds his ostearthritis, manifested by pain and limited elbow flexion and extension, is already properly accounted for within his disability rating for his left ulnar nerve disability (discussed later). His left ulnar nerve disability rating is based on his limited elbow flexion and extension (and accompanying symptomatology), which compensates him for limitation of motion. And arthritis under DC 5003 or DC 5010 is rated on the basis of limitation of movement. To grant a separate arthritis rating would result in duplicate compensation for limitation of motion, which is prohibited. See 38 C.F.R. § 4.14. Finally, the Board recognizes that DC 5206 (limitation of forearm flexion) and DC 5207 (limitation of forearm extension), individually, are applicable in this instance. But for reasons that will be discussed later, to award the Veteran a disability rating under these diagnostic codes would constitute impermissible pyramiding because these symptoms are accounted for within the Veteran's rating for his left ulnar nerve disability. See 38 C.F.R. § 4.14. The Board finds no other diagnostic code is appliable to the Veteran's ulnar joint disability or accompanying symptomatology, not otherwise accounted for. 3. Prior to December 27, 2020, a disability rating in excess of 40 percent for status post left ulnar nerve transposition with limitation of elbow flexion 4. Prior to December 27, 2020, a compensable disability rating for status post ulnar nerve transposition with limitation of elbow extension As the facts and analyses for issues #3 and #4 overlap, the Board will address them together. Rating Criteria Ulnar Nerve The Veteran is service connected for status post left ulnar nerve transposition (ulnar nerve disability). The VA Regional Office has rated his ulnar nerve disability on two separate symptoms: (1) limited flexion of the forearm/elbow and (2) limited extension of the forearm/elbow. 38 C.F.R. § 4.124a, DCs 8516-5206, 8156-5207. A hyphenated diagnostic code is used when a rating under one code requires use of an additional code to identify the basis for the rating assigned. The additional code is shown after the hyphen. The hyphenated diagnostic code in this case indicates that the ulnar nerve disability, DC 8516, is the service-connected disability, and the residual condition to which the ulnar nerve disability is rated by analogy is limitation of flexion and extension of the forearm/elbow, DCs 5206 and 5207. 38 C.F.R. §§ 4.124a, 4.71a. Diagnostic Code 8516 is found under the rating group "Diseases of the Peripheral Nerves." Diagnostic Code 8516 ("The ulnar nerve") provides: Rating (%) Major Minor Paralysis of: Complete; the "griffin claw" deformity, due to flexor contraction of ring and little fingers, atrophy very marked in dorsal interspace and thenar and hypothenar eminences; loss of extension of ring and little fingers cannot spread the fingers (or reverse), cannot adduct the thumb; flexion of wrist weakened 60 50 Incomplete: Severe 40 30 Moderate 30 20 Mild 10 10 The terms "major" and "minor" refer to a veteran's "dominant" and "non-dominant" side, respectively. See Yonek, 722 F.3d at 1357; 38 C.F.R. § 4.69. 38 C.F.R. § 4.124a defines the phrase "incomplete paralysis," with respect to peripheral nerves, as indicating "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." Furthermore, section 4.124a states that "when the involvement is wholly sensory, the rating should be for the mild, or at most, the moderate degree." Diagnostic Code 8516 does not define the terms "mild," "moderate," or "severe," nor does it associate them with specific symptoms. This lack of objective criteria for differentiating between the specified severity levels means the Board must analyze the criteria in the context of all available, relevant evidence. See 38 C.F.R. § 4.6. Normally, the Board would seek to define the terms "mild," "moderate," and "severe" at this point, but doing so for this analysis is unnecessary. Notably, the highest possible rating for the Veteran's left (minor) ulnar nerve disability, absent complete paralysis, is 30 percent. The Veteran, however, is rated at 40 percent disabled under DC 5206. As will be explained below, the Veteran does not have complete paralysis of his left ulnar nerve for the appeal period. Thus, he is not able to receive a 50 percent rating under DC 8516. Diagnostic Code 5206 provides: Rating (%) Major Minor Forearm, limitation of flexion of: Flexion limited to 45° 50 40 Flexion limited to 55° 40 30 Flexion limited to 70° 30 20 Flexion limited to 90° 20 20 Flexion limited to 100° 10 10 Flexion limited to 110° 0 0 Diagnostic Code 5207 provides: Rating (%) Major Minor Forearm, limitation of extension of: Extension limited to 110° 50 40 Extension limited to 100° 40 30 Extension limited to 90° 30 20 Extension limited to 75° 20 20 Extension limited to 60° 10 10 Extension limited to 45° 0 0 The Board must also consider whether the factor found within 38 C.F.R. §§ 4.40 and 4.45 are accounted for within the rating criteria for the Veteran's ulnar nerve disability. Analysis Prior to December 27, 2020, the Veteran's left ulnar nerve disability caused limited elbow flexion and extension, as previously discussed above, in addition to general functional loss of his left arm. Importantly, the Veteran has been assigned the maximum disability rating for his limited flexion, 40 percent, under DC 5206. He has been assigned a non-compensable rating for his limited extension under DC 5207. First, the Board finds the Veteran is not entitled to 50 percent disability rating under DC 8516 because his left ulnar nerve disability did not manifest as complete paralysis during the appeal period. None of the Veteran's treating medical professionals, nor the examiners, have medically concluded that the Veteran suffered from complete paralysis of the left ulnar nerve prior to December 27, 2020. Nor does the lay evidence of record indicate, or reasonably suggest, complete paralysis. He retained movement of his forearm/elbow in both flexion and extension, although limited. He likewise retained limited movement in his forearm/hand in both pronation and supination. While limited, he also was able to use his left arm/elbow to function in daily life. Complete paralysis under DC 8516 has defined criteria, none of which the Veteran has exhibited. His left ulnar nerve disability has not manifested as a "griffin claw deformity" because of "flexor contraction of ring and little fingers, atrophy very marked in dorsal interspace and thenar and hypothenar eminences; loss of extension of ring and little fingers," inability to spread the fingers (or reverse), inability to adduct the thumb, and weakened flexion of the wrist. 38 C.F.R. § 4.124a, DC 8516. His VA medical examinations documented muscle strength in the left arm as 4 out 5 (5 out of 5 being normal), and his VA medical records in 2018 also documented reduced muscle strength, but not absence of muscle strength. No treating or examining medical professional documented left forearm/elbow atrophy. The Board acknowledges the Veteran's symptoms are significant, and the Board finds his reports of his symptoms credible and probative. For example, the Veteran has consistently reported a feeling of tingling, coldness, and numbness radiating from his left arm to his fingers. He has consistently reported associated pain and weakness. He has credibly reported how his ulnar nerve disability affected his daily activities, from having trouble picking up a coffee cup to being unable to type and being unable to sleep. All of these symptoms are important, but they do not rise to the level of "complete" paralysis under DC 8516. As to the Veteran's current 40 percent disability rating under DC 5206, that is the highest disability rating possible. And as to his noncompensable rating under DC 5207, the Veteran's left elbow extension has never manifested as limited to more than 45 degrees. The Board has considered whether a higher rating is warranted under DC 5207 based on the factors found within sections 4.40 and 4.45 but finds they are properly encompassed by his 40 percent disability rating under DC 5206 for the appeal period. As there is no evidence indicating, or reasonably suggesting, that the Veteran's pain, weakness, fatiguability, and/or incoordination on extension are separate and distinct from his same symptoms on flexion, then to count them twice would be impermissible pyramiding. 38 C.F.R. § 4.14. VA regulation 38 C.F.R. § 4.14 prohibits duplicate compensation for the same manifestation (i.e., symptom) of disability under different diagnoses, known as "pyramiding." See generally Boggs v. Peake, 520 F.3d 1330, 1337 (Fed. Cir. 2008) ("[A] veteran cannot be compensated more than once for the same disability."). "[T]he key consideration in determining whether rating under more than one diagnostic code is in order is whether the ratings under different diagnostic code would be based on the same manifestation of disability or whether none of the symptomatology upon which the separate ratings would be based is duplicative or overlapping." VAOPGCPREC 9-2004. VA General Counsel precedential opinions are binding on the Board. 38 U.S.C. § 7104(c); 38 C.F.R. § 14.507. As the Veteran's limited elbow flexion and extension are each symptoms of his ulnar nerve disability, he is not entitled to a separate rating for the factors cited in sections 4.40 and 4.45 twice, that being under DC 5206 and DC 5207. Nor is the Veteran entitled to a separate rating for limitation of elbow flexion and extension under his ulnar joint disability. This would constitute pyramiding because it would be compensating the Veteran twice for the same symptoms (even though the nerve symptoms might also be related to his ulnar joint disability); they are not separate and distinct. By rating the Veteran's limited elbow flexion in connection with his ulnar nerve disability under DC 8516-5206, the RO provided the Veteran a higher rating than he would have otherwise been afforded solely under DC 8516. In sum, prior to December 27, 2020, the Veteran's ulnar nerve disability did not manifest as complete paralysis, nor did his associated symptomatology of limited elbow flexion and extension warrant a higher disability rating than assigned. 5. As of December 27, 2020, a disability rating of 60 percent, but no more, for status post left ulnar nerve transposition with limitation of flexion and extension On December 27, 2020, a VA-contracted examiner evaluated the severity of the Veteran's service-connected left ulnar nerve disability. To note, prior to that examination, the Veteran's treating and examining medical professionals had only identified a nerve condition involving the left ulnar nerve in relation to the Veteran's service-connected disability. The December 2020 examiner concluded that the Veteran's disability had progressed, now encompassing incomplete moderate paralysis of his left radial, median, ulnar, musculocutaneous, circumflex, long thoracic, upper radicular group (5th & 6th cervical), middle radicular group, and lower radicular group of nerves. Given this finding, the Board concludes that DC 8513 ("all radicular groups") is the most appropriate diagnostic code under which to rate these multiple affected nerves. Rating Criteria All Radicular Groups Diagnostic Code 8513, entitled "All radicular groups," provides: Rating (%) Major Minor Paralysis of: Complete 90 80 Incomplete: Severe 70 60 Moderate 40 30 Mild 20 20 Noticeably different from DC 8516 is the higher rating assignments. This is due to the regulation taking into consideration multiple affected nerves rather than, for example, only one or two affected nerves. In this case, all of the Veteran's left upper extremity nerves are affected, which warrants application of DC 8513 over DC 8516 or other individual diagnostic codes. Moreover, the medical evidence of record does not indicate that it is possible to attribute certain symptoms to certain nerves, further making application of DC 8513 the most logical choice. The previous definitions under 38 C.F.R. § 4.124a still apply, as discussed above. As mentioned, the regulations do not define "mild," "moderate," or "severe." VA has provided procedural and analytical guidance when assessing levels of incomplete paralysis under these criteria, which the Board finds persuasive and applicable to this case. See Gray v. Sec'y of Veterans Affairs, 875 F.3d 1102, 1108 (Fed. Cir. 2017); Overton v. Wilkie, 30 Vet. App. 257, 264 (2018). VA's guidance is as follows: Mild As this is the lowest level of evaluation for each nerve, this is the default assigned based on the symptoms, however slight, as long as they were sufficient to support a diagnosis of the peripheral nerve impairment for service-connection purposes. In general look for a disability limited to sensory deficits that are lower graded, less persistent, or affecting a small area. A very minimal reflex or motor abnormality potentially could also be consistent with mild incomplete paralysis. Moderate Moderate is the maximum evaluation reserved for the most significant cases of sensory-only impairment. Symptoms will likely be described by the claimants and medically graded as significantly disabling. In such cases a larger area in the nerve distribution may be affected by sensory symptoms. Other sign/symptom combinations that may fall into the moderate category include combinations of significant sensory changes and reflex or motor changes of a lower degree, or motor and/or reflex impairment such as weakness or diminished or hyperactive reflexes (with or without sensory impairment) graded as medically moderate. Severe In general, expect motor and/or reflex impairment (for example, atrophy, weakness, or diminished or hyperactive reflexes) at a grade reflecting a very high level of limitation or disability. Trophic changes may be seen in severe longstanding neuropathy cases. Even though severe incomplete paralysis cases should show findings substantially less than representative findings for complete impairment of the nerve, the disability picture for severe incomplete paralysis may contain signs/symptoms resembling some of those expected in cases of complete paralysis of the nerve. "Complete paralysis" is also not defined by VA regulations, and there is no VA procedural guidance. Absent an express definition, it is presumed that VA regulations employ words using their ordinary dictionary meanings at the time the regulations were promulgated. See Nielson v. Shinseki, 607 F.3d 802, 80506 (Fed. Cir. 2010). Thus, the Board turns to the generally understood definition of "complete." As an adjective in this instance, "complete" means "total, absolute." Complete, Merriam-Webster Dictionary Online, https://www.merriam-webster.com/dictionary/complete, definition 2.a. (last visited May 6, 2021). "Paralysis is the loss of muscle function in part of your body." Paralysis, MedlinePlus Medical Encyclopedia, U.S. National Library of Medicine, https://medlineplus.gov/paralysis (last visited May 6, 2021). Accordingly, "complete paralysis" is the total or absolute loss of the muscle function. Using the above definitions as guidance, the Board must arrive at an equitable and just decision based on an evaluation of all relevant evidence. 38 C.F.R. §§ 4.2, 4.6. It should also be noted that use of terminology such as "mild, moderate, or severe" by VA examiners or other physicians, although an element of evidence to be considered by the Board, is not dispositive of an issue. In addition, objective and subject evidence are each appropriate to consider under DC 8513. Cf. English v. Wilkie, 30 Vet. App. 347, 353 (2018); Petitti v. McDonald, 27 Vet. App. 415, 424 (2015). The Board must also consider whether the factor found within 38 C.F.R. §§ 4.40 and 4.45 are accounted for within the rating criteria for the Veteran's left ulnar nerve disability. Analysis The Board observes that the Veteran is currently rated 40 percent disabled for his left ulnar nerve disability. There are only two ratings under DC 8513 greater than 40 percent: 80 percent for complete paralysis and 60 percent for incomplete severe paralysis. The Board finds the Veteran is entitled to a disability rating of 60 percent as of December 27, 2020, for incomplete severe paralysis of his left ulnar nerve disability, to include limited elbow flexion and extension, and no higher. The most credible and probative evidence of record is the December 27, 2020 VA-contracted examination. Although the examiner indicated the Veteran's nerve conditions were "moderate" in severity, the Board finds the Veteran's associated symptoms more closely reflect "severe" incomplete paralysis. First, during the examination, the Veteran reported "constant pain up and down" his left arm and hand, painful range of motion, constant sensations of burning, tingling, and numbness in his left arm and hand. His left hand felt cold "all the time." Due to his left arm and hand pain, he is unable to sleep restfully. He is unable to accomplish buttoning or zipping items with his left arm, so he wears sweatpants. If he stands or sits for prolonged periods, his left hand feels numb, with sharp sensations. He is required to wear a brace on his left arm constantly. The examiner recorded, based on the Veteran's statements, that he suffered from "severe" left upper extremity symptoms of pain, paresthesias and/or dysesthesias, and numbness. The Board agrees with the examiner, the Veteran's described symptoms are severe, and the Board finds the Veteran's descriptions of his symptoms credible and highly probative. The examiner recorded that the Veteran did exhibit lessened muscle strength during left elbow and wrist flexion and extension, left grip testing, and left pinch (thumb to index finger) testing. He recorded a 4 out of 5 rating for each, indicating "active movement against some resistance." The examiner also documented decreased sensation to light touch on the left inner/outer forearm (C6/T1) and hand/finger (C68). These lessened muscle movements and decreased sensations to touch, although relatively mild, are still probative to the Veteran's overall disability picture. As previously discussed, the Veteran's left forearm/elbow are limited in flexion, and the Board finds his flexion is severely limited. This conclusion is supported by the fact that the Veteran meets the highest rating criteria for limited elbow flexion under DC 5206. He also exhibits mild limited elbow extension, which is not compensable under DC 5207 as discussed. The Veteran's use of a left arm brace constantly is indicative of a more serious disability, as compared to using a brace on occasion or sparingly. Finally, and significantly, the examiner provided an opinion about the extent to which the Veteran's left nerve disability influenced his daily functioning, stating, There would be significant limitation in the types of jobs the veteran is able to perform due to pain, limited range of motion, numbness, soreness and discomfort. Numbness can prevent the veteran from safely lifting objects of varying sizes. For example, in his most recent employment, veteran reported he was unable to pick up objects using hands and instead, used a walking stick/trash picker to pick up light weighted objects from the ground. Cold temperatures can aggravate pain and numbness further. There is decreased ability to utilize both upper extremities increasing the workload of the functional extremity and increasing risk of overuse injuries. There is limited ability to safely perform activities that require full range of motion, strength and sensation. Pain may also interfere with concentration and increase risk of injury-this would impair the performance of both physical and sedentary type of jobs. Additionally, veteran would need to take frequent breaks to re-position[.] The Board finds Veteran's left forearm/elbow nerve disability is severe. He is limited in flexion and extension due to his symptoms, he has reduced muscle strength, decreased sensations to touch, and has significant functional limitation in his daily activities, to include his social and occupation impairment. Accordingly, the Veteran is entitled to a 60 percent disability rating under DC 8513 as of December 27, 2020, for his left forearm/elbow nerve disability, as it now encompasses all radicular upper left extremity nerve groups. The Board has also considered the factors stated in 38 C.F.R. §§ 4.40 and 4.45 and finds they are appropriately captured by the 60 percent disability rating under DC 8513. The Veteran's disability does not more closely resemble complete paralysis of the left forearm/elbow. Notably, he maintains the ability to function, but at a lessened degree. The December 2020 examiner did not document muscle atrophy, ankylosis, reduced reflexes, or trophic changes in the Veteran's left forearm/elbow. As discussed, he still maintained relatively good muscle strength, some flexion, and a large degree of extension. The Veteran's medical records around December 2020, and thereafter, do not indicate, or reasonably suggest, symptoms associated with complete paralysis. The Veteran continued to have functional ability associated with his left arm. Accordingly, the Board concludes that the Veteran's left forearm/elbow nerve disability did not manifest as complete paralysis as of December 27, 2020, as he did not have total or absolute loss of function. Therefore, a higher disability rating is not warranted. As a final note, the Board has considered the Veteran's limited elbow flexion and extension when rating his left forearm/elbow nerve disability under DC 5813. As that symptomatology is due to the Veteran's left forearm/elbow nerve disability, the Veteran is no longer entitled to a separate disability rating under DC 5026 (limited elbow flexion) or DC 5207 (limited elbow extension) because there is no separate and distinct limitation of flexion or extension apart from his left forearm/elbow nerve disability. Thus, his limitation of elbow flexion and extension are encompassed in his increased disability rating under DC 8513. To award him separate disability ratings for those symptoms would be impermissible pyramiding. 38 C.F.R. § 4.14. Finally, the Board finds no other diagnostic code applicable to the Veteran's left forearm/elbow nerve disability as of December 27, 2020, because there is no indication, or reasonably suggestion, that any of his symptoms are separate and distinct apart from his left forearm/elbow nerve disability. In sum, the Board finds the Veteran is entitled to a disability rating of 60 percent as of December 27, 2020, under DC 8513 for incomplete severe paralysis of all radicular nerve groups of his left forearm/elbow nerve disability, to include limited elbow flexion and extension, and no higher. M. Tenner Veterans Law Judge Board of Veterans' Appeals Attorney for the Board J. F. Sawka, 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.