Citation Nr: 21031712 Decision Date: 05/24/21 Archive Date: 05/24/21 DOCKET NO. 09-39 010 DATE: May 24, 2021 ORDER Entitlement to a rating of 40 percent, and not higher, for the period from December 31, 2007, for degenerative disc disease of lumbar spine disability is granted. Entitlement to a rating in excess of 40 percent for the period since November 12, 2010 for degenerative disc disease of lumbar spine disability is denied. Entitlement to a rating of 20 percent, and not higher, for the period prior to February 11, 2014, for right lower extremity (RLE) neuralgia parenthetical is granted. Entitlement to a rating in excess of 20 percent for the period since February 11, 2014 for RLE neuralgia parenthetical is denied. Entitlement to a separate compensable rating for the period prior to November 12, 2010, and thereafter, an initial rating in excess of 10 percent for left lower extremity (LLE) sciatic nerve disability is denied. Entitlement to a separate rating of 10 percent for RLE femoral nerve disability for the period from November 12, 2010, and not earlier, is granted. Entitlement to a separate rating of 10 percent for LLE femoral nerve disability for the period from November 12, 2010, and not earlier, is granted. Entitlement to a rating in excess of 10 percent for the period prior to December 15, 2020, and thereafter, in excess of 20 percent for RLE femoral nerve disability is denied. Entitlement to a rating in excess of 10 percent for the period prior to December 15, 2020, and thereafter, in excess of 20 percent for LLE femoral nerve disability is denied. REMANDED Entitlement to service connection for diabetes mellitus, to include as secondary to service-connected disabilities is remanded. Entitlement to service connection for high cholesterol to include as secondary to service-connected disabilities is remanded. Entitlement to service connection for erectile dysfunction, to include as secondary to service-connected disabilities is remanded. FINDINGS OF FACT 1. For the period from December 31, 2007, the Veteran's lumbar spine disability was manifested by pain and functional loss that more closely approximated limitation of flexion to 30 degrees. 2. At no point during the pendency of the appeal has the Veteran's lumbar spine disability been productive of functional impairment comparable to unfavorable ankyloses of the entire thoracolumbar spine or resulted incapacitating episodes totally at least six weeks. 3. Prior to February 11, 2014, the RLE neuralgia parenthetical disability more closely approximated moderate incomplete paralysis of the sciatic nerve. 4. At no point during the pendency of the appeal has the Veteran's RLE neuralgia parenthetical disability been manifested by more than moderate incomplete paralysis of the sciatic nerve. 5. Throughout the appeal period, the Veteran's LLE sciatic nerve disability has been manifested, at most, by mild incomplete paralysis of the sciatic nerve. 6. As of November 12, 2010, the Veteran's RLE radiculopathy associated with his lumbar spine disability has included mild femoral nerve involvement. 7. As of November 12, 2010, the Veteran's LLE radiculopathy associated with his lumbar spine disability has included mild femoral nerve involvement 8. Prior to December 15, 2020, the Veteran's RLE femoral nerve disability has been manifested, at most, by mild incomplete paralysis of the femoral nerve. 9. Prior to December 15, 2020, the Veteran's LLE femoral nerve disability has been manifested, at most, by mild incomplete paralysis of the femoral nerve. 10. Since December 15, 2020, the Veteran's RLE femoral nerve disability has been manifested by no more than moderate incomplete paralysis of the femoral nerve. 11. Since December 15, 2020, the Veteran's LLE femoral nerve disability has been manifested by no more than moderate incomplete paralysis of the femoral nerve. CONCLUSIONS OF LAW 1. The criteria for entitlement to a rating of 40 percent, and not higher, for the period from December 31, 2007 for a lumbar spine disability have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.7, 4.20, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5242. 2. The criteria for entitlement to a rating in excess of 40 percent for the period since November 12, 2010 for lumbar spine disability have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.7, 4.20, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5242. 3. The criteria for entitlement to a rating of 20 percent, and not higher, for the period prior to February 11, 2014, RLE neuralgia parenthetical have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.321, 4.1-4.3, 4.7, 4.124a, Diagnostic Code 8520. 4. The criteria for entitlement to a rating in excess of 20 percent for the period since February 11, 2014 for RLE parenthetical have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.321, 4.1-4.3, 4.7, 4.124a, Diagnostic Code 8520. 5. The criteria for entitlement to a separate compensable rating for the period prior to November 12, 2010, and thereafter an initial rating in excess of 10 percent for LLE sciatic nerve disability have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.321, 4.1-4.3, 4.7, 4.124a, Diagnostic Code 8520. 6. The criteria for entitlement to a separate rating of 10 percent for RLE femoral nerve disability for the period from November 12, 2010 have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.321, 4.1-4.3, 4.7, 4.124a, Diagnostic Code 8526. 7. The criteria for entitlement to a separate rating of 10 percent for LLE femoral nerve disability for the period from November 12, 2010 have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.321, 4.1-4.3, 4.7, 4.124a, Diagnostic Code 8526. 8. The criteria for entitlement to a rating in excess of 10 percent for the period prior to December 15, 2020, and thereafter, in excess of 20 percent for RLE femoral nerve disability have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.321, 4.1-4.3, 4.7, 4.124a, Diagnostic Code 8526. 9. The criteria for entitlement to a rating in excess of 10 percent for the period prior to December 15, 2020, and thereafter, in excess of 20 percent for LLE femoral nerve disability have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.321, 4.1-4.3, 4.7, 4.124a, Diagnostic Code 8526. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from December 1976 to November 1993 in the United States Marine Corps, to include active duty service in the Gulf War Era. These matters come before the Board of Veterans' Appeals (Board) on appeal from a rating decision by a Department of Veterans Affairs (VA) Regional Office (RO). In June 2017 and October 2020, the Board remanded these issues for additional development. Increased Ratings Disability evaluations are determined by the application of VA's Schedule for Rating Disabilities, which is based on average impairment of earning capacity resulting from a service-connected disability. 38 U.S.C. § 1155; 38 C.F.R. Part 4. Where there is a question as to which of two ratings shall be applied, the higher rating 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. After careful consideration of the evidence, any reasonable doubt remaining is resolved in favor of the Veteran. 38 C.F.R. § 4.3. 1. Entitlement to increase rating for lumbar spine disability The Veteran seeks higher evaluation for his lumbar spine disability for the entire period under appeal. He contends that his disability is manifested by more severe symptomatology than contemplated by the current assigned staged ratings. See Appellate Brief (April 2021). The Veteran reports that he has severe low back pain, which is worst in the morning, and gradually improves with movement and pain medications. He reports flare-ups of low back pain occur in the morning upon waking and can render him unable to get out of bed without altering his bodily mechanics, where he sometimes needs to crawl across floor and climb up wall in order to raise to feet. He describes back muscle spasms which cause his back to freeze up. The Veteran reports that his lumbar spine disability causes him functional impairment where he is unable to bend down to tie his shows, perform heavy lifting, squat, and run, and he has difficulty with getting in and out of vehicles, and prolonged walking and standing. Prior to his retirement, the Veteran reported that he missed days of work due to low back pain. See Correspondence (April 2008) and (February 2011), Hearing Testimony (Decision Review Office) (October 2010), VA examination (November 2010), and C&P Exam (February 2014). The Veteran filed a claim for an increased rating that was received by VA in December 2007. The Veteran's lumbar spine degenerative joint disease disability is currently rated as 20 percent disabling prior to November 12, 2010, and thereafter, rated as 40 percent disabling under the General Rating Formula for Diseases and Injuries of the Spine (General Rating Formula). See 38 C.F.R. § 4.71a, Diagnostic Codes 5235-5243. Based on the evidence of record, the Board concludes that a rating of 40 percent under The General Rating Formula for lumbar spine disability is warranted for the entire period under appeal. However, at no point does the evidence of record support the assignment of a rating in excess of 40 percent for lumbar spine disability. The General Rating Formula encompasses such disabling symptoms as pain, ankylosis, limitation of motion, muscle spasms, and tenderness. See 38 C.F.R. § 4.71a, Diagnostic Codes 5235-5243. The General Rating Formula provides for a 20 percent rating is warranted where there is forward flexion of the thoracolumbar spine greater than 30 degrees, but not greater than 60 degrees; the combined range of motion of the thoracolumbar spine is not greater than 120 degrees; or there is muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour, such as scoliosis, reversed lordosis, or abnormal kyphosis. A 40 percent rating is warranted where there is forward flexion of the thoracolumbar spine is 30 degrees or less, or favorable ankylosis of the entire thoracolumbar spine. A 50 percent rating is available for unfavorable ankylosis of the entire thoracolumbar spine. A 100 percent rating is available for unfavorable ankylosis of the entire spine. For VA compensation purposes, normal forward flexion of the thoracolumbar spine is zero to 90 degrees, extension is zero to 30 degrees, left and right lateral flexion are zero to 30 degrees, and left and right lateral rotation are zero to 30 degrees. The combined range of motion refers to the sum of the range of forward flexion, extension, left and right lateral flexion, and left and right rotation. The normal combined range of motion of the thoracolumbar spine is 240 degrees. The normal ROMs for each component of spinal motion provided in this note are the maximum that can be used for calculation of the combined range of motion. 38 C.F.R. § 4.71a, Diagnostic Codes 5235-5243, Note (2); see also Plate V. Effective from February 7, 2020, VA made non-substantive edits to the parenthetical of Diagnostic Code 5242 so that it now includes degenerative disc disease (other than intervertebral disc syndrome). VA also made clarifying changes to Diagnostic Code 5243 so that it is only assigned when there is disc herniation with compression and/or irritation of the adjacent nerve root and provides that all other disc diagnoses are evaluated under Diagnostic Code 5242. See 85 Federal Register, 76453, 76462 (November 30, 2020). Unfavorable ankylosis is defined as "a condition in which the entire cervical spine, the entire thoracolumbar spine, or the entire spine is fixed in flexion or extension, and the ankylosis results in one or more of the following: difficulty walking because of a limited line of vision; restricted opening of the mouth and chewing; breathing limited to diaphragmatic respiration; gastrointestinal symptoms due to pressure of the costal margin on the abdomen; dyspnea or dysphagia; atlantoaxial or cervical subluxation or dislocation; or neurologic symptoms due to nerve root stretching." Id. at Note 5. Additionally, fixation of a spinal segment in neutral position (zero degrees) is "always" considered favorable ankylosis. Id. When evaluating musculoskeletal disabilities based on limitation of motion, 38 C.F.R. § 4.40 requires consideration of functional loss caused by pain or other factors listed in that section that could occur during flare-ups or after repeated use and, therefore, not be reflected on range-of-motion testing. 38 C.F.R. § 4.45 requires consideration also be given to less movement than normal, more movement than normal, weakened movement, excess fatigability, incoordination, and pain on movement. See DeLuca v. Brown, 8 Vet. App. 202 (1995); see also Mitchell v. Shinseki, 25 Vet. App. 32, 44 (2011). Nonetheless, even when the background factors listed in § 4.40 or 4.45 are relevant when evaluating a disability, the rating is assigned based on the extent to which motion is limited, pursuant to 38 C.F.R. § 4.71a; a separate or higher rating under § 4.40 or 4.45 itself is not appropriate. See Thompson v. McDonald, 815 F.3d 781, 785 (Fed. Cir. 2016) ("[I]t is clear that the guidance of § 4.40 is intended to be used in understanding the nature of the veteran's disability, after which a rating is determined based on the § 4.71a criteria."). Under 38 C.F.R. § 4.59, painful motion is a factor to be considered with any form of arthritis; however, 38 C.F.R. § 4.59 is not limited to disabilities involving arthritis. See Burton v. Shinseki, 25 Vet. App. 1 (2011). Based on the foregoing evidence, the Board finds that a 40 percent rating under the General Rating Criteria for the lumbar spine disability is warranted for the entire period under appeal; however, the preponderance of the evidence is against a rating in excess of 40 percent at any point. See 38 C.F.R. § 4.71a, Diagnostic Code 5235-5243. Throughout the pendency of the appeal, the Veteran has described functional loss due to constant chronic low back pain, decreased range of motion, difficulty with prolonged standing and sitting, and increased pain during flare-ups and after repetitive use. He has consistently reported that he has difficulty getting into and out of vehicles, and he is unable to bend down to tie his shoes due to low back pain. When considering the Veteran's lay reports of symptoms and noted functional loss, the degree of additional limitation reflected by the statements would result in limitation of motion that more nearly approximates forward flexion limited to 30 degrees or less prior to November 12, 2010. See 38 C.F.R. §§ 4.40, 4.45, and DeLuca, 8 Vet. App. at 204 -07. Accordingly, a rating of 40 percent for lumbar spine disability is warranted for the entire period under appeal. See 38 C.F.R. § 4.71a, Diagnostic Code 5235-5243. Moreover, the findings from a November 12, 2010 VA back examination report showed the Veteran had limitation of forward flexion to 5 degrees when pain begins, which supports the assignment of the current 40 percent rating under the General Rating Criteria. See 38 C.F.R. § 4.71a, Diagnostic Code 5235-5243. The Board has considered the findings from a May 2008 VA examination report which reflect range of motion with forward flexion greater than 30 degrees. However, this VA examination report is inadequate, and cannot be used for adjudication purposes in this case. First, the May 2008 VA examination report does not comply with the United States Court of Appeals for the Veterans' Court (Court) holding in Correia v. McDonald, 28 Vet. App. 158 (2016) and Sharp v. Shulkin, 29 Vet. App. 26, 33 (2017) in that the VA examiner failed to provide the necessary information with regard to active/passive motion, weight/non-weight bearing, and flare ups. Second, the Veteran asserts, and the Board agrees, that May 2008 VA examiner failed consider the impact the pain medication that he was taking on the range of motion results. See Correspondence (October 2010). The Court has held that in assigning a disability rating, VA may not consider the ameliorative effects of medication where such effects are not explicitly contemplated by the rating criteria. See Jones v. Shinseki, 26 Vet. App. 56 (2012). In this case, VA treatment records reflect that the Veteran had been prescribed narcotic pain medication to treat his low back pain since September 2007, and during the VA examination, he informed the VA examiner that he was presently taking that pain medication up to four times a day. The findings in the examination do not reflect consideration of the ameliorative effects of his pain medications on the measured ranges of motion or other manifestations during clinical examination. Based on the foregoing, the Board finds that the May 2008 VA examination report is inadequate, and the range of motion results cannot be considered in this appeal. Based on a review of the claims folder, the Board finds that a rating greater than 40 percent is not warranted under the General Rating Formula at any point during the pendency of the appeal. In this regard, the medical evidence of record shows that the Veteran at worst had limitation of forward flexion to 5 degrees, limitation of extension to 10 degrees, and combined range of motion limited to 45 degrees due to pain after repeated use overtime. None of the VA examiners nor VA treating physicians have observed clinical evidence of unfavorable ankylosis of the spine. See C&P Exam (February 2014), (November 2019), and (December 2020). The Veteran's level of restricted motion, albeit significant, is not tantamount to or indicative of ankylosis either favorable or unfavorable. Ankylosis is stiffening or fixation of the joint as the result of a disease process, with fibrous or bony union across the joint. Dinsay v. Brown, 9 Vet. App. 79, 81 (1996) citing Dorland's Illustrated Medical Dictionary at 86 (27th ed. 1988). Ankylosis is "immobility and consolidation of a joint due to disease, injury, or surgical procedure." See Coyalong v. West, 12 Vet. App. 524, 528 (1999); Lewis v. Derwinski, 3 Vet. App. 259 (1992) [citing Saunders Encyclopedia and Dictionary of Medicine, Nursing, and Allied Health at 68 (4th ed. 1987)]. The Board has also considered the Veteran's reported flare-ups, to include muscle spasms where it feels like his lumbar spine freezes or locks up; however, such flare-ups of symptomatology does not indicate a level of disability comparable to ankylosis. Pertinently, the Veteran has consistently reported that he is able to treat his flare-ups with heat, rest and pain medication, and they do not result in a long-term reduction of motion equivalent to that of ankylosis. Moreover, no medical provider has determined that the Veteran's lumbar spine disability is the functional equivalent of ankylosis, even during periods of flare-ups. In the December 2020 VA medical opinion report the VA examiner concluded that based on findings from the previous clinical evaluations, there was no evidence suggesting the Veteran has the functional equivalent of ankylosis due to flare-ups. The VA examiner noted that the 2019 VA examination report did not contain range of motion results for repeated use overtime or during flare-ups, despite acknowledging presence of functional loss. However, the December 2020 VA examiner noted that there was no additional functional loss after repetitive use testing. The VA examiner conclude that based on the findings from the previous clinical examination, the Veteran would likely experience additional loss of motion of 5 to 10 degrees from baseline across all planes due to flare-ups. Though limiting, this does not constitute functional ankylosis. While the Veteran has significant limitation of motion of lumbar spine, he retains some measure of motion, so this segment of his spine is not fixated, therefore not ankylosed either favorably or unfavorably. Consequently, no greater than a 40 percent rating is warranted. See 38 C.F.R. § 4.71a, General Rating Formula for Diseases and Injuries of the Spine. Consideration has also been given to assigning a rating under the Formula for Rating Intervertebral Disc Syndrome (IVDS) Based on Incapacitating Episodes. The IVDS Rating Formula provides that a maximum 60 percent rating is available when the condition is manifested by incapacitating episodes having a total duration of at least six weeks, during the past 12 months. See 38 C.F.R. § 4.71a, Diagnostic Code 5243. Here, none of the VA examiners found that the Veteran had IVDS. See VA examination (May 2008), (November 2010), and C&P Exam (February 2014) and (November 2019). The Board acknowledges a February 2011 private treatment record shows that the Veteran was prescribed bedrest of a few days following an exacerbation of his low back pain. See Medical Treatment Record - Non-Government Facility (February 2011). However, at no point does the evidence of record show that the Veteran was ever prescribed bed rest by a physician for a duration of six weeks or more that meets the criteria for a 60 percent rating. See 38 C.F.R. § 4.71a, Formula for Rating IVDS based on Incapacitating Episodes. The Board has also considered whether the Veteran is entitled to a separate rating for associated neurologic conditions. Notably, the Veteran has already been granted service connection for neurologic impairment in the right and left lower extremities, which are addressed below. There is no other neurologic impairment that has been associated with the Veteran's lumbar spine disability to support the assignment of another separation compensable rating. For the foregoing reasons, the Board finds that a rating of 40 percent for lumbar spine disability is warranted for the entire period under appeal. However, the preponderance of the evidence is against assignment of a rating in excess of 40 percent for lumbar spine disability. Thus, the benefit of the doubt doctrine is not for application and the Veteran's claim for increased rating must be denied. 38 U.S.C. § 5107 (b); 38 C.F.R. § 4.3. Finally, neither the Veteran nor his representative has raised any other issues, nor have any other issues been reasonably raised by the record. See Doucette v. Shulkin, 28 Vet. App. 366, 371 (2017). The Board has already considered and awarded TDIU based on the severity of the Veteran's service-connected disabilities. See BVA Decision (June 2017). 2. Entitlement to increased rating for RLE neuralgia parenthetical disability 3. Entitlement to increased rating for LLE sciatic nerve disability The Veteran seeks higher ratings for his disabilities due to sciatic nerve impairment in both of his lower extremities. He contends that his disabilities are more severe than contemplated by the current assigned ratings. See Appellate Brief (April 2021). The Veteran reports that he experiences pain, numbness, and weakness in both of his lower extremities. The Veteran reported that he occasionally drags his right foot, and he has difficulty raising his right leg when ambulating. See Correspondence (April 2008). During the pendency of the appeal, the Veteran has described functional impairment due to difficulty with ambulation, prolonged standing, walking, and sitting because of his bilateral lower extremity disabilities. See VA examination (December 2011), C&P Exam (February 2014), November 2019), and (December 2020). The Veteran's bilateral lower extremity radiculopathy of the sciatic nerve has been rated pursuant to 38 C.F.R. § 4.124a, Diagnostic Code 8520. He is currently assigned a 10 percent rating prior to February 11, 2014, and thereafter, a 20 percent rating for right lower extremity neuralgia parenthetical of the sciatic nerve disability, and assigned a 10 percent rating, effective from November 12, 2010, for left lower extremity sciatic nerve disability. His bilateral lower extremity radiculopathy of the femoral nerve has been rated pursuant to 38 C.F.R. § 4.124a, Diagnostic Code 8526. He is currently assigned 10 percent ratings prior to December 15, 2020, and thereafter 20 percent ratings for each leg based on femoral nerve disabilities. The Board concludes that the evidence of record supports the assignment of a 20 percent rating, but no higher, for RLE neuralgia parenthetical disability for the entire pendency of the appeal. However, the Board finds that the evidence does not support the assigment of a separate compensable rating prior to November 12, 2010, or thereafter, a rating in excess of 10 percent rating for LLE sciatic nerve disability. The Board also concludes that separate compensable 10 percent ratings for RLE and LLE femoral nerve disabilities from November 12, 2010, and not earlier, are warranted. However, the evidence does not support the assignment of ratings in excess of 10 percent prior to December 15, 2020, and thereafter in excess of 20 percent ratings for each leg based on femoral nerve disabilities. Under Diagnostic Code 8520, for paralysis of the sciatic nerve, moderate incomplete paralysis warrants a 20 percent disability evaluation; moderately severe incomplete paralysis warrants a 40 percent evaluation; and, severe, with marked muscular atrophy, incomplete paralysis warrants a 60 percent disability evaluation. An 80 percent evaluation is warranted for complete paralysis where the foot dangles and drops, with no active movement possible of muscles below the knee, with flexion of knee weakened or (very rarely) lost. 38 C.F.R. § 4.124a, Diagnostic Code 8520. Under Diagnostic Code 8526, for paralysis of the femoral nerve, moderate incomplete paralysis warrants a 20 percent disability evaluation and severe incomplete paralysis warrants a 30 percent evaluation. A 40 percent evaluation is warranted for complete paralysis of the quadriceps extensor muscles. 38 C.F.R. § 4.124a, Diagnostic Code 8526. The words "mild," "moderate," and "severe" as used in the various Diagnostic Codes are not defined in the Rating Schedule. Regulations provide that ratings for peripheral neurological disorders are to be assigned based the relative impairment of motor function, trophic changes, or sensory disturbance. 38 C.F.R. § 4.120. Consideration is also given for loss of reflexes, pain, and muscle atrophy. See 38 C.F.R. §§ 4.123, 4.124. 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 is for the mild, or at most, the moderate degree. The disability ratings for the peripheral nerves are for unilateral involvement; when bilateral, the ratings combine with application of the bilateral factor. 38 C.F.R. § 4.124a, Note at "Diseases of the Peripheral Nerves." The Note to 38 C.F.R. § 4.124a establishes a maximum disability rating for conditions that are wholly sensory, as opposed to a minimum disability rating for conditions that are more than wholly sensory. See Miller v. Shulkin, 28 Vet. App. 376 (2017). The maximum rating which may be assigned for neuritis not characterized by organic changes will be moderately severe incomplete paralysis for sciatic nerve involvement. See 38 C.F.R. § 4.123. Turning first to the Veteran's RLE neuralgia parenthetical disability, the Board notes that the Veteran's claim for increased rating arises from an April 16, 2008 correspondence in which he asserted that the neurologic impairment in his RLE had worsened. He described difficulty with ambulation due to difficulty raising his right leg which occasionally caused his foot to drag and to stub his toes. See Correspondence (April 2008). The medical evidence prior to February 11, 2014 shows that the Veteran's RLE neuralgia parenthetical disability was manifested by complaints of mild pain, numbness, and weakness, with objective evidence of decreased sensation, some trophic changes below the ankles, and mild incomplete paralysis of the right sciatic nerve. See VA examination (May 2008), (November 2010) and (December 2011). In considering the Veteran's reported functional impairment with ambulation due to right leg weakness and numbness along with the objective findings from the clinical evaluations, the Board finds that the Veteran's neurologic impairment in his RLE more closely approximates moderate incomplete paralysis of the sciatic nerve prior to February 11, 2014. As such, a higher rating of 20 percent prior to February 11, 2014 for RLE neuralgia parenthetical disability is warranted. See 38 C.F.R. § 4.124a, Diagnostic Code 8526. At no point does the evidence does support a rating in excess of 20 percent for RLE neuralgia parenthetical disability based on impairment of the sciatic nerve. In this regard, the record does not reflect that the Veteran's radiculopathy of the RLE sciatic nerve has resulted in more than moderate impairment. The Veteran has complained of, at most, moderate constant pain, moderate intermittent pain, mild paresthesias and dysesthesias, and moderate numbness, and he has been assessed with no more than moderate incomplete paralysis of the right sciatic nerve. See C&P Exam (February 2014), (November 2019), and (December 2020) Although his sciatic nerve impairment has been determined to impact his ability to ambulate without difficulty, he consistently had normal muscle strength, muscle tone, and reflexes in his right leg. Essentially, no more than moderate pathology has been shown, and the evidence of record does not more closely approximate the symptomatology required for severe incomplete paralysis or complete paralysis of the sciatic nerve since February 11, 2014. As such, a rating in excess of 20 percent for RLE neuralgia parenthetical disability since February 11, 2014 is not warranted. See 38 C.F.R. § 4.124a, Diagnostic Code 8520. With respect to the Veteran's LLE sciatic nerve disability, the Board finds that a separate compensable rating prior to November 12, 2010 and a rating in excess of 10 percent from November 21, 2010 are not warranted. Although the Veteran described numbness and weakness involving both his lower extremities prior to November 2010, the May 2008 VA examination report shows the VA examiner only found clinical evidence to support a diagnosis of radiculopathy in the right leg, and not the left leg. See VA examination (May 2008). The first objective evidence of radiculopathy in the LLE comes from the November 12, 2010 VA examination. In the absence of a clinical diagnosis and objective findings, a separate compensable rating is not warranted prior to November 12, 2010 for LLE sciatic nerve disability. See 38 C.F.R. § 4.124a, Diagnostic Code 8520. The findings from the November 12, 2010 VA examination show the Veteran complained of radiating pain, numbness, paresthesia, weakness, and unsteadiness, and with objective evidence of decreased sensation but normal reflexes and muscle strength in the lower extremity, which supported the current assignment of a separate 10 percent rating. See 38 C.F.R. § 4.124a, Diagnostic Code 8520. The Board finds that ratings in excess of 10 percent for LLE sciatic nerve disability is not warranted. The medical evidence of record reflects that the Veteran's LLE sciatic nerve is primarily manifested by complaints mild constant pain, moderate intermittent pain, mild paresthesia, dysesthesias, and numbness, with decreased sensation, some trophic changes below the ankles, and mild incomplete paralysis of the left sciatic nerve. See VA examination (November 2010) and (December 2011), and C&P Exam (February 2014), (November 2019), and (December 2020). Essentially, no more than mild pathology has been shown, and the evidence of record does not more closely approximate the symptomatology required for moderate incomplete paralysis or worse of the sciatic nerve. The Board finds that the level of impairment associated with the Veteran's LLE radiculopathy is most analogous to mild incomplete paralysis of the left sciatic nerve. The Board finds that the currently assigned 10 percent rating for LLE sciatic nerve disability is appropriate. As such, a rating in excess of 10 percent for LLE sciatic nerve disability is not warranted. See 38 C.F.R. § 4.124a, Diagnostic Code 8520. The Board notes the December 2011 and February 2014 VA peripheral nerve examinations reflect that the Veteran has multiple types of RLE and LLE radiculopathies, including external popliteal (common peroneal), musculocutaneous (superficial peroneal), anterior tibial (deep peroneal), internal popliteal (tibial), posterior tibial, internal saphenous, external cutaneous, and ilio-inguinal nerves of the left and right lower extremities. However, the separate ratings for right and left lower radiculopathy based on sciatic and femoral nerve impairments already encompass the other nerves separately identified/described. A claimant may not be compensated twice for the same symptomatology as "such a result would overcompensate the claimant for the actual impairment of his earning capacity." Brady v. Brown, 4 Vet. App. 203, 206 (1993) (interpreting 38 U.S.C. § 1155). Separate ratings for each nerve would violate the prohibition against pyramiding in 38 C.F.R. § 4.14. The Board has considered all other potentially applicable Diagnostic Codes, but there is no evidence showing the Veteran has neurological impairment associated with any other peripheral nerves that have not already been service-connected. Therefore, a separate or higher rating under a different Diagnostic Code is not warranted. In conclusion, the Board finds that a rating of 20 percent, and not higher, prior to February 11, 2014 for RLE neuralgia parenthetical disability is warranted. However, the Board finds that the preponderance of the evidence is against the Veteran's claims for a rating in excess of 20 percent rating for RLE neuralgia parenthetical disability at any point. In addition, the Board finds that the preponderance of the evidence is against the assignment of a separate compensable rating prior to November 12, 2010, or thereafter, a rating in excess of 10 percent rating for LLE sciatic nerve disability. 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. 4. Entitlement to increased rating for RLE femoral nerve disability 5. Entitlement to increased rating for LLE femoral nerve disability The Veteran seeks higher ratings for his disabilities due to femoral nerve impairment in both of his lower extremities. He contends that his disabilities are more severe than contemplated by the current assigned ratings. See Appellate Brief (April 2021). The Veteran reports that he experiences pain, numbness, and weakness in both of his lower extremities. During the pendency of the appeal, the Veteran has described functional impairment due to difficulty with ambulation, prolonged standing, walking, and sitting because of his bilateral lower extremity disabilities. See VA examination (November 2010) and (December 2011), C&P Exam (February 2014), November 2019), and (December 2020). The Veteran's bilateral lower extremity radiculopathy of the femoral nerve has been rated pursuant to 38 C.F.R. § 4.124a, Diagnostic Code 8526. He is currently assigned 10 percent ratings prior to December 15, 2020, and thereafter 20 percent ratings for each leg based on femoral nerve disabilities. The Board concludes that separate compensable 10 percent ratings for RLE and LLE femoral nerve disabilities from November 12, 2010, and not earlier, are warranted. However, the evidence does not support the assignment of ratings in excess of 10 percent prior to December 15, 2020, and thereafter in excess of 20 percent ratings for each leg based on femoral nerve disabilities. Under Diagnostic Code 8526, for paralysis of the femoral nerve, moderate incomplete paralysis warrants a 20 percent disability evaluation and severe incomplete paralysis warrants a 30 percent evaluation. A 40 percent evaluation is warranted for complete paralysis of the quadriceps extensor muscles. 38 C.F.R. § 4.124a, Diagnostic Code 8526. First, the Board finds that separate compensable ratings under Diagnostic Code 8526 for femoral nerve impairment as of November 12, 2010 for each leg are warranted. In this regard, the findings from the November 12, 2010 VA examination report shows evidence of bilateral femoral nerve involvement manifested by decreased sensation, which supports the assignment of 10 percent ratings for RLE femoral nerve disability and LLE femoral nerve disability as of the date of that VA examination. See 38 C.F.R. § 4.124a, Diagnostic Code 8526. Although prior to the date of this examination, the Veteran complained of similar symptoms of numbness and weakness involving both his lower extremities, the May 2008 VA examiner does not reflect evidence of femoral nerve radiculopathy in either leg. The first objective evidence of femoral nerve impairment in both lower extremities comes from the November 12, 2010 VA examination. See VA examination (May 2008) and (November 2010). In the absence of a clinical diagnosis and objective findings, separate compensable ratings are not warranted prior to November 12, 2010. See 38 C.F.R. § 4.124a, Diagnostic Code 8526. Next, the Board finds that ratings in excess of 10 percent each lower extremity femoral nerve disability prior to December 15, 2020 are not warranted. Here, the medical evidence of record reflects that the Veteran's RLE and LLE femoral nerve disabilities are primarily manifested by moderate intermittent to constant pain, moderate paresthesias, moderate numbness, some decreased sensation the lower extremities, some trophic changes below the ankles, and mild incomplete paralysis of the right and left femoral nerves. See VA examination (May 2008), (November 2010) and (December 2011), and C&P Exam (February 2014) and (November 2019). Essentially, no more than mild pathology has been shown, and the competent evidence does not more closely approximate the symptomatology required for moderate incomplete paralysis of the femoral nerve prior December 15, 2020. The Board finds that the level of impairment associated with the Veteran's RLE and LLE femoral nerve disabilities are most analogous to mild incomplete paralysis of the right femoral nerve and mild incomplete paralysis of the left femoral nerve. The Board finds that the currently assigned 10 percent ratings for each lower extremity femoral nerve disability is appropriate. As such, ratings in excess of 10 percent for RLE femoral nerve disability and LLE femoral nerve disability prior to December 15, 2020 are not warranted. See 38 C.F.R. § 4.124a, Diagnostic Code 8526. The findings from the December 15, 2020 VA peripheral nerve examination report show the Veteran complained of pain, numbness, and paresthesia, with evidence of absent sensation and moderate incomplete paralysis of the femoral nerve, which supported the current assignment of 20 percent rating for each leg. See 38 C.F.R. § 4.124a, Diagnostic Code 8526. However, the evidence does not support a higher rating for RLE and LLE femoral nerve involvement. In this regard, the record does not reflect that the Veteran's radiculopathy of the femoral nerve in either leg has resulted in more than moderate impairment since December 15, 2020. The Veteran had normal muscle strength, muscle tone, and reflexes in each leg, and his difficulty with ambulation has already been considered by the rating assigned for his RLE neuralgia parenthetical disability. Essentially, no more than moderate pathology has been shown, and the evidence of record does not more closely approximate the symptomatology required for severe incomplete paralysis or complete paralysis of the femoral nerve at any point during the pendency of the appeal. As such, ratings in excess of 20 percent for RLE and LLE femoral nerve disabilities since December 15, 2020 are not warranted. See 38 C.F.R. § 4.124a, Diagnostic Code 8526. The Board has considered all other potentially applicable Diagnostic Codes, but there is no evidence showing the Veteran has neurological impairment associated with any other peripheral nerves that have not already been service-connected. Therefore, a separate or higher rating under a different Diagnostic Code is not warranted. In conclusion, the Board finds that separate compensable 10 percent ratings for RLE and LLE femoral nerve disabilities from November 12, 2010, and not earlier, are warranted. However, the Board finds that the preponderance of the evidence is against the Veteran's claims for ratings in excess of 10 percent prior to December 15, 2020, and thereafter in excess of 20 percent ratings for each leg based on femoral nerve disabilities. 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. REASONS FOR REMAND The Board finds that more development is necessary prior to final adjudication of the claims remaining on appeal. In remanding these matters, the Board makes no finding, implicit or otherwise, as to the credibility of the Veteran's assertions. Neither the Veteran's credibility nor any lack thereof should be presumed in this remand. The Veteran seeks entitlement to service connection for diabetes mellitus. He contends that he developed diabetes mellitus as a result of his service-connected disabilities. In particular, the Veteran believes that his diabetes mellitus is secondary to his PTSD disability. He reports that after he was diagnosed with PTSD, his treating VA medical providers informed him that he had elevated blood sugar levels which later progressed to a diagnosis of diabetes mellitus. He contends that his PTSD disability affected his blood sugar level and ultimately lead to the development of his diabetes mellitus. See Correspondence (September 2011). In support of his claim, the Veteran has submitted internet articles that state studies have shown that individuals with PTSD are more likely to have diabetes. It was noted that unhealthy behaviors associated with PTSD (poor eating habits) may place a person at risk for developing diabetes mellitus. See Third Party Correspondence (Geisinger Healthcare Professionals, Co-Morbidities with PTSD) (September 2011). Another internet article purporting the association between PTSD and diabetes stated that researchers have observed that individuals with PTSD weigh more, had higher body mass index (BMI), and poor glycemic control. See Third Party Correspondence (About.com Post Traumatic Stress (PTSD), Health Problems among People with PTSD and Diabetes) (September 2011). A remand by the Board imposes upon the Secretary of VA a concomitant duty to ensure compliance with the terms of the remand. Where remand orders of the Board are not complied with, the Board errs in failing to ensure compliance. Stegall v. West, 11 Vet. App. 268 (1998). The Board previously remanded the claim in October 2020 for a VA medical opinion to address whether the Veteran's diabetes mellitus was proximately due to, the result of, or aggravated by a service-connected disability. See BVA Decision (October 2020). In various February 2021 VA medical reports, the same VA examiner concluded that the Veteran's diabetes mellitus was less likely than not proximately due to, the result of, or aggravated by the Veteran's service-connected disabilities. The VA examiner noted that obesity was one of the primary factors contributing to the development of diabetes mellitus. The VA examiner further noted that the Veteran's obesity was result of him consuming more calories than his body burns, which was a choice and not a result of a service-connected disability. See C&P Exam (February 2021). However, the VA examiner did not provide an adequate discussion on why the Veteran's PTSD disability did not cause his obesity and result in the development of his diabetes mellitus. In this regard, no explanation was provided regarding whether the Veteran's overeating was associated with his PTSD disability and resulted in his obesity. VA's Office of General Counsel has held that obesity may be an intermediate step between a service-connected disability and a current disability that may be connected on a secondary basis. See VAOPGCPREC 1-2017. In order to meet such criteria, the evidence must show that a previously service-connected disability caused a veteran to become obese; that obesity was a substantial factor in causing the secondary disability; and the secondary disability would not have occurred but for the obesity. Id. Given the above, the Board may not fully rely on the February 2021 VA medical opinion concerning whether the Veteran's diabetes mellitus is secondary to his PTSD disability in its present form. Therefore, the Board finds that remand is necessary for a VA medical opinion to discuss whether the Veteran's diabetes mellitus is secondary to obesity related to his service-connected PTSD disability. Accordingly, as the Board has a duty to ensure compliance with the terms of its remand, remand is again required. See Stegall, 11 Vet. App. 268. The Veteran seeks entitlement to service connection for high cholesterol and erectile dysfunction as secondary to his diabetes mellitus. See Military Personnel Record (internet article submitted by the Veteran) (September 2011). Since a decision on the remanded issue of entitlement to service connection for diabetes mellitus could significantly impact a decision on the issues of entitlement to service connection for high cholesterol and erectile dysfucntion, the issues are inextricably intertwined. See Henderson v. West, 12 Vet. App. 11 (1998), citing Harris v. Derwinski, 1 Vet. App. 180 (1991), for the proposition that where a decision on one issue would have a "significant impact" upon another, and that impact in turn could render any review of the decision on the other claim meaningless and a waste of appellate resources, the claims are inextricably intertwined. The matters are REMANDED for the following action: 1. The RO should take appropriate steps to confirm the Veteran's address, to include contacting the representative. Thereafter, the Veteran should be requested to provide the names, addresses and approximate dates of treatment of all medical care providers, VA and non-VA, who have treated her for the disabilities on appeal. After the Veteran has signed the appropriate releases, those records should be obtained and associated with the claims folder. 2. Obtain an addendum VA medical opinion for the Veteran's diabetes mellitus. The clinician must review the claims file. Based on review of the record, to include medical and lay evidence, the clinician is asked to address the following: (a.) Is it at least as likely as not that the Veteran's diabetes mellitus is proximately due to, a result of, or aggravated by, service-connected PTSD? (b.) Is it at least as likely as not that the Veteran's service-connected PTSD caused the Veteran to become obese? (c.) Is it at least as likely as not that the Veteran's obesity was a substantial factor in causing or aggravating his diabetes mellitus? (d.) Is it at least as likely as not that the Veteran's diabetes mellitus would not have occurred but for the obesity? In providing the requested opinion, consider the Veteran's reported history onset of diabetes mellitus after his PTSD disability, as well as the internet articles that discuss association between PTSD and diabetes mellitus. See Correspondence (September 2011) and Third Party Correspondence (September 2011). If there is any medical reason to accept or reject the proposition that the Veteran's overeating, weight gain, and/or poor glycemic control are result of his PTSD disability and caused his obesity which lead to development of diabetes mellitus. Stated another way, do the Veteran's reports about his symptoms align with how the currently diagnosed disability is known to develop or are the Veteran's reports generally inconsistent with medical knowledge or implausible? Ensure that the VA medical opinions obtained include a complete rationale for the conclusions reached. The medical opinions must support the conclusions reached with an analysis that is adequate for the Board to consider and weigh against other evidence of record; medical opinions must contain not only clear conclusions with supporting data, but also a reasoned medical explanation connecting the two. If an opinion cannot be expressed without resort to speculation, ensure that the clinician so indicates and discusses why an opinion is not possible, to include whether there is additional evidence that could enable an opinion to be provided, or whether the inability to provide the opinion is based on the limits of medical knowledge. 3. After the above development, and any additionally indicated development, has been completed, readjudicate the issues on appeal. If the benefit sought is not granted to the Veteran's satisfaction, send the Veteran and his representative a Supplemental Statement of the Case and provide an opportunity to respond. If necessary, return the case to the Board for further appellate review. James A. DeFrank Acting Veterans Law Judge Board of Veterans' Appeals Attorney for the Board J. Murray 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.