Citation Nr: A21009027 Decision Date: 05/10/21 Archive Date: 05/10/21 DOCKET NO. 200716-99565 DATE: May 10, 2021 ORDER 1. Entitlement to compensation under 38 U.S.C. § 1151 for amputation of the right second and third toes due to cancer claimed as resulting from a medication for weight-loss prescribed by VA is denied. 2. Entitlement to compensation under 38 U.S.C. § 1151 for a heart disorder claimed as resulting from a medication for weight-loss prescribed by VA is denied. 3. Entitlement to compensation under 38 U.S.C. § 1151 for a stomach disorder claimed as resulting from a medication for weight-loss prescribed by VA is denied. 4. Entitlement to compensation under 38 U.S.C. § 1151 for a disability manifested by constipation, claimed as resulting from a medication for weight-loss prescribed by VA is denied. 5. Entitlement to service connection for a heart disorder secondary to a lumbar spine disorder is denied. 6. Entitlement to a rating in excess of 20 percent for a left shoulder disability is denied. 7. Entitlement to a rating in excess of 40 percent for cystitis is denied. REMANDED 8. Entitlement to service connection for a dental disorder is remanded. 9. Entitlement to service connection for a lumbar spine disorder with bilateral lower extremity radiculopathy is remanded. FINDINGS OF FACT 1. There is no competent evidence that the Veteran has an additional disability, to include amputation of the right second and third toes due to cancer, a heart disorder, a stomach disorder, and constipation, resulting from VA treatment, including with medication, or competent evidence that alleged treatment provided involved carelessness, negligence, lack of proper skill, error in judgment, or other fault on the part of VA. 2. The preponderance of the evidence is against a finding that any heart disorder is etiologically related to the Veteran's active service or was caused or aggravated by a service-connected disability. 3. The Veteran's left (major) shoulder disability is manifested by painful motion, but is not shown to have been manifested by ankylosis, motion limited to midway between side and shoulder level, humerus impairment, or clavicle or scapula impairment with malunion, nonunion, or dislocation. 4. The Veteran's cystitis is not shown to require the use of an appliance or require wearing of absorbent materials which must be changed more than four times per day. CONCLUSIONS OF LAW 1. The criteria for establishing entitlement to compensation under 38 U.S.C. § 1151 are not met with respect to amputation of the right second and third toes due to cancer, a heart disorder, a stomach disorder, or constipation, all claimed as resulting from a weight loss medication prescribed by VA. 38 U.S.C. §§ 1151, 5107; 38 C.F.R. § 3.361 2. Service connection for a heart disorder, to include as secondary to a lumbar spine disability, is not warranted. 38 U.S.C. § 1110; 38 C.F.R. §§ 3.303, 3.304, 3.310. 3. A rating in excess of 20 percent is not warranted for the Veteran's left shoulder disability. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.321, 4.1, 4.71a, Diagnostic Codes (Code) 5010, 5200-03. 4. A rating in excess of 40 percent is not warranted for cystitis. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.321, 4.1, 4.7, 4.115b, Code 7512. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The appellant is a Veteran who had active service from May 1966 to April 1968. A July 2011 rating decision denied the Veteran's request to reopen claims of service connection claims for a lumbar spine disorder with bilateral lower extremity radiculopathy, and a heart disorder claimed as secondary to a lumbar spine disability. In May 2016, a hearing in the matter was held before a Veterans Law Judge; a transcript is in the record. An August 2017 rating decision denied the Veteran's request to reopen a claim of service connection claim for a dental disorder and claims seeking increased ratings for a left shoulder disability and cystitis. In March 2018 the Board remanded all of these matters for further development. The Veteran thereafter opted into the modernized review system, also known as the Appeals Modernization Act (AMA), by submitting a Rapid Appeals Modernization Program (RAMP) election form and selecting the supplemental claim lane. The agency of original jurisdiction (AOJ) issued a RAMP Notice regarding these claims. A May 2019 rating decision denied the claims seeking compensation under 38 U.S.C. § 1151; and a July 2019 rating decision denied the claims seeking service connection and increased ratings listed above. In a July 16, 2020 Board Appeal Request (VA Form 10182), the Veteran requested to extend the period of time to file VA Form 10182 regarding the May 2019 rating decision due to COVID. An extension of the period for filing a VA Form 10182 may be granted for good cause. Whether good cause has been shown will be determined by the Board. Based on a review of the record, the Board finds that the Veteran has identified good cause for an extension of time to submit his VA Form 10182. 38 U.S.C. § 7105; 38 C.F.R. § 20.203. Consequently, his appeal to the Board is considered timely, and the Board has jurisdiction in these matters. appealed the May 2019 and July 2019 ratings decisions to the Board and requested evidence reviewed by a Veterans Law Judge in his July 16, 2020 VA Form 10182. Therefore, the Board may only consider the evidence of record at the time of the AOJ decision on appeal, as well as any evidence submitted by the Veteran or his representative with, or within 90 days following receipt of the VA Form 10182. 38 C.F.R. § 20.303. No additional evidence was received within those 90 days. Evidence was added to the claims file during a period when new evidence was not allowed. As the Board is deciding the claims seeking compensation under 38 U.S.C. § 1151, service connection for a heart disorder as secondary to a lumbar spine disorder, and increased ratings for a left shoulder disability and cystitis, the Board may not consider such evidence in its decision. 38 C.F.R. § 20.300. The Veteran may file a Supplemental Claim and submit or identify this evidence. 38 C.F.R. § 3.2501. If the evidence is new and relevant, VA will issue another decision on the claim, considering the new evidence. Specific instructions for filing a Supplemental Claim are included with this decision. As the Board is remanding the claims of entitlement to service connection for a dental disorder and a lumbar spine disorder for further development, the additional evidence will be considered by the RO when those claims are readjudicated. A July 2020 rating decision reopened the claims of service connection for a dental disorder, a lumbar spine disorder, and a heart disorder claimed as secondary to a lumbar spine disorder. The Board is bound by these favorable findings. 38 C.F.R. § 3.104(c). As the reopened claim was limited to the matter of service connection for a dental disability for compensation purposes, this decision is likewise limited to such consideration (and does not address the matter of service connection for a dental disability for treatment purpose (as those claims are initially decided by VHA). Finally, as explained below, the issues seeking service connection for left and right lower extremity radiculopathy are inextricably intertwined with the claim of service connection for a lumbar spine disorder. Hence, consideration of those appeals must be deferred pending resolution of the service connection for a lumbar spine disorder claim. Harris v. Derwinski, 1 Vet. App. 180, 183 (1991). This case has been advanced on the Board's docket. 38 U.S.C. § 1151 Claims The Veteran has asserted that VA was negligent in prescribing weight-loss medications, and that those medications resulted in the disability requiring right 2nd and 3rd toe amputations, a heart disorder, a stomach disorder, and a disability manifested by constipation [the Board observes that constipation of itself is a symptom, and not a compensable disability, so this issue is characterized to reflected that it is the disability underlying the constipation that is at issue]. Under 38 U.S.C. § 1151, compensation shall be awarded for a qualifying additional disability or a qualifying death of a veteran in the same manner as if such additional disability were service connected. A disability or death is a qualifying additional disability or qualifying death if the disability or death was not the result of the veteran's willful misconduct, the disability or death was caused by hospital care, medical or surgical treatment, or examination furnished the veteran under any law administered by the Secretary, either by a Department employee or in a Department facility, and the proximate cause of the disability or death was either carelessness, negligence, lack of proper skill, error in judgment, or similar instance of fault on the part of the Department in furnishing the hospital care, medical or surgical treatment, or examination; or an event not reasonably foreseeable. See 38 U.S.C. § 1151. The record shows that in August 2013, weight-loss was discussed with the Veteran, including the use of a diet pill Orlistat. In September 2013, he received a prescription for Orlistat. In October 2013, he requested a refill for Orlistat. In November 2013, he reported that Orlistat caused diarrhea and that he would prefer to stop taking it. In August 2014, VA reviewed the Veteran's prescribed medications and found there were no known interactions between his other prescribed medications and Orlistat. He was advised that Orlistat may cause loose stools. He was counselled on the proper use of Orlistat and advised not to take other weight loss drugs while taking Orlistat. In October 2014, the Veteran reported that VA provided Orlistat that made him sick. He reported that Orlistat caused vomiting, hard stools, hands shaking, shortness of breath, problems urinating, and sleeping 16 to 20 hours per day. He stated that taking Orlistat resulted in his going to an emergency room for treatment. In June 2015, the Veteran reported that Orlistat resulted in pain, heart problems, feet swelling, and a decline in his health. In June 2016, the Veteran submitted a VA letter dated in April 2014. The salutation was "Dear Veteran" (not specific to the Veteran). The letter indicated that prescriptions for Orlistat were being recalled for package tampering. In the instant claim received in November 2018, the Veteran stated that medication prescribed by VA for weight-loss resulted in amputation of the right second and third toes due to cancer, a heart disorder, a stomach disorder, and constipation. In December 2018, VA notified the Veteran of what evidence was required in order to establish entitlement to compensation under 38 U.S.C. § 1151. He was asked to provide the name, address, and the approximate time of treatment of the person, agency, or company with records that he thought would help decide his claim, and the condition for which the Veteran was treated. To establish entitlement to benefits under 38 U.S.C. § 1151, the Veteran must show both that he has (or has had) the claimed disability/additional disability and that it was caused by VA hospital care or medical treatment (with the proximate cause of the additional disability involving carelessness, lack of proper skill, error in judgment, or similar instance of fault (on the part of VA), or an event not reasonably foreseeable). To establish actual causation, the evidence must show that the hospital care, medical or surgical treatment resulted in the Veteran's additional disability. A mere showing that he received care, treatment, or examination, and that he has /has had an additional disability, does not establish cause. The Veteran did not respond to the letter and did not provide any additional information or evidence showing that medication (and specifically, as claimed, Orlistat), prescribed by VA resulted in the disabilities here at issue (amputation of the right 2nd and 3rd toes, a heart disorder, a stomach disorder, and a disability manifested by constipation). The etiology of the claimed disabilities is a medical question that is beyond the scope of common knowledge and incapable of resolution by lay observation. See Jandreau v. Nicholson, 492 F.3d, 1372, 1377. Here, while the Veteran was advised that loose stools may be a side -effect of his prescribed Orlistat, there is no competent (medical) evidence in the record indicating or suggesting that his claimed toe amputations, heart disability, stomach disability, or disability manifested by amputations were caused by his prescribed Orlistat. The Veteran is a layperson, and his own opinion is not competent evidence, and has no probative value, in this matter. Consequently, the Veteran has not (with respect of any of these claims) met a threshold requirement for substantiating a claim under 38 U.S.C. §1151 (competent evidence that the claimed disability resulted from VA treatment). [While the analysis does not need to proceed further, the Board also notes that there is also no competent evidence that the VA prescription of Orlistat treatment provided involved carelessness, negligence, lack of proper skill, error in judgment, or similar instance of fault on the part of by VA (which is another medical question). The Board acknowledges the evidence submitted include a VA notice of recall of Orlistat due to tapering with packaging. However, since there is no competent evidence that the Veteran's use of Orlistat caused the claimed disabilities, whether such was an unforeseeable event is a moot question that needs not be addressed.] Considering the foregoing, the Board finds that the preponderance of the evidence is against these claims. Therefore, the appeals in these matters must be denied. Service Connection Service connection will be granted if the evidence demonstrates that a current claimed disability resulted from an injury or disease incurred in or aggravated by active military service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303. Substantiating a claim of service connection requires competent evidence showing: (1) the existence of a present disability; (2) incurrence or aggravation of a disease or injury in-service; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Certain chronic diseases (to include cardiovascular disabilities) may be presumed to be service connected if manifested to compensable degree within a specified period of time following service (one year for cardiovascular disabilities). 38 U.S.C. §§ 1101, 1112, 1113; 38 C.F.R. §§ 3.307, 3.309(a). Under 38 C.F.R. § 3.303(b) service connection may be established, where a condition in service is noted, but is not, in fact, shown chronic, or where a diagnosis of chronicity may be legitimately questioned by showing continuity of symptomatology. The continuity of symptomatology provisions of 38 C.F.R. § 3.303(b) have been interpreted as an alternative to establish service connection only for the specific chronic diseases listed in 38 C.F.R. § 3.309(a). See Walker v. Shinseki, 718 F.3d 1331 (Fed. Cir. 2013). Service connection may be established on a secondary basis for a disability which is proximately due to, or the result of, a service-connected disability. 38 C.F.R. § 3.310(a). Secondary service connection may also be established for a disability which is aggravated by a service-connected disability. To substantiate a claim of secondary service connection, the record must show (1) a current disability (for which secondary service connection is sought); (2) an already service-connected disability; and (3) that the already service-connected disability caused or aggravated the disability for which service connection is sought. Wallin v. West, 11 Vet. App. 509 (1998). The Veteran asserts that he has a heart disorder that is secondary to a lumbar spine disorder. The Veteran's service treatment records (STRs) do not show complaints, treatment, or a diagnosis of a heart disorder. On a January 1968 examination, his heart was normal on clinical evaluation. On a February 1968 examination, his heart was normal on clinical evaluation. And on April 1968 examination for separation from service, his heart was normal on clinical evaluation, and he specifically denied having palpitations or pounding heart. The Veteran was not seen or treated for a heart disability within a year following his separation from active service. A May 1968 chest x-ray showed that his heart was not enlarged. An October 1968 chest x-ray showed a normal heart. On January 1969 VA examination, no heart abnormalities were noted. A May 1972 chest x-ray showed his heart was borderline to slightly enlarged, but a chronic heart disability was not diagnosed. A June 1983 EKG showed slight brachycardia, or a slow heart rate. In August 1984, his heart was normal, and he did not have coronary artery disease (CAD). A January 1990 chest x-ray showed a normal heart. A January 1991 chest x-ray showed his heart was within normal limits with no evidence of congestive heart failure. In March 1998, three decades after his separation from active service, the Veteran's complaint of heart symptoms was noted. The record outlined above does not show or suggest, and the Veteran does not allege, that any current heart is directly related to his active duty service. His stated theory of entitlement in this matter is one of secondary service connection; he asserts that a heart disability is secondary to his lumbar spine disorder. Whether a current heart disability may have been caused or aggravated by a lumbar spine disability is a medical question. However, with respect to the secondary service connection, there is a threshold legal requirement that the primary [here, back] disability underlying the claim must be service-connected. Service connection for a back disability has not yet been established, and as explained below that matter will be pending development. Under the prior (legacy) appeals system, consideration of claim would be deferred, and further development was permitted if such was needed upon resolution of the service connection for a back disability claim. However, as the Veteran has opted, into the AMA appeals system, which provides for a closed record, the Board review is limited to the evidence of record at the time of the July 2019 rating decision (or submitted within 90 days following). As a low back disability was not service-connected during the period for consideration herein, the claim of service connection for a heart disability as secondary to a low back disability lacks legal merit. 38 C.F.R. § 3.310. The preponderance of the evidence is against this claim. Accordingly, the appeal in this matter must be denied. Increased Ratings Disability ratings are determined by applying a schedule of ratings that is based on average impairment of earning capacity. Separate diagnostic codes identify the various disabilities. 38 U.S.C. § 1155; 38 C.F.R., Part 4. Each disability must be viewed in relation to its history and the limitation of activity imposed by the disabling condition should be emphasized. 38 C.F.R. § 4.1. Examination reports are to be interpreted in light of the whole recorded history, and each disability must be considered from the point of view of the appellant working or seeking work. 38 C.F.R. § 4.2. Where there is a question as to which of two disability evaluations shall be applied, the higher evaluation is to be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating is to be assigned. 38 C.F.R. § 4.7. Reasonable doubt regarding degree of disability is to be resolved in favor of the claimant. 38 C.F.R. § 4.3. Left Shoulder Disability The criteria for rating shoulder disabilities are in 38 C.F.R. Part 4, Codes 5200 through 5203. As the Veteran is left-handed, his left shoulder is considered his major extremity. The Veteran's left shoulder disability is rated 20 percent under Code 5010-5201 (for arthritis due to trauma based on limitation of motion of the shoulder). Code 5200 pertains to ratings for ankylosis of the shoulder; Code 5202 pertains to rating for impairment of the humerus (to include malunion, fibrous union, and non-union, as well as dislocation of the scapulohumeral joint); and Code 5203 pertains to impairment of the clavicle or scapula (dislocation, malunion or nonunion). As the record does not show such pathology or impairment, those Codes have no applicability in this matter. Code 5201 pertains to ratings for limitation of shoulder motion. For the major upper extremity, a 20 percent rating is assigned for limitation at the shoulder level. A 30 percent rating is assigned for limitation at midway between the side and shoulder level. A 40 percent rating is assigned for limitation to 25 degrees from the side. 38 C.F.R. § 4.71a. Normal ranges of motion of the shoulder are flexion (forward elevation) from 0 degrees to 180 degrees, abduction from 0 to 180 degrees, external rotation from 0 to 90 degrees, and internal rotation from 0 to 90 degrees. 38 C.F.R. § 4.71, Plate I. In determining the degree of limitation of motion, the provisions of 38 U.S.C. §§ 4.10, 4.40, and 4.45 are for consideration. See DeLuca v. Brown, 8 Vet. App. 202 (1995). The basis of disability evaluation is the ability of the body as a whole, or of the psyche, or of a system or organ of the body to function under the ordinary conditions of daily life including employment. 38 C.F.R. § 4.10. Disability of the musculoskeletal system is primarily the inability, due to damage or infection in parts of the system, to perform the normal working movements of the body with normal excursion, strength, speed, coordination, and endurance. Functional loss may be due to the absence or deformity of structures or other pathology, or it may be due to pain, supported by adequate pathology and evidenced by the visible behavior in undertaking the motion. Weakness is as important as limitation of motion, and a part that becomes painful on use must be regarded as seriously disabled. 38 C.F.R. § 4.40. With respect to joints, in particular, the factors of disability reside in reductions of normal excursion of movements in different planes. Inquiry will be directed to more or less than normal movement, weakened movement, excess fatigability, incoordination, pain on movement, swelling, deformity or atrophy of disuse. 38 C.F.R. § 4.45. The instant claim for increase was received in April 2017. The Veteran's treatment records show treatment for left shoulder symptoms, but do not show findings warranting a higher rating under Code 5201. For example, in August 2018, his physician noted limited left shoulder limitation of motion, but did not provide ranges of motion in degrees. On June 2017 VA examination, the Veteran reported chronic left shoulder pain. He denied being on medication for his left shoulder disability., and denied having aflare-ups. He reported having functional loss and that he avoided overhead lifting or reaching. On examination, left shoulder flexion and abduction were each normal, to 180 degrees. The examiner indicated that pain was noted on examination but did not result in or cause functional loss, and that the Veteran range of motion found did not contribute to a functional loss. There was no evidence of pain with weight bearing or non-weight bearing. The examiner noted that the Veteran was not examined immediately after repetitive use testing, and indicated that no loss of range of motion due to repetitive use was suspected, but that avoidance of [repetitive use] as a [pain] triggering activity was likely. The examiner opined that pain limited functional ability during repetitive use but did not result in any further loss of range of motion. The examiner indicated that there were no additional contributing factors of disability. There was no muscle atrophy, ankylosis, rotator cuff condition, shoulder instability, dislocation, or labral pathology, a clavicle, scapula, acromioclavicular (AC) joint or sternoclavicular joint condition, or humerus impairment. The current 20 percent rating under Code 5010-5201 is assigned for left shoulder arthritis with limitation of motion, and reflects limitation of motion at the shoulder level. The next higher (30 percent) rating requires limitation of major shoulder motion to midway between side and shoulder. Such limitation (to include as due to pain) is not shown. The Veteran had normal range of motion on June 2017 VA examination. While his physician noted in August 2018 that left shoulder motion was limited, the extent of limitation was not given, and that record does not provide a basis for finding that the limitation was at midway between the shoulder and side. The criteria for a 30 percent rating are not shown to be met or approximated. See 38 C.F.R. § 4.7. No examination found, and no treatment record shows, ankylosis, humerus impairment, or clavicle or scapula impairment with malunion, nonunion, or dislocation; consequently, rating the disability under alternate criteria based on such manifestations and functional impairment is not for consideration. The Board has considered whether a higher disability evaluation may be warranted on the basis of functional loss due to weakness, fatigability, incoordination, or pain on movement of a joint under 38 C.F.R. §§ 4.40 and 4.45. See also DeLuca, 8 Vet. App. 202. The June 2017 VA examiner noted that pain limited functional ability during repetitive use, but did not indicate any additional loss of range of motion at such times. Accordingly, a higher rating is not warranted for functional loss due to pain. While the Veteran reported experiencing left shoulder pain, pain alone is not sufficient to warrant a higher rating, unless it results in additional loss of function. Mitchell v. Shinseki, 25 Vet. App. 32, 36-38 (2011). The Board has no reason to question that the Veteran's left shoulder disability results in functional limitations. Such limitations are contemplated by the criteria for the 20 percent rating that is assigned. The Board finds that the Veteran's left shoulder symptoms do not include any that are not adequately addressed by the schedular rating criteria. The disability picture presented is not shown to be exceptional, nor is it asserted to be, so as to suggest referral for consideration of an extraschedular rating under 38 C.F.R. § 3.321 may be warranted. Considering the foregoing, the Board finds that the preponderance of the evidence is against the claim for a rating in excess of 20 percent for the Veteran's left shoulder disability. Accordingly, the appeal in this matter must be denied. Cystitis Cystitis is rated under Code 7512 (for chronic cystitis), which provides for rating as voiding dysfunction, which in turns provides for rating based on urinary leakage, urinary frequency, or obstructed voiding. For urinary leakage, a 40 percent rating is assigned for when absorbent materials must be changed two to four times per day. A 60 percent rating is assigned where use of an appliance or the wearing of absorbent materials which must be changed more than four times per day is required. For urinary frequency, a 40 percent (maximum) rating is assigned for daytime voiding interval less than one hour, or awakening to void five or more times per night. As a higher than 40 percent schedular rating is not available based on urinary frequency, rating under such criteria would be of no benefit to the Veteran, and those criteria will not be discussed further. For obstructed voiding and urinary tract infection, the maximum rating is 30 percent. Consequently, consideration of the claim under based on obstructed voiding likewise would not be of any benefit to the Veteran, and is not necessary. The instant claim for increase was received in April 2017. The Veteran 's treatment records do not show findings that would warrant a higher rating based on the applicable rating criteria. Specifically, there is no evidence that the Veteran requires use of an appliance for voiding (or is required to use absorbent materials that must be changed) for his chronic cystitis; for example, in January 2018 and March 2018, he voided without frequency, discomfort, urgency, or difficulty. On June 2017 VA examination, the Veteran reported that urinary frequency, urgency, and some dysuria. Upon examination of the Veteran, the examiner indicated that he requires use of absorbent materials which must be changed less than twice daily. It was noted that the Veteran had urinary frequency with a daytime voiding interval of less than one hour. The examiner indicated that the Veteran's symptoms of obstructed voiding were hesitancy, slow stream, weak stream, decreased force of stream, and stricture that required dilation, and noted that the Veteran had a history of recurrent symptomatic bladder or urethral infections that required intermittent antibiotic treatment. On March 2019 VA examination, the Veteran reported that he continued to have problems from cystitis including frequency, dysuria, and nocturia. On examination the examiner indicated that the Veteran's voiding dysfunction did not cause urine leakage and did not require use of an appliance. It was noted that the Veteran had urinary frequency with a daytime voiding interval of less than one hour and nighttime awaking to void five times or more. The examiner indicated that the Veteran's symptoms were slow stream, weak stream, decreased force of stream, stricture disease that required dilation, and urinary retention requiring intermittent catheterization. The examiner indicated that the Veteran had a history of recurrent symptomatic bladder or urethral infections due to urethral stenosis that resulted in one to two hospitalizations per year and drainage during the previous 12 months. The current 40 percent rating under Code 7512 is assigned for the Veteran's cystitis based on a daytime voiding interval of less than one hour (and awakening to void 5 or more times at night. The only higher schedular rating available is a 60 percent rating for voiding dysfunction that requires the use of an appliance or the wearing of absorbent materials which must be changes more than four times per day. The June 2017 VA examiner indicated that the Veteran required absorbent material which must be changed less than two times per day. The March 2019 VA examiner indicated that the Veteran did not have urine leakage or require use of an appliance. The Veteran's medical records do not show that use of an appliance was required or that that he must wear absorbent materials which must be changed more than four times a day. Consequently, the criteria for a 60 percent rating are not met or approximated. A schedular rating in excess of 40 percent is not warranted. The Board has no reason to question that the Veteran's cystitis results in functional limitations. Such limitations are contemplated by the criteria for the 40 percent rating that is assigned. The Board also finds that the Veteran's cystitis symptoms do not include any that are not adequately addressed by the schedular rating criteria. The disability picture presented is not shown to be exceptional, nor is it asserted to be exceptional, so as to suggest that referral for consideration of an extraschedular rating under 38 C.F.R. § 3.321 may be warranted. Considering the foregoing, the Board finds that the preponderance of the evidence is against the claim for a rating in excess of 40 percent for the cystitis. Accordingly, the appeal in this matter must be denied. REASONS FOR REMAND Regarding the claims of service connection claims for a dental disorder and a lumbar spine disorder with bilateral lower extremity radiculopathy, the Veteran's STRs show that he was involved in a motor vehicle accident (MVA) in April 1968, just prior to his separation from active service. His STRs show that he sustained facial trauma, to include facial lacerations over his left eye and left cheek. On April 1968 separation physical, he reported having recurrent back pain and severe tooth or gum trouble from the MVA. Just after his separation from active service, a May 1968 lumbar spine x-ray showed a transitional first sacral segment. In October 1968, the Veteran reported back pain following the MVA in service. A January 1969 lumbar spine x-ray showed slight scoliosis, but was otherwise normal. He was noted to have back pain and needing a [back] brace. In February 1969, a back brace for a chronic lumbar spine sprain was requested. In April 1969, he requested another back brace. In May 1969, he was referred to an oral surgeon for dental complaints that included a jaw fracture. In October 1971, he reported having problems with his back since the motor vehicle accident in service. An October 1972 lumbar spine x-ray showed slight joint space narrowing. In September 1990, the Veteran's dentist reported that he cared for the Veteran prior to his active service and that he then had no special dental conditions. In January 1991, the Veteran was seen for back complaints he related to his MVA in service. The physician opined that the complaints were related to trauma. On VA examinations in January 1969 and March 1993 the examiners did not offer an opinion regarding the etiology of the Veteran's back disability. On September 1994 VA examination, a history of a 1968 MVA with possible mandibular injury and chronic low back strain was noted. The examiner noted that the Veteran brought many medical records, but did not indicate that the records or the Veteran's claims file were reviewed. On November 1998 VA examination the examiner did not review the Veteran's claims file or offer an opinion regarding etiology of any dental disorder. On December 2015 VA examination, the examiner opined that the Veteran's lumbar spine disorder clearly and unmistakably preexisted his active service and clearly and unmistakably was not aggravated by his active service. The Veteran's medical records show that he has undergone numerous oral surgeries, including March 1982 mandible surgery. He has also consistently reported back symptoms that he relates to a MVA in service. In January 1990, the Veteran's sister-in-law noted that he was in a MVA in service and afterwards was not in good condition. She stated that [providers] wanted to pull his teeth but that she stopped them. She stated that the Veteran had trouble with his jaw, and also reported that he had injuries to his back. At a September 1990 hearing, the Veteran testified that after a MVA in service, providers wanted to pull two teeth, but his sister-in-law intervened. He testified that he has had constant back pain since the MVA in service. At a November 1999 hearing, he testified that he had to have his jaw reformed and that they wanted to pull two teeth, but his sister-in-law stopped the extractions. He testified that he had to have his jaw rebroken and he has lost teeth and bone due to the MVA in service. He testified that he two back braces were prescribed [soon] after his separation from active service ,and that his back has never stopped hurting since the MVA. At a May 2016 hearing, he testified that he had constant back symptoms after the MVA in service and has a diagnosis of lumbar spine radiculopathy. After a complete review of the entire record, the Board finds that on de novo review the previous VA examinations are inadequate for rating purposes. No VA examiner has directly or adequately addressed whether the Veteran has a compensable dental disorder and/or a lumbar spine disorder his MVA in service. Treatment records from soon just after his active service show that he was seen for back pain, given back braces, and was referred to an oral surgeon for a (possible) jaw fracture, and that he consistently attributed his back and dental problems to the MVA in service. The failure to arrange for adequate examinations/medical opinions considering the circumstances shown is a pre-decisional duty to assist omission that requires correction, followed by readjudication. The matters are REMANDED for the following: 1. Arrange for the Veteran's record to be forwarded to an appropriate clinician (in orthopedics) for review and an opinion regarding the nature and likely etiology of all his current lumbar spine disorders. If further examination of the Veteran is deemed necessary for an opinion sought, such should be arranged. The consulting clinician should provide opinions that respond to the following: a. Identify each current low back disability shown by the record (or found on examination, if one is conducted) by diagnosis. Regarding each low back disability diagnosed indicate (explaining in detail) whether it is a congenital anomaly (defect) or in the nature of acquired pathology (that may result from disease or injury)? b. Identify the likely etiology for each low back disability entity diagnosed. Noting (and addressing the significance of) the Veteran's MVA in service and his complaints noted in service and soon following separation (discussed above), as well as his (and supporting) lay reports on ongoing back complaints ever since service, is it ar least as likely as not (a 50 % or better probability) that the diagnosed disability was incurred in service? c. Regarding any diagnosed back disability that is determined to not be etiologically related to the Veteran's service (and his complaints and MVA in service), identify the etiology that is considered to be more likely, and explain why that is so. d. Identify the likely etiology for any right or left leg radiculopathy found. Specifically, is it at least as likely as not that it was incurred in service or is a manifestation of a current back disability that is determined to be related to the Veteran's service? All opinions must include a complete explanation of rationale with citation to supporting factual data and medical principles (as deemed appropriate). 2. Also arrange for the Veteran's record to be forwarded to a dentist for review and an advisory medical opinion regarding the nature and likely etiology of his claimed dental disability. [If further dental examination of the Veteran is deemed necessary for any opinion sought, such should be arranged.] The consulting dentist should review the history of the Veteran's dental disability as shown by historical dental records (commenting on any opinions previously offered), his and his sister's accounts describing their recollections of his dental history, and 38 C.F.R. § 4.150 (including the notes to the codes), and provide opinions that respond to the following: a. Identify by diagnosis each current dental disability entity shown by the record (or found on examination, if conducted). Regarding each diagnosed dental disability, identify whether it is a compensable disability (e.g., a mandible injury or loss of teeth due to trauma or due to osteomyelitis) or is a noncompensable disability (such as loss of alveolar process due to periodontal disease). b. Identify the likely etiology for any current compensable dental disability diagnosed. Specifically, is it at least as likely as not (a 50 percent or greater probability) that the current dental disorder was incurred in service, and specifically as due to facial trauma sustained in a MVA therein? All opinions must include complete explanation of rationale with citation to clinical data, and medical principles, as appropriate. GEORGE R. SENYK Veterans Law Judge Board of Veterans' Appeals Attorney for the Board T. Berryman, 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.