Citation Nr: 22013196 Decision Date: 03/08/22 Archive Date: 03/08/22 DOCKET NO. 19-34 748 DATE: March 8, 2022 ORDER Entitlement to service connection for cervical spine posttraumatic arthritis is granted. Entitlement to service connection for right upper extremity radiculopathy is granted. Entitlement to service connection for left upper extremity radiculopathy is granted. Entitlement to a disability evaluation in excess of 40 percent for lumbar spine degenerative disc disease is denied. REMANDED Entitlement to service connection for a sinus disability is remanded. Entitlement to service connection for tremors of the bilateral upper extremities, to include as due to exposure to herbicides, is remanded. Entitlement to service connection for tremors of the neck and head, to include as due to exposure to herbicides, is remanded. Entitlement to a disability evaluation in excess of 10 percent for left lower extremity radiculopathy, prior to April 14, 2021, is remanded. Entitlement to a disability evaluation in excess of 20 percent for left lower extremity radiculopathy, from April 14, 2021, is remanded. Entitlement to a disability evaluation in excess of 10 percent for right lower extremity radiculopathy, prior to April 14, 2021, is remanded. Entitlement to a disability evaluation in excess of 20 percent for right lower extremity radiculopathy, from April 14, 2021, is remanded. Entitlement to a disability evaluation in excess of 10 percent for gastroesophageal reflux disease (GERD) is remanded. Entitlement to special monthly compensation for aid and attendance is remanded. Entitlement to a total disability rating based on individual unemployability (TDIU) is remanded. FINDINGS OF FACT There is a causal connection between the Veteran's current cervical spine arthritis and an injury or disease incurred in service. There is a causal connection between the Veteran's current right upper extremity radiculopathy and an injury or disease incurred in service. There is a causal connection between the Veteran's current left upper extremity radiculopathy and an injury or disease incurred in service. The Veteran's lumbar spine degenerative disk disease is not manifest by unfavorable ankylosis. CONCLUSIONS OF LAW Cervical spine posttraumatic arthritis was incurred in service. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303. Right upper extremity radiculopathy was incurred in service. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303. Left upper extremity radiculopathy was incurred in service. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303. The criteria for a rating in excess of 40 percent for lumbar spine degenerative disc disease have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from June 1964 to May 1966. The Board notes that the scope of the Veteran's claim for service-connection for a cervical spine (neck) disability includes any disability that reasonably may be encompassed by his description of the claim, reported symptoms, and the other information of record. See Clemons v. Shinseki, 23 Vet. App. 1, 5 (2009). Here, when the Veteran filed his service connection claim for a neck disability, he also sought service connection for upper extremity disabilities (tremors), and VA treatment records show cervical radiculopathy was an active problem. Thus, under Clemons, the Board finds that the Veteran's claim for service connection for a neck condition reasonably encompassed any related neurologic impairment in the left and right upper extremities. See also 38 C.F.R. § 4.71(a), General Rating Formula for Diseases and Injuries of the Spine, Note 1 (providing that objective neurologic abnormalities are to be rated separately under an appropriate diagnostic code). Service Connection Entitlement to service connection for cervical spine arthritis Entitlement to service connection for right upper extremity radiculopathy Entitlement to service connection for left upper extremity radiculopathy The Veteran contends he has neck pain that began in service. See June 2019 report of general information. Alternatively, he contends that his cervical spine condition is related to his service-connected lumbar spine degenerative disc disease. See August 2016 claim for benefits and November 2019 substantive appeal. i. Applicable Law Generally, to establish service connection, a claimant must show: (1) a present disability; (2) an in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service, the so-called "nexus" requirement. See 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303; see also Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Service connection may also be established for a current disability on the basis of a presumption that certain chronic diseases, to include arthritis, manifesting themselves to a certain degree within a certain time after service must have had their onset in service. 38 U.S.C. §§ 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.303, 3.307, 3.309(a). Generally, the disease must have manifested to a degree of 10 percent or more within one year of service. 38 C.F.R. § 3.307(a)(3). Degenerative disc disease and spondylosis are considered arthritis. Except as provided in § 3.300(c), disability which is proximately due to or the result of a service-connected disease or injury shall be service connected. When service connection is thus established for a secondary condition, the secondary condition shall be considered a part of the original condition. 38 C.F.R. § 3.310. ii. Evidence and Analysis The Board concludes that the Veteran has current disabilities that are related to an in-service injury or disease. 38 U.S.C. §§ 1110, 1131, 5107(b); Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009); 38 C.F.R. § 3.303(a). A September 1994 radiology diagnostic report reveals the Veteran has degenerative disc disease and spondylosis of the cervical spine. Subsequent records reveal the Veteran has cervical radiculopathy of the upper extremities. During service, the Veteran was seen for complaints of neck pain in March 1965. Thus, the question becomes whether the current disabilities are related to service. On this question there are probative opinions in favor of and against the claim. The evidence against the claim includes a September 2019 VA medical professional's opinion that the Veteran's neck condition is less likely than not incurred in or caused by service. In support of the opinion, it was explained that the Veteran's in-service neck condition was acute only, and that there is no evidence of a chronicity of care for a chronic neck condition from service to present. Additionally, the Veteran's spine and upper extremities were found to be normal during a March 1966 separation examination. However, the contemporaneous report of medical history did not specifically ask the Veteran about his neck. The evidence in favor of the claim includes an April 2021 VA examination report and related opinions provided in May 2021. The examiner stated, "Even though he was previously denied service connection for his neck condition because service treatment records show a single instance of neck pain in 1966, I cannot confirm that the spondylosis and degenerative disc disease of the cervical spine were not actually the result of an injury he suffered while in the service. Based on thorough review of Veteran's medical records and today's physical examination, the cervical degenerative disc disease with radiculopathy of upper extremities were at least as likely as not (50 percent or greater probability) incurred in or caused by the military service." The examiner also cited medical literature in support of the opinion, which states that osteoarthritis, "may occur early, in less than a year, or remain asymptomatic for a long period of time, even 1020 years after an injury, and this is the case with the Veteran, he developed neck pain many years after leaving the service." The Board finds the April 2021 examiner's opinion to be more probative. Medical literature supports the May 2021 opinion and addresses the lack of care noted by the September 2019 medical professional. Moreover, the September 2019 opinion and rationale did not address the Veteran's report of neck pain since service. See June 2019 report of general information. "The examiner must address the veteran's lay statements to provide the Board with an adequate medical opinion." Miller v. Wilkie, 32 Vet. App. 249, 260 (2020). Therefore, the Board finds the April 2021 examiner's opinion to have more probative value. The Board notes that there is conflicting evidence on whether the Veteran's current neck symptoms began in service. See, e.g., treatment records form September 7, 1994 (lower back, shoulder and neck pain onset two weeks prior) and September 14, 1994 (cervical spine pain developed three weeks prior, but was noted to be "of recurrent type"; also noting left upper extremity radiculopathy). However, to the extent the April 2021 examiner did not consider the Veteran's reporting or found it to not be credible, the examiner did not rely on a continuity of symptomology to provide the positive opinion. To the contrary, the examiner cited medical literature that indicated an individual can be asymptomatic for several years after an injury. In light of this, and the lack of evidence of a post-service neck injury, the Board need not address whether the Veteran has had neck pain since service. Upon review of the record, the Board finds the evidence weighs in favor as to whether the Veteran's current cervical spine arthritis and upper extremity radiculopathy is related to service. Accordingly, after resolving all doubt in favor of the Veteran, the Board finds that service connection for cervical spine arthritis, left upper extremity radiculopathy and right upper extremity radiculopathy is warranted. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. As the Board is granting the Veteran's claims on a direct basis, we need not address whether service connection is warranted on a presumptive or secondary basis. Increased Rating 1. Entitlement to a disability evaluation in excess of 40 percent for lumbar spine degenerative disc disease The Veteran seeks a rating in excess of 40 percent for his service-connected lumbar spine degenerative disc disease. i. Applicable Law The Veteran's service-connected lumbar spine degenerative disc disease is rated under 38 C.F.R. § 4.71a, Diagnostic Code (DC) 5242. Under the General Rating Formula for Diseases and Injuries of the Spine, a 10 percent rating is warranted for forward flexion of the thoracolumbar spine greater than 60 degrees but not greater than 85 degrees; or, combined range of motion of the thoracolumbar spine greater than 120 degrees but not greater than 235 degrees; or, muscle spasm, guarding, or localized tenderness not resulting in abnormal gait or abnormal spinal contour; or, vertebral body fracture with loss of 50 percent or more of the height. A 20 percent rating is warranted for forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees; or the combined range of motion of the thoracolumbar spine not greater than 120 degrees; or, 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 for forward flexion of the thoracolumbar spine to 30 degrees or less; or, favorable ankylosis of the entire thoracolumbar spine. A 50 percent rating is warranted for unfavorable ankylosis of the entire thoracolumbar spine. A 100 percent evaluation is warranted for unfavorable ankylosis of the entire spine. 38 C.F.R. § 4.71a, General Rating Formula for Diseases and Injuries of the Spine. Any associated objective neurological abnormalities, including, but not limited to, bowel or bladder impairment, are to be evaluated separately under an appropriate diagnostic code. 38 C.F.R. § 4.71a, General Rating Formula for Diseases and Injuries of the Spine, Note (1). 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. 38 C.F.R. § 4.71a, General Rating Formula for Diseases and Injuries of the Spine, Note (5). 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). In Correia v. McDonald, 28 Vet. App. 158 (2016), the Court held that the final sentence of 38 C.F.R. § 4.59 requires that the examiner record the results of range of motion testing "for pain on both active and passive motion [and] in weight-bearing and non-weight-bearing and, if possible, with range of motion measurements of the opposite undamaged joint." The spine has no opposite joint. In Sharp v. Shulkin, 29 Vet. App. 26 (2017), the Court held that VA examiners must obtain information about the severity, frequency, duration, precipitating and alleviating factors, and extent of functional impairment of flares from the veterans themselves, when a flare-up is not observable at the time of examination. The Board notes that 38 C.F.R. § 4.71a was amended effective February 7, 2021, but the changes do not affect the analysis of the Veteran's lumbar spine degenerative disc disease rating. ii. Evidence and Analysis The Veteran attended VA back examinations in September 2016 and April 2021. The Veteran reported worsening of his disability in November 2019, and the examination reports are consistent with this reporting. During the April 2021 examination, the Veteran reported he cannot bend over, perform heavy lifting, twist or turn, or stand, walk or sit for a prolonged period. Difficulty with bathing, "house chores, grocery shopping [etcetera]" was also noted. See April 2021 VA back examination report, page 6. The Veteran also reported daily severe flare-ups that last 5 to 6 hours. Upon examination, the Veteran was found to have forward flexion limited to 30 degrees. However, forward flexion was estimated to be limited to 5 degrees during flare-ups, with zero degrees of motion for additional planes of motion, including right and left lateral flexion. In other words, lateral flexion was estimated to be fixed in neutral position during flare-ups. A review of the record, including treatment records and the September 2016 examination report, does not reveal range of motion worse than that found and estimated during the April 2021 examination. The Board finds that the evidence of record persuasively weighs against a rating in excess of 40 percent for lumbar spine degenerative disc disease (DDD). The Board acknowledges the Veteran's lay reports of symptoms and that there was functional loss, particularly during flare-ups. However, even when considering the Veteran's lay reports of symptoms and noted functional loss, the degree of additional limitation reflected by the reporting of daily severe flare-ups would not result in symptoms more nearly approximating unfavorable ankylosis of the entire thoracolumbar spine. The Board has considered whether the Veteran's symptoms during flare-ups result in the functional equivalent of ankylosis. See Chavis v. McDonough, 34 Vet. App. 1 (2021). However, even when considering functional limitation during a flare-up, the Veteran's symptoms result in no more than favorable ankylosis. Notably, the April 2021 examiner considered the Veteran's reports of severe flare-ups and opined the Veteran was able to move in forward flexion, albeit only to 5 degrees, despite pain, fatigability and weakness during flare-ups. The examiner also estimated the Veteran's lateral flexion to be fixed in neutral position (zero degrees). This ability to move in forward flexion is consistent with the Veteran's current 40 percent rating, as it represents forward flexion of the thoracolumbar spine to 30 degrees or less, rather than the entire thoracolumbar spine being fixed in flexion or extension. Similarly, although the Veteran is not estimated to have other ranges of motion, the examiner's estimates indicate any fixation is in neutral position. As noted above, "[f]ixation of a spinal segment in neutral position (zero degrees) always represents favorable ankylosis." 38 C.F.R. § 4.71a, General Rating Formula for Diseases and Injuries of the Spine, Note (5). Accordingly, the Veteran's disability is not found to result in unfavorable ankylosis. Consideration has also been given to assigning a rating under the Formula for Rating Intervertebral Disc Syndrome (IVDS) Based on Incapacitating Episodes. However, the evidence of record is against a finding that the Veteran was ever prescribed bed rest by a physician for a duration that meets the criteria for a higher rating, i.e. at least 6 weeks in a 12 month period. See 38 C.F.R. § 4.71a, Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes. Regarding neurological impairment, the Veteran has already been granted service connection for lower extremity radiculopathy and the lay and medical evidence of record is against a finding that the Veteran has any other neurological abnormality associated with his spine disability. Lower extremity radiculopathy is addressed in the remand section below. For the foregoing reasons, the evidence of record persuasively weighs against the Veteran's claim for a rating in excess of 40 percent for lumbar spine degenerative disc disease. As the evidence of record persuasively weighs against a rating in excess of 40 percent, the benefit-of-the-doubt rule does not apply. 38 U.S.C. § 5107(b); 38 C.F.R. §§ 4.3, 4.7; Lynch v. McDonough, No. 2020-2067, 2021 U.S. App. LEXIS 37307 (Fed. Cir. Dec. 17, 2021). REASONS FOR REMAND Entitlement to service connection for a sinus disability is remanded. Upon review of the evidence of record, the Board finds remand is warranted to ensure substantial compliance with the Board's July 2020 remand directives, and to obtain an additional medical opinion. As part of the Board's July 2020 remand directives, opinions on whether the Veteran's sinusitis clearly and unmistakably pre-existed service and whether the Veteran's sinusitis was clearly and unmistakably not aggravated in service. The Veteran attended a relevant examination in April 2021. While the examiner opined the Veteran's sinusitis clearly and unmistakably pre-existed service, the examiner opined "the Veteran's Sinusitis less likely than not (less than 50 percent probability) aggravated beyond natural progression by the military service." See May 2021 opinion report, page 8. The examiner erred in using the "less likely than not" standard. In order to rebut the presumption of soundness, the government is required to rebut the presumption by "clear and unmistakable evidence", i.e., undebatable evidence, that the veteran's disability was both preexisting and not aggravated by service. 38 U.S.C. § 1111. "The effect of section 1111 on claims for service-connected disability thus may be summarized as follows. When no preexisting condition is noted upon entry into service, the veteran is presumed to have been sound upon entry. The burden then falls on the government to rebut the presumption of soundness by clear and unmistakable evidence that the veteran's disability was both preexisting and not aggravated by service. The government may show a lack of aggravation by establishing that there was no increase in disability during service or that any 'increase in disability [was] due to the natural progress of the' preexisting condition." 38 U.S.C. § 1153. If this burden is met, then the veteran is not entitled to service-connected benefits. However, if the government fails to rebut the presumption of soundness under section 1111, the veteran's claim is one for service connection. This means that no deduction for the degree of disability existing at the time of entrance will be made if a rating is awarded. See 38 C.F.R. § 3.322. "On the other hand, if a preexisting disorder is noted upon entry into service, the veteran cannot bring a claim for service connection for that disorder, but the veteran may bring a claim for service-connected aggravation of that disorder. In that case section 1153 applies and the burden falls on the veteran to establish aggravation. See Jensen v. Brown, 19 F.3d 1413, 1417 (Fed. Cir. 1994). If the presumption of aggravation under section 1153 arises, the burden shifts to the government to show a lack of aggravation by establishing 'that the increase in disability is due to the natural progress of the disease.' 38 U.S.C. § 1153; see also 38 C.F.R. § 3.306; Jensen, 19 F.3d at 1417." Wagner v. Principi, 370 F.3d 1089, 1096 (2004). The examiner utilized the wrong standard when responding to the Board's request for opinions. This does not constitute substantial compliance with the Board's remand directive. See Stegall v. West, 11 Vet. App. 268 (1998); Dyment v. West, 13 Vet. App. 141 (1999). Therefore, remand is warranted to obtain an opinion that complies with the Board's remand directives. Additionally, the Board notes that the April 2021 examiner relied on medical literature in providing a positive nexus opinion for the Veteran's rhinitis claim. The Board reviewed this literature and finds it reasonably raises the possibility of a relationship between rhinitis and sinusitis. Therefore, on remand, secondary service connection opinions will be sought. Entitlement to service connection for tremors of the bilateral upper extremities, to include as due to exposure to herbicides, is remanded. Entitlement to service connection for tremors of the neck and head, to include as due to exposure to herbicides, is remanded. Upon review of the evidence of record, the Board finds remand is warranted to obtain additional medical opinions and records. The Veteran attended a VA peripheral nerves examination in April 2021. The examiner opined the Veteran's tremor disabilities are less likely than not related to service. Although the examiner provided multiple opinions, the examiner's rationale with regard to herbicides is of particular importance. In support of the negative nexus opinion, the examiner explained there "are no records indicating that the Veteran served in Vietnam, or that he was exposed to herbicides, and even though he asserts that he went through a rigorous training, which replicated the environment in Vietnam, being exposed to different chemicals, there is no evidence in the medical literature linking herbicides to tremors." The examiner appears to have found the Veteran's reporting regarding exposure to chemicals in service to be credible, as the examiner relied on such reporting to provide a positive nexus opinion for the Veteran's rhinitis claim. However, despite the examiner's statement that there is no evidence in the medical literature linking herbicides to tremors, VA has recognized a relationship between certain herbicide agents and Parkinson's disease, particularly herbicide agents used in Vietnam during the Vietnam War. Parkinson's disease is known to cause tremors, and the Veteran was provisionally diagnosed with Parkinson's disease prior to the April 2021 examination. See February 25, 2021 VA treatment record; see also April 17, 2020 VA treatment record (Parkinson's disease status post deep brain stimulator). While the examiner did not expressly state the Veteran's tremors were due to Parkinson's disease, the examiner did state they are a disorder of the nervous system. See April 2021 VA peripheral nerves conditions examination report, page 13. The Board notes Parkinson's disease is a disorder of the central nervous system, and the examiner did not address whether the Veteran's Parkinson's disease is related to the reported in-service chemical exposures. Therefore, the Board finds remand is warranted for additional medical opinions. See DeLisio v. Shinseki, 25 Vet. App. 45, 54-55 (2011) (when a pending claim is for a condition that is caused by a disease or other disability that may be associated with service, and that causal disease or disability is, in fact, related to service, the pending claim reasonably encompasses a claim for benefits for the causal disease or disability). Additionally, VA treatment records indicate the Veteran had surgery to install a deep brain stimulator. The Veteran reported this surgery occurred through VA's CHOICE program, but these medical records are not in the Veteran's claims file. See June 2019 report of general information. Therefore, on remand the Veteran will have the opportunity to provide private medical records or a release that will allow VA to obtain them on his behalf. Entitlement to a disability evaluation in excess of 10 percent for left lower extremity radiculopathy, prior to April 14, 2021, is remanded. Entitlement to a disability evaluation in excess of 20 percent for left lower extremity radiculopathy, from April 14, 2021, is remanded. Entitlement to a disability evaluation in excess of 10 percent for right lower extremity radiculopathy, prior to April 14, 2021, is remanded. Entitlement to a disability evaluation in excess of 20 percent for right lower extremity radiculopathy, from April 14, 2021, is remanded. Upon review of the evidence of record, the Board finds remand is warranted for additional medical examinations and opinions. The Board remanded the Veteran's claims previously due to a report of worsening symptoms. Consistent with the Board's remand directives, the Veteran attended a VA back examination in April 2021, in which his lower extremity radiculopathy was evaluated. The examination revealed a worsening in the Veteran's disabilities, but the examiner's evaluation was limited to their severity around the time of examination, and did not address when there was a change in severity. Furthermore, the Veteran's medical records are limited with regard to lower extremity radiculopathy. In light of this, remand is warranted for additional examination and opinion which will allow an examiner to solicit necessary information to inform an opinion on when the severity of the Veteran's disabilities changed. See Chotta v. Peake, 22 Vet. App. 80, 86 (2008) (VA may obtain retrospective opinions). Entitlement to a disability evaluation in excess of 10 percent for gastroesophageal reflux disease (GERD) is remanded. Upon review of the evidence of record, the Board finds remand is warranted for an additional medical opinion. The Board remanded the Veteran's claims previously in light of a report of worsening symptoms. Consistent with the Board's remand directives, the Veteran attended a VA esophageal conditions examination in April 2021, in which his GERD was evaluated. The examiner noted the Veteran was taking medication to treat his GERD; however, there is no indication that the examiner took into account the ameliorative effects of medication when assessing the severity of the Veteran's disability. A proposed VA regulation would provide for a diagnostic code that is specific to GERD and would take into account medication. However, the Veteran's GERD is currently evaluated by analogy to hiatal hernia under diagnostic code 7346. This diagnostic code does not permit consideration of the ameliorative effects of medication, and the evidence of record is insufficient to make a determination without an additional medical opinion. Therefore, remand is warranted to obtain an opinion on the severity of the Veteran's GERD as if he was not medicated, specifically whether his symptoms would be productive of considerable impairment of health if not for his medication. Entitlement to special monthly compensation for aid and attendance is remanded. Need for aid and attendance means helplessness or being so nearly helpless as to require the regular aid and attendance of another person. 38 C.F.R. § 3.351(b); see also 38 C.F.R. §§ 3.351(c) and 3.352 (criteria to establish need for aid attendance). In light of the Veteran's reporting during the April 2021 VA back examination, the Board finds the issue of entitlement to special monthly compensation based on the need for regular aid an attendance has been raised by the record. However, there is inadequate information to make a determination on this issue. Compare October 6, 2020 VA treatment record (finding Veteran independent in activities of daily living, including bathing) with April 2021 VA back examination report (difficulty bathing self; flare-ups precipitated by showering). Therefore, the Board finds remand is warranted for an examination regarding whether the Veteran is in need of regular aid attendance due to service-connected disabilities. Entitlement to a total disability rating based on individual unemployability (TDIU) is remanded. Finally, because a decision on the above remanded issues could significantly impact a decision on the issue of entitlement to a TDIU, the issues are inextricably intertwined. Accordingly, remand of the claim for entitlement to a TDIU is required. The matters are REMANDED for the following action: 1. Obtain the Veteran's up-to-date VA treatment records. 2. Ask the Veteran to complete a VA Form 21-4142 for providers of treatment, including those that provide treatment through VA's CHOICE program. Make two requests for the authorized records, unless it is clear after the first request that a second request would be futile. 3. Schedule the Veteran for a VA examination for his sinus disability claim. The examiner must review the claims file. The examiner is asked to provide a response to the following: Identify each of the Veteran's current sinus disabilities. For each identified disability, to include sinusitis, answer the following: Did the disability clearly and unmistakably (undebatable) preexist the Veteran's service? If the examiner finds the disability did clearly and unmistakably preexist service, was it clearly and unmistakably not aggravated by service? If the examiner finds that the disability either did not clearly and unmistakably preexist service or was not clearly and unmistakably not aggravated by service, the examiner must opine whether it is at least as likely as not related to service, including reported chemical exposure. Is the disability at least as likely as not proximately due to service-connected disease or injury, including but not limited to rhinitis? Is the disability at least as likely as not aggravated, i.e., worsened beyond its natural progression, by service-connected disease or injury, including but not limited to rhinitis? Provide rationale to support the opinions. 4. Schedule the Veteran for a VA examination for his tremor disabilities claims. The examiner must review the claims file. The examiner is asked to provide a response to the following: Is it at least as likely as not that the Veteran's head and/or neck tremors are related to Parkinson's disease? Is it at least as likely as not that the Veteran's upper extremity tremors are related to Parkinson's disease? If any tremors are related to Parkinson's disease, is it at least as likely as not that Parkinson's disease is related to service, including but not limited to reported chemical exposures? Provide rationale to support the opinions. 5. Schedule the Veteran for an examination by an appropriate clinician to determine the current severity of his service-connected bilateral lower extremity radiculopathy. The examiner should provide a full description of the disability and report all signs and symptoms necessary for evaluating the Veteran's disability under the rating criteria. The examiner should solicit a history of the Veteran's lower extremity radiculopathy and evaluate the Veteran's disability retrospectively, opining if and when the severity of the Veteran's left or right lower extremity radiculopathy changed. Provide rationale for opinions. 6. Schedule the Veteran for an examination by an appropriate clinician to determine the current severity of his service-connected GERD. The examiner should provide a full description of the disability and report all signs and symptoms necessary for evaluating the Veteran's disability under the rating criteria. The examiner should opine the severity of the Veteran's GERD if he was not taking medication. The examiner should solicit a history of the Veteran's GERD and evaluate the Veteran's disability retrospectively, opining if and when the severity of the Veteran's GERD changed if he was not taking medication. (Continued on the next page) Provide rationale for opinions. 7. Schedule the Veteran for an aid and attendance examination. David Gratz Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Gregory T. Shannon, 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.