Citation Nr: 25003239 Decision Date: 03/06/25 Archive Date: 03/06/25 DOCKET NO. 17-08 165 DATE: March 6, 2025 ORDER From July 9, 2015 to April 30, 2019, entitlement to a 40 percent rating, but no higher, for a thoracolumbar spine disability is granted. From May 1, 2019, entitlement to a rating in excess of 40 percent for a thoracolumbar spine disability is denied. From February 24, 2015 to July 16, 2019, a 20 percent rating, but no higher, for right sciatic radiculopathy is granted. From July 17, 2019 to January 30, 2024, a rating in excess of 20 percent for right sciatic radiculopathy is denied. From January 31, 2024, a 40 percent rating, but no higher, for right sciatic radiculopathy is granted. From February 24, 2015 to July 16, 2019, a 20 percent rating, but no higher, for left sciatic radiculopathy is granted. From July 17, 2019 to January 30, 2024, a rating in excess of 20 percent for left sciatic radiculopathy is denied. From January 31, 2024, a 40 percent rating, but no higher, for left sciatic radiculopathy is granted. From February 24, 2015 to July 16, 2019, a rating in excess of 10 percent for right femoral radiculopathy is denied. From July 17, 2019 to January 30, 2024, a rating in excess of 20 percent for right femoral radiculopathy is denied. From January 31, 2024, a 30 percent rating, but no higher, for right femoral radiculopathy is granted. From July 17, 2019 to January 30, 2024, a rating in excess of 20 for left femoral radiculopathy is denied. From January 31, 2024, a 30 percent rating, but no higher, for left femoral radiculopathy is granted. REMANDED Entitlement to service connection for a sleep impairment disability, including as secondary to a thoracolumbar spine disability, is remanded. FINDINGS OF FACT 1. From July 9, 2015 to April 30, 2019, it is at least a likely as not, the Veteran's thoracolumbar spine disability was manifested by forward flexion limited to less than 30 degrees. 2. There is no evidence, at any time, that the Veteran's thoracolumbar spine disability was manifested by ankylosis or the functional equivalent of ankylosis. 3. From February 24, 2015 it is factually ascertainable that the Veteran experienced increased lower extremity radiculopathy symptoms. 4. From February 24, 2015 to January 30, 2024, the Veteran's right and left sciatic nerve radiculopathy disabilities were manifested by moderate symptomatology, but moderately severe symptomatology, severe symptomatology, muscular atrophy, and complete paralysis of the sciatic nerves were not shown. 5. From January 31, 2024, the Veteran's right and left sciatic nerve radiculopathy disabilities were manifested by moderately severe symptomatology, but severe symptomatology, muscular atrophy, or complete paralysis of the sciatic nerves was not shown. 6. From February 24, 2015 to July 16, 2019, moderate or severe right lower extremity femoral nerve symptomatology is not shown. 7. From July 17, 2019 to January 30, 2024, the Veteran's right and left femoral nerve radiculopathy disabilities were manifested by moderate symptomatology, but severe symptomatology or complete paralysis of a quadriceps extensor muscle were not shown. 8. From January 31, 2024, the Veteran's right and left femoral nerve radiculopathy disabilities were manifested by severe symptomatology, but complete paralysis of a quadriceps extensor muscle was not shown. CONCLUSIONS OF LAW 1. From July 9, 2015, the criteria for a 40 percent rating, but no higher, for a thoracolumbar spine disability are met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, Diagnostic Code 5242. 2. From February 24, 2015 to January 30, 2024, the criteria for 20 percent ratings, but no higher, for right and left lower extremity sciatic nerve radiculopathy disabilities are met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.124a, Diagnostic Code 8520. 3. From January 31, 2024, the criteria for a 40 percent ratings, but no higher, for right and left lower extremity sciatic nerve radiculopathy disabilities are met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.124a, Diagnostic Code 8520. 4. From February 24, 2015 to July 16, 2019, the criteria for a rating in excess of 10 percent for a right lower extremity femoral radiculopathy are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.124a, Diagnostic Code 8526. 5. From July 17, 2019 to January 30, 2024, the criteria for 20 percent ratings, but no higher, for right and left lower extremity femoral nerve radiculopathy disabilities are met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.124a, Diagnostic Code 8526. 6. From January 31, 2024, the criteria for a 30 percent ratings, but no higher, for right and left lower extremity femoral nerve radiculopathy disabilities are met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.124a, Diagnostic Code 8526. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from June 1980 to June 2004. This matter is before the Board of Veterans' Appeals (Board) on appeal of a December 2015, June 2019, and October 2019 rating decisions of a Regional Office (RO) of the Department of Veterans Affairs (VA). In October 2022, the Board restored a 20 percent rating for the Veteran's thoracolumbar spine disability from September 21, 2015 to April 30, 2019 and granted a rating of 40 percent from April 30, 2019. The October 2022 decision denied a rating in excess of 20 percent from September 21, 2015 to April 30, 2019 and denied a rating in excess of 40 percent thereafter. The Veteran appealed the October 2022 Board decision as to the denial of an increased thoracolumbar spine rating to the United States Court of Appeals for Veterans Claims (Court). In an August 2023, CAVC granted a Joint Motion for Partial Remand (JMPR) filed by the Veteran and the Secretary of VA. In approving the JMPR, the Court vacated the Board's denial of a rating in excess of 20 percent from September 21, 2015 to April 30, 2019 and in excess of 40 percent thereafter. Following the directives of the JMPR, in January 2024, the Board determined the issues of increased ratings for bilateral lower extremity radiculopathy disabilities were included in the Veteran's appeal seeking an increased rating for his thoracolumbar spine disability. The Board remanded the thoracolumbar spine claim to obtain an adequate VA examination and a retrospective opinion as to loss of range of motion due to pain and functional loss, including during periods of flare up. The issues of increased ratings for the bilateral lower extremity radiculopathy disabilities were remanded as intertwined with the thoracolumbar spine rating. In January 2024, the Board also added issue of entitlement to a total disability rating based on individual unemployability (TDIU) to the appeal as it was raised by the record as part and parcel of the increased ratings issues. See Rice v. Shinseki, 22 Vet. App. 447 (2009). Thereafter a May 2024 Board decision granted entitlement to a TDIU and a June 2024 rating decision established an effective date of March 6, 2013 for the award of TDIU. As TDIU is in effect over the entire appeal period applicable to the issues now before the Board, the May 2024 Board decision and the June 2024 rating decision are a complete grant as to this benefit. The issue of entitlement to a TDIU is no longer in appellate status. The issue of entitlement to service connection for a sleep impairment disability, secondary to the thoracolumbar spine disability, is added to the appeal and discussed in detail in the Remand section below. See Bailey v. Wilkie, 33 Vet. App. 188, 203 (2021). Increased Rating Disability ratings are determined by applying the criteria set forth in VA's Schedule for Rating Disabilities, which is based on the average impairment of earning capacity. Individual disabilities are assigned separate Diagnostic Codes (DCs). 38 U.S.C. § 1155; 38 C.F.R. § 4.1. Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating. Otherwise, the lower rating will be assigned. See 38 C.F.R. § 4.7. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, VA shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107(b); 38 C.F.R. § 4.3. The Board must consider all the evidence of record and make appropriate determinations of competence, credibility, and weight. Wood v. Derwinski, 1 Vet. App. 190 (1991); Washington v. Nicholson, 19 Vet. App. 362 (2005). In general, when an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). Staged ratings are appropriate in any increased-rating claim in which distinct time periods with different ratable symptoms can be identified. Hart v. Mansfield, 21 Vet. App. 505 (2007). Disabilities must be viewed in relation to their entire history. 38 C.F.R. § 4.1. VA is required to interpret reports of examination in light of the whole recorded history, reconciling the various reports into a consistent picture so that the current rating may accurately reflect the elements of disability. 38 C.F.R. § 4.2. VA is also required to evaluate functional impairment on the basis of lack of usefulness and the effects of the disabilities upon the claimant's ordinary activity. 38 C.F.R. § 4.10. The effective date of an award of increased compensation may be the earliest date as of which it is factually ascertainable based on all evidence of record that an increase in disability had occurred, if an application for increase in compensation is received within one year from such date. See 38 U.S.C. § 5110(b)(2); 38 C.F.R. § 3.400(o)(2). 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. 1. Entitlement to an increased rating for a thoracolumbar spine disability, currently rated as 20 percent prior to May 1, 2019 and as 40 percent thereafter Spine disabilities are typically rated under the same general formula, except for IVDS, which has an alternate rating formula for incapacitating episodes. 38 C.F.R. § 4.71a, DCs 5235-5243. Certain changes to the musculoskeletal rating criteria went into effect on February 7, 2021, including to the diagnostic code relevant to IVDS. This code now requires there be disc herniation with compression and/or irritation of the adjacent nerve root. The rating criteria formula remained the same. The Board notes no changes were made to the General Rating Formula for Diseases or Injuries of the Spine or associated diagnostic codes. Under the General Rating Formula for Diseases or Injuries of the Spine, a 10 percent rating for a lumbar spine disability is warranted where forward flexion of the thoracolumbar spine is greater than 60 degrees but not greater than 85 degrees; the combined range of motion of the thoracolumbar spine is greater than 120 degrees but not greater than 235 degrees; there is muscle spasm, guarding, or localized tenderness not resulting in an abnormal gait or spinal contour; or there is vertebral body fracture with loss of 50 percent or more of the height. A 20 percent evaluation is assigned 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 evaluation is warranted for forward flexion of the thoracolumbar spine of 30 degrees or less. A 50 percent rating is assigned for unfavorable ankylosis of the entire thoracolumbar spine, and a 100 percent rating is assigned for unfavorable ankylosis of the entire spine. All of these evaluations under the general formula for rating spine injuries consider the disabilities with or without symptoms such as pain (whether or not it radiates), stiffness, or aching in the area of the spine affected by residuals of injury or disease. The Formula for Rating IVDS Based on Incapacitating Episodes provides a 20 percent disability rating for IVDS with incapacitating episodes having a total duration of at least 2 weeks but less than 4 weeks during the past 12 months. A 40 percent disability rating is warranted for IVDS with incapacitating episodes having a total duration of at least 4 weeks but less than 6 weeks during the past 12 months. A 60 percent disability rating is warranted for IVDS with incapacitating episodes having a total duration of at least 6 weeks during the past 12 months. 38 C.F.R. § 4.71a, DC 5243. Note (1) to DC 5243 provides that, for purposes of ratings under DC 5243, an incapacitating episode is a period of acute signs and symptoms due to IVDS that requires bed rest prescribed by a physician and treatment by a physician. Id. Under Note 1 of the General Rating Formula for Diseases and Injuries of the Spine, neurologic abnormalities associated with a spine disability are to be evaluated separately under the appropriate diagnostic code. 38 C.F.R. § 4.71a. Ankylosis is defined as "immobility and consolidation of a joint due to disease, injury, or surgical procedure." Dorland's Illustrated Medical Dictionary, 94 (32nd ed. 2012). Fixation of a spinal segment in neutral position (zero degrees) always represents favorable ankylosis. 38 C.F.R. § 4.71a at Note 5. On July 9, 2015, the Veteran filed a claim seeking an increased rating for his back disability. This disability is identified as degenerative disc disease of the thoracolumbar spine. It is currently rated as 20 percent disabling prior to May 1, 2019 and as 40 percent disabling thereafter under DC 5242. A VA back conditions examinations was provided in September 2015. The examiner confirmed the diagnosis of degenerative disc disease of the thoracolumbar spine. He noted the Veteran was unable to walk or bend, had difficulty breathing, and needed to rest in bed during flare ups of his back disability. On initial measurements, forward flexion was observed to 75 degrees. On observed repetitive use testing, and as estimated for repeated use over time and during flare ups, forward flexion was reduced to 70 degrees. The examiner found there was no ankylosis of the spine. In May 2019, a VA examiner noted the Veteran's report of back pain and stiffness with bending, turning, twisting, standing, walking, running and with weight bearing. Forward flexion was observed to 40 degrees on initial testing and on testing after three repetitive movements. The examiner did not provide any estimates for the Veteran's limitations with repeated use over time or during flare ups. Ankylosis of the spine was not present. In August 2019, a VA examiner noted current symptoms of back pain. The Veteran described flare ups of burning pain which sometimes extended into his leg or was accompanied by a muscle spasm. Sometime pain woke him up and he at times had difficulty getting comfortable. He was unable to sit, stand or walk for long periods. On initial testing and after observed repetitive use, forward flexion was measured to 40 degrees and pain, causing functional loss, was noted in all ranges of motion. With use over time and during flare ups, the examiner indicated functional ability would be further limited but he did not anticipate any reduction in range of motion. Ankylosis was not present. As detailed in the August 2023 Court approved JMPR, the September 2015, May 2019 and August 2019 VA examinations are inadequate to evaluate the claim because they do not fully address loss of motion due to pain or during flare ups. Subsequently, a January 2024 VA back conditions examination was provided. The examiner noted current symptoms of pain, stiffness, sleep disturbances, and muscle spasms. The Veteran did not report flare ups because his back symptoms were constant. He described needing to constantly change positions and being unable to tolerate prolonged standing, sitting, or laying down. He had difficulty dressing. On initial testing, forward flexion was observed to 70 degrees. Pain was exhibited in all ranges of motion. There was evidence of pain, causing functional loss, with weight bearing, nonweight bearing, active motion, passive motion, and on rest. Passive range of motion testing was not performed as it was medically contraindicated. Repetitive use testing was not performed due to increased pain. Estimates for additional range of motion were not provided for repeated use over time or for flare ups. However, the Veteran did not experience flare ups as his symptoms were constant and he did not experience use over time as he frequently shifted positions to avoid prolonged repetitive use of his back. The examiner has provided the evaluation needed to address the Veteran's claim. The examination is adequate. Here, the September 2015, May 2019, August 2019, and January 2024 VA back conditions examinations do not include range of motion measurements or estimated range of motion measurements which show the Veteran's forward flexion of the thoracolumbar spine was limited to 30 degrees or less. However, the Veteran consistently reported his back disability caused stiffness, difficulty bending, and general limitation on his ability to move around. Resolving reasonable doubt in favor of the Veteran, it is at least as likely as not the forward flexion of his thoracolumbar spine was limited to 30 degrees or less, particularly during flare ups or with increased use over time. A 40 percent rating is warranted from July 9, 2015, the date the Veteran filed his claim. 38 C.F.R. § 4.71a, DCs 5235-5243 The September 2015, May 2019, August 2019, and January 2024 VA back conditions examinations and other medical evidence of record do not include any diagnosis of ankylosis. Further, this medical evidence and the Veteran's lay reports show the Veteran retained movement in his back at all times; thus, there is no evidence demonstrating the functional equivalent of ankylosis. A rating in excess of 40 percent is not warranted at any time. Id. 2. Entitlement to an increased rating for right lower extremity radiculopathy of the sciatic nerve, currently rated as 20 percent disabling from July 17, 2019 3. Entitlement to an increased rating for left lower extremity radiculopathy of the sciatic nerve, rated as 10 percent disabling from May 1, 2019 to July 16, 2019 and as 20 percent disabling thereafter 4. Entitlement to an increased rating for right lower extremity radiculopathy of the femoral nerve, rated as 10 percent disabling from February 24, 2015 to July 16, 2019 and as 20 percent disabling thereafter 5. Entitlement to an increased rating for left lower extremity radiculopathy of the femoral nerve, rated as 20 percent disabling from July 17, 2019 Under DC 8520, incomplete paralysis of the sciatic nerve is rated 10 percent when mild, 20 percent when moderate, 40 percent when moderately severe, and 60 percent when severe, with marked muscular atrophy. Complete paralysis of the sciatic nerve, where the foot dangles and drops, no active movement possible of the muscles below the knee, flexion of the knee weakened or, very rarely, lost warrants an 80 percent rating. 38 C.F.R. § 4.124a. DC 8520. Under DC 8526 incomplete paralysis of the femoral nerve is rated 10 percent when mild, 20 percent when moderate, and 30 percent when severe. Complete paralysis of the quadriceps extensor muscle warrants a 40 percent rating. 38 C.F.R. § 4.124a, DC 8526. The words "mild," "moderate," "moderately severe," and "severe" as used in the various diagnostic codes are not defined in the VA Rating Schedule. Rather than applying a mechanical formula, the Board must evaluate all of the evidence to ensure that its decisions are "equitable and just." 38 C.F.R. § 4.6. It should also be noted that use of terminology such as "severe" by VA examiners and others, although an element of evidence to be considered by the Board, is not dispositive of an issue. All evidence must be evaluated in arriving at a decision regarding an increased rating. 38 C.F.R. §§ 4.2, 4.6. The term "incomplete paralysis" indicates a degree of lost or impaired function substantially less than the type pictured 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. See Note at "Diseases of the Peripheral Nerves" in 38 C.F.R. § 4.124(a). In January 2024, the Board found the Veteran's July 2015 claim seeking an increased spine disability rating included a claim for increased lower extremity radiculopathy disability ratings. The evidence of record includes a February 24, 2015 EMG (electromyography) and NCV (nerve conduction velocity) study which was provided to evaluate the Veteran's worsening leg pain. Accordingly, an increase in the Veteran's radicular pain is shown from February 24, 2015. The increase is demonstrated within one year of the date the Veteran file his claim. The February 24, 2015 nerve test studies confirm the Veteran's report of pain in the bilateral anterior thighs and numbness in the bilateral anterior and lateral thighs. The study interpretation noted right lumbar radiculopathy (L4 and L5 levels) and possible left lumbar radiculopathy (S1 level). The study interpretation did not attribute the radicular symptoms to a particular nerve root or roots. In September 2015, a VA examiner noted bilateral straight leg test results were negative. He diagnosed moderate right sciatic nerve radiculopathy and confirmed right lower extremity symptoms of moderate intermittent pain, moderate paresthesias or dysesthesias, and moderate numbness. No left lower extremity symptoms were documented. On May 1, 2019, a VA examiner noted the Veteran's medical history of back pain and stiffness with radiculopathy. Bilateral straight leg test results were positive. The examiner diagnosed bilateral lumbar radiculopathy of the sciatic nerve with mild severity. He confirmed moderate bilateral symptoms of constant pain, intermittent pain, and paresthesias or dysesthesias. On July 17, 2019, the Veteran submitted a claim asserting he experienced chronic pain in his lower extremities. In August 2019, a VA examiner noted the Veterans reports of tingling in the lower extremities. During flare ups the Veteran described a burning sensation shooting down his legs. The examiner confirmed positive bilateral straight leg raising test results. He diagnosed bilateral femoral and bilateral sciatic nerves with moderate severity. He confirmed symptoms of bilateral moderate intermittent pain and moderate paresthesias or dysesthesias. On January 31, 2024, a VA examiner noted the Veteran's reports of numbness, tingling and "sciatic issues." He confirmed positive bilateral straight leg test results. He diagnosed bilateral femoral and bilateral sciatic nerve radiculopathy. These conditions were manifested by symptoms of severe bilateral constant pain. No muscle atrophy was present. Sciatic Nerve Radiculopathy Consistent with the Veteran's reports of increased leg pain, a February 24, 2015 nerve study showed right lower extremity radiculopathy and possible left lower extremity radiculopathy. The September 2015 examiner diagnosed right side sciatic radiculopathy, but he did not diagnose any left side condition. The May 2019 and August 2019 VA examinations diagnosed bilateral sciatic radiculopathy. Resolving reasonable doubt in favor of the Veteran, right sciatic radiculopathy and intermittent left sciatic radiculopathy disabilities are shown from February 24, 2015. From February 24, 2015 to January 30, 2024, moderate bilateral radiculopathy symptoms are shown. There is no evidence of moderately severe radiculopathy symptoms, severe radiculopathy symptoms, muscular atrophy, or complete paralysis. Subsequently, the January 31, 2024 VA examiner described severe bilateral constant pain, but he did not identify muscle atrophy or complete paralysis of the right or left sciatic nerve. For the right lower extremity, from February 24, 2015 to July 16, 2019, the criteria for a 20 percent rating, but no higher, for right sciatic radiculopathy are met and entitlement to a 20 percent rating is granted. From July 17, 2019 to January 30, 2024 the criteria for a rating in excess of 20 percent for right sciatic radiculopathy are not met and rating in excess of 20 percent is denied. From January 31, 2024, the criteria for a 40 percent rating, but no higher, for right sciatic radiculopathy are met and 40 percent rating, but no higher, is granted. For the left lower extremity, from February 24, 2015 to July 16, 2019, the criteria for a 20 percent rating, but no higher, for left sciatic radiculopathy are met and entitlement to a 20 percent rating is granted. From July 17, 2019 to January 30, 2024 the criteria for a rating in excess of 20 percent for left sciatic radiculopathy are not met and rating in excess of 20 percent is denied. From January 31, 2024, the criteria for a 40 percent rating, but no higher, for left sciatic radiculopathy are met and 40 percent rating, but no higher, is granted. See 38 C.F.R. § 4.124a. DC 8520. Femoral Nerve Radiculopathy Consistent with the Veteran's reports of increased leg pain, February 24, 2015 nerve studies indicated right lower extremity radiculopathy and possible left lower extremity radiculopathy. This study did not identify the nerve root associated with the radicular symptoms. Subsequently, September 2015 and May 2019 examinations confirmed sciatic radiculopathy and did not diagnose any femoral radiculopathy. On July 17, 2019, the Veteran asserted he experienced chronic pain in his lower extremities. An August 2019 VA examination diagnosed left and right femoral radiculopathy. The examiner confirmed moderate symptoms. On January 31, 2024, a VA examination continued the diagnosis of bilateral femoral radiculopathy disabilities and observed symptoms of severe constant pain. Over the entire appeal period, there is no evidence of complete paralysis of the quadriceps extensor muscle. For the right lower extremity, from February 24, 2015 to July 16, 2019, there is no evidence of moderate or severe right femoral radiculopathy symptoms or of complete paralysis of the quadriceps extensor muscle. A rating in excess of 10 percent is denied, From July 19, 2019 to January 30, 2024, there is no evidence of severe right femoral radiculopathy symptoms or of complete paralysis of the quadriceps extensor muscle. A rating in excess of 20 percent is denied. From January 31, 2024, the evidence shows severe right femoral radiculopathy symptoms. There is no evidence of complete paralysis of the quadriceps extensor muscle. A 30 percent rating, but no higher, is granted. For the left lower extremity, from July 17, 2019 to January 30, 2024, there is no evidence of severe left femoral radiculopathy symptoms or of complete paralysis of the quadriceps extensor muscle. A rating in excess of 20 percent is denied. From January 31, 2024, the evidence shows severe left femoral radiculopathy symptoms. There is no evidence of complete paralysis of the quadriceps extensor muscle. A 30 percent rating, but no higher, is granted. See 38 C.F.R. § 4.124a. DC 8526. REASONS FOR REMAND Entitlement to service connection for a sleep impairment disability, including as secondary to a thoracolumbar spine disability, is remanded. In Bailey, the United States Court of Appeals for Veterans Claims held that, pursuant to 38 C.F.R. § 3.155(d)(2), it is not necessary for a claimant to file a formal secondary service connection claim for additional complications related to a service-connected disability when such residual complications are reasonably raised by the record during the rating period for the primary disability, explaining VA's duty to maximize benefits requires it to exhaust all schedular alternatives, including entitlement to secondary service connection, when evaluating a disability. Here, the Veteran reported sleep difficulties associated with his thoracolumbar spine disability. The issue of entitlement to service connection for a sleep impairment disability, secondary to the thoracolumbar spine disability, is raised by the record. The evidence of record is inadequate to determine the claim. The matters are REMANDED for the following action: Schedule the Veteran for a VA examination for a sleep impairment disability. The examiner must review the claims file. If a diagnosis cannot be provided but the Veteran's condition manifests in symptoms that cause functional impairment, then the examiner should consider them a "disability" for the purpose of providing the requested opinion(s) below. The examiner is asked to provide a response to the following: Is it at least as likely as not that the Veteran has a sleep impairment disability? If so, is the sleep impairment disability at least as likely as not caused by the Veteran's service-connected lumbar spine disability? If not, is the sleep impairment disability at least as likely as not aggravated by the Veteran's service-connected lumbar spine disability? If the Veteran is found to have a sleep impairment disability that is either caused or aggravated by his service-connected lumbar spine disability, the examiner must describe the nature and severity of the symptoms associated with the sleep impairment disability during the appeal period. The opinion provided must explicitly address both causation and aggravation to be deemed adequate, acknowledging these are separate inquires that require different rationales. In this context, the examiner must be advised aggravation means any increase in disability, i.e., additional functional impairment in earning capacity, resulting from the secondarily claimed condition due to the primary disability. There is no requirement that such increase be permanent in nature. An opinion that simply states there is no anatomical or biological connection between the conditions without addressing whether there is additional functional impairment in earning capacity will be deemed insufficient to facilitate an informed decision on the Veteran's claim. M. HYLAND Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Jeanne Celtnieks 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.