PARKINSON'S DISEASE

K. PARAKKAL · 2026 · Case ID: A26036071

MIXED

Summary

The Veteran, a U.S. Navy Veteran who served from April 1983 to July 1989, appeals the denial of increased disability evaluations for Parkinson's disease with associated symptoms, loss of use of lower extremities, urinary problems, right and left upper extremity bradykinesia, tremors, muscle rigidity, and stiffness, bilateral speech changes, and bilateral loss of automatic movements. The Veteran also sought a compensable evaluation for loss of sense of smell and sexual dysfunction. The Board reviewed the case under the Appeals Modernization Act (AMA). The Veteran's claims for Parkinson's disease residuals, loss of use of lower extremities, urinary problems, bilateral speech changes, and bilateral loss of automatic movements were denied at the highest claimed evaluation levels for the periods reviewed. Specifically, the Board found the criteria for higher evaluations were not met for Parkinson's disease, loss of use of lower extremities, urinary problems, and bilateral speech and automatic movement changes. The claims for loss of sense of smell and sexual dysfunction were also denied. The Board granted a 50 percent evaluation for the right upper extremity symptoms for a specific period and a 40 percent evaluation for the left upper extremity symptoms for another specific period. The case was remanded for further development regarding bilateral lower extremity balance impairment, bradykinesia, tremors, muscle rigidity, and stiffness, as the prior evaluation did not adequately consider the ameliorative effects of medication.

Rationale

Criteria for higher evaluation not met; Symptoms did not meet higher evaluation thresholds

Service Branch

NAVY

Special Benefit

NO SPECIAL BENEFIT

Docket No.

251027-602436

Full Decision Text

Citation Nr: A26036071
Decision Date: 04/17/26 Archive Date: 04/17/26

DOCKET NO. 251027-602436
DATE: April 17, 2026

ORDER

Entitlement to an evaluation in excess of 50 percent evaluation for Parkinson's disease with depression and sleep disturbance from May 11, 2016 to June 20, 2024 is denied.

Entitlement to an evaluation in excess of 70 percent evaluation for Parkinson's disease with depression and sleep disturbance from June 20, 2024 is denied.

Entitlement to an evaluation in excess of 100 percent for loss of use of lower extremities is denied.

Entitlement to an evaluation in excess of 20 percent for urinary problems from May 11, 2016 to January 28, 2020 is denied.

Entitlement to an evaluation in excess of 40 percent for urinary problems from January 28, 2020 to June 20, 2024 is denied.

Entitlement to an evaluation in excess of 60 percent for urinary problems from June 20, 2024 is denied.

Entitlement to an evaluation in excess of 30 percent for right upper extremity bradykinesia, tremors, muscle rigidity, and stiffness from May 11, 2016 to September 28, 2019 is denied.

Entitlement to a 50 percent evaluation and not higher for right upper extremity bradykinesia, tremors, muscle rigidity, and stiffness from September 28, 2019 to June 20, 2024 is granted.

Entitlement to an evaluation in excess of 50 percent for right upper extremity bradykinesia, tremors, muscle rigidity, and stiffness from June 20, 2024 is denied.

Entitlement to an evaluation in excess of 40 percent for left upper extremity bradykinesia, tremors, muscle rigidity, and stiffness from May 11, 2016 to January 28, 2020 is denied.

Entitlement to an evaluation of 40 percent and not higher for left upper extremity bradykinesia, tremors, muscle rigidity, and stiffness from September 28, 2019 to June 20, 2024 is granted.

Entitlement to an evaluation in excess of 40 percent for left upper extremity bradykinesia, tremors, muscle rigidity, and stiffness from June 20, 2024 is denied.

Entitlement to an evaluation in excess of 30 percent for difficulty chewing and swallowing is denied.

Entitlement to an evaluation in excess of 30 percent for constipation is denied.

Entitlement to a compensable evaluation for loss of sense of smell is denied.

Entitlement to a compensable evaluation for sexual dysfunction is denied.

Entitlement to an evaluation in excess of 30 percent for bilateral speech changes from May 11, 2016 to January 28, 2020 is denied.

Entitlement to an evaluation of 30 percent and not higher for bilateral speech changes from January 28, 2020 to June 20, 2024 is granted.

Entitlement to an evaluation in excess of 30 percent for bilateral speech changes from June 20, 2024 is denied.

Entitlement to an evaluation in excess of 20 percent for bilateral loss of automatic movements from May 11, 2016 to January 28, 2020 is denied.

Entitlement to an evaluation of 20 percent and not higher for bilateral loss of automatic movements from January 28, 2020 to June 20, 2024 is granted.

Entitlement to an evaluation in excess of 20 percent for bilateral loss of automatic movements from June 20, 2024 is denied.

Entitlement to an evaluation in excess of 10 percent for bilateral stooped posture from May 11, 2016 to June 20, 2024 is denied.

Entitlement to a 20 percent evaluation and no higher for bilateral stooped posture from June 20, 2024 is granted.

Entitlement to an effective date prior to May 11, 2016 for the grant of entitlement to special monthly compensation based on aid and attendance is denied.

Entitlement to an effective date prior to May 11, 2016 for the grant of entitlement to special monthly compensation based on loss of use of a creative organ is denied.

Entitlement to an effective date prior to June 20, 2024 for the grant of special monthly compensation due to the need for regular aid and attendance and an additional, higher level of care is denied.

REMANDED

Entitlement to an evaluation in excess of 20 percent evaluation for bilateral lower extremity balance impairment, bradykinesia, tremors, muscle rig
4 is granted.

Entitlement to an effective date prior to May 11, 2016 for the grant of entitlement to special monthly compensation based on aid and attendance is denied.

Entitlement to an effective date prior to May 11, 2016 for the grant of entitlement to special monthly compensation based on loss of use of a creative organ is denied.

Entitlement to an effective date prior to June 20, 2024 for the grant of special monthly compensation due to the need for regular aid and attendance and an additional, higher level of care is denied.

REMANDED

Entitlement to an evaluation in excess of 20 percent evaluation for bilateral lower extremity balance impairment, bradykinesia, tremors, muscle rigidity, and stiffness from May 11, 2016 to June 20, 2024 is remanded.

FINDINGS OF FACT

1. The Veteran's Parkinson's disease with depression and sleep disturbance does not result in occupational and social impairment with deficiencies in most areas from May 11, 2016 to June 20, 2024.

2. The Veteran's Parkinson's disease with depression and sleep disturbance does not result in total occupational and social impairment from June 20, 2024.

3. The Veteran's loss of use of the lower extremities do not warrant an extraschedular evaluation from June 20, 2024.

4. The Veteran's urinary problems do not require absorbent materials which must be changed 2 to 4 times per day from May 11, 2016 to January 28, 2020.

5. The Veteran's urinary problems do not require the use of an appliance or the wearing of absorbent materials which must be changed more than 4 times per day from January 28, 2020 to June 20, 2024.

6. The Veteran's urinary problems do not warrant an extraschedular evaluation from June 20, 2024.

7. The Veteran's right-side upper extremity bradykinesia, tremors, muscle rigidity, and stiffness do not result in severe symptoms from May 11, 2016 to September 28, 2019.

8. The Veteran's right-side upper extremity bradykinesia, tremors, muscle rigidity, and stiffness result in severe symptoms from September 28, 2019 to June 20, 2024.

9. The Veteran's left-side upper extremity bradykinesia, tremors, muscle rigidity, and stiffness do not result in complete paralysis from May 11, 2016 to September 28, 2019.

10. The Veteran's left-side upper extremity bradykinesia, tremors, muscle rigidity, and stiffness results in severe symptoms from September 28, 2019 to June 20, 2024.

11. The Veteran's bilateral upper extremity bradykinesia, tremors, muscle rigidity, and stiffness do not result in complete paralysis from June 20, 2024.

12. The Veteran's difficulty chewing and swallowing does not result in severe structure of the esophageus permitting liquids only.

13. The Veteran's constipation does not result in symptoms of pain, vomiting, material weight loss and hematemesis or melena with moderate anemia or other symptom combinations productive of severe impairment of health.

14. The Veteran does not have a complete loss of the sense of smell.

15. The Veteran's sexual dysfunction is not characterized by a deformity.

16. The Veteran's bilateral speech changes did not manifest in complete paralysis from May 11, 2016 to January 28, 2020.

17. The Veteran's bilateral speech changes manifested in severe incomplete paralysis from January 28, 2020 to June 20, 2024.

18. The Veteran's bilateral speech changes did not manifest in complete paralysis from June 20, 2024.

19. The Veteran's bilateral loss of automatic movements does not result in complete paralysis from May 11, 2016 to January 28, 2020.

20. The Veteran's bilateral loss of automatic movements results in severe incomplete paralysis from January 28, 2020 to June 20, 2024.

21. The Veteran's bilateral loss of automatic movements does not result in complete paralysis from June 20, 2024.

22. The Veteran's bilateral stooped posture results in moderate incomplete paralysis from May 11, 2016 to June 20, 2024.

23. The Veteran's bilateral stooped posture results in severe incomplete paralysis from June 20, 2024.

24. The Veteran does not have an unadjudicated formal or informal claim seeking service connection for Parkinson's disease or asserting the need for regular aid and attendance prior to May
20. The Veteran's bilateral loss of automatic movements results in severe incomplete paralysis from January 28, 2020 to June 20, 2024.

21. The Veteran's bilateral loss of automatic movements does not result in complete paralysis from June 20, 2024.

22. The Veteran's bilateral stooped posture results in moderate incomplete paralysis from May 11, 2016 to June 20, 2024.

23. The Veteran's bilateral stooped posture results in severe incomplete paralysis from June 20, 2024.

24. The Veteran does not have an unadjudicated formal or informal claim seeking service connection for Parkinson's disease or asserting the need for regular aid and attendance prior to May 11, 2016.

25. The Veteran does not have an unadjudicated formal or informal claim seeking service connection for sexual dysfunction or residuals of Parkinson's disease prior to May 11, 2016.

26. The Veteran's disabilities did not require a higher level of care in addition to the need for regular aid and attendance prior to June 20, 2024.

CONCLUSIONS OF LAW

1. The criteria for entitlement to an evaluation in excess of 50 percent for Parkinson's disease with depression and sleep disturbance from May 11, 2016 to June 20, 2024 have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.124a, 4.130, Diagnostic Codes 8004-9434.

2. The criteria for entitlement to an evaluation in excess of 70 percent for Parkinson's disease with depression and sleep disturbance from June 20, 2024 have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.124a, 4.130, Diagnostic Codes 8004-9434.

3. The criteria for entitlement to an extraschedular evaluation for loss of use of lower extremities have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.321(b), 4.1, 4.3, 4.7, 4.71a, Diagnostic Code 5110.

4. The criteria for entitlement to an evaluation in excess of 20 percent for urinary problems from May 11, 2016 to January 28, 2020 have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.115b, Diagnostic Code 7542.

5. The criteria for entitlement to an evaluation in excess 40 percent for urinary problems from January 28, 2020 to June 20, 2024 have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.115b, Diagnostic Code 7542.

6. The criteria for entitlement to an extraschedular evaluation for urinary problems from June 20, 2024 have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.321(b), 4.1, 4.3, 4.7, 4.115b, Diagnostic Code 7542.

7. The criteria for entitlement to an evaluation in excess of 30 percent for right upper extremity bradykinesia, tremors, muscle rigidity, and stiffness from May 11, 2016 to September 28, 2019 have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.124a, Diagnostic Code 8514.

8. The criteria for entitlement to an evaluation of 50 percent and not higher for right upper extremity bradykinesia, tremors, muscle rigidity, and stiffness from September 28, 2019 to June 20, 2024 have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.124a, Diagnostic Code 8514.

9. The criteria for entitlement to an evaluation in excess of 50 percent for right upper extrem
.1, 4.3, 4.7, 4.124a, Diagnostic Code 8514.

9. The criteria for entitlement to an evaluation in excess of 50 percent for right upper extremity bradykinesia, tremors, muscle rigidity, and stiffness from June 20, 2024 have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.124a, Diagnostic Code 8514.

10. The criteria for entitlement to an evaluation in excess of 40 percent for left upper extremity bradykinesia, tremors, muscle rigidity, and stiffness from May 11, 2016 to September 28, 2019 have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.124a, Diagnostic Code 8514.

11. The criteria for entitlement to an evaluation of 40 percent and no higher for left upper extremity bradykinesia, tremors, muscle rigidity, and stiffness from September 28, 2019 to June 20, 2024 have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.124a, Diagnostic Code 8514.

12. The criteria for entitlement to an evaluation in excess of 40 percent for left upper extremity bradykinesia, tremors, muscle rigidity, and stiffness from June 20, 2024 have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.124a, Diagnostic Code 8514.

13. The criteria for entitlement to an evaluation in excess of 30 percent for difficulty chewing and swallowing have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.114, Diagnostic Code 7203.

14. The criteria for entitlement to an evaluation in excess of 30 percent for constipation have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.114, Diagnostic Codes 7346-7319.

15. The criteria for entitlement to a compensable evaluation for loss of sense of smell have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.87a, Diagnostic Code 6275.

16. The criteria for entitlement to a compensable evaluation for sexual dysfunction have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.115b, Diagnostic Code 7522.

17. The criteria for entitlement to an evaluation in excess of 30 percent for bilateral speech changes from May 11, 2016 to January 28, 2020 have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.124a, Diagnostic Code 8210.

18. The criteria for entitlement to an evaluation of 30 percent and not higher for bilateral speech changes from January 28, 2020 to June 20, 2024 have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.124a, Diagnostic Code 821
6 to January 28, 2020 have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.124a, Diagnostic Code 8210.

19. The criteria for entitlement to an evaluation in excess of 30 percent for bilateral speech changes from June 20, 2024 have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.124a, Diagnostic Code 8210.

20. The criteria for entitlement to an evaluation in excess of 20 percent for bilateral loss of automatic movements from May 11, 2016 to January 28, 2020 have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.124a, Diagnostic Code 8207.

21. The criteria for entitlement to an evaluation of 20 percent and not higher for bilateral loss of automatic movements from January 28, 2020 to June 20, 2024 have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.124a, Diagnostic Code 8207.

22. The criteria for entitlement to an evaluation in excess of 20 percent for bilateral loss of automatic movements from June 20, 2024 have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.124a, Diagnostic Code 8207.

23. The criteria for entitlement to an evaluation in excess of 10 percent for bilateral stooped posture from May 11, 2016 to June 2024 have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.124a, Diagnostic Code 8211.

24. The criteria for entitlement to a 20 percent evaluation and no higher for bilateral stooped posture from June 20, 2024 have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.124a, Diagnostic Code 8211.

25. The criteria for entitlement to an effective date prior to May 11, 2016 for the grant of entitlement to special monthly compensation based on aid and attendance have not been met. 38 U.S.C. § 5110; 38 C.F.R. § 3.155, 3.400, 3.2500(c).

26. The criteria for entitlement to an effective date prior to May 11, 2016 for the grant of entitlement to special monthly compensation based on loss of use of a creative organ have not been met. 38 U.S.C. § 5110; 38 C.F.R. § 3.155, 3.400, 3.2500(c).

27. The criteria for entitlement to an effective date prior to June 20, 2024 for the grant of entitlement to special monthly compensation due to the need for regular aid and attendance and an additional, higher level of care have not been met. 38 U.S.C. § 1114 (r)(2), 5110; 38 C.F.R. § 3.155, 3.350(h), 3.400, 3.2500(c).

REASONS AND BASES FOR FINDINGS AND CONCLUSIONS

The Veteran served in the U.S. Navy from April 1983 to July 1989.

This case is being reviewed according to the appellate process set forth under the Appeals Modernization Act (AMA). 38 C.F.R. § 19.2. The AMA or modernized review system applies to all claims, requests
the need for regular aid and attendance and an additional, higher level of care have not been met. 38 U.S.C. § 1114 (r)(2), 5110; 38 C.F.R. § 3.155, 3.350(h), 3.400, 3.2500(c).

REASONS AND BASES FOR FINDINGS AND CONCLUSIONS

The Veteran served in the U.S. Navy from April 1983 to July 1989.

This case is being reviewed according to the appellate process set forth under the Appeals Modernization Act (AMA). 38 C.F.R. § 19.2. The AMA or modernized review system applies to all claims, requests for reopening of finally adjudicated claims, and requests for revision based on clear and unmistakable error for which VA issues notice of an initial decision on or after February 19, 2019, the effective date of the modernized review system. See 38 C.F.R. § 3.2400.

This matter comes before the Board of Veterans' Appeals (Board) following a decision issued in October 2024 by the Department of Veterans Affairs (VA) Regional Office (RO) which granted a May 11, 2016 effective date for the grant of service connection for Parkinson's disease, its residuals, special monthly compensation based on aid and attendance criteria being met, and special monthly compensation based on loss of use of a creative organ. The decision also granted entitlement to special monthly compensation due to the need for a higher level of care in addition to the need for regular aid and attendance.

The Veteran filed a May 11, 2016 Intent to File and within one year completed a June 2016 claim seeking to reopen his claim of entitlement to service connection for Parkinson's disease. A September 2016 rating decision denied his claim.

The Veteran filed a Notice of Disagreement under the Legacy system in November 2016 and a then opted into the AMA via the Rapid Appeals Modernization Program (RAMP) in May 2018 choosing the Supplemental Claim option. A RAMP rating decision was issued in January 2019 which denied the Veteran's claim.

The Veteran filed a VA Form 10182, Decision Review Request: Board Appeal (Notice of Disagreement) in February 2019 and elected the Hearing docket. A Board hearing was held in July 2022, and a transcript is included with the file.

In November 2019, the Veteran submitted a VA Form 20-0995, Decision Review Request: Supplemental Claim, and requested readjudication of entitlement to service connection for Parkinson's disease most recently addressed in a January 2019 rating decision. In January 2020, the agency of original jurisdiction (AOJ) issued a supplemental claim decision, which found that new and relevant evidence had been received and denied the claim based on the evidence of record at the time of that decision. The Veteran filed a VA Form 10182, Decision Review Request: Board Appeal (Notice of Disagreement) in June 2020 and elected the Direct Review docket. In February 2022, the Board dismissed the appeal stemming from the June 2020 VA Form 10182 as the issue was already pending final adjudication at the time of the June 2020 submission.

In an April 2023 decision, the Board remanded entitlement to service connection for Parkinson's disease for additional development.

An April 2024 rating decision granted entitlement to service connection for Parkinson's and its residuals with August 10, 2022 effective dates. The decision also granted entitlement to special monthly compensation based on loss of use of a creative organ effective August 10, 2022.

On June 20, 2024, within a year of the April 2024 rating decision, the Veteran submitted a VA 21-2680 Examination for Housebound Status or Permanent Need for Regular Aid and Attendance which was regarded as a request for increased ratings for Parkinson's disease and its residuals. An August 2024 rating decision increased the Veteran's evaluations for Parkinson's disease and its residuals with June 20, 2024 effective dates. The decision also granted entitlement to special monthly compensation based on aid and attendance criteria being met effective August 10, 2022.

In October 2024, the Veteran submitted a VA Form 20-0996, Decision Review Request: Higher-Level Review (HLR), and requested review of an August 2024 decision. In October 2024, the agency of original jurisdiction (AOJ) issued an HLR decision on appeal, which considered the evidence of record at the time of the prior August 2024 decision. The HLR decision granted entitlement to a May 11, 2016 effective date for the grant of service connection for Parkinson's disease, its
its residuals with June 20, 2024 effective dates. The decision also granted entitlement to special monthly compensation based on aid and attendance criteria being met effective August 10, 2022.

In October 2024, the Veteran submitted a VA Form 20-0996, Decision Review Request: Higher-Level Review (HLR), and requested review of an August 2024 decision. In October 2024, the agency of original jurisdiction (AOJ) issued an HLR decision on appeal, which considered the evidence of record at the time of the prior August 2024 decision. The HLR decision granted entitlement to a May 11, 2016 effective date for the grant of service connection for Parkinson's disease, its residuals, special monthly compensation based on aid and attendance criteria being met, and special monthly compensation based on loss of use of a creative organ. The decision also granted entitlement to special monthly compensation due to the need for a higher level of care in addition to the need for regular aid and attendance.

The Veteran filed a VA Form 10182, Decision Review Request: Board Appeal (Notice of Disagreement) in October 2025 and elected the Direct Review docket.

Therefore, the Board may only consider the evidence of record at the time of the August 2024 agency of original jurisdiction (AOJ) decision, which was subsequently subject to higher-level review. 38 C.F.R. § 20.301. If evidence was submitted during the period after the AOJ issued the decision, which was subsequently subject to higher-level review the Board did not consider it in its decision. 38 C.F.R. §§ 20.300, 20.301, 20.801.

If the Veteran would like VA to consider any evidence that was submitted that the Board could not consider, the Veteran may file a Supplemental Claim (VA Form 20-0995) 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 claims, considering the new evidence in addition to the evidence previously considered. Id. Specific instructions for filing a Supplemental Claim are included with this decision.

However, because the Board is remanding the claim seeking an increased evaluation for disabilities of the bilateral lower extremities for the period from May 11, 2016 to June 20, 2024, any evidence the Board could not consider will be considered by the AOJ in the adjudication of those claims. 38 C.F.R. § 3.103(c)(2)(ii).

Law and Analysis

Disability evaluations (ratings) are determined by evaluating the extent to which a veteran's service-connected disability adversely affects his ability to function under the ordinary conditions of daily life, including employment, by comparing the symptomatology with the criteria set forth in the Schedule for Rating Disabilities (Rating Schedule). 38 U.S.C. § 1155; 38 C.F.R. §§ 4.1, 4.2, 4.10.

In evaluating a disability, the Board considers the current examination reports in light of the entire record to ensure that the current rating accurately reflects the severity of the condition. The Board has a duty to acknowledge and consider all regulations that are potentially applicable. Schafrath v. Derwinski, 1 Vet. App. 589 (1991). 38 C.F.R. §§ 4.1, 4.2, 4.10.

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 required for that rating. Otherwise, the lower rating will be assigned. See 38 C.F.R. § 4.7. Reasonable doubt regarding the degree of disability will be resolved in the veteran's favor. 38 C.F.R. § 4.3.

Except as otherwise provided by law, a claimant has the responsibility to present and support a claim for benefits. VA shall consider all information and lay and medical evidence of record in a case and 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; Lynch v. McDonough, 21 F.4th 776 (Fed. Cir. 2021) (benefit-of-the-doubt rule not for application when evidence persuasively favors one side or the other).

Parkinson's Disease

The Veteran seeks entitlement to increased evaluations for service-connected Parkinson's disease which is afforded a 50 percent evaluation from May 11, 2016 and a 70 percent evaluation from June 20, 2024.

The Veteran's condition is rated by analogy under Diagnostic Codes (DC
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; Lynch v. McDonough, 21 F.4th 776 (Fed. Cir. 2021) (benefit-of-the-doubt rule not for application when evidence persuasively favors one side or the other).

Parkinson's Disease

The Veteran's condition is rated by analogy under Diagnostic Codes (DC) 8004-9434 for paralysis agitans and major depressive disorder. See 38 C.F.R. § 4.20 (conditions that are not specifically listed in the Rating Schedule may be rated by analogy under the diagnostic code of a closely related disease or injury).

Under DC 8004, the minimum evaluation is 30 percent. Neurological conditions and convulsive disorders evaluated under 38 C.F.R. § 4.124a are rated from 10 percent to 100 percent in proportion to the impairment of motor, sensory, or mental function with consideration especially afforded to psychotic manifestations, complete or partial loss of use of one or more extremities, speech disturbances, impairment of vision, disturbances of gait, tremors, visceral manifestations, etc., referring to the appropriate bodily system of the schedule. Accordingly, the Board applies the criteria of DC 9434 due to the Veteran's psychiatric manifestations.

DC 9434 utilizes the General Rating Formula for Mental Disorders (General Rating Formula), which is used to assign ratings ranging between 0 and 100 percent.

Under the General Rating Formula, a 30 percent evaluation is assigned for occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, mild memory loss (such as forgetting names, directions, recent events). 38 C.F.R. § 4.130, DC 9411.

A 50 percent rating is assigned for occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped, speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short and long term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; and difficulty in establishing and maintaining effective work and social relationships. Id.

A 70 percent rating is assigned when a psychiatric disorder causes occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work-like setting); inability to establish and maintain effective relationships. Id.

A 100 percent disability rating is assigned total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; and memory loss for names of close relatives, or for the veteran's own occupation or name. Id.

The Veteran was afforded VA examinations in December 2019 and August 2024.

The December 2019 examination noted a diagnosis of adjustment disorder with mixed anxiety and depressed mood noting anxiety and depression about worsening impairment and functional loss from Parkinson's disease. The examiner noted occupational and social impairment with reduced reliability and productivity. The Veteran reported living with his spouse, daughter, and two grandchildren who provided him with good social support. He avoids communication as Parkinson's has impaired his speech. His impaired motor function and fear of accidents prevents him from performing household repairs, yard work or enjoying puzzles and off-roading. He noted small falls weekly. The Veteran continued to enjoy golfing, cycling, skiing, and swimming. He previously worked as a nurse but has been unemployed since February 2009 due to motor impairment associated with Parkinson's disease. He previously led a support group for Parkinson's disease and received counseling for depression associated with unemployment, lost
anxiety and depression about worsening impairment and functional loss from Parkinson's disease. The examiner noted occupational and social impairment with reduced reliability and productivity. The Veteran reported living with his spouse, daughter, and two grandchildren who provided him with good social support. He avoids communication as Parkinson's has impaired his speech. His impaired motor function and fear of accidents prevents him from performing household repairs, yard work or enjoying puzzles and off-roading. He noted small falls weekly. The Veteran continued to enjoy golfing, cycling, skiing, and swimming. He previously worked as a nurse but has been unemployed since February 2009 due to motor impairment associated with Parkinson's disease. He previously led a support group for Parkinson's disease and received counseling for depression associated with unemployment, lost functioning, and strain on his prior marriage. His symptoms of depression, fatigue, impairment of speech, walking ability, swallowing, sleep disturbances, bladder/constipation, blood pressure changes, smell dysfunction, pain, memory, impaired sexual performance, and manual dexterity had all worsened since his Parkinson's diagnosis. The examiner noted symptoms of depressed mood, anxiety, chronic sleep impairment disturbances of motivation and mood, and difficulty in establishing and maintaining effective work and social relationships. The Veteran was alert and oriented during the examination. He ambulated by shuffling with fast-paced steps, use of a walking stick, and immobile right arm. The Veteran had an intermittent hand and arm tremor with soft and slightly slurred speech. He was cooperative, agreeable, with full range of affect and congruent mood. The examiner noted logical, goal directed thought process, no evidence of psychosis or memory abnormalities, and good insight and judgment. The Veteran denied suicidal ideation, plan, intent, or attempts.

The August 2024 VA examiner noted a diagnosis of depressive disorder due to other medical conditions with anxiety and major depressive like episodes, distress. The examiner noted this results in occupational and social impairment with reduced reliability and productivity. The Veteran reported living with his spouse and experiencing significant decline in his physical condition due to Parkinson's and is mostly homebound. He uses a wheelchair and can barely communicate with others due to his speech impairment. The Veteran's adult children visit. Due to her visual impairment, the Veteran's spouse cannot drive, and they mostly remain at home. The Veteran has increased depression and spends most of his days lying in bed. The Veteran requires total assistance. He has a psychologist and a physical therapist come to his home. He reported worries and anxieties about his future and family, sleeping most of the time, passive suicidal ideation, and social isolation. The examiner noted symptoms of depressed mood; anxiety; chronic sleep impairment; mild memory loss, such as forgetting names, directions or recent events; flattened affect; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships; difficulty adapting to stressful circumstances, including work or a work like setting; inability to establish and maintain effective relationships; suicidal ideation. The Veteran was at home for the examination. His speech was difficult to understand, and his spouse answered most of the questions. He was wheelchair bound and had a depressed mood. His affect was congruent to thought content with no delusion or hallucinations noted. He had logical and relevant thoughts and was cooperative.

The Veteran submitted a June 2024 examination where the provider noted a diagnosis of depression. The Veteran needed assistance with bathing and showering, eating or self-feeding, dressing, ambulating, testing to hygiene needs, transferring in or out of bed and chairs, toileting, medication management, and additional activities. He was noted to be clean and well cared for.

Based on the foregoing, the Board finds the Veteran's disability does not warrant an evaluation in excess of 50 percent evaluation from May 11, 2016 and does not warrant an evaluation in excess of 70 percent from June 20, 2024.

For the period prior to June 20, 2024, the Veteran's symptoms do not result in occupational and social impairment with deficiencies in most areas as contemplated by the higher rating criteria. The Veteran is noted to have symptoms of depressed mood, anxiety, chronic sleep impairment disturbances of motivation and mood, and difficulty in establishing and maintaining effective work and social relationships. These symptoms are contemplated by the 50 percent criteria and lesser. He also reported fatigue and memory difficulty which approximate depressed mood and impairment of memory which are contemplated by the 50 percent criteria and lesser. Accordingly, the Board finds the Veteran's symptoms do not rise to the level of severity contemplated by the higher rating criteria for the period prior to June 20, 2024.

For the period beginning June 20, 2024, the Board finds the Veteran's symptoms do not result in total occupational and social impairment as contemplated by the 100 percent rating criteria. Worsening of the Veteran's depression was first noted in the June 2024 evaluation. During this period, the Veteran
in establishing and maintaining effective work and social relationships. These symptoms are contemplated by the 50 percent criteria and lesser. He also reported fatigue and memory difficulty which approximate depressed mood and impairment of memory which are contemplated by the 50 percent criteria and lesser. Accordingly, the Board finds the Veteran's symptoms do not rise to the level of severity contemplated by the higher rating criteria for the period prior to June 20, 2024.

For the period beginning June 20, 2024, the Board finds the Veteran's symptoms do not result in total occupational and social impairment as contemplated by the 100 percent rating criteria. Worsening of the Veteran's depression was first noted in the June 2024 evaluation. During this period, the Veteran is noted to have symptoms of depressed mood; anxiety; chronic sleep impairment; mild memory loss, such as forgetting names, directions or recent events; flattened affect; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships; difficulty adapting to stressful circumstances, including work or a work like setting; inability to establish and maintain effective relationships; suicidal ideation. These symptoms are contemplated by the 70 percent criteria and lesser.

The Veteran also reports social isolation which approximates difficulty in establishing and maintaining effective work and social relationships which is contemplated by the 50 percent criteria.

The Board notes that due to the Veteran's physical disabilities, he is unable to perform activities of daily living including maintenance of minimal personal hygiene. This symptom is characteristic of his physical conditions which are addressed below. The Board finds the Veteran's psychiatric disability does not result in symptoms contemplated by the higher rating criteria for the period from June 20, 2024.

The evidence indicates the Veteran's children visit him when possible and he lives with his spouse which weighs against a finding of total social impairment. The Veteran has not been able to maintain employment since February 2009 due to his motor impairment associated with of Parkinson's disease which is addressed below.

Accordingly, entitlement to evaluations in excess of 50 percent from May 11, 2016 and in excess of 70 percent from June 20, 2024 for psychiatric residuals of Parkinson's disease are not warranted. The Veteran's claim is denied.

As the evidence is persuasively against a grant of increased evaluations, the benefit of the doubt doctrine under 38 U.S.C. §5107(b), is not for application. Lynch v. McDonough, 21 F.4th 776 (Fed. Cir. 2021) (en banc) (only when the evidence persuasively favors one side or another is the benefit of the doubt doctrine not for application).

Bilateral Lower Extremities

The Veteran seeks increased evaluations for disabilities of the bilateral lower extremities. He is afforded a 20 percent evaluation for bilateral lower extremity balance impairment, bradykinesia, tremors, muscle rigidity, and stiffness associated with Parkinson's disease with depressive disorder with anxious distress, major depressive like episodes, and cognitive impairment from May 11, 2016 to June 20, 2024. He is afforded a 100 percent evaluation for loss of use of lower extremities associated with Parkinson's disease with depressive disorder with anxious distress, major depressive like episodes, and cognitive impairment from June 20, 2024.

The period from May 11, 2016 to June 20, 2024 is addressed separately below.

The Veteran's condition is evaluated under DC 5110 from June 20, 2024.

Under DC 5110 for the loss of use of both feet, a 100 percent evaluation is warranted with additional consideration for entitlement to special monthly compensation. The Board addresses entitlement to special monthly compensation separately below.

VA Medical Center (VAMC) records from April 2024 document the Veteran's slow, shuffled gait with festination and freezing with turns.

During the period beginning from June 20, 2024, the Veteran submitted a June 2024 private evaluation and was afforded VA examination in August 2024.

The June 2024 examination noted contractures in all extremities. The provider noted the Veteran's legs are rigid and contracted. He has limited ability to walk and only with great difficulty. When he ambulates, he cannot pick up his feet and will shuffle. He falls multiple times weekly.

The August 2024 examiner noted a moderate tremor and moderate muscle rigidity and stiffness of the bilateral lower extremities. The Veteran had severe bradykinesia. During an August 2024 mental health examination, the Veteran was noted to be wheelchair-bound.

Based on the foregoing, the Board finds that from June 20, 2024, worsening of the Veteran's symptoms are noted as the provider found contractures in all extremities, rigidity, and great difficulty ambulating a limited distance with frequent falls. The
Veteran's legs are rigid and contracted. He has limited ability to walk and only with great difficulty. When he ambulates, he cannot pick up his feet and will shuffle. He falls multiple times weekly.

Based on the foregoing, the Board finds that from June 20, 2024, worsening of the Veteran's symptoms are noted as the provider found contractures in all extremities, rigidity, and great difficulty ambulating a limited distance with frequent falls. The Veteran was noted to be wheelchair-bound. The 100 percent evaluation for loss of use of lower extremities under DC 5110 is the highest schedular evaluation. The Board addresses entitlement to special monthly compensation separately below.

The Veteran's 100 percent evaluation is the highest possible under the rating schedule and a rating in excess of 100 percent would constitute an extraschedular rating. The determination of whether a claimant is entitled to an extraschedular rating under 38 C.F.R. § 3.321 (b) is a three-step inquiry. The threshold factor for extraschedular consideration is a finding that the evidence before VA presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. Thun v. Peake, 22 Vet. App. 111, 115 (2008) (citing Fisher v. Principi, 4 Vet. App. 57, 60 (1993), and Floyd v. Brown, 9 Vet. App. 88, 95 (1996)). Therefore, initially, there must be a comparison between the level of severity and symptomatology of the claimant's service-connected disability with the established criteria found in the rating schedule for that disability...[I]f the criteria reasonably describe the claimant's disability level and symptomatology, then the claimant's disability picture is contemplated by the rating schedule, the assigned schedular evaluation is, therefore, adequate. Thun, 4 Vet. App at 115.

In October 2025, the Court of Appeals for Veterans Claims (CAVC) decided Witkowski v. Collins, 2025 U.S. App. Vet. Claims LEXIS 1423 (October 21, 2025), which overruled Bowling v. Principi, 15 Vet. App. 1 (2001), holding that the Board may consider a claim on an extraschedular basis in the first instance, without first receiving a decision from VBA's Executive Director of Compensation Service. Accordingly, the Board has considered whether an extraschedular rating is appropriate.

With respect to the first prong of Thun, the Board finds that the weight of the evidence does not show such an exceptional disability picture that the available schedular evaluation for the Veteran's bilateral lower extremity is inadequate. The Veteran's symptoms are contemplated by the schedular criteria, and the schedular criteria anticipates loss of use of lower extremities. See also 38 C.F.R. § 4.1. As such, the available schedular criteria for the Veteran's service-connected bilateral lower extremity condition are adequate and an extraschedular evaluation is not warranted.

Accordingly, the Veteran's claim seeking entitlement to an evaluation in excess of 100 percent from June 20, 2024 is denied.

As the evidence is persuasively against an extraschedular evaluation from June 20, 2024, the benefit of the doubt doctrine under 38 U.S.C. §5107(b), is not for application. Lynch v. McDonough, 21 F.4th 776 (Fed. Cir. 2021) (en banc) (only when the evidence persuasively favors one side or another is the benefit of the doubt doctrine not for application).

Urinary Problems

The Veteran seeks entitlement to increased evaluations for urinary problems associated with Parkinson's disease with depressive disorder with anxious distress, major depressive like episodes, and cognitive impairment. The Veteran's disability is afforded a 20 percent evaluation from May 11, 2016, a 40 percent evaluation from January 28, 2020, and a 60 percent evaluation from June 20, 2024.

The Veteran's condition is evaluated under Diagnostic Code (DC) 7542. The criteria for DC 7542 was amended November 14, 2021, during the pendency of the Veteran's appeal. The pre-amended criteria evaluate neurogenic bladder as voiding dysfunction. The amended criteria rate neurogenic bladder as voiding dysfunction or urinary tract infection.

The criteria for voiding dysfunction was not altered by the amendment. A 20 percent rating is warranted
like episodes, and cognitive impairment. The Veteran's disability is afforded a 20 percent evaluation from May 11, 2016, a 40 percent evaluation from January 28, 2020, and a 60 percent evaluation from June 20, 2024.

The criteria for voiding dysfunction was not altered by the amendment. A 20 percent rating is warranted for a disability requiring the wearing of absorbent materials which must be changed less than 2 times per day. A 40 percent is warranted for a disability requiring the wearing of absorbent materials which must be changed 2 to 4 times per day. A 60 percent rating is warranted for a disability requiring the use of an appliance or the wearing of absorbent materials which must be changed more than 4 times per day.

The pre-amendment criteria for urinary tract infection afforded a 10 percent evaluation for long-term drug therapy, 1-2 hospitalizations per year and/or requiring intermittent intensive management. A 30 percent evaluation was warranted for recurrent symptomatic infection requiring drainage/frequent hospitalization (greater than two times/year), and/or requiring continuous intensive management. Poor renal function is to be evaluated as renal dysfunction.

The amended criteria for a urinary tract infection assign a noncompensable evaluation to recurrent symptomatic infection not requiring hospitalization, but requiring suppressive drug therapy for less than 6 months. A 10 percent evaluation is warranted for recurrent symptomatic infection requiring 1-2 hospitalizations per year or suppressive drug therapy lasting six months or longer. A 30 percent evaluation is warranted for recurrent symptomatic infection requiring drainage by stent or nephrostomy tube; or requiring greater than 2 hospitalizations per year; or requiring continuous intensive management.

Generally, if a law or regulation changes during the course of a claim or an appeal, the version more favorable to the Veteran will apply, to the extent permitted by any stated effective date in the amendment in question. 38 U.S.C. § 5110 (g). If the revised version of the regulation is more favorable, the implementation of that regulation under 38 U.S.C. § 5110 (g) can be no earlier than the effective date of that change. If the former version is more favorable, VA can apply the earlier version of the regulation for the period prior to, and from, the effective date of the change. 38 U.S.C. § 5110. Here, the Board finds the Veteran's symptoms more closely approximate voiding dysfunction rather than urinary tract infection as the record does not document urinary tract infections. The Veteran's medical treatment records document urinary incontinence and increased frequency. See VAMC medical records.

Accordingly, the Board applies the rating criteria for voiding dysfunction to the Veteran's claim consistent with the provisions of DC 7542 and notes the criteria for voiding dysfunction was not altered by the criteria amendments.

VA Medical Cener (VAMC) treatment records document the Veteran's overactive bladder with urgency and frequency with incontinence. See October 2019 treatment record.

The Veteran submitted a May 2013 examination which noted moderate urinary problems requiring one absorbent material per day. He denied use of an appliance.

The Veteran was afforded VA examinations in January 2020, December 2023, and August 2024.

During the January 2020 examination, the Veteran reported use of two to four absorbent materials per day due to urinary problems. He denied use of an appliance.

During the December 2023 examination, the Veteran reported greater than four absorbent materials per day due to urinary problems. He denied use of an appliance.

During the August 2024 examination, the Veteran reported greater than four absorbent materials per day due to urinary problems and noted use of an appliance.

The Veteran also submitted a June 2024 examination where the provider noted the Veteran was no longer continent of bowel or bladder and is unable to get to the bathroom in time due to poor balance and speed.

The Board affords great probative weight to the January 2020, December 2023, and August 2024 VA examinations as well as the June 2024 private evaluation as the examiners conducted objective testing to evaluate all signs and symptoms which indicate the severity of the Veteran's disability. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 302 (2009).

Based on the foregoing the Board finds the Veteran's urinary disability warrants a 20 percent evaluation from May
The Veteran also submitted a June 2024 examination where the provider noted the Veteran was no longer continent of bowel or bladder and is unable to get to the bathroom in time due to poor balance and speed.

Based on the foregoing the Board finds the Veteran's urinary disability warrants a 20 percent evaluation from May 11, 2016, a 40 percent evaluation from January 28, 2020, and a 60 percent evaluation from June 20, 2024. Prior to January 28, 2020, the evidence indicates use of absorbed material one time per day which does not meet the criteria greater than 20 percent. From January 28, 2020 to June 20, 2024, the evidence indicates use of absorbent materials two to four times per day without an assistive appliance which does not meet the criteria greater than 40 percent. Finally, worsening of the Veteran's disability is noted from June 20, 2024 when it was noted the Veteran was no longer continent of bowel or bladder. The August 2024 examination indicated the Veteran required use of an assistive device and absorbent materials greater than four times per day.

The Veteran's 60 percent evaluation is the highest possible under the rating schedule and a rating in excess of 60 percent would constitute an extraschedular rating. The determination of whether a claimant is entitled to an extraschedular rating under 38 C.F.R. § 3.321 (b) is a three-step inquiry. The threshold factor for extraschedular consideration is a finding that the evidence before VA presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. Thun v. Peake, 22 Vet. App. 111, 115 (2008) (citing Fisher v. Principi, 4 Vet. App. 57, 60 (1993), and Floyd v. Brown, 9 Vet. App. 88, 95 (1996)). Therefore, initially, there must be a comparison between the level of severity and symptomatology of the claimant's service-connected disability with the established criteria found in the rating schedule for that disability...[I]f the criteria reasonably describe the claimant's disability level and symptomatology, then the claimant's disability picture is contemplated by the rating schedule, the assigned schedular evaluation is, therefore, adequate. Thun, 4 Vet. App at 115.

With respect to the first prong of Thun, the Board finds that the weight of the evidence does not show such an exceptional disability picture that the available schedular evaluation for the Veteran's urinary disability is inadequate. The Veteran's symptoms are contemplated by the schedular criteria, and the schedular criteria anticipates urinary disability requiring the use of an appliance and greater than four absorbent materials per day. See also 38 C.F.R. § 4.1. As such, the available schedular criteria for the Veteran's service-connected urinary disability are adequate, and an extraschedular rating is not warranted.

Accordingly, the Board finds evaluations in excess of 20 percent from May 11, 2016, in excess of 40 percent from January 28, 2020, and in excess of 60 percent from June 20, 2024 are denied.

Bilateral Upper Extremities

The Veteran seeks entitlement to increased evaluations for bilateral upper extremity brady
11, 2016, in excess of 40 percent from January 28, 2020, and in excess of 60 percent from June 20, 2024 are denied.

Bilateral Upper Extremities

The Veteran seeks entitlement to increased evaluations for bilateral upper extremity bradykinesia, tremors, muscle rigidity, and stiffness associated with Parkinson's disease with depressive disorder with anxious distress, major depressive like episodes, and cognitive impairment. The Veteran's right-side disability is afforded a 30 percent evaluation from May 11, 2016, a 20 percent evaluation from January 28, 2020, and a 50 percent from June 20, 2024. His left-side disability is afforded a 40 percent evaluation from May 11, 2016, a 20 percent from January 28, 2020, and a 40 percent evaluation from June 20, 2024.

The Veteran's condition is evaluated under Diagnostic Code (DC) 8514. The Veteran is right-hand dominant. Under DC 8514 for incomplete paralysis of the major side, mild symptoms warrant a 20 percent evaluation, moderate symptoms warrant a 30 percent evaluation, and severe symptoms warrant a 50 percent evaluation. For incomplete paralysis of the minor side, mild symptoms warrant a 20 percent evaluation, moderate symptoms warrant a 20 percent evaluation, and severe symptoms warrant a 40 percent evaluation. Complete paralysis of the major side warrants a 70 percent evaluation and 60 percent of the minor side. Complete paralysis consists of drop of hand and fingers, wrist and fingers perpetually flexed, the thumb adducted falling within the line of the outer border of the index finger; can not extend hand at wrist, extend proximal phalanges of fingers, extend thumb, or make lateral movement of wrist; supination of hand, extension and flexion of elbow weakened, the loss of synergic motion of extensors impairs the hand grip seriously; total paralysis of the triceps occurs only as the greatest rarity.

The terms mild, moderate, and severe are not defined in the diagnostic code and, therefore, rather than applying a mechanical formula, the Board must evaluate all the evidence in arriving at a decision regarding an increased rating. 38 C.F.R. 4.6. The Board finds, however, that these terms are unambiguous and, therefore, a plain dictionary meaning is an appropriate definition. Cf. Kisor v. Wilkie, 139 S. Ct. 2400, 2415 (2019); see also 38 C.F.R. § 4.6 (noting, in general, the Board does not evaluate evidence by applying a mechanical formula, but rather conscientiously to the end that its decisions are equitable and just). According to Merriam Webster's Collegiate Dictionary 999 (11th Ed. 2007), "mild" means small in amount. "Moderate" means limited in scope or effect. "Severe" means very painful or harmful or of a great degree. Although a medical examiner's use of descriptive terminology is an element of evidence to be considered by the Board, it is not dispositive of an issue. The Board must evaluate all evidence in arriving at a decision regarding an increased rating. 38 C.F.R. §§ 4.2, 4.6.

During a September 2019 re-evaluation, the Veteran was noted to be actively using his right hand and arm rather than his left and he reported a bilateral upper extremity tremor controlled with deep brain stimulation. See medical treatment record. November 2019 treatment records indicate his left side symptoms were worse than the right which was found to be mild. The Veteran reported left hand numbness and used his right hand for movements such as removing his glasses. See medical treatment records. He reported worsening left side tremors in June 2023. In November 2023, he reported tingling and numbness of his upper extremities and the ability to perform activities of daily living with his left hand. During a January 2024 assessment, the Veteran reported his left hand tremors, festination, and freezing were progressively worse. Though the Veteran is right hand dominant, he reported using his left hand for feeding and other tasks due to the numbness and impaired function in his right hand. He also reported needing assistance for threading his upper extremities through shirts and will not change clothes if a caregiver is
The Veteran reported left hand numbness and used his right hand for movements such as removing his glasses. See medical treatment records. He reported worsening left side tremors in June 2023. In November 2023, he reported tingling and numbness of his upper extremities and the ability to perform activities of daily living with his left hand. During a January 2024 assessment, the Veteran reported his left hand tremors, festination, and freezing were progressively worse. Though the Veteran is right hand dominant, he reported using his left hand for feeding and other tasks due to the numbness and impaired function in his right hand. He also reported needing assistance for threading his upper extremities through shirts and will not change clothes if a caregiver is not available to provide assistance.

The Veteran submitted a May 2013 examination which noted mild tremors of the right upper extremity and moderate tremors of the left upper extremity. The provider also noted moderate muscle rigidity and stiffness of the bilateral upper extremities. Moderate bradykinesia or slower motion was also noted.

The Veteran was afforded VA examinations in January 2020, December 2023, and August 2024.

During the January 2020 examination, the Veteran was noted to have no tremor of the bilateral upper extremities. He was found to have mild muscle rigidity and stiffness of the right and left sides. Moderate bradykinesia or slower motion was also noted.

The December 2023 examiner noted a tremor characterized by hand shaking and pill-rolling that was of moderate severity in the right upper extremity and mild severity of the left upper extremity. He was also found to have severe muscle rigidity and stiffness of the right upper extremity and moderate symptoms of the left upper extremity. Severe bradykinesia or slower motion was also noted.

The August 2024 VA examiner noted a severe tremor of the right upper extremity and a moderate tremor of the left upper extremity. The Veteran was found to have moderate muscle rigidity and stiffness of the bilateral upper extremities. Severe bradykinesia or slower motion was also noted.

A June 2024 private examination noted the Veteran had lost most of his upper extremity motor skills compound with bilateral tremors. He had no fine motor movements, a loose grip that frequently dropped items, and required assistance to dress and feed himself most foods.

Based on the foregoing, the Board finds the appropriate stages for the Veteran's bilateral upper extremity disabilities are from May 11, 2016 through September 28, 2019, from September 28, 2019 through June 20, 2024, and from June 20, 2024 onwards. The Board addresses each period below.

For the period from May 11, 2016 through September 28, 2019, the Board finds the Veteran's right-side upper extremity disability did not result in severe incomplete paralysis warranting a rating in excess of 30 percent. His left side disability did not result in complete paralysis warranting an evaluation in excess of 40 percent for the minor side.

Regarding the Veteran's right upper extremity for the period from May 11, 2016 to September 28, 2019, the Board finds the Veteran's disability manifests in moderate symptoms warranting a 30 percent evaluation and not higher as the evidence indicates he experienced mild tremors, moderate muscle rigidity and stiffness, and moderate bradykinesia. The evidence of record does not document severe symptoms of the right upper extremity during this period.

Regarding the Veteran's left upper extremity for the period from May 11, 2016 to September 28, 2019, the Board finds the Veteran's disability did not manifest in complete paralysis as the evidence of record indicates some ability to enact movement.

For the period from September 28, 2019 to June 20, 2024, the Board finds the Veteran's bilateral upper extremity disability symptoms were severe and the January 2020 VA examination inadequately represents the Veteran's level of impairment during this period. Worsening of the Veteran's disability was noted in September 2019 medical treatment records which document the Veteran's right arm weakness and numbness, tremor, and use of his right hand and arm rather than his left to perform basic tasks. He also reported left hand numbness and weakness in his right hand particularly with grasping objects. Treatment records continue to reflect worsening symptoms including tingling, numbness, and tremors. He reported relying on his left hand to perform tasks due to the severity of impairment in his right hand, however his left hand continued to worsen with festination and freezing. The December 2023 VA examination during this period noted a tremor characterized by hand shaking and pill-rolling that was of moderate severity in the
orsening of the Veteran's disability was noted in September 2019 medical treatment records which document the Veteran's right arm weakness and numbness, tremor, and use of his right hand and arm rather than his left to perform basic tasks. He also reported left hand numbness and weakness in his right hand particularly with grasping objects. Treatment records continue to reflect worsening symptoms including tingling, numbness, and tremors. He reported relying on his left hand to perform tasks due to the severity of impairment in his right hand, however his left hand continued to worsen with festination and freezing. The December 2023 VA examination during this period noted a tremor characterized by hand shaking and pill-rolling that was of moderate severity in the right upper extremity and mild severity of the left upper extremity. He was also found to have severe muscle rigidity and stiffness of the right upper extremity and moderate symptoms of the left upper extremity. Severe bradykinesia or slower motion was also noted. As the January 2020 examination is inconsistent with the additional medical evidence of record documenting worsening and severe symptoms of the bilateral upper extremities, it is found to be inadequate and afforded no consideration in evaluating the severity of the Veteran's disability from September 28, 2019 to June 20, 2024.

Accordingly, for the period from September 28, 2019 to June 20, 2024, the Board finds the evidence supports a finding of severe incomplete paralysis of the bilateral upper extremities. The Veteran was noted to have the ability to enact movement with his right and left sides therefore a finding of complete paralysis is not warranted.

The Board notes an effective date of September 28, 2019 is warranted for the grant of an increased evaluation as this is the earliest date as of which it is factually ascertainable that an increase in disability had occurred. Swain v. McDonald, 27 Vet. App. 219, 224 (2015) (holding that the effective date for an increased rating is predicated on when the increase in the disability can be ascertained).

For the period from June 20, 2024 onwards, the Board finds the Veteran's disability did not result in complete paralysis such that an increased evaluation is warranted. The June and August 2024 examinations document a worsening of symptoms as the providers found the Veteran had lost most of his upper extremity motor skills compound with bilateral tremors and noted a severe tremor with moderate muscle rigidity and stiffness. While the Veteran's level of disability is significant during this period, he maintains some capacity to enact movement and therefore is not found to be completely paralyzed.

Here, the Board notes the deep brain stimulation treatment the Veteran received does not constitute an ameliorative effect of medication as contemplated by Jones v. Shinseki, 26 Vet. App. 56, 63 (2012) and therefore the provisions of Jones do not apply.

Therefore, an evaluation of 50 percent and not higher for severe incomplete paralysis of the right-side upper extremity with bradykinesia, tremors, muscle rigidity, and stiffness associated with Parkinson's disease with depressive disorder with anxious distress, major depressive like episodes, and cognitive impairment for the period from September 28, 2019 to June 20, 2024 is granted. An evaluation of 40 percent for severe incomplete paralysis of the Veteran's left-side upper extremity with bradykinesia, tremors, muscle rigidity, and stiffness associated with Parkinson's disease with depressive disorder with anxious distress, major depressive like episodes, and cognitive impairment is warranted for the entire period on appeal beginning from May 11, 2016. Increased evaluations for disability of the bilateral upper extremities for all other periods on appeal are denied.

Chewing and Swallowing

The Veteran seeks entitlement to an evaluation in excess of 30 percent evaluation for difficulty chewing and swallowing associated with Parkinson's disease with depressive disorder with anxious distress, major depressive like episodes, and cognitive impairment.

The Veteran's condition is afforded a 30 percent evaluation effective from May 11, 2016 under Diagnostic Code (DC) 7203.

DC 7203 was amended on May 19, 2024. The pre-amended criteria of DC 7203 afforded a 30 percent evaluation for moderate stricture of the esophagus. A 50 percent evaluation is warranted for severe structure of the esophageus permitting liquids only. An 80 percent evaluation is warranted where the disability permits passage of liquids only, with marked impairment of general health.

Under the amended criteria of DC 7203, a noncompensable evaluation is warranted with documented history without daily symptoms or requirement for daily medications. A 10 percent evaluation is warranted with documented history of esophageal stricture(s) that requires daily medications to control dysphagia otherwise asymptomatic. A 30 percent evaluation is warranted with documented history of recurrent esophageal stricture(s) causing dysphagia which requires dilatation no more than 2 times per year. A 50 percent evaluation is warranted with documented history of recurrent or refractory esophageal stricture(s) causing dysphagia which requires at least one of the following (1) dilatation 3 or more times per year, (2) dilatation using steroids at least one time per year, or (3) esophageal stent placement. An 80 percent evaluation is warranted with documented history of recurrent or refractory esophageal stricture(s) causing dysphagia with at least one of the symptoms present: (1) aspiration, (2) undernutrition, and/or (3) substantial weight loss as defined by § 4.112(a) and treatment with either surgical correction or percutaneous esophago-gastrointestinal tube (PEG tube).

Note 1 to DC 7203 states findings must be documented by barium swallow, computerized tomography, or esophagogastroduodenoscopy. Note 2 states non-gastrointestinal complications of procedures should be rated under the appropriate system. Note 3 states this diagnostic code applies, but is not limited to, esophagitis, mechanical or chemical; Mallory Weiss syndrome (bleeding at junction of esophagus and stomach due to tears) due to caustic ingestion of alkali or acid; drug-induced or infectious esophagitis due to Candida, virus, or other organism; idiopathic eosinophilic, or lymphocytic esophagitis; esophagitis due to radiation therapy; esophagitis due to peptic stricture; and any esophageal condition that requires treatment with sclerotherapy. Note 4 states recurrent esophageal stricture is defined as the inability to maintain target esophageal diameter beyond 4 weeks after the target diameter has been achieved. Note 5 states refractory esophageal stricture is defined as the inability to achieve target esophageal diameter despite receiving no fewer than 5 dilatation sessions performed at 2-week intervals.

Generally, if a law or regulation changes during the course of a claim or an appeal, the version more favorable to the Veteran will apply, to the extent permitted by any stated effective date in the amendment in question. 38 U.S.C. § 5110 (g). If the revised version of the regulation is more favorable, the implementation of that regulation under 38 U.S.C. § 5110 (g) can be no earlier than the effective date of that change. If the former version is more favorable, VA can apply the earlier version of the regulation for the period prior to, and from, the effective date of the change. 38 U.S.C. § 5110. As such, the Board will consider whether an increased rating is warranted under either regulation from May 19, 2024.

VA Medical Center (VAMC) treatment records note the Veteran experiences dysphagia with both solids and liquids that is most difficult with dry foods. He had a December 2017 study that was normal. The records document no recent weight loss. He consumes regular solids and thin liquids. See medical treatment records.

The Veteran submitted a May 2013 examination which noted moderate difficulty chewing and swallowing.

VA examinations in January 2020 and December 2023 noted moderate difficulty chewing and swallowing. An August 2024 VA examination found severe difficulty chewing and swallowing.

A June 2024 examination noted the Veteran can feed himself finger foods though he tires easily as he has difficulty getting his hand to his mouth. He requires assistance getting food from the kitchen to the table to feed himself.

Based on the foregoing, the Board finds the Veteran's disability warrants a 30 percent evaluation under the pre-amended criteria throughout the period on appeal. Here, the evidence indicates the Veteran has been able to consume both solids and liquids during the period on appeal which does not meet the criteria of the higher rating criteria for a
moderate difficulty chewing and swallowing.

VA examinations in January 2020 and December 2023 noted moderate difficulty chewing and swallowing. An August 2024 VA examination found severe difficulty chewing and swallowing.

The Board notes the pre-amended criteria of DC 7203 is most favorable to the Veteran as his disability does not require dilatation no more than 2 times per year as noted in the amended criteria. Therefore, the Board applies the pre-amended criteria.

Accordingly, the Veteran's disability does not warrant an evaluation in excess of 30 percent for service-connected difficulty chewing and swallowing associated with Parkinson's disease and his claim seeking an increased evaluation is denied.

As the evidence is persuasively against the grant of an increased evaluation, the benefit of the doubt doctrine under 38 U.S.C. §5107(b), is not for application. Lynch v. McDonough, 21 F.4th 776 (Fed. Cir. 2021) (en banc) (only when the evidence persuasively favors one side or another is the benefit of the doubt doctrine not for application).

Constipation

The Veteran seeks entitlement to an evaluation in excess of 30 percent for constipation with gastroesophageal reflux disease associated with Parkinson's disease with depressive disorder with anxious distress, major depressive like episodes, and cognitive impairment. A 30 percent evaluation is assigned under DC 7319 from May 11, 2016 and a 30 percent evaluation is afforded under DCs 7346-7319 from February 21, 2019.

The Veteran's condition is rated by analogy under Diagnostic Codes (DC) 7346-7319. See 38 C.F.R. § 4.20 (conditions that are not specifically listed in the Rating Schedule may be rated by analogy under the diagnostic code of a closely related disease or injury).

DC 7346 was amended effective May 19, 2024. The pre-amended criteria of 7346 for hiatal hernia affords a 10 percent evaluation for two or more of the symptoms for the 30 percent evaluation of less severity. A 30 percent evaluation is warranted for persistently recurrent epigastric distress with dysphagia, pyrosis, and regurgitation, accompanied by substernal or arm or shoulder pain, productive of considerable impairment of health. A 60 percent evaluation is warranted for symptoms of pain, vomiting, material weight loss and hematemesis or melena with moderate anemia; or other symptom combinations productive of severe impairment of health.

The amended criteria of DC 7346 notes to rate hiatal hernia and paraesophageal hernia as stricture of esophagus under DC 7203. The Board notes the Veteran's difficulty chewing and swallowing is evaluated under DC 7203 and addressed above.

DC 7319 was amended effective May 19, 2024. The pre-amended criteria affords a noncompensable evaluation for mild symptoms characterized by disturbances of bowel function with occasional episodes of abdominal distress. A 10 percent evaluation is warranted for moderate symptoms characterized by frequent episodes of bowel disturbance with abdominal distress. A 30 percent evaluation is warranted for severe symptoms characterized by diarrhea, or alternating diarrhea and constipation, with more or less constant abdominal distress.

The amended criteria of DC 7319 affords a 10 percent evaluation for abdominal pain related to defecation at least once during the previous three months; and two or more of the following: (1) change in stool frequency, (2) change in stool form, (3) altered stool passage (straining and/or urgency), (4) mucorrhea, (5) abdominal bloating, or (6) subjective distension. A 20 percent evaluation is warranted for abdominal pain related to defecation for at least three days per month during the previous three months; and two or more of the following: (1) change in stool frequency, (2) change in stool form, (3) altered stool passage (straining and/or urgency), (4) mucorrhea, (5) abdominal bloating, or (6) subjective distension. A 30 percent evaluation is warranted for abdominal pain related to defecation at least one day per week during the previous three months; and two or more
altered stool passage (straining and/or urgency), (4) mucorrhea, (5) abdominal bloating, or (6) subjective distension. A 20 percent evaluation is warranted for abdominal pain related to defecation for at least three days per month during the previous three months; and two or more of the following: (1) change in stool frequency, (2) change in stool form, (3) altered stool passage (straining and/or urgency), (4) mucorrhea, (5) abdominal bloating, or (6) subjective distension. A 30 percent evaluation is warranted for abdominal pain related to defecation at least one day per week during the previous three months; and two or more of the following: (1) change in stool frequency, (2) change in stool form, (3) altered stool passage (straining and/or urgency), (4) mucorrhea, (5) abdominal bloating, or (6) subjective distension. A note to DC 7319 states this diagnostic code may include functional digestive disorders (see § 3.317 of this chapter), such as dyspepsia, functional bloating and constipation, and diarrhea. Evaluate other symptoms of a functional digestive disorder not encompassed by this diagnostic code under the appropriate diagnostic code, to include gastrointestinal dysmotility syndrome (DC 7356), following the general principles of § 4.14 and this section.

Generally, if a law or regulation changes during the course of a claim or an appeal, the version more favorable to the Veteran will apply, to the extent permitted by any stated effective date in the amendment in question. 38 U.S.C. § 5110 (g). If the revised version of the regulation is more favorable, the implementation of that regulation under 38 U.S.C. § 5110 (g) can be no earlier than the effective date of that change. If the former version is more favorable, VA can apply the earlier version of the regulation for the period prior to, and from, the effective date of the change. 38 U.S.C. § 5110. Here, the Board will apply the regulation which most closely approximates the Veteran's symptoms and is the most advantageous to the Veteran to include consideration under the amended regulations from May 19, 2024.

VA Medical Center (VAMC) treatment records note constipation with a bowel movement every other day. See VAMC records.

The Veteran submitted a May 2013 examination which noted moderate constipation.

He was afforded VA examinations in January 2020, December 2023, and August 2024. The January 2020 examiner noted mild constipation. The December 2023 and August 2024 examiners both noted severe constipation.

The Veteran submitted a June 2024 examination noting worsening of all symptoms and reporting neurogenic bowel and bladder. The provider noted the Veteran is no longer continent of bowel or bladder and is unable to get to the bathroom on time or clean himself appropriately. He requires assistance for all activities of daily living.

The Board applies the pre-amended criteria of DC 7319 to the Veteran's disability as the criteria most closely approximates his symptom of constipation and is the most favorable to the Veteran. The Board notes a 30 percent evaluation is the highest possible under the schedule for DC 7319. The Veteran has not sought extraschedular evaluation and his severe symptoms of constipation are contemplated by the pre-amended criteria of DC 7319.

The evidence of record does not indicate a higher evaluation under DC 7346 is warranted as the Veteran's disability does not manifest in pain, vomiting, material weight loss and hematemesis or melena with moderate anemia; or other symptom combinations productive of severe impairment of health.

As the evidence is persuasively against the grant of an increased evaluation for service-connected constipation, the benefit of the doubt doctrine under 38 U.S.C. §5107(b), is not for application. Lynch v. McDonough, 21 F.4th 776 (Fed. Cir. 2021) (en banc) (only when the evidence persuasively favors one side or another is the benefit of the doubt doctrine not for application).

Sense of Smell

The Veteran seeks entitlement to a compensable evaluation for loss of sense of smell associated with Parkinson's disease with depressive disorder with anxious distress, major depressive like episodes, and cognitive impairment.

The Veteran's condition is evaluated under Diagnostic Code (DC) 6275. Under 6275, a complete loss of sense of smell is afforded a 10 percent evaluation.

In every instance where the schedule does not provide a zero percent evaluation for a diagnostic code, a zero percent evaluation shall be assigned when the requirements for a compensable evaluation are not met. See 38 C.F.R.
(en banc) (only when the evidence persuasively favors one side or another is the benefit of the doubt doctrine not for application).

Sense of Smell

The Veteran's condition is evaluated under Diagnostic Code (DC) 6275. Under 6275, a complete loss of sense of smell is afforded a 10 percent evaluation.

The Veteran submitted a May 2013 examination which noted partial loss of smell.

The Veteran was afforded VA examinations in January 2020, December 2023, and August 2024. All three examinations indicate a partial loss of smell.

The Board affords great probative weight to the May 2013 private evaluation, January 2020, December 2023, and August 2024 VA examinations as the examiners conducted objective testing to evaluate all signs and symptoms which indicate the severity of the Veteran's disability. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 302 (2009).

Here, the Board finds the Veteran's disability does not rise to the compensable level as the evidence does not support a finding that he has a complete loss of smell during the period on appeal.

Accordingly, entitlement to a compensable evaluation for loss of sense of smell associated with Parkinson's disease with depressive disorder with anxious distress, major depressive like episodes, and cognitive impairment is denied.

Sexual Dysfunction

The Veteran seeks entitlement to a compensable evaluation for sexual dysfunction associated with Parkinson's disease with depressive disorder with anxious distress, major depressive like episodes, and cognitive impairment. The Veteran's condition is afforded a noncompensable evaluation from May 11, 2016.

The Veteran's condition is evaluated under Diagnostic Code (DC) 7522 which was amended November 14, 2021 during the pendency of the Veteran's appeal.

The pre-amended criteria of DC 7522 for penis deformity with loss of erectile power is noted to be afforded a 20 percent evaluation with additional consideration for special monthly compensation under 38 C.F.R. § 3.350.

Under the amended criteria of DC 7522, erectile dysfunction, with or without penile deformity is afforded a noncompensable evaluation. A Note to DC 7522 states for the purpose of VA disability evaluation, a disease or traumatic injury of the penis resulting in scarring or deformity shall be rated under diagnostic code 7522.

Generally, if a law or regulation changes during the course of a claim or an appeal, the version more favorable to the Veteran will apply, to the extent permitted by any stated effective date in the amendment in question. 38 U.S.C. § 5110 (g). If the revised version of the regulation is more favorable, the implementation of that regulation under 38 U.S.C. § 5110 (g) can be no earlier than the effective date of that change. If the former version is more favorable, VA can apply the earlier version of the regulation for the period prior to, and from, the effective date of the change. 38 U.S.C. § 5110. As such, the Board will consider whether a compensable rating is warranted under either regulation from November 14, 2021.

The evidence of record indicates the Veteran has erectile dysfunction and does not document penile deformity. See VAMC records.

Sexual dysfunction was noted in a May 2013 private examination and VA examinations from January 2020, December 2023, and August 2024.

Under the pre-amended criteria, the Veteran's disability warrants a noncompensable evaluation as his symptoms do not meet the compensable criteria.

Under the amended criteria, the Veteran's erectile dysfunction without penile deformity warrants a noncompensable evaluation.

Accordingly, the Board finds the Veteran's condition does not warrant a compensable evaluation as his symptoms do not rise to the level contemplated by the pre-amendment compensable criteria. The Board separately addresses special monthly compensation based on loss of use of a creative organ below.

Bilateral Speech Changes

The Veteran seeks entitlement to increased evaluations for bilateral speech changes associated with Parkinson's disease with depressive disorder with anxious distress, major depressive like episodes, and cognitive impairment. The Veteran's disability is afforded a 30 percent evaluation from May 11, 2016 to January 28, 2020, a 10 percent evaluation from January 28, 2020 to
erectile dysfunction without penile deformity warrants a noncompensable evaluation.

Bilateral Speech Changes

The Veteran seeks entitlement to increased evaluations for bilateral speech changes associated with Parkinson's disease with depressive disorder with anxious distress, major depressive like episodes, and cognitive impairment. The Veteran's disability is afforded a 30 percent evaluation from May 11, 2016 to January 28, 2020, a 10 percent evaluation from January 28, 2020 to June 20, 2024, and a 30 percent evaluation from June 20, 2024. The Board notes the right and left sides are afforded distinct evaluations.

The Veteran's condition is evaluated under Diagnostic Code (DC) 8210. Under DC 8210, moderate incomplete paralysis warrants a 10 percent evaluation and severe incomplete paralysis warrants a 30 percent evaluation. Complete paralysis warrants a 50 percent evaluation. A note to DC 8210 states evaluations are dependent upon extent of sensory and motor loss to organs of voice, respiration, pharynx, stomach and heart.

The terms moderate and severe are not defined in the pre-amended diagnostic code and, therefore, rather than applying a mechanical formula, the Board must evaluate all the evidence in arriving at a decision regarding an increased rating. 38 C.F.R. 4.6. The Board finds, however, that these terms are unambiguous and, therefore, a plain dictionary meaning is an appropriate definition. Cf. Kisor v. Wilkie, 139 S. Ct. 2400, 2415 (2019); see also 38 C.F.R. § 4.6 (noting, in general, the Board does not evaluate evidence by applying a mechanical formula, but rather conscientiously to the end that its decisions are equitable and just). According to Merriam Webster's Collegiate Dictionary 999 (11th Ed. 2007), "moderate" means limited in scope or effect. "Severe" means very painful or harmful or of a great degree. Although a medical examiner's use of descriptive terminology is an element of evidence to be considered by the Board, it is not dispositive of an issue. The Board must evaluate all evidence in arriving at a decision regarding an increased rating. 38 C.F.R. §§ 4.2, 4.6.

The Veteran submitted a May 2013 evaluation which noted severe speech changes.

VA Medical Center (VAMC) treatment records note fluent speech in April 2015. In October and November 2019, the Veteran exhibited soft, slurred speech with hypophonia and dysarthria. See medical records. Slow speech was noted in November 2020, and the Veteran was issued a speech assistance application in August 2022. An August 2023 therapy progress note found the Veteran's speech was unintelligible. A September 2023 treatment record found spontaneous speech was difficult to understand without aphasia and noted hypophonia and severe dysarthria. Communication was primarily conducted through texts on the Veteran's phone. Some, but not most, sentences were understood.

The Veteran was afforded VA examinations in January 2020, December 2023, and August 2024.

The January 2020 examiner noted moderate speech changes. The December 2023 and August 2024 examiner each noted severe speech changes.

The Veteran submitted a June 2024 examination that reported overall worsening of the Veteran's Parkinson's disease symptoms.

During a December 2019 VA mental health examination, the Veteran was noted to have speech impairment described as a soft volume with slight slurring. During an August 2024 mental health evaluation, the examiner found the Veteran's speech was difficult to understand and noted his spouse responded to most question.

The Board finds the January 2020 examination inadequately represents the severity of the Veteran's bilateral speech changes for the period from January 28, 2020 to June 20, 2024. During this period, the Veteran's treatment records document worsening of his symptoms including the need for a speech assistance application and unintelligible speech. The Veteran had noted hypophonia, severe dysarthria, and relied upon his phone to communicate via texting as his sentences were primarily not understood. The December 2023 VA examination was completed during this period and notes severe speech changes. The Board finds the January 2020 examination is inadequate to evaluate the Veteran's disability from January 28, 2020 to June 20, 2024 as the finding that the Veteran has moderate speech changes is inconsistent with the severe level of impairment reflected in
changes for the period from January 28, 2020 to June 20, 2024. During this period, the Veteran's treatment records document worsening of his symptoms including the need for a speech assistance application and unintelligible speech. The Veteran had noted hypophonia, severe dysarthria, and relied upon his phone to communicate via texting as his sentences were primarily not understood. The December 2023 VA examination was completed during this period and notes severe speech changes. The Board finds the January 2020 examination is inadequate to evaluate the Veteran's disability from January 28, 2020 to June 20, 2024 as the finding that the Veteran has moderate speech changes is inconsistent with the severe level of impairment reflected in other medical evidence of record.

Based on the foregoing, the Board finds the Veteran's disability warrants a 30 percent evaluation for severe incomplete paralysis throughout the entire period on appeal beginning May 11, 2016.

Here, the evidence from May 11, 2016 through January 28, 2020 indicates severe speech changes of the right and left side characterized by soft volume and slurring which warrants a 30 percent evaluation.

From January 28, 2020 to June 20, 2024, the Veteran's treatment records document worsening speech changes which are described as slow, unintelligible, and difficult to understand with hypophonia and severe dysarthria. The Veteran required the use of texting on a phone and a speech assistance application to communicate. The December 2023 VA examination noted severe symptoms. The Board finds the evidence for this period indicates the Veteran's symptoms rise to the level of severe incomplete paralysis contemplated by the 30 percent evaluation.

Finally, the evidence indicates worsening of the Veteran's disability from June 20, 2024. The August 2024 examinations noted severe speech changes and the Veteran's spouse responding to most questions as the Veteran's speech was difficult to understand. The Veteran's disability does not warrant a rating in excess of 30 percent during the period on appeal as the evidence indicates the Veteran is able to enact some speech which weighs against a finding of complete paralysis.

Accordingly, the Veteran's claim seeking an evaluation in excess of 30 percent from May 11, 2016 to January 28, 2020 is denied. His claim seeking an evaluation in excess of 10 percent from January 28, 2020 to June 20, 2024 is granted as the Board finds a 30 percent evaluation and no higher is warranted for this period. His claim seeking an evaluation in excess of 30 percent from June 20, 2024 is denied. Therefore, the Veteran's evaluation for bilateral speech changes is 30 percent throughout the period on appeal beginning from May 11, 2016.

Loss of Automatic Movements

The Veteran seeks entitlement to increased evaluations for bilateral loss of automatic movements associated with Parkinson's disease with depressive disorder with anxious distress, major depressive like episodes, and cognitive impairment. The Veteran's disability is afforded a 20 percent evaluation from May 11, 2016 to January 28, 2020, a 10 percent evaluation from January 28, 2020 to June 20, 2024, and a 20 percent evaluation from June 20, 2024. The Board notes the right and left sides are afforded distinct evaluations.

The Veteran's condition is evaluated under Diagnostic Code (DC) 8207. Under 8207, moderate incomplete paralysis warrants a 10 percent evaluation, severe incomplete paralysis warrants a 20 percent evaluation, and complete paralysis warrants a 30 percent evaluation. A Note to DC 8207 states evaluations are dependent upon relative loss of innervation of facial muscles.

The terms moderate and severe are not defined in the diagnostic code and, therefore, rather than applying a mechanical formula, the Board must evaluate all the evidence in arriving at a decision regarding an increased rating. 38 C.F.R. 4.6. The Board finds, however, that these terms are unambiguous and, therefore, a plain dictionary meaning is an appropriate definition. Cf. Kisor v. Wilkie, 139 S. Ct. 2400, 2415 (2019); see also 38 C.F.R. § 4.6 (noting, in general, the Board does not evaluate evidence by applying a mechanical formula, but rather conscientiously to the end that its decisions are equitable and just). According to Merriam Webster's Collegiate Dictionary 999 (11th Ed. 2007), "moderate" means limited in scope or effect. "Severe" means very painful or harmful or of a great degree. Although a medical examiner's use of descriptive terminology is an element of evidence to be considered by the Board, it is not dispositive of an issue. The Board must evaluate all evidence in arriving at a
139 S. Ct. 2400, 2415 (2019); see also 38 C.F.R. § 4.6 (noting, in general, the Board does not evaluate evidence by applying a mechanical formula, but rather conscientiously to the end that its decisions are equitable and just). According to Merriam Webster's Collegiate Dictionary 999 (11th Ed. 2007), "moderate" means limited in scope or effect. "Severe" means very painful or harmful or of a great degree. Although a medical examiner's use of descriptive terminology is an element of evidence to be considered by the Board, it is not dispositive of an issue. The Board must evaluate all evidence in arriving at a decision regarding an increased rating. 38 C.F.R. §§ 4.2, 4.6.

The Veteran submitted a May 2013 examination which noted a severe loss of automatic movements.

VA Medical Center (VAMC) treatment records document assessment of the Veteran's facial expression capacity. Records document normal facial sensation to light touch in all three divisions with symmetric facial appearance at rest and no asymmetry on grimace. A June 2021 oral mechanic examination noted significantly reduced range of motion across orofacial structures consistent with Parkinson's disease and adequate strength. In December 2021, records note no cranial nerve deficit, dysarthria, or facial asymmetry. The Veteran's facial expression was found to have severe impairment in June 2022 with masked facies with lips parted most of the time when the mouth is at rest. In September 2022, it was noted the Veteran had moderate impairment with the same symptoms noted. Finally, in December 2022, the provider noted mild impairment with decreased eye-blink frequency, masked facies present in lower face, and fewer movements around mouth including less spontaneous smiling, but lips not parted. See VAMC records.

The Veteran was afforded VA examinations in January 2020, December 2023, and August 2024.

The January 2020 and December 2023 examiners noted a moderate loss of automatic movements. The August 2024 examiner noted a severe loss of automatic movements.

The Board finds the January 2020 examination inadequately represents the severity of the Veteran's loss of automatic movements for the period from January 28, 2020 to June 20, 2024. During this period, the Veteran's medical treatment records documenting worsening of his symptoms including severe impairment in June 2022 with masked facies with lips parted most of the time when the mouth is at rest. The Board acknowledges the Veteran's medical records also note moderate and mild symptoms in September and December 2022. However, the symptoms of masked facies with lips parted most of the time when the mouth is at rest were consistently noted. The December 2022 record also documented decreased eye-blink frequency and fewer movements around mouth including less spontaneous smiling. The Board therefore finds the January 2020 VA examination inadequately evaluates the severity of the Veteran's loss of automatic movements from January 28, 2020 to June 20, 2024 as it is inconsistent with his medical treatment records finding severe impairment.

Based on the foregoing, the Board finds the Veteran has severe incomplete loss of automatic movements throughout the period on appeal. From May 11, 2016 to January 28, 2020, the evidence documents the Veteran maintained some capacity to enact movement which weighs against a finding of complete paralysis.

From January 28, 2020 to June 20, 2024, the evidence indicates the Veteran had severe incomplete paralysis. Evidence documents significantly reduced range of motion across orofacial structures consistent with Parkinson's disease; severe impairment with masked facies with lips parted most of the time when the mouth is at rest; and decreased eye-blink frequency, masked facies present in lower face, and fewer movements around mouth including less spontaneous smiling, but lips not parted. The Board finds the Veteran's symptoms rise to the level of severe incomplete paralysis contemplated by the 20 percent evaluation. As the Veteran maintained some capacity to enact automatic movements, a higher evaluation of 30 percent for complete paralysis is not warranted.

Worsening of the Veteran's disability was noted in a June 20, 2024 examination and an August 2024 VA examination found a severe loss of automatic movements. The evidence does not indicate a complete loss of automatic movements at any point during the periods on appeal therefore an increased evaluation of 30 percent is not warranted.

Accordingly, the Board finds the Veteran's claim seeking an evaluation in excess of 20 percent from May 11, 2016 through January 28, 2020 is denied. His claim seeking an increased evaluation for the period from January 28, 2020 to June 20, 2024 is granted as the Veteran's disability warrants an increased evaluation of 20 percent and no higher for severe incomplete paralysis. Finally, for the period from January 28, 2020 to June 20, 2024, the Veteran claim seeking an increased evaluation is denied.

Therefore, the Veteran's bilateral loss of automatic movements warrants a 20 percent evaluation for severe incomplete paralysis and not higher throughout the period on appeal.

Stooped Posture

The Veteran seeks entitlement to increased evaluations for bilateral stooped posture associated with Parkinson's disease with depressive disorder with anxious distress, major depressive like episodes, and cognitive impairment. The Veteran's disability is afforded a 10 percent evaluation from May 11, 2016 and a noncompensable evaluation from January 28, 2020. The Board notes the right and left sides are afforded distinct evaluations.

The Veteran's condition is evaluated under Diagnostic Code (DC) 8211. Under 8211, moderate incomplete paralysis warrants a 10 percent evaluation, severe incomplete paralysis warrants a 20 percent evaluation, and complete paralysis warrants a 30 percent evaluation. A Note to DC 8211 states evaluations are dependent upon loss of motor function of sternomastoid and trapezius muscles.

VAMC treatment records note the Veteran had postural faults including some instability. See August 2018 treatment record. In January 2024, the Veteran's posture was described as a slight stoop that was not quite erect, but could be normal for an older person. A July 2024 record notes moderate stooped posture, scoliosis, or leaning to one side that cannot be corrected volitionally to a normal posture by the Veteran.

The Veteran submitted a May 2013 examination which noted moderate stooped posture.

The Veteran was afforded VA examinations in January 2020, December 2023, and August 2024.

The January 2020 and December 2023 examiners noted a mild stooped posture. The August 2024 examiner noted a moderate stooped posture.

The Veteran submitted a June 2024 examination which noted he is kyphotic and cannot stand straight. The provider noted contractures in all extremities with very limited movement. The Veteran was unable to sit up straight due to spinal stenosis and Parkinson's disease. He requires constant support to be upright.

Based on the foregoing, the Board finds the Veteran's disability resulted in moderate incomplete paralysis of the right and left sides prior to June 20, 2024 as the evidence documents a moderate stooped posture with instability. The Board acknowledges the January 2020 and December 2023 examiners noted a mild stooped posture. However, the evidence also documents moderate stooped posture and instability prior to June 20, 2024. Therefore, the Board finds the evidence is in approximate balance and resolves doubt in favor of the Veteran. The evidence does not support a
all extremities with very limited movement. The Veteran was unable to sit up straight due to spinal stenosis and Parkinson's disease. He requires constant support to be upright.

Based on the foregoing, the Board finds the Veteran's disability resulted in moderate incomplete paralysis of the right and left sides prior to June 20, 2024 as the evidence documents a moderate stooped posture with instability. The Board acknowledges the January 2020 and December 2023 examiners noted a mild stooped posture. However, the evidence also documents moderate stooped posture and instability prior to June 20, 2024. Therefore, the Board finds the evidence is in approximate balance and resolves doubt in favor of the Veteran. The evidence does not support a finding of severe incomplete paralysis during this period as neither examinations nor medical records document severe symptoms. Therefore, an evaluation in excess of 10 percent is not warranted.

From June 20, 2024, the Veteran is found to have worsened symptoms which reach the level of severe incomplete paralysis of the right and left sides as the evidence documents an inability to stand straight, the need for support to remain upright, and contracture in all extremities.

The Board notes the Veteran's condition does not warrant a 30 percent evaluation for complete paralysis as the June 2024 examiner noted the Veteran does retain a limited capacity for movement which indicates he does not have complete paralysis.

Accordingly, the Board finds entitlement to a 10 percent evaluation is warranted for the period prior to June 20, 2024, and an increased evaluation of 20 percent is warranted for the period beginning June 20, 2024 onwards.

Special Monthly Compensation

The Veteran seeks entitlement to an effective date prior to May 11, 2016 for the grant of entitlement to special monthly compensation based on loss of use of a creative organ and based on aid and attendance criteria being met.

Generally, except as otherwise provided, the effective date for a grant of service connection is the day after separation from service or day entitlement arose, if a claim is received within one year of separation from service; otherwise, the effective date for a grant of service connection is the date of receipt of claim, or the date entitlement arose, whichever is later. 38 U.S.C. § 5110(b)(1); 38 C.F.R. § 3.400(b)(2)(i).

A "claim" is defined broadly to include a formal or informal communication in writing requesting a determination of entitlement to a benefit. 38 C.F.R. § 3.1(p). Any communication indicating an intent to apply for a benefit under the laws administered by the VA may be considered an informal claim provided it identifies, but not necessarily with specificity, the benefit sought. See 38 C.F.R. § 3.155(a). Effective March 24, 2015, VA amended its regulations to require that all claims governed by VA's adjudication regulations be filed on a standard form.

As to SMC based on loss of use of a creative organ, loss of a creative organ will be shown by acquired absence of one or both testicles (other than undescended testicles) or ovaries or other creative organ. SMC is payable at a specified rate if the claimant, as the result of service-connected disability, has suffered the anatomical loss or loss of use of one or more creative organs. See 38 U.S.C. § 1114(k); 38 C.F.R. § 3.350(a). The statute is interpreted as including erectile dysfunction as loss of use of a creative organ.

The Veteran is service connected for sexual dysfunction with a noncompensable evaluation and for SMC based on aid and attendance criteria being met from May 11, 2016. These effective dates are based on the Veteran's May 11, 2016 Intent to File. Within one year of the Intent to File, the Veteran completed a June 27, 2016 claim seeking entitlement to service connection for Parkinson's disease which ultimately led to the grant of service connection for sexual dysfunction associated with Parkinson's disease with depressive disorder with anxious distress, major depressive like episodes, and cognitive impairment.

Here, there are no communications prior to May 11, 2016, formal or informal, that can be construed as a claim of service connection for sexual dysfunction or Parkinson's disease.

The Veteran sought entitlement to service connection for Parkinson's disease in January 2011 and a July 2011 rating decision denied his claim. The Veteran was notified on July 13, 2011. He did not submit a Notice of Disagreement or new and material evidence within one year of the decision notification and the July 2011 decision became final. The Board acknowledges the Veteran submitted a May 2013 examination which noted a diagnosis of Parkinsons's disease with severe sexual dysfunction. However, this medical record was not accompanied by a statement seeking to reopen his previously denied claim and therefore is not considered an unadjudicated, informal claim seeking entitlement to service connection for sexual dysfunction or Parkinson's disease. 38 C.F.R. § 3.157(a)(2012); Criswell v. Nicholson, 20 Vet. App. 501, 504 (2006) (stating that "[t]he mere existence of medical records generally cannot be construed as an informal claim; rather, there must be some intent by the claimant to apply for a benefit").

Accordingly, the Veteran does not meet the criteria for SMC based on loss of use of a creative organ or based on aid and attendance criteria being met prior to May 11, 2016 and his claims seeking earlier effective dates are denied.

Higher-Level Special Monthly Compensation

The Veteran seeks entitlement to an effective date prior to June 20, 2024 for the grant of special monthly compensation (SMC) under 38 U.S.C. § 1114 (r)(2) and 38 C.F.R. 3.350(h) due to the need for regular aid and attendance and an additional, higher level of care.

Under 38 U.S.C. § 1114 (r)(2), if the veteran, in addition to such need for regular aid and attendance, is in need of a higher level of care, such veteran shall be paid a monthly aid and attendance allowance at the rate of $2,983, in lieu of the allowance authorized in clause (1) of this subsection, if the Secretary finds that the veteran, in the absence of the provision of such care, would require hospitalization, nursing home care, or other residential institutional care.

The need for a higher level of care shall be considered to be a need for personal health-care services provided on a daily basis in the veteran's home by a person who is licensed to provide such services or who provides such services under the regular supervision of a licensed health-care professional. The existence of the need for such care shall be determined by a physician employed by the Department or, in areas where no such physician is available, by a physician carrying out such function under contract or fee arrangement based on an examination by such physician. For the purposes of section 1134, such allowance shall be considered as additional compensation payable for disability.

Personal health-care services include (but are not limited to) such services as physical therapy, administration of injections, placement of indwelling catheters, and the changing of sterile dressings, or like functions which require professional health-care training or the regular supervision of a trained health-care professional to perform. A licensed health-care professional includes (but is not limited to) a doctor of medicine or osteopathy, a registered nurse, a licensed practical nurse, or a physical therapist licensed to practice by a State or political subdivision thereof. See 38 C.F.R. § 3.352(b)(3).

During the July 2022 Board hearing, the Veteran reported the need for full-time care which was provided by his partner of seven years. The evidence of record does not indicate the Veteran's spouse was acting under the regular supervision of a licensed health-care professional in providing such care during the period in question.

VA Medical Center (VAMC) treatment records note the Veteran was independent with his activities of daily living in April 2024 and a July 2024 treatment plan notes a longterm goal of maintaining activities of daily living. A January 2024 treatment records noted that while the Veteran is wheelchair-bound he does not require total assistance with the activities of daily living and transfers. The record documents the Veteran required some assistance with daily living tasks due to numbness and impaired function in his right hand but had the continued ability to use his left hand to eat during the period in question. See VAMC treatment record.

Based on the foregoing, the Board finds the evidence does not indicate the Veteran required a higher-level of care prior to July 20, 2024 as his medical treatment records indicate the continued ability to independently perform some activities of daily living
April 2024 and a July 2024 treatment plan notes a longterm goal of maintaining activities of daily living. A January 2024 treatment records noted that while the Veteran is wheelchair-bound he does not require total assistance with the activities of daily living and transfers. The record documents the Veteran required some assistance with daily living tasks due to numbness and impaired function in his right hand but had the continued ability to use his left hand to eat during the period in question. See VAMC treatment record.

Accordingly, entitlement to an effective date prior to June 20, 2024 for the grant of special monthly compensation under 38 U.S.C. § 1114 (r)(2) and 38 C.F.R. 3.350(h) due to the need for regular aid and attendance and an additional, higher level of care is denied.

REASONS FOR REMAND

As a preliminary matter, the Board notes that under the AMA, the Board shall remand the appeal to the agency of original jurisdiction (AOJ) for correction of an error on the part of the AOJ to satisfy its duties under 38 U.S.C. § 5103A if the error occurred prior to the date of the AOJ decision on appeal. 38 U.S.C. § 5103A; 38 C.F.R. § 20.802(a). The Board may remand for correction of any other error by the AOJ in satisfying a regulatory or statutory duty if correction of the error would have a reasonable possibility of aiding in substantiating the appellant's claim. 38 C.F.R. § 20.802(a). The error identified below is a pre-decisional error warranting remand.

Bilateral Lower Extremities

The Veteran seeks an evaluation in excess of 20 percent for bilateral lower extremity balance impairment, bradykinesia, tremors, muscle rigidity, and stiffness associated with Parkinson's disease with depressive disorder with anxious distress, major depressive like episodes, and cognitive impairment for the period from May 11, 2016 to June 20, 2024.

The Veteran's condition is evaluated under Diagnostic Code (DC) 8520 from May 11, 2016 to June 20, 2024 which does not contemplate the ameliorative effects of medication.

Under DC 8520 for incomplete paralysis, mild symptoms warrant a 10 percent evaluation, moderate symptoms warrant a 20 percent evaluation, moderately severe symptoms warrant a 40 percent evaluation, and severe symptoms with marked musculare atrophy warrant a 60 percent evaluation. An 80 percent evaluation is warranted for complete paralysis where the foot dangles and drops, no active movement possible of muscles below the knee, flexion of knee weakened or (very rarely) lost.

The Board may not deny entitlement to a higher rating on the basis of relief provided by medication when those effects are not specifically contemplated by the rating criteria. Jones v. Shinseki, 26 Vet. App. 56, 63 (2012); Ingram v. Collins, No. 23-1798.

VA Medical Center (VAMC) records document the Veteran received multiple Botox injections in the left lower extremity beginning in November 2018. An August 2018 treatment record notes a shuffling gait with narrow station and no need for assistance with ambulation. In October 2021, records document lower limb dystonia. The VAMC records indicate the Botox injections were consistently found to work well for the Veteran's lower extremity inward ankle turns.

During this period, the Veteran submitted a May 2013 private evaluation and was afforded VA examinations in January 2020 and December 2023.

The Veteran submitted a May 2013 examination where the provider noted a mild tremor and moderate muscle rigidity and stiffness of the bilateral lower extremities. The Veteran had moderate bradykinesia. The provider also noted that despite the Veteran's deep brain stimulation treatment, he has difficulty performing the activities of daily living such as dressing, bathing, and toileting.

The January 2020 examiner found no tremor of the bilateral lower extremities. The Veteran was found to have moderate muscle rigidity and stiffness. The Veteran had moderate bradykinesia.

The December 2023 examiner noted a moderate tremor of the right lower extremity and a mild tremor of the left lower extremity. The Veteran had moderate muscle rigidity and stiffness of the right and left sides. The Veteran had severe bradykinesia.

The May 2013, January 2020,
The Veteran had moderate bradykinesia. The provider also noted that despite the Veteran's deep brain stimulation treatment, he has difficulty performing the activities of daily living such as dressing, bathing, and toileting.

The January 2020 examiner found no tremor of the bilateral lower extremities. The Veteran was found to have moderate muscle rigidity and stiffness. The Veteran had moderate bradykinesia.

The May 2013, January 2020, and December 2023 examiners did not acknowledge the Veteran's history of Botox injections or indicate if the ameliorative effect of such treatment was taken into account when evaluating the severity of the Veteran's bilateral lower extremity disabilities. The Board therefore finds them inadequate for adjudication.

As there is not an adequate medical examination at the time of the October 2024 rating decision, the Board finds a predecisional duty to assist error has occurred and a remand is warranted to obtain a retrospective medical evaluation. See Barr v. Nicholson, 21 Vet. App. 303, 312 (2007) (holding that when VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate).

The matters are REMANDED for the following action:

Schedule the Veteran for a VA examination to determine the severity of his bilateral lower extremity disability for the period from May 11, 2016 to June 20, 2024. The examiner should provide a full description of the disability and report all signs and symptoms in the absence of the ameliorative effects of medication necessary for evaluating the Veteran's disability under the rating criteria.

If the examiner cannot provide a retrospective evaluation without resorting to mere speculation, he or she should provide a complete explanation for why an evaluation cannot be rendered. In so doing, the examiner shall explain whether the inability to provide a more definitive assessment is the result of a need for additional information, or that he or she has exhausted the limits of current medical knowledge in providing an answer to that particular question(s).

K. Parakkal

Veterans Law Judge

Board of Veterans' Appeals

Attorney for the Board Filsinger, Alexandra Q.

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.

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