Case A26040371

L. M. BARNARD · 2026 · Case ID: A26040371

MIXED

Summary

The Veteran served on active duty from April 1987 to December 2006. This case involves multiple appeals related to various conditions and benefits, with a significant procedural history including prior remands and supplemental claim decisions. The Veteran sought increased ratings for headaches, bilateral pes planus, right carpal tunnel syndrome (CTS), low back disability, bilateral lower extremity peripheral neuropathy, cervical spine conditions, bilateral shin splints, and various forms of Special Monthly Compensation (SMC). The Board reviewed evidence from VA examinations and a private medical opinion. For headaches, the Board found the July 2015 VA examination insufficient as it did not consider ameliorative effects of medications or Botox used by the Veteran, necessitating a remand for a retrospective opinion. For right CTS, conflicting medical opinions regarding the severity and potential loss of use of the upper extremities required a remand for a new VA examination. Several claims for increased ratings for pes planus, sinusitis, wrist scars, lumbar spine, peripheral neuropathy, and cervical spine conditions were granted at specific percentages based on the evidence and resolving doubt in the Veteran's favor. However, claims for higher ratings for headaches, lumbar spine, peripheral neuropathy, cervical spine, and shin splints were denied as the criteria were not met. The Board also remanded issues related to effective dates for TDIU, Dependents' Educational Assistance (DEA), and SMC, as these were inextricably intertwined with other remanded issues.

Special Benefit

SMC - AID & ATTENDANCE; SMC - HOUSEBOUND; TDIU

Docket No.

251017-599152

Full Decision Text

Citation Nr: A26040371
Decision Date: 04/29/26 Archive Date: 04/29/26

DOCKET NO. 251017-599152
DATE: April 29, 2026

ORDER

Entitlement to a rating in excess of 50 percent for headaches from August 23, 2024 is denied.

Entitlement to a 50 percent rating for bilateral pes planus, effective October 17, 2019, is granted.

Entitlement to an initial rating in excess of 30 percent for bilateral pes planus prior to October 17, 2019 is denied.

Entitlement to an initial rating in excess of 30 percent for sinusitis status post nasoplasty, prior to October 17, 2019, is denied.

Entitlement to an initial 10 percent rating for right wrist scar, effective March 19, 2019, is granted.

Entitlement to an initial 10 percent rating for left wrist scar, effective March 19, 2019, is granted.

Entitlement to a rating in excess of 40 percent for degenerative arthritis and degenerative disc disease of the lumbar spine is denied.

Entitlement to an initial rating in excess of 20 percent for peripheral neuropathy of the right lower extremity is denied.

Entitlement to an initial rating in excess of 20 percent for peripheral neuropathy of the left lower extremity is denied.

Entitlement to a rating in excess of 30 percent for degenerative disc disease and degenerative joint disease of the cervical spine is denied.

Entitlement to an initial compensable rating for right leg shin splints is denied.

Entitlement to an initial compensable rating for left leg shin splints is denied.

REMANDED

Entitlement to a compensable rating for headaches prior to August 23, 2024, is remanded.

Entitlement to a rating in excess of 40 percent for right hand/wrist carpal tunnel syndrome (CTS) with radiculopathy upper and middle radicular groups is remanded.

Entitlement to an effective date prior to February 29, 2016, for a total disability rating based on individual unemployability (TDIU) due to service-connected disabilities is remanded.

Entitlement to an effective date prior to February 29, 2016, for the grant of eligibility for Dependents' Educational Assistance (DEA) under 38 USC chapter 35 is remanded.

Entitlement to an effective date prior to February 29, 2016, for the award of special monthly compensation (SMC) based on housebound status is remanded.

Entitlement to an effective date prior to October 5, 2017, for SMC based on the need for regular aid and attendance is remanded.

Entitlement to SMC under 38 U.S.C. § 1114 (m) based on loss of use of the upper extremities is remanded.

Entitlement to SMC 38 U.S.C. § 1114 (l) based on the need for regular aid and attendance due to service-connected disabilities other than the upper extremities is remanded.

Entitlement to SMC based on the need for regular aid and attendance at a higher level, specifically under 38 U.S.C. § 1114 (r)(1), is remanded.

FINDINGS OF FACT

1. From August 23, 2024, the Veteran has been awarded a maximum 50 percent rating for his tension headaches; the Veteran has not raised a claim for extraschedular consideration, and the evidence shows that the Veteran's symptoms are adequately contemplated by the currently assigned 50 percent evaluation under 38 C.F.R. § 4.124a, Diagnostic Code 8100 for migraine headaches.

2. From October 17, 2019, when resolving the benefit of the doubt in his favor, the Veteran's service-connected bilateral pes planus has more closely approximated pronounced acquired bilateral flatfoot.

3. Prior to October 17, 2019, the Veteran's bilateral pes planus was manifested by severe bilateral flatfoot, but without pronounced flatfoot.

4. From the date of award of service connection, June 27, 2014, when resolving the benefit of the doubt in his favor, the Veteran's service-connected sinusitis status post nasoplasty more nearly approximated at least six non-incapacitating episodes of sinusitis per year characterized by headaches, pain, and purulent discharge or crusting, but without radical surgery with chronic osteomyelitis, or; near constant sinusitis characterized by headaches, pain and tenderness of affected sinus, and purulent discharge or crusting after repeated surgeries.

5. From the date of award of service connection, March 19, 2019, when resolving the
severe bilateral flatfoot, but without pronounced flatfoot.

5. From the date of award of service connection, March 19, 2019, when resolving the benefit of the doubt in favor in his favor, the Veteran's service-connected right wrist scar has been characterized as painful.

6. From the date of award of service connection, March 19, 2019, when resolving the benefit of the doubt in favor in his favor, the Veteran's service-connected left wrist scar has been characterized as painful.

7. Throughout the course of the appeal, the Veteran's service-connected degenerative arthritis and degenerative disc disease of the lumbar spine has been manifested by pain with limitation of motion, but without the functional equivalent of unfavorable ankylosis of the entire thoracolumbar spine, or incapacitating episodes totaling at least 6 weeks in a 12-month period.

8. Throughout the course of the appeal, the Veteran's service-connected peripheral neuropathy of the right lower extremity, has been manifested by moderate incomplete paralysis of the sciatic nerve, but without moderately severe incomplete paralysis of the sciatic nerve.

9. Throughout the course of the appeal, the Veteran's service-connected peripheral neuropathy of the left lower extremity, has been manifested by moderate incomplete paralysis of the sciatic nerve, but without moderately severe incomplete paralysis of the sciatic nerve.

10. Throughout the curse of the appeal, the Veteran's service-connected degenerative disc disease and degenerative joint disease of the cervical spine has not been productive of the functional equivalent of ankylosis, incapacitating episodes totaling at least four weeks in a 12-month period or associated neurological abnormalities.

11. From the date of award of service connection, June 27, 2014, the Veteran's service-connected right leg shin splints has not been manifested as the functional impairment equivalent to malunion or non-union of the tibia or fibula with slight or worse knee or ankle disability; or required treatment for no less than 12 consecutive months; and unresponsive to surgery and either shoe orthotics or other conservative treatment.

12. From the date of award of service connection, June 27, 2014, the Veteran's service-connected left leg shin splints has not been manifested as the functional impairment equivalent to malunion or non-union of the tibia or fibula with slight or worse knee or ankle disability; or required treatment for no less than 12 consecutive months; and unresponsive to surgery and either shoe orthotics or other conservative treatment.

CONCLUSIONS OF LAW

1. The criteria for a rating in excess of 50 percent for the Veteran's service-connected tension headaches, effective August 23, 2024, have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. Part 4, including § 4.7, 4.124a, Diagnostic Code 8100.

2. The criteria for a 50 percent rating for bilateral pes planus, effective October 17, 2019, have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. Part 4, including § 4.71a, Diagnostic Code 5276.

3. The criteria for an initial rating in excess of 30 percent for bilateral pes planus prior to October 17, 2019, have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. Part 4, including § 4.71a, Diagnostic Code 5276.

4. The criteria for an initial 30 percent rating, but no higher, for sinusitis status post nasoplasty, effective June 27, 2014, have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. Part 4, including § 4.97, Diagnostic Code 6513.

5. The criteria for an initial 10 percent rating, but no higher, for right wrist scar, effective March 19, 2019, have been met. 38 U.S.C. §§ 1155, 510
38 C.F.R. Part 4, including § 4.71a, Diagnostic Code 5276.

5. The criteria for an initial 10 percent rating, but no higher, for right wrist scar, effective March 19, 2019, have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. Part 4, including § 4.118, Diagnostic Code 7804.

6. The criteria for an initial 10 percent, but no higher, for left wrist scar, effective March 19, 2019, have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. Part 4, including § 4.118, Diagnostic Code 7804.

7. The criteria for a rating in excess of 40 percent rating for degenerative arthritis and degenerative disc disease of the lumbar spine have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. Part 4, including § 4.71a, Diagnostic Codes 5235 to 5243.

8. The criteria for a rating in excess of 20 percent for peripheral neuropathy of the right lower extremity have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. Part 4, including § 4.124a, Diagnostic Code 8520.

9. The criteria for a rating in excess of 20 percent for peripheral neuropathy of the left lower extremity have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. Part 4, including § 4.124a, Diagnostic Code 8520.

10. The criteria for a rating in excess of 30 percent for degenerative disc disease and degenerative joint disease of the cervical spine have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. Part 4, including 4.71a, Diagnostic Codes 5235 to 5243.

11. The criteria for an initial compensable rating for right leg shin splints have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. Part 4, including § 4.71a, Diagnostic Codes 5299-5262 (both prior to and after February 7, 2021).

12. The criteria for an initial compensable rating for left leg shin splints have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. Part 4, including § 4.71a, Diagnostic Codes 5299-5262 (both prior to and after February 7, 2021).

REASONS AND BASES FOR FINDINGS AND CONCLUSIONS

The Veteran served on active duty from April 1987 to December 2006.

This case has a long procedural history. By way of background, the Board remanded the issues on appeal in July 2024. After further development, the agency of original jurisdiction (AOJ) issued a rating decision in October 2024 addressing the issues remanded by the Board.

In March 2025, the Veteran submitted a VA Form 20-0995, Decision Review Request: Supplemental Claim, and requested readjudication of the issues of entitlement to increased ratings for pes planus, right carpal tunnel syndrome, low back disability, bilateral lower extremity peripheral neuropathy, cervical spine, and bilateral shin splints as well as SMC at a higher level. In April 2025, the AOJ issued the supplemental claim decision on appeal, which found that new and relevant evidence had been received and denied the claims based on the evidence of record at the time of that decision.

In the October 2025 VA Form 10182, Decision Review Request: Board Appeal (Notice of Disagreement), the Veteran elected the Direct Review docket. Therefore, the Board may only consider the evidence of record at the time of the October 2024 and April 2025 decisions on appeal. 38 C.F.R. § 20.301. Any evidence submitted after the
neuropathy, cervical spine, and bilateral shin splints as well as SMC at a higher level. In April 2025, the AOJ issued the supplemental claim decision on appeal, which found that new and relevant evidence had been received and denied the claims based on the evidence of record at the time of that decision.

With respect to the issues decided herein, 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 issues of entitlement to increased ratings for headaches prior to August 23, 2024 and right CTS; entitlement to an effective date prior to February 29, 2016 for the award of TDIU, DEA and SMC at the housebound rate; and the additional issues concerning entitlement to SMC, 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).

With respect to the Veteran's claims for SMC at higher levels, although the April 2025 rating decision simply stated the issue as the level of SMC, for clarification purposes, the Board has characterized the SMC issues as set forth above to hopefully better reflect what the Veteran is actually seeking.

As a final preliminary matter, the Board acknowledges that the Veteran's representative in a statement accompanying the October 2025 Notice of Disagreement waived all rights under VA's duty to assist, including any pre-decisional duty to assist errors. A claimant may waive the duty to assist when such waiver is based on an understanding of the consequences of such a waiver, which may be presumed when a claimant is represented by counsel. Janssen v. Principi, 15 Vet. App. 370, 374 (2001). However, in this case, the Board respectfully declines the waiver because a remand is necessary in order to have adequate VA examinations and/or opinions to decide the remaining claims, and to not remand would be to the detriment of the Veteran.

Importantly, the pre-decisional duty to assist errors identified below have resulted in an insufficient record for a decision. In turn, the Board finds that VA remains bound by the duty to assist the Veteran and, thus, a remand is warranted for the pre-decisional duty to assist errors identified below. The Board further observes that waiver of the right to additional assistance under the duty to assist does not compel the Board to issue a decision if development of the record is incomplete. See, e.g., Clark v. McDonough, 35 Vet. App. 317 (2022) (non-precedential decision) (dismissing appeal of Board remand, where appellant purported to waive duty to assist and requested a final Board decision). Consequently, the Board finds that VA remains bound by the duty to assist the Veteran in these matters.

Increased Rating Claims

Disability evaluations are determined by the application of the Schedule for Rating Disabilities, which assigns ratings based on the average impairment of earning capacity resulting from a service-connected disability. 38 U.S.C. § 1155; 38 C.F.R. Part 4. Where there is a question as to which of two 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. 38 C.F.R. § 4.7.

To evaluate the level of disability and any changes in condition, it is necessary to consider the complete medical history of the Veteran's condition. Schafrath v. Derwinski, 1 Vet. App. 589, 594 (1991). As with the issues of entitlement to an increased rating for headaches, lumbar spine disability, peripheral neuropathy of the lower extremities and cervical spine disability, where an increase in the level of a disability is at issue, the primary concern is the present level of disability. Francisco v. Brown, 7 Vet. App. 55 (1994). However, where, as with the remaining issues decided herein, the appeal arises from the original assignment of a disability evaluation following an award of service connection, the severity of the disability at issue is to be considered during the entire period from the initial assignment of the disability rating to the present time. See Fenderson v. West, 12 Vet. App. 119 (1999). As in the instant case, separate ratings can be assigned for separate periods of time based on the facts found, a practice known as "staged" ratings. Id. at 126; see also Hart v. Mansfield, 21 Vet. App. 505 (2007).

Headaches

The Veteran's headaches have been rated under Diagnostic Code 8100, which addresses migraines. Under this code, a maximum 50 percent rating is assigned for migraines with very frequent completely prostrating and prolonged attacks productive of severe economic inadaptability.

From August 23, 2024, the Veteran has been awarded a 50 percent rating, which again is the highest rating assignable under the rating criteria for migraine headaches. See 38 C.F.R. § 4.124(a), Diagnostic Code 8100; Grantham v. Brown, 114 F. 3d 1156, 1158 (Fed. Cir. 1997). Neither the Veteran nor his representative has raised any other issues, including seeking extraschedular consideration, nor have any other issues been reasonably raised by the record. See Doucette v. Shulkin, 28 Vet. App. 366 (2017). In turn, a rating in excess of 50 percent from August 24, 2024, is denied.

Bilateral Pes Planus

The present appeal is also seeking an increased rating for bilateral pes planus. The Veteran's bilateral pes planus has been rated as 30 percent disabling prior to August 23, 2024, and 50 percent thereafter.

Disabilities of the feet are contemplated by Diagnostic Codes 5276 through 5284, which in some instances, provide for disability ratings for unilateral or bilateral disabilities. 38 C.F.R. § 4.71a.

Under 38 C.F.R. § 4.71a, Diagnostic Code 5276, which addresses flatfoot, acquired, a 30 percent rating is assigned for severe symptoms, described as objective evidence of marked deformity (either pronation or abduction, etc.), pain on manipulation and use accentuated, indication of swelling on use, and characteristic callosities, affecting the feet bilaterally. A maximum 50 percent rating is warranted for bilateral acquired flatfoot with pronounced symptoms, with manifestations of marked pronation, extreme tenderness of plantar surfaces of the foot, marked inward displacement and severe spasm of the tendo-achilles on manipulation, not improved by orthopedic shoes or appliances. 38 C.F.R. § 4.71a, Diagnostic Code 5276.

The Board observes that during the pendency of the appeal, the rating criteria for evaluating musculoskeletal disabilities under 38 C.F.R. § 4.71a were amended effective February 7, 2021. See Schedule for Rating Disabilities: Musculoskeletal System and Muscle Injuries, 85 Fed. Reg. 76453, 76463 (Nov. 30, 2020). The amendments did not change the applicable criteria for disabilities evaluated pursuant to Diagnostic Code 5276 (flat feet). However, the February 7, 2021 amendments included Diagnostic Code 5269, which now provides the rating criteria for evaluating plantar fasciitis.

Under Diagnostic Code 5269, a 10 percent rating is warranted for unilateral or bilateral plantar fasciitis. A
culoskeletal disabilities under 38 C.F.R. § 4.71a were amended effective February 7, 2021. See Schedule for Rating Disabilities: Musculoskeletal System and Muscle Injuries, 85 Fed. Reg. 76453, 76463 (Nov. 30, 2020). The amendments did not change the applicable criteria for disabilities evaluated pursuant to Diagnostic Code 5276 (flat feet). However, the February 7, 2021 amendments included Diagnostic Code 5269, which now provides the rating criteria for evaluating plantar fasciitis.

Under Diagnostic Code 5269, a 10 percent rating is warranted for unilateral or bilateral plantar fasciitis. A 20 percent rating is warranted for unilateral plantar fasciitis with no relief from non-surgical and surgical treatment. A 30 percent rating is warranted for bilateral plantar fasciitis with no relief from non-surgical and surgical treatment. 38 C.F.R. § 4.71a, Diagnostic Code 5269.

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.

Therefore, for the appeal period beginning on February 7, 2021, the Board will consider the new rating criteria applicable to plantar fasciitis pursuant to Diagnostic Code 5269, in addition to considering the rating criteria for Diagnostic Code 5276, in arriving at a decision regarding the requested higher disability rating.

Initially, based on the evidence of record and as observed in the prior Board remand, an October 17, 2019 VA clinical record indicated that the Veteran had worsening chronic foot pain. Subsequently, the Veteran was afforded a VA examination in August 2024, which corroborated worsening symptoms. Thereafter, based on this examination, the AOJ awarded a 50 percent rating. As the first evidence showing an increase in symptoms was dated on October 17, 2019 and as such increase was confirmed in the subsequent VA examination, when resolving the benefit of the doubt in favor of the Veteran, the Board finds that a 50 percent rating is warranted from that date.

In sum, a 50 percent rating for bilateral pes planus under Diagnostic Code 5276 is granted, effective October 17, 2019. As of this date, the Veteran has been assigned the maximum schedular rating of 50 percent under Diagnostic Code 5276. As the maximum rating under Diagnostic Code 5276 for bilateral pes planus has been assigned, the Veteran's claim for a rating in excess of 50 percent for bilateral pes planus under this diagnostic code from October 17, 2019, is not available. The Veteran has not asserted, and the evidence does not show that he is seeking a rating in excess 50 on an extraschedular basis.

The Board acknowledges that the recent August 2024 VA examination also shows a diagnosis of plantar fasciitis. Again, Diagnostic Code 5269, which is applicable for plantar fasciitis from February 7, 2021, provides a maximum schedular rating of 30 percent. Thus, rating the Veteran's feet disabilities pursuant to Diagnostic Code 5269 from February 7, 2021, would not result in a more favorable rating, as the Veteran has been awarded a 50 percent rating pursuant to Diagnostic Code 5276.

The Board has considered whether separate ratings for the Veteran's pes planus and plantar fasciitis disabilities are warranted from February 7, 2021, the date of the revised regulations. Separate ratings may be assigned for distinct disabilities resulting from the same injury so long as the symptomatology for one condition is not duplicative of the symptomatology of the other condition. 38 C.F.R. § 4.14; Esteban v. Brown, 6 Vet. App. 259, 262 (1994). VA regulation specifically states that evaluation of the same disability or the same manifestations of disability under multiple diagnoses (i.e., pyramiding) is to be avoided. 38 C.F.R. § 4.14. A claimant may not be compensated twice for the same symptomatology as "such a
February 7, 2021, the date of the revised regulations. Separate ratings may be assigned for distinct disabilities resulting from the same injury so long as the symptomatology for one condition is not duplicative of the symptomatology of the other condition. 38 C.F.R. § 4.14; Esteban v. Brown, 6 Vet. App. 259, 262 (1994). VA regulation specifically states that evaluation of the same disability or the same manifestations of disability under multiple diagnoses (i.e., pyramiding) is to be avoided. 38 C.F.R. § 4.14. A claimant may not be compensated twice for the same symptomatology as "such a result would overcompensate the claimant for the actual impairment of his earning capacity." Brady v. Brown, 4 Vet. App. 203, 206 (1993).

The Board finds that a separate rating for plantar fasciitis under Diagnostic Code 5269, in addition to the rating for pes planus under Diagnostic Code 5276, would result in prohibited pyramiding, as the Veteran has not been noted to have plantar fasciitis symptomatology that is separate and distinct from his pes planus disability at any time since the addition of this code. 38 C.F.R. § 4.14.

Moreover, the Board finds that the evidence persuasively weighs against a rating in excess of 30 percent for pes planus prior to October 17, 2019. In this regard, the evidence does not show that the criteria for a higher 50 percent were met any time prior to this date. Importantly, while the May 2019 VA examiner observed extreme tenderness of both feet, the examiner explicitly found that the Veteran did not have marked pronation, or marked inward displacement and severe spasm of the Achilles tendon (rigid hindfoot) on manipulation, which are the criteria for a 50 percent rating. There is no other evidence during this period showing that a higher rating is warranted. The first evidence indicating an increase in severity is the October 17, 2019, treatment record. In sum, a rating in excess of 30 percent under Diagnostic Code 5276 is not warranted prior to October 17, 2019.

The Board has considered the application of other diagnostic codes pertaining to the foot, specifically Diagnostic Code 5284 pertaining to foot injuries. However, importantly, in Copeland v. McDonald, 27 Vet. App. 333 (2015), the Court held that Diagnostic Code 5284 does not apply to the eight-foot conditions specifically enumerated under § 4.71a because applying Diagnostic Code 5284 to those listed conditions "would essentially render the diagnostic codes of the enumerated conditions] redundant." 27 Vet. App. at 338 (quoting Prokarym v. McDonald, 27 Vet. App. 307, 311 (2015)). Pursuant to Copeland, the Board is prevented from rating the disability resultant from flat feet under Diagnostic Code 5284. In sum, the Board determines that the Veteran's symptoms of bilateral flat feet are appropriately rated under Diagnostic Code 5276.

The Board notes that the regulations pertaining to the feet do not contemplate the use of medication. The Board is cognizant of the Court decision in Ingram v. Collins, in which the Court reaffirmed prior holdings that in rating disabilities, the Board must discount the beneficial effects of medication when the relevant rating criteria do not contemplate medication use. Ingram v. Collins, 38 Vet. App. 130 (2025); see also Jones v. Shinseki, 26 Vet. App. 56 (2012); McCarroll v. McDonald, 28 Vet. App. 267 (2016). However, even considering the ameliorative effects of medication, there is no indication that the Veteran suffered pronounced flatfeet during this period to warrant a higher rating.

The Board has carefully reviewed and considered the Veteran's statements regarding the severity of his bilateral pes planus. The Board acknowledges that the Veteran, in advancing this appeal, believes that the disability on appeal has been more severe than the assigned disability rating reflects. In this case, however, the competent medical evidence offering detailed specific specialized determinations pertinent to the rating criteria are the most probative evidence with regard to evaluating the pertinent symptoms for the disability on appeal; the medical evidence also largely contemplates the Veteran's descriptions of symptoms. The Board specifically considered the lay evidence in awarding a 50 percent rating from October 17, 2019. In sum, the lay evidence has been considered together with the probative medical evidence clinically evaluating the severity of the pertinent disability symptoms.

The Board has considered whether further staged ratings
bilateral pes planus. The Board acknowledges that the Veteran, in advancing this appeal, believes that the disability on appeal has been more severe than the assigned disability rating reflects. In this case, however, the competent medical evidence offering detailed specific specialized determinations pertinent to the rating criteria are the most probative evidence with regard to evaluating the pertinent symptoms for the disability on appeal; the medical evidence also largely contemplates the Veteran's descriptions of symptoms. The Board specifically considered the lay evidence in awarding a 50 percent rating from October 17, 2019. In sum, the lay evidence has been considered together with the probative medical evidence clinically evaluating the severity of the pertinent disability symptoms.

The Board has considered whether further staged ratings under Fenderson, supra, are appropriate or the Veteran's service-connected pes planus; however, the Board finds that his symptomatology has been stable both before and after October 17, 2019. Therefore, assigning further staged ratings for such disability is not warranted.

In conclusion, when resolving the benefit of the doubt in favor of the Veteran, a 50 percent rating, but no higher, is warranted for bilateral pes planus, effective October 17, 2019. However, the evidence persuasively weighs against rating in excess of 30 percent prior to October 17, 2019. In denying a higher rating, the Board finds the benefit of the doubt doctrine is not applicable. 38 U.S.C. § 5107; 38 C.F.R. §§ 4.3, 4.7.

Sinusitis status post nasoplasty

The present appeal also includes the issue of entitlement to an initial higher rating for the Veteran's sinusitis status post nasoplasty. Here, a noncompensable rating was assigned prior to August 23, 2024, and a 30 percent rating was assigned thereafter. During the course of the appeal, in a July 2020 rating decision, the AOJ awarded an effective date of June 27, 2014 for the award of service connection for sinusitis. As such, this appeal has been ongoing since the award of service connection and this matter has been characterized as such in light of Fenderson.

The Veteran's sinusitis status post nasoplasty has been rated under 38 C.F.R. § 4.97, Diagnostic Code 6513. Under this code, a noncompensable rating is warranted when detected by x-ray only and a 10 percent evaluation is warranted for one or two incapacitating episodes per year of sinusitis requiring prolonged (lasting four to six weeks) antibiotic treatment, or three to six non-incapacitating episodes per year of sinusitis characterized by headaches, pain, and purulent discharge or crusting. A 30 percent evaluation is warranted when there are three or more incapacitating episodes per year of sinusitis requiring prolonged (lasting four to six weeks) antibiotic treatment, or more than six non-incapacitating episodes per year of sinusitis characterized by headaches, pain, and purulent discharge or crusting. A maximum 50 percent evaluation is assigned following radical surgery with chronic osteomyelitis, or; near constant sinusitis characterized by headaches, pain and tenderness of affected sinus, and purulent discharge or crusting after repeated surgeries. A note following this section provides that an incapacitating episode of sinusitis means one that requires bed rest and treatment by a physician. 38 C.F.R. § 4.97.

Initially, the Board finds that when resolving the benefit of the doubt in favor of the Veteran, a 30 percent rating for sinusitis statis post nasoplasty is warranted from the date of award of service connection. In this regard, the Board finds that the most probative evidence of record is the August 2024 VA examination, which found that the Veteran suffered from seven or more non-incapacitating episodes per year. The Board acknowledges that the November 2017 VA examiner found that the Veteran only had five non-incapacitating episodes over the previous twelve months. However, this examination contains some discrepancies, which makes it less probative. In this regard, initially, the examiner indicated that the Veteran did not have a sinus disorder and then proceeded to diagnose sinusitis. Moreover, the examination report does not appear to have been signed by the examiner so it is unclear whether it is complete. Significantly, similar symptoms outlined at the more recent examination were also documented in the November 2017 report, including episodes of sinusitis, headaches, pain, tenderness, crusting, dental pain, and daily postnasal drip.

The Veteran was afforded a VA examination in July 2015, but the examiner did not address the severity of the Veteran's sinusitis for rating purposes. Accordingly,
, this examination contains some discrepancies, which makes it less probative. In this regard, initially, the examiner indicated that the Veteran did not have a sinus disorder and then proceeded to diagnose sinusitis. Moreover, the examination report does not appear to have been signed by the examiner so it is unclear whether it is complete. Significantly, similar symptoms outlined at the more recent examination were also documented in the November 2017 report, including episodes of sinusitis, headaches, pain, tenderness, crusting, dental pain, and daily postnasal drip.

The Veteran was afforded a VA examination in July 2015, but the examiner did not address the severity of the Veteran's sinusitis for rating purposes. Accordingly, based on the probative August 2024 VA examination, the Board finds that the Veteran's sinusitis more nearly approximates an initial 30 percent rating since the award of service connection, June 27. 2014.

However, a rating in excess of 30 percent is not warranted at any point since the award of service connection. In this regard, the evidence does not show that the Veteran has had radical surgery with chronic osteomyelitis, or; near constant sinusitis characterized by headaches, pain and tenderness of affected sinus, and purulent discharge or crusting after repeated surgeries. The August 2024 VA examiner specifically found that the Veteran had not had radical sinus surgery or near constant sinusitis. The contemporaneous CT showed normal sinuses. Prior VA examinations as well as VA clinical records also do not document such findings. In sum, the Veteran's symptoms are adequately contemplated by the current 30 percent rating and a higher rating is not warranted.

The Board has carefully reviewed and considered the Veteran's statements regarding the severity of his sinusitis, status post nasoplasty. The Board acknowledges that the Veteran, in advancing this appeal, believes that the disability on appeal has been more severe than the assigned disability rating reflects. In this case, however, the competent medical evidence offering detailed specific specialized determinations pertinent to the rating criteria are the most probative evidence with regard to evaluating the pertinent symptoms for the disability on appeal; the medical evidence also largely contemplates the Veteran's descriptions of symptoms. The Board specifically considered the lay evidence in awarding a 30 percent rating from the date of award of service connection. In sum, the lay evidence has been considered together with the probative medical evidence clinically evaluating the severity of the pertinent disability symptoms.

The Board has considered whether staged ratings under Fenderson, supra, are appropriate or the Veteran's service-connected sinusitis status post nasoplasty; however, the Board finds that his symptomatology has been stable since the award of service connection. Therefore, assigning staged ratings for such disability is not warranted.

In conclusion, when resolving the benefit of the doubt in favor of the Veteran, an initial 30 percent rating is warranted for sinusitis status post nasoplasty, effective June 27, 2014. However, the evidence persuasively weighs against an initial rating in excess of 30 percent. In denying a higher rating, the Board finds the benefit of the doubt doctrine is not applicable. 38 U.S.C. § 5107; 38 C.F.R. §§ 4.3, 4.7.

Right and left wrist scars

The Veteran is also seeking initial higher ratings for his right and left wrist scars. In the prior July 2024 decision, the Board assigned an effective date of March 19, 2019, but no earlier, for the award of service connection for right and left wrist scars.

Scars are evaluated pursuant to 38 C.F.R. § 4.118, Diagnostic Codes 7800, 7801, 7802, 7804, and 7805. Diagnostic Code 7800 is not for application as it applies to burn scars or other scars of the head, face or neck. 38 C.F.R. § 4.118, Diagnostic Code 7800. Diagnostic Code 7801 contemplates burn scars or scars due to other causes, not of the head, face, or neck, that are associated with underlying soft tissue damage. 38 C.F.R. § 4.118, Diagnostic Code 7801. Under this code, a 10 percent rating is awarded when the area of the scar(s) covers at least 6 square inches (39 square centimeters), but less than 12 square inches (77 square centimeters). Higher ratings are available for when scars cover greater areas.

Diagnostic Code 7802 applies to burn scars or scars due to other causes, not of the head, face, or neck that are not associated with underlying soft tissue damage. Under this code, a scar exceeding an area or areas of 144
due to other causes, not of the head, face, or neck, that are associated with underlying soft tissue damage. 38 C.F.R. § 4.118, Diagnostic Code 7801. Under this code, a 10 percent rating is awarded when the area of the scar(s) covers at least 6 square inches (39 square centimeters), but less than 12 square inches (77 square centimeters). Higher ratings are available for when scars cover greater areas.

Diagnostic Code 7802 applies to burn scars or scars due to other causes, not of the head, face, or neck that are not associated with underlying soft tissue damage. Under this code, a scar exceeding an area or areas of 144 square inches (929 square centimeters) warrants a compensable, maximum 10 percent rating. Note (1) reads: For the purposes of Diagnostic Codes 7801 and 7802, the six (6) zones of the body are defined as each extremity, anterior trunk, and posterior trunk. The midaxillary line divides the anterior trunk from the posterior trunk. Note (2) reads: A separate evaluation may be assigned for each affected zone of the body. Combine the separate evaluations under §4.25. Alternatively, if a higher evaluation would result from adding the areas affected from multiple zones of the body, a single evaluation may also be assigned under this diagnostic code. 38 C.F.R. § 4.118, Diagnostic Code 7802.

Diagnostic Code 7804 provides disability ratings for scars that are unstable or painful. A 10 percent rating is warranted for one or two scars that are unstable or painful. A 20 percent rating is warranted for three or four scars that are unstable or painful. A maximum 30 percent rating is warranted for five or more scars that are unstable or painful. Note (1) states that an unstable scar is one where, for any reason, there is frequent loss of covering of skin over the scar. Note (2) provides that if one or more scars are both unstable and painful, an additional 10 percent should be added to the evaluation based on the total number of unstable or painful scars. Note (3) states that scars evaluated under diagnostic codes 7800, 7801, 7802, or 7805 may also receive an evaluation under this diagnostic code, when applicable. 38 C.F.R. § 4.118, Diagnostic 7804.

Lastly, Diagnostic Code 7805 provides instructions to evaluate any disabling effect(s) not considered in a rating provided under diagnostic codes 7800-04 under an appropriate diagnostic code.

Based on the evidence of record, when resolving the benefit of the doubt in his favor, the Board finds that the criteria for initial 10 percent ratings under Diagnostic Code 7804 for right and left wrist scars have been met since the award of service connection. The Board finds that the most probative evidence of record addressing the severity of the Veteran's wrist scars is the August 2024 VA examination. This examiner found that the Veteran has painful scars on both wrists. The only other evidence concerning the Veteran's wrist scars was a May 2019 VA peripheral nerve examination. Although indicating that the Veteran's scars were not painful, the Board finds that this examination has less probative value than the August 2024 VA examination, which specifically addressed the severity of the Veteran's scars. As such, given the August 2024 examination findings, the Board finds that initial 10 percent ratings are warranted from March 19, 2019, under Diagnostic Code 7804. In rendering this decision, the Board finds that the issues are at least in a state of equipoise.

However, based on the evidence of record, initial ratings in excess of 10 percent are not warranted. In this regard, as the evidence does not show that the Veteran has three or four scars on each wrist that are unstable and painful, initial higher ratings under Diagnostic Code 7804 are not warranted. The VA examination clearly documents two painful scars on the right wrist and one painful scar on the left wrist.

Turning to other applicable diagnostic codes, there is no evidence that the Veteran's scars cover at least 6 square inches (39 square centimeters) to warrant a higher or separate rating under Diagnostic Codes 7801. The right wrist scars covered 2.5 cm, and the left wrist scars covered 3.75. Likewise, the scars do not exceed an area or areas of 144 square inches (929 square centimeters) to warrant a separate compensable, maximum 10 percent rating under Diagnostic Code 7802. Further, the VA examiner clearly found that there was no limitation of function to warrant a separate or higher rating under Diagnostic Code 7805. In sum, the prob
on the left wrist.

The Board has carefully reviewed and considered the Veteran's statements regarding the severity of his scars. The Board acknowledges that the Veteran, in advancing this appeal, believes that the disability on appeal has been more severe than the assigned disability ratings reflect. Moreover, the Veteran is competent to report observable symptoms. Layno v. Brown, 6 Vet. App. 465 (1994). In this case, the competent medical evidence offering detailed, specific, and specialized determinations pertinent to the rating criteria is the most probative evidence for evaluating the Veteran's symptoms for the scar on appeal. The Board specifically considered the lay evidence in awarding initial 10 percent ratings from the date of award of service connection. The medical evidence also largely contemplates the Veteran's descriptions of symptoms.

The Board has also considered whether staged ratings are appropriate; however, the Board finds that his symptomatology has been stable since the award of service connection. Therefore, assigning staged ratings for such disabilities is not warranted.

In conclusion, the Board finds that initial 10 percent ratings each for the right and left wrist scars from the date of award of service connection, March 19. 2019, is warranted. However, the evidence persuasively weighs against initial higher ratings. In denying such ratings, the Board finds the benefit of the doubt doctrine is not applicable. 38 U.S.C. § 5107; 38 C.F.R. §§ 4.3, 4.7.

Degenerative arthritis and degenerative disc disease of the lumbar spine

The Veteran also generally asserts that an increased rating for his lumbar spine disability is warranted. In an October 2018 final rating decision, the AOJ continued the 10 percent rating for the Veteran's low back. The Veteran filed his current claim for an increased rating on April 12, 2019 and in the June 2019 rating decision, the AOJ awarded a 40 percent rating, effective October 6, 2018, the date it was factually ascertainable that an increased rating was warranted. In a June 2020 rating decision, the AOJ corrected the date to October 15, 2018.

The General Rating formula for Diseases and Injuries of the Spine provides for the disability ratings under Diagnostic Codes 5235 to 5243, unless the disability rated under Code 5243 is evaluated under the Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes, for diseases and injuries of the spine, with or without symptoms such as pain (whether or not it radiates), stiffness, or aching in the area of the spine affected by residuals of injury or disease.

Under the General Rating formula, ratings are assigned as follows: a 30 percent rating is warranted for forward flexion of the cervical spine 15 degrees or less; or, favorable ankylosis of the entire cervical spine; a 40 percent rating is assigned for unfavorable ankylosis of the entire cervical spine; or, forward flexion of the thoracolumbar spine 30 degrees or less; or favorable ankylosis of the entire thoracolumbar spine; a 50 percent rating is awarded for unfavorable ankylosis of the entire thoracolumbar spine; and a 100 percent rating is warranted for unfavorable ankylosis of the entire spine.

Note (1) to the rating formula specifies that any associated objective neurologic abnormalities, including, but not limited to, bowel or bladder impairment, should be separately evaluated under an appropriate diagnostic code.

Note (2): (See also Plate V.) For VA compensation purposes, normal forward flexion of the cervical spine is zero to 45 degrees, extension is zero to 45 degrees, left and right lateral flexion are zero to 45 degrees, and left and right lateral rotation are zero to 80 degrees. Normal forward flexion of the thoracolumbar spine is zero to 90 degrees, extension is zero to 30 degrees, left and right lateral flexion are zero to 30 degrees, and left and right lateral rotation are zero to 30 degrees. The combined range of motion refers to the sum of the range of forward flexion, extension, left and right lateral flexion, and left and right rotation. The normal combined range of motion of the cervical spine is 340 degrees and of the thoracolumbar spine is 240 degrees. The normal ranges of motion for each component of spinal motion provided in this note are the maximum that can be used for calculation of the combined range of motion.

Note (3): In exceptional cases, an examiner may state that because of age, body habitus, neurologic disease, or other factors not the result of disease or injury of the spine, the range of motion of the spine in a particular individual should be considered normal for that individual, even though it does not conform to the normal range of motion stated in Note (2). Provided that the examiner supplies an explanation, the examiner's assessment that the range of motion is normal for that individual will be accepted.

Note (4): Round each range of motion measurement to the nearest five degrees.

Note (5): For VA compensation purposes, unfavorable ankylosis is a condition in which the entire cervical spine, the entire thoracolumbar spine, or the entire spine is fixed in flexion or extension, and the ankylosis results in one or more of the following: difficulty walking because of a limited line of vision; restricted opening of the mouth and chewing; breathing limited to diaphragmatic respiration; gastrointestinal symptoms due to pressure of the costal margin on the abdomen; dyspnea or dysphagia; atlantoaxial or cervical subluxation or dislocation; or neurologic symptoms due to nerve root stretching. Fixation of a spinal segment in neutral position (zero degrees) always represents favorable ankylosis.

Note (6): Separately evaluate disability of the thoracolumbar and cervical spine segments, except when there is unfavorable ankylosis of both segments, which will be rated as a single disability.

The Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes provides that a 40 percent evaluation is warranted when there are incapacitating episodes having a total duration of at least 4 weeks but less than 6 weeks during the past 12 months. A 60 percent evaluation is warranted when there are incapacitating episodes having a total duration of at least 6 weeks during the past 12 months.

During the pendency of the appeal, the rating criteria evaluating musculoskeletal disabilities under 38 C.F.R. § 4.71a were amended, effective February 7, 2021. 85 Fed. Reg. 230 (November 30, 2020). However, the Veteran's lumbar spine disability is rated under the General Formula for Disease and Injuries of the Spine, which did not change. The Board observes that Diagnostic 5243 for intervertebral disc syndrome was revised to only apply when there is disc herniation with compression and/or irritation of the adjacent nerve root. Nevertheless, the Board will still consider the previous criteria for Intervertebral disc syndrome as it is more favorable to the Veteran.

For disabilities evaluated on the basis of limitation of motion, VA is required to apply the provisions of 38 C.F.R. §§ 4.40, 4.45, pertaining to functional impairment. The United States Court of Appeals for Veterans Claims (Court) has instructed that in applying these regulations VA should obtain examinations in which the examiner determined whether the disability was manifested by weakened movement, excess fatigability, incoordination, or pain. Such inquiry is not to be limited to muscles or nerves. These determinations are, if feasible, to be expressed in terms of the degree of additional range-of-motion loss due to any weakened movement, excess fatigability, incoordination, flare-ups, or pain. DeLuca v. Brown, 8 Vet. App. 202 (1995); see Johnston v. Brown, 10 Vet.
4.40, 4.45, pertaining to functional impairment. The United States Court of Appeals for Veterans Claims (Court) has instructed that in applying these regulations VA should obtain examinations in which the examiner determined whether the disability was manifested by weakened movement, excess fatigability, incoordination, or pain. Such inquiry is not to be limited to muscles or nerves. These determinations are, if feasible, to be expressed in terms of the degree of additional range-of-motion loss due to any weakened movement, excess fatigability, incoordination, flare-ups, or pain. DeLuca v. Brown, 8 Vet. App. 202 (1995); see Johnston v. Brown, 10 Vet. App. 80, 84-5 (1997); 38 C.F.R. § 4.59 (2006); see also Mitchell v. Shinseki, 25 Vet. App. 32 (2011); cf. Powell v. West, 13 Vet. App. 31, 34 (1999); Hicks v. Brown, 8 Vet. App. 417, 421 (1995); Schafrath v. Derwinski, 1 Vet. App. 589, 592 (1991).

A VA examination of the joints must, wherever possible, include the results of the range of motion testing described in the final sentence of" 38 C.F.R. § 4.59. See Correia v. McDonald, 28 Vet. App. 158 (2016). Specifically, the final sentence of 38 C.F.R. § 4.59 requires that VA examinations include joint testing for pain on both active and passive motion, in weight-bearing and non-weight bearing and, if possible, with range of motion measurements of the opposite undamaged joint. Review of the August 2024 VA examination report, which is discussed further below, showed that joint testing for pain on both active and passive motion as well as non-weight bearing with range of motion measurements of the opposite undamaged joint was done in compliance with Correia.

In Chavis v. McDonough, 34 Vet. App. 1 (2021), the Court held that the application of §§ 4.40 and 4.45 permits consideration of an evaluation based on ankylosis, if a claimant's functional loss is consistent with that contemplated by ankylosis, that is, if the demonstrated functional loss is the functional equivalent of ankylosis. Ankylosis is stiffening or fixation of a joint as the result of a disease process, with fibrous or bony union across the joint. Dinsay v. Brown, 9 Vet. App. 79, 81 (1996); see also Villareal v. Principi, 18 Vet. App. 13 (2001) (defining ankylosis to mean that "a joint is fixed, or 'frozen' in one position").

Initially, again, the record shows that the Veteran's claim for increase was first received by VA on April 12, 2019. Thus, it must be determined whether it became factually ascertainable that the Veteran met the criteria for an increased rating one year prior to this date. See Quarles v. Derwinski, 3 Vet. App. 129, 135 (1992); see also Harper v. Brown, 10 Vet. App. 125, 126 (1997) (38 U.S.C. § 5110 (b)(2) and 38 C.F.R. § 3.400 (o)(2). However, there is no lay or medical evidence of record showing that the criteria for a 40 percent rating were met prior to October 15, 2018. In this regard, there are simply no findings that flexion was limited to 30 degrees or less. Thus, it was not factually ascertainable that he met the criteria for a 40 percent rating during this period.

Furthermore, after reviewing the record, the Board finds that the evidence persuasively weighs against finding that the Veteran is entitled to a disability evaluation in excess of 40 percent. A higher disability evaluation of 50 percent is warranted when there is evidence of unfavorable ankylosis of the entire thoracolumbar spine. 38 C.F.R. § 4.71a. The August 2024 VA examiner clearly found that the Veteran did not have ankylosis of the lumbar spine. Even considering additional impairment during flare-ups, at its most restrictive, the Veteran still retained some motion in flexion, extension, lateral flexion and rotation. The remaining medical evidence also does not show the functional equivalent of ankylosis.

, the Board finds that the evidence persuasively weighs against finding that the Veteran is entitled to a disability evaluation in excess of 40 percent. A higher disability evaluation of 50 percent is warranted when there is evidence of unfavorable ankylosis of the entire thoracolumbar spine. 38 C.F.R. § 4.71a. The August 2024 VA examiner clearly found that the Veteran did not have ankylosis of the lumbar spine. Even considering additional impairment during flare-ups, at its most restrictive, the Veteran still retained some motion in flexion, extension, lateral flexion and rotation. The remaining medical evidence also does not show the functional equivalent of ankylosis.

Moreover, the evidence fails to show that the Veteran's low back disability results in one or more of the following as required to be considered unfavorable: difficulty walking because of a limited line of vision; restricted opening of the mouth and chewing; breathing limited to diaphragmatic respiration; gastrointestinal symptoms due to pressure of the costal margin on the abdomen; dyspnea or dysphagia; atlantoaxial or cervical subluxation or dislocation; or neurologic symptoms due to nerve root stretching as set forth in Note (5). Importantly, the rating criteria clearly state that fixation of a spinal segment in neutral position (zero degrees) always represents favorable ankylosis.

While the Veteran experiences pain and significant impairment due to his spine disability, he has maintained some degree of motion despite his functional loss. Therefore, a higher disability evaluation based on functional impairment is not warranted. In sum, the evidence demonstrates that the Veteran does not suffer from the functional equivalent of unfavorable ankylosis to warrant a higher rating.

A 100 percent disability evaluation is also warranted if there is evidence of unfavorable ankylosis of the entire spine. Id. However, for the same reasons noted in the preceding paragraph, the Veteran is not entitled to a higher rating as he does not suffer from the functional equivalent of unfavorable ankylosis of the entire spine.

Moreover, the Board finds that a 60 percent disability evaluation is not warranted under the criteria for intervertebral disc syndrome as there is no evidence of incapacitating episodes having a total duration of at least 6 weeks during the past 12 months. 38 C.F.R. § 4.71a, Diagnostic Code 5242. Again, the August 2024 VA examiner was silent with respect to any required physician prescribed bed rest. The remaining medical evidence is also silent. Neither the Veteran nor his representative has provided any lay evidence of physician prescribed bed rest.

Furthermore, with the exception of the already service-connected peripheral neuropathy of the Veteran's lower extremities, which are discussed further below, there is simply no objective medical evidence of any other associated neurological abnormalities. The most recent VA examination clearly found there were no additional neurological abnormalities, and the remaining evidence is also silent with respect to any such findings. Thus, an additional separate compensable rating is not warranted for any other neurological symptoms and the Veteran's current symptoms are adequately contemplated under the assigned 40 percent disability rating.

The Board notes that the General Ratng Formula does not contemplate the use of medication. Again, the Board is cognizant of the Court decision in Ingram v. Collins, in which the Court reaffirmed prior holdings that in rating disabilities, the Board must discount the beneficial effects of medication when the relevant rating criteria do not contemplate medication use. Ingram v. Collins, 38 Vet. App. 130 (2025); see also Jones v. Shinseki, 26 Vet. App. 56 (2012); McCarroll v. McDonald, 28 Vet. App. 267 (2016). However, even considering the ameliorative effects of medication, there is no indication that the Veteran suffers from unfavorable ankylosis of the entire thoracolumbar spine to warrant a higher rating.

The Board acknowledges that the Veteran, in advancing this appeal, believes that the disability on appeal has been more severe than the assigned disability rating reflects. Moreover, the Veteran is competent to report observable symptoms. Layno v. Brown, 6 Vet. App. 465 (1994). In this case, however, the competent medical evidence offering detailed specific specialized determinations pertinent to the rating criteria are the most probative evidence with regard to evaluating the pertinent symptoms for the disability on appeal; the medical evidence also largely contemplates the Veteran's descriptions of symptoms. The lay testimony has been considered together with the probative medical evidence clinically evaluating the severity of the pertinent disability symptoms.

Based upon the guidance of the Court in Hart cited above, the Board has considered whether a staged rating is appropriate. However, as outlined above, the Veteran has not been entitled to
rating reflects. Moreover, the Veteran is competent to report observable symptoms. Layno v. Brown, 6 Vet. App. 465 (1994). In this case, however, the competent medical evidence offering detailed specific specialized determinations pertinent to the rating criteria are the most probative evidence with regard to evaluating the pertinent symptoms for the disability on appeal; the medical evidence also largely contemplates the Veteran's descriptions of symptoms. The lay testimony has been considered together with the probative medical evidence clinically evaluating the severity of the pertinent disability symptoms.

In conclusion, the evidence persuasively weighs against a rating in excess of 40 percent for degenerative arthritis and degenerative disc disease of the lumbar spine. In denying a higher rating, the Board finds the benefit of the doubt doctrine is not applicable. 38 U.S.C. § 5107; 38 C.F.R. §§ 4.3, 4.7.

Peripheral neuropathy, right and left lower extremities

The Veteran has been awarded separate 20 percent ratings for peripheral neuropathy of both lower extremities affecting the sciatic nerve. In the July 2024 decision, the Board denied an effective date prior to October 15, 2018, for the award of separate ratings for bilateral lower extremity peripheral neuropathy. This matter was not appealed.

The Veteran's sciatic nerve impairment of both lower extremities has been rated under 38 C.F.R. § 4.124a, Diagnostic Code 8520. Under this code, a 20 percent rating requires moderate incomplete paralysis of the sciatic nerve; a 40 percent rating requires moderately severe incomplete paralysis of the sciatic nerve, and a 60 percent rating required severe, with marked muscular atrophy, incomplete paralysis of the sciatic nerve.

For purposes of the below analyses, the Board observes that a note in the Rating Schedule pertaining to "Diseases of the Peripheral Nerves" provides that the term "incomplete paralysis" indicates a degree of lost or impaired function which is substantially less than that which results from complete paralysis of these nerve groups, whether the loss is due to the varied level of the nerve lesion or to partial nerve regeneration. When the involvement is wholly sensory, the rating should be for the mild, or at most, the moderate degree. 38 C.F.R. § 4.124a, Diagnostic Codes 8510 through 8540.

The regulations specifically provide that when rating peripheral nerve injuries and residuals related thereto, attention should be given to the site and character of the injury, the relative impairment in motor function, trophic changes, and/or sensory disturbances. 38 C.F.R. § 4.120. Consideration is also given to loss of reflexes, muscle atrophy, sensory disturbances, and pain. See 38 C.F.R. §§ 4.123, 4.124, 4.124a.

The Board notes that words such as "severe" and "moderate" are not defined in the Rating Schedule. Rather than applying a mechanical formula, VA must evaluate all evidence, to the end that decisions will be equitable and just. 38 C.F.R. § 4.6. Although the use of similar terminology by medical professionals should be considered, is not dispositive of an issue. Instead, all evidence must be evaluated in arriving at a decision regarding a request for an increased disability rating. 38 U.S.C. § 7104; 38 C.F.R. §§ 4.2, 4.6.

As with any regulatory interpretation where the terms are not defined in the regulation, we presume those terms carry their ordinary dictionary meaning. See Moody v. Wilkie, 30 Vet. App. 329, 336 (2018). The Board finds 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). The Board has considered the general definitions of the terms "mild," "moderate" and "severe." "Mild" is defined as "not severe" or temperate; with "temperate" being defined as "
336 (2018). The Board finds 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). The Board has considered the general definitions of the terms "mild," "moderate" and "severe." "Mild" is defined as "not severe" or temperate; with "temperate" being defined as "keeping or held within limits" and "not extreme or excessive." See MERRIAM-WEBSTER'S DICTIONARY. "Moderate" is defined as "tending toward the mean or average amount," "not violent, severe, or intense," and "limited in scope or effect." Id. "Severe" is defined as "very painful or harmful" or "of a great degree." Id. The term "severe" is used throughout the rating schedule to indicate a very great degree of the specific listed disability, in order to differentiate between lesser (or sometimes greater) cases of that same disability within the specific diagnostic code. Moderately severe is a combination of moderate and severe and characterizes disabilities between moderate and severe.

Based on the evidence of record, the Board finds that ratings in excess of 20 percent for bilateral neuropathy of the sciatic nerve are not warranted at any point during the course of the appeal. There is no medical evidence showing moderately severe incomplete paralysis of the right and left lower extremities. Importantly, both the May 2019 and August 2024 VA examiners characterized the severity of the Veteran's sciatic nerve impairment as "moderate" incomplete paralysis. At the May 2019 VA examination, the Veteran had normal strength. Reflexes were described as hypoactive at the knee and ankle. There were no trophic changes and sensory was decreased as foot/toes, but normal for ankle and knee.

Moreover, the recent VA examination showed that muscle strength testing and reflex examination were normal. The Veteran exhibited decreased sensory at the foot/toes, ankle, and knee. The Veteran had no muscle atrophy or trophic changes. The examiner also found that the Veteran's peripheral neuropathy did not impact his ability to work. In sum, the main symptoms documented at this examination are wholly sensory, which again at most rates as moderate impairment. When the examiners' characterizations are considered together with the findings as to the Veteran's symptoms, the Board concludes that the criteria for ratings in excess of 20 percent under Diagnostic 8520 have not been met for either lower extremity.

The Board notes that Diagnostic Code 8520 does not contemplate the use of medication. Here, the Veteran did not report that the use of any medication ameliorated his symptoms in any way, and the Board has thus discounted the ameliorative effects of medication in reaching its determination in this case. See Ingram v. Collins, 38 Vet. App. 130 (2025).

The Board acknowledges that at the recent VA examination, the Veteran described his symptoms as severe. While the Veteran is competent to report his observable symptoms, he is not competent to report that his symptoms are of sufficient severity to warrant a higher rating under VA's tables for rating such disabilities because such an opinion requires medical expertise which he has not been shown to have. Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009); Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007); Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006); Charles v. Principi, 16 Vet. App. 370 (2002). While the Veteran had subjective complaints of pain and other symptoms, the objective medical evidence demonstrates that there was not moderately severe incomplete paralysis of the left or right lower extremity, severe incomplete paralysis with marked muscular atrophy, or complete paralysis. To the extent that the Veteran alleges that he is entitled to a higher rating due to pain or difficulty with prolonged ambulation or standing, such symptoms are contemplated under the currently assigned ratings.

Consideration has been given to a staged rating. However, at no time during the period in question has the disability warranted a higher schedular rating than that assigned. Hart, supra. Neither the Veteran nor his representative have raised any other issues, nor have any other issues been reasonably raised by the record. Doucette v
subjective complaints of pain and other symptoms, the objective medical evidence demonstrates that there was not moderately severe incomplete paralysis of the left or right lower extremity, severe incomplete paralysis with marked muscular atrophy, or complete paralysis. To the extent that the Veteran alleges that he is entitled to a higher rating due to pain or difficulty with prolonged ambulation or standing, such symptoms are contemplated under the currently assigned ratings.

In sum, the evidence persuasively weighs against finding that ratings in excess of 20 percent each for right and left peripheral neuropathy is warranted. In denying higher ratings, the Board finds the benefit of the doubt doctrine is not applicable. 38 U.S.C. § 5107; 38 C.F.R. §§ 4.3, 4.7.

Degenerative disc disease and degenerative joint disease of the cervical spine

The Veteran is also seeking a rating in excess of 30 percent for his cervical spine disability. He generally contends that a higher rating is warranted.

Based on the evidence of record, the Board finds when applying the General Rating Formula outlined above to the Veteran's cervical spine disability, he is not entitled to a disability evaluation in excess of 30 percent at any point since the award of service connection. A higher disability evaluation of 40 percent is warranted when there is evidence of unfavorable ankylosis of the entire cervical spine. 38 C.F.R. § 4.71a. The August 2024 VA examiner clearly found that the Veteran did not have ankylosis of the cervical spine. The examiner found that the Veteran still retained flexion to 10 degrees during flare-ups. The remaining medical evidence is also silent with respect to any findings equaling the functional equivalent of ankylosis. The Veteran has been capable of motion in his cervical spine throughout the pendency of this claim. In sum, there has been no competent medical evidence showing that the Veteran has the functional equivalent of ankylosis of his cervical spine. Chavis v. McDonough, 34 Vet. App. 1 (2021).

Moreover, the evidence fails to show that the Veteran has ankylosis resulting in one or more of the following as required to be considered unfavorable: difficulty walking because of a limited line of vision; restricted opening of the mouth and chewing; breathing limited to diaphragmatic respiration; gastrointestinal symptoms due to pressure of the costal margin on the abdomen; dyspnea or dysphagia; atlantoaxial or cervical subluxation or dislocation; or neurologic symptoms due to nerve root stretching as set forth in Note (5). Importantly, the rating criteria clearly state that fixation of a spinal segment in neutral position (zero degrees) always represents favorable ankylosis.

While the Veteran experiences pain and significant impairment due to his cervical spine disability, he has maintained some degree of motion despite his functional loss. Therefore, a higher disability evaluation based on functional impairment is not warranted. In sum, the evidence demonstrates that the Veteran does not suffer from the functional equivalent of unfavorable ankylosis to warrant a higher rating.

Moreover, with the exception of upper extremity radiculopathy, there is simply no objective medical evidence of any other associated neurological abnormalities. The most recent VA examination clearly found there were no additional neurological abnormalities, and the remaining evidence is also silent with respect to any such findings. Thus, an additional separate compensable rating is not warranted for any other neurological symptoms and the Veteran's current symptoms are adequately contemplated under the assigned 30 percent disability rating.

Finally, a 40 percent disability evaluation is also not warranted for intervertebral disc syndrome (IVDS) with incapacitating episodes having a total duration of at least 4 weeks during the past 12 months. 38 C.F.R. § 4.71a, Diagnostic Code 5242. Here, there is no evidence to suggest that the Veteran has suffered from incapacitating episodes, as defined at 38 C.F.R. § 4.71a, for a total time period of at least 4 weeks during any 12
such findings. Thus, an additional separate compensable rating is not warranted for any other neurological symptoms and the Veteran's current symptoms are adequately contemplated under the assigned 30 percent disability rating.

Finally, a 40 percent disability evaluation is also not warranted for intervertebral disc syndrome (IVDS) with incapacitating episodes having a total duration of at least 4 weeks during the past 12 months. 38 C.F.R. § 4.71a, Diagnostic Code 5242. Here, there is no evidence to suggest that the Veteran has suffered from incapacitating episodes, as defined at 38 C.F.R. § 4.71a, for a total time period of at least 4 weeks during any 12-month period. In this regard, the August 2024 VA examination report clearly shows that the Veteran did not have IVDS requiring episodes of bed rest. Prior VA examinations are also silent with respect to any required bed rest. Moreover, the Veteran has not identified any treatment records that show incapacitation requiring physician prescribed bed rest for this duration of time. As such, a higher disability evaluation is not warranted based on incapacitating episodes.

The Board again notes that the General Ratng Formula does not contemplate the use of medication. However, even considering the ameliorative effects of medication, there is no indication that the Veteran suffers from unfavorable ankylosis of the entire cervical spine to warrant a higher rating. See Ingram v. Collins, 38 Vet. App. 130 (2025).

The Board has carefully reviewed and considered the Veteran's statements regarding the severity of his cervical spine disability. The Board acknowledges that the Veteran, in advancing this appeal, believes that the disability on appeal has been more severe than the assigned disability rating reflects. Moreover, the Veteran is competent to report observable symptoms. Layno v. Brown, 6 Vet. App. 465 (1994). In this case, however, the competent medical evidence offering detailed specific specialized determinations pertinent to the rating criteria are the most probative evidence with regard to evaluating the pertinent symptoms for the disability on appeal; the medical evidence also largely contemplates the Veteran's descriptions of symptoms. The lay testimony has been considered together with the probative medical evidence clinically evaluating the severity of the pertinent disability symptoms.

Based upon the guidance of the Court in Hart, cited above, the Board has considered whether a staged rating is appropriate. However, as outlined above, the Veteran has not been entitled to a disability evaluation in excess of 30 percent at any time during the course of the appeal. As such, staged ratings are not warranted.

In conclusion, a rating in excess of 30 percent rating for degenerative disc disease and degenerative joint disease of the cervical spine is not warranted. In reaching this conclusion, the Board has applied the benefit-of-the doubt doctrine but finds that the evidence persuasively weighs against assignment of any higher rating. See 38 U.S.C. § 5107 (b); 38 C.F.R. §§ 3.102, 4.7; Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990).

Right and left leg shin splints

The Veteran seeks a compensable rating for his right and left leg shin splints. He has generally asserted that higher ratings are warranted.

The Veteran's right lower extremity shin splints and left lower extremity shin splints are rated as noncompensable under 38 C.F.R. § 4.71a, Diagnostic Code 5262, for impairment of the tibia and fibula.

Effective February 7, 2021, VA amended the rating criteria for disabilities of the knee and leg. The amended Diagnostic Code 5262 continues to provide a rating for impairment of the tibia and fibula. The rating criteria are split into three categories: medial tibial stress syndrome (MTSS), or shin splints; malunion; and nonunion.

Prior to February 7, 2021, the Veteran's shin splints were rated by analogy based on impairment of the tibia under Diagnostic Code 5299-5242. Under this prior code, a 10 percent rating is warranted for malunion of tibia and fibula with slight knee or ankle disability. A 20 percent rating is warranted for malunion of the tibia and fibula with moderate knee or ankle disability. A 30 percent rating is warranted for malunion of the tibia and fibula with marked knee or ankle disability. A maximum 40 percent rating is warranted for nonunion of the tibia and fibula with loose motion requiring a brace. 38 C.F.R. § 4.71a, Diagnostic Code 5262.

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ints were rated by analogy based on impairment of the tibia under Diagnostic Code 5299-5242. Under this prior code, a 10 percent rating is warranted for malunion of tibia and fibula with slight knee or ankle disability. A 20 percent rating is warranted for malunion of the tibia and fibula with moderate knee or ankle disability. A 30 percent rating is warranted for malunion of the tibia and fibula with marked knee or ankle disability. A maximum 40 percent rating is warranted for nonunion of the tibia and fibula with loose motion requiring a brace. 38 C.F.R. § 4.71a, Diagnostic Code 5262.

According to MERRIAM WEBSTER'S COLLEGIATE DICTIONARY 999 (11th Ed. 2007), "slight" means small in amount. "Moderate" means limited in scope or effect. "Marked" means having a distinctive or emphasized character.

Under the revised criteria for MTSS, or shin splints, a noncompensable rating is warranted for treatment less than 12 consecutive months, one or both lower extremities. A 10 percent rating is warranted where treatment is required for no less than 12 months, and unresponsive to either shoe orthotics or other conservative treatment, one or both lower extremities. A 20 percent rating is warranted where treatment is required for no less than 12 consecutive months, and unresponsive to surgery and either shoe orthotics or other conservative treatment, one lower extremity. A maximum 30 percent rating is warranted where treatment is required for no less than 12 consecutive months, and unresponsive to surgery and either shoe orthotics or other conservative treatment, both lower extremities.

For malunion of the tibia and fibula, evaluate under diagnostic codes 5256, 5257, 5260, or 5261 for the knee, or 5270 or 5271 for the ankle, whichever results in the highest evaluation.

The Court has distinguished when rating criteria are conjunctive versus disjunctive. If conjunctive, such as evidenced by the use of the word "and" in a statutory provision or when reciting the relevant regulatory requirements, then all of the criteria must be satisfied to warrant a higher rating. See Melson v. Derwinski, 1 Vet. App. 334, 337 (1991). Whereas, if disjunctive, as evidenced by the use of the word "or" instead, then only one of the listed requirements must be met in order for an increased rating to be assigned. See Johnson v. Brown, 7 Vet. App. 95 (1994).

In this case, for the period before February 7, 2021, the prior regulations will be applied, and from February 7, 2021, either the prior or amended rating criteria will be applied, whichever are more favorable rating for the Veteran. See Kuzma v. Principi, 341 F.3d 1327, 1328 (2003); 38 C.F.R. § 4.20.

The Board finds that the evidence of record persuasively weighs against an initial compensable rating for right and left lower extremity shin splints under both the prior and current regulations. In this regard, the only medical evidence addressing the severity of the Veteran's shin splints during the period prior to February 7, 2021 is a July 2015 VA examination. The examiner observed that the Veteran experienced mild symptoms when running. The examiner explicitly found that the Veteran's shin splints did not affect range of motion of the knees or ankles. The examiner also found that there was no functional impairment. Moreover, the August 2024 VA examiner also found that the Veteran's shin splints do not affect the range of motion of the right and left knees, and right and left ankles. As such, given that there is no slight disability of the knees or ankles associated with the Veteran's shin splints, his bilateral shin splints do not meet the criteria for a compensable rating under the prior Diagnostic Code 5262.

Likewise, under the new criteria, the August 2024 VA examiner found that the Veteran's shin splints were unresponsive to shoe orthotics or other conservative treatment. However, the examiner did not find that the Veteran required treatment for 12 consecutive months or more; nor was the Veteran's disorder unresponsive to surgery. In order to assign a 10 percent evaluation under the new Diagnostic Code 5262 the use of the "and" means that "unresponsive to surgery" is a required element that must be met. However, here, the Veteran's bilateral shin splints were not unresponsive to
bilateral shin splints do not meet the criteria for a compensable rating under the prior Diagnostic Code 5262.

Likewise, under the new criteria, the August 2024 VA examiner found that the Veteran's shin splints were unresponsive to shoe orthotics or other conservative treatment. However, the examiner did not find that the Veteran required treatment for 12 consecutive months or more; nor was the Veteran's disorder unresponsive to surgery. In order to assign a 10 percent evaluation under the new Diagnostic Code 5262 the use of the "and" means that "unresponsive to surgery" is a required element that must be met. However, here, the Veteran's bilateral shin splints were not unresponsive to surgery, as the evidence demonstrates that the Veteran did not undergo surgery for his bilateral shin splints. Therefore, the Board finds that there is no basis upon which to award a compensable rating under the amended Diagnostic Code 5262.

As the Veteran's shin splints do not affect the knees or ankles, the remaining diagnostic codes pertaining to the knees and ankles are not applicable.

The Board has carefully reviewed and considered the Veteran's statements regarding the severity of his shin splints. However, here, the competent medical evidence offering detailed specific specialized determinations pertinent to the rating criteria are the most probative evidence with regard to evaluating the pertinent symptoms for the disability on appeal; the medical evidence also largely contemplates the Veteran's descriptions of symptoms. In sum, the lay evidence has been considered together with the probative medical evidence clinically evaluating the severity of the pertinent disability symptoms.

The Board has considered whether staged ratings under Fenderson, supra, are appropriate or the Veteran's service-connected right and left shin splints; however, the Board finds that his symptomatology has been stable since the award of service connection. Therefore, assigning staged ratings for such disability is not warranted.

In conclusion, the evidence persuasively weighs against initial compensable ratings for right and left leg shin splints. In denying a higher rating, the Board finds the benefit of the doubt doctrine is not applicable. 38 U.S.C. § 5107; 38 C.F.R. §§ 4.3, 4.7.

REASONS FOR REMAND

Entitlement to a compensable rating for headaches prior to August 23, 2024 is remanded.

The Board finds that the medical evidence is insufficient to rate the Veteran's headaches prior to August 23, 2024, the date a maximum schedular rating was assigned. In this regard, the only examination during this period was the July 2015 VA examination. At that examination, the Veteran reported that he took Advil for his headaches. However, the VA examiner did not consider the ameliorative effects of medications the Veteran uses to treat his headaches. Moreover, VA clinical records shows that the Veteran also used Botox to treat his headaches during this period. See Ingram v. Collins, 38 Vet. App. 130, 131 (2025). As such, the Board finds that a retrospective medical opinion is necessary to determine the severity of the Veteran's headaches prior to August 23, 2024, excluding any ameliorative effects of medications. See Chotta v. Peake, 22 Vet. App. 80, 85 (2008) (holding that the duty to assist may include obtaining a retrospective medical opinion to fill in gaps in the medical evidence of record). A remand is necessary to correct this pre-decisional duty to assist error.

Entitlement to a rating in excess of 40 percent for right hand/wrist CTS with radiculopathy upper and middle radicular groups is remanded.

The August 2024 VA peripheral nerve examination showed that the Veteran's right hand/wrist CTS was manifested by moderate incomplete paralysis of the median nerve, upper radicular group and middle radicular group. The examiner explicitly found that functioning was not so diminished that amputation with prosthesis would equally serve the Veteran. However, in support of his claim, the Veteran submitted a March 2025 private opinion indicating that the Veteran suffered from loss of use of his upper extremities. The examiner specifically opined that it is at least as likely as not that his service-connected bilateral upper extremities had no effective remaining function other than that which would be equally well served by an amputation stump with the use of a suitable prosthetic appliance.

Given these conflicting medical findings as well as the possibility of an increase in severity, the Veteran should be afforded another VA examination addressing the severity of the Veteran's right hand/wrist CTS, to include whether the Veteran suffers from loss of use of his upper extremities. A remand is necessary to correct this pre-decisional duty to assist error
claim, the Veteran submitted a March 2025 private opinion indicating that the Veteran suffered from loss of use of his upper extremities. The examiner specifically opined that it is at least as likely as not that his service-connected bilateral upper extremities had no effective remaining function other than that which would be equally well served by an amputation stump with the use of a suitable prosthetic appliance.

Entitlement to an effective date prior to February 29, 2016 for a TDIU due to service-connected disabilities is remanded; entitlement to an effective date prior to February 29, 2016 for the grant of eligibility for DEA under 38 USC chapter 35 is remanded; and entitlement to an effective date prior to February 29, 2016 for the award of SMC based on housebound status is remanded.

These issues are inextricably intertwined with the remaining issues on appeal. Harris v. Derwinski, 1 Vet. App. 180, 183 (1991) (issues are "inextricably intertwined" when a decision on one issue would have a "significant impact" on a Veteran's claim for the second issue). The Veteran was awarded service connection for posttraumatic stress disorder (PTSD) on February 29, 2016, and from that date, the Veteran has been awarded a TDIU based on his service-connected PTSD alone. However, importantly, the record prior to February 19, 2016, does not adequately address the functional impairment caused by his service-connected disabilities either alone or combined on the Veteran's employability. Thus, the Board finds that a remand is also necessary to obtain a retrospective medical opinion addressing the functional impairment caused by the Veteran's service-connected disabilities on his ability to maintain substantially gainful employment prior to February 29, 2016. A remand is necessary to correct this pre-decisional duty to assist error.

Entitlement to an effective date prior to October 5, 2017 for SMC based on the need for regular aid and attendance is remanded; entitlement to SMC under 38 U.S.C. § 1114 (m) based on loss of use of the upper extremities is remanded; entitlement to SMC 38 U.S.C. § 1114 (l) based on the need for regular aid and attendance due to service-connected disabilities other than the upper extremities is remanded; entitlement to SMC based on the need for regular aid and attendance at a higher level, specifically under 38 U.S.C. § 1114 (r)(1), is remanded.

These issues are also inextricably intertwined with the remaining issues on appeal. Moreover, again prior to the AOJ decision on appeal, the Veteran submitted a March 2025 private opinion indicating that the Veteran was entitled to a higher level of SMC. In turn, the Board also finds that an additional VA aid and attendance examination and opinions are necessary in order to have a complete record to make a determination as to the appropriate level of SMC. A remand is necessary to correct these pre-decisional duty to assist errors.

Again, the above examination pertaining to the right upper extremity should also address whether the Veteran has loss of use of his upper extremities under the requirements for SMC 38 U.S.C. § 1114 (m).

Moreover, the AOJ awarded SMC based on the need for aid and attendance, effective the date of claim, which was submitted on October 5, 2017. However, the issue of entitlement to SMC is part and parcel of a claim for increased compensation and does not require submission of a separate claim. See Akles v. Derwinski, 1 Vet. App. 118 (1991). As such, given that some of the rating claims on appeal date back to the original award of service connection, July 27, 2014, the Board finds that a retrospective medical opinion is necessary to determine whether the Veteran required regular aid and attendance since that date.

Furthermore, the March 2025 private opinion also indicated that since at least October 2018, the Veteran's service-connected disabilities other than his upper extremities required the regular need of aid and attendance. However, the examiner did not proffer an adequate description of the functional impairment caused by these disabilities that prevented him from performing his activities of daily living without assistance. In this regard, the examiner
, 1 Vet. App. 118 (1991). As such, given that some of the rating claims on appeal date back to the original award of service connection, July 27, 2014, the Board finds that a retrospective medical opinion is necessary to determine whether the Veteran required regular aid and attendance since that date.

Furthermore, the March 2025 private opinion also indicated that since at least October 2018, the Veteran's service-connected disabilities other than his upper extremities required the regular need of aid and attendance. However, the examiner did not proffer an adequate description of the functional impairment caused by these disabilities that prevented him from performing his activities of daily living without assistance. In this regard, the examiner mentioned an inability to prepare meals or take care of hygiene needs, but the description would appear to indicate that the ability to perform these tasks were at least in some part affected by his upper extremities. As such, an opinion is also necessary to address whether the Veteran requires the regular need of aid and attendance due to his service-connected disabilities other than his upper extremities.

Finally, as the Veteran is seeking the highest level of SMC available, an opinion is also necessary to determine whether the Veteran requires a higher level of care that in the absence of such higher level of care he would require some form of institutionalization, i.e., hospitalization, nursing home care, or other residential institutional care.

The matters are REMANDED for the following action:

1. Obtain a retrospective opinion with an appropriate clinician to determine the severity of the Veteran's headaches prior to August 23, 2024. The need for another VA examination is left to the discretion of the examiner. After reviewing the claims file, the examiner should opine as to the nature and frequency of characteristic prostrating attacks prior to August 23, 2024. Specifically, the examiner should state whether at any point prior to this date, the Veteran had very frequent, completely prostrating and prolonged attacks productive of severe economic inadaptability. If there is a change in the severity of the Veteran's headaches at any point prior to August 23, 2024, the examiner should give the date of increase, if possible. The examiner must address the severity of the Veteran's symptoms absent the ameliorative effects of any medication, including both prescription and over-the-counter medications.

2. Schedule the Veteran for an examination with an appropriate clinician to address the severity of his right hand/wrist CTS with radiculopathy upper and middle radicular groups. The examiner must review the claims file. The examiner should provide a full description of the disability and report all signs and symptoms necessary for evaluating the Veteran's disability under the rating criteria. Specifically, the examiner must determine whether the Veteran's right hand CTS with radiculopathy more closely approximates severe incomplete paralysis or complete paralysis. The examiner must also determine whether functioning is so diminished that amputation with prosthesis would equally serve the Veteran. The examiner must address the severity of the Veteran's symptoms absent the ameliorative effects of any medication, including both prescription and over-the-counter medications. If the Veteran is unable to report for an examination, opinions should still be obtained based on review of the record if possible.

3. Obtain a retrospective opinion concerning the impact of the Veteran's service-connected disabilities either alone or combined on his ability to work prior to February 29, 2016, to include the functional impairment on his employment caused by the service-connected disabilities, given his education and employment history. The claims file must be reviewed and a detailed rationale must be provided for any opinions rendered. The need for another examination is left to the discretion of the examiner.

4. Schedule the Veteran for an examination with an appropriate clinician to determine the need for SMC based on the need for regular aid and attendance, or at a higher level due solely to his service-connected disabilities. The examiner must respond to the following:

a) Was the Veteran in need of regular aid and attendance due to his service-connected disabilities alone prior to October 5, 2017. The examiner should determine whether, as a result of the service-connected disabilities during this period, the Veteran required assistance on a regular basis to: dress or undress himself, keep himself ordinarily clean and presentable; feed himself due to loss of coordination of upper extremities or through extreme weakness; attend to the wants of nature; or to protect himself from the hazards or dangers incident to his daily environment.

b) If and only if it is determined that Veteran experiences loss of use of his upper extremities at any point during the course of the appeal, from this point, is the Veteran's need for aid and attendance due solely to his other service-connected disabilities irrespective of his service-connected upper extremities
October 5, 2017. The examiner should determine whether, as a result of the service-connected disabilities during this period, the Veteran required assistance on a regular basis to: dress or undress himself, keep himself ordinarily clean and presentable; feed himself due to loss of coordination of upper extremities or through extreme weakness; attend to the wants of nature; or to protect himself from the hazards or dangers incident to his daily environment.

c) At any point during the course of the appeal, is the Veteran receiving a "higher level of care" by an unlicensed person, including a family member, performing a regimen of personal health-care services; and receiving a regimen of such services which is or are prescribed by a health-care professional; and does the person performing a regimen of personal health-care services consult on at least a monthly basis with the prescribing health-care professional, either by in-person consultation or by telephonic communication. The examiner is advised that the term "higher level of care" means that in the absence of such higher level of care the Veteran would require some form of institutionalization, i.e., hospitalization, nursing home care, or other residential institutional care.

In rendering the above opinions, all functional impairments caused by the service- connected disorders should be clearly reported. The examiner must provide a reasonable explanation for all of the above findings and specifically address the March 2025 private opinion. If the Veteran is unable to report to an examination in person, the examiner should review the record and answer the above questions if possible.

L. M. BARNARD

Veterans Law Judge

Board of Veterans' Appeals

Attorney for the Board J.N. Moats, Counsel

The Board's decision in this case is binding only with respect to the instant matter decided. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.

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