Citation Nr: 23013987 Decision Date: 03/08/23 Archive Date: 03/08/23 DOCKET NO. 16-00 001A DATE: March 8, 2023 ORDER Entitlement to service connection for an acquired psychiatric disorder other than posttraumatic stress disorder (PTSD) is granted. Entitlement to service connection for nerve damage of the left lower extremity as secondary to service-connected thoracolumbar spine disability is granted. Entitlement to service connection for right upper extremity radiculopathy as secondary to service-connected residuals of a neck injury, degenerative joint disease (DJD) of the cervical spine is granted. Entitlement to service connection for a headache disability as secondary to service-connected residuals of a neck injury, DJD of the cervical spine, is granted. Entitlement to a rating of 70 percent prior to May 11, 2018, for PTSD is granted. Entitlement to a rating greater than 70 percent for PTSD since May 11, 2018, is denied. Entitlement to a rating greater than 20 percent for residuals of a neck injury, DJD of the cervical spine is denied. Entitlement to a rating greater than 20 percent for left upper extremity cervical radiculopathy associated with residuals of a neck injury, DJD of the cervical spine is denied. REMANDED Entitlement to reopen a claim for service connection for diabetes mellitus is remanded. Entitlement to service connection for a disability manifested by shortness of breath, claimed as due to exposure to environmental hazards during the Persian Gulf War is remanded. Entitlement to service connection for residuals of removal of the gallbladder, to include as due to contaminated water at Camp Lejeune, and claimed as due to exposure to environmental hazards during the Persian Gulf War is remanded. Entitlement to service connection for a disability manifested by swelling of the joints, claimed as due to exposure to environmental hazards during the Persian Gulf War is remanded. FINDINGS OF FACT 1. The Veteran's acquired psychiatric disorder other than PTSD, is proximately due to or the result of his service-connected PTSD. 2. The Veteran's nerve damage of the left lower extremity is proximately due to or the result of his service-connected thoracolumbar strain disability. 3. The Veteran's right upper extremity cervical radiculopathy is proximately due to or the result of his service-connected residuals of a neck injury, DJD of the cervical spine. 4. The Veteran's headache disability is proximately due to or the result of his service-connected residuals of a neck injury, degenerative joint disease (DJD) of the cervical spine. 5. Prior to May 11, 2018, the severity, frequency and duration of the Veteran's PTSD symptomatology is characterized by occupational and social impairment in most areas, with symptoms to include paranoia, intrusive thoughts, intense rage, and significant anxiety; however, the severity, frequency and duration of symptoms do not approximate total occupational and social impairment. 6. Since May 11, 2018, the Veteran's PTSD is characterized by occupational and social impairment in most areas; however, the severity, frequency, and duration of symptoms do not approximate total occupational and social impairment due to PTSD. 7. The Veteran's residuals of a neck injury, DJD of the cervical spine is characterized by decreased range of motion and stiffness of the neck resulting in limitation of motion; however, forward flexion is not limited to 15 degrees or less, and there is not ankylosis or intervertebral disc syndrome of the cervical spine. 8. The Veteran's left upper extremity cervical radiculopathy associated with residuals of a neck injury, DJD of the cervical spine was manifested by no worse than pain, numbness, tingling, paresthesias and/or dysesthesias with functional limitations such as reported weakness and loss of strength, but no atrophy, and normal muscle testing and reflex testing, best characterized as mild symptomatology. CONCLUSIONS OF LAW 1. The criteria for service connection for an acquired psychiatric disorder other than PTSD, as secondary to service-connected PTSD are met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.310(a). 2. The criteria for service connection for nerve damage of the left lower extremity to include as secondary to service-connected thoracolumbar strain disability are met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.310(a). 3. The criteria for service connection for right upper extremity cervical radiculopathy associated with residuals of a neck injury, DJD of the cervical spine are met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.310(a). 4. The criteria for a headache disability as secondary to service-connected residuals of a neck injury, degenerative joint disease (DJD) of the cervical spine are met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.310(a). 5. The criteria for a rating of 70 percent prior to May 11, 2018, for PTSD are met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.126, 4.130, DC 9411. 6. The criteria for a rating greater than 70 percent for PTSD since May 11, 2018. are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.126, 4.130, DC 9411. 7. The criteria for a rating greater than 20 percent for residuals of a neck injury, DJD of the cervical spine are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.2, 4.10, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5010- 5242. 8. The criteria for a rating greater than 20 percent for left upper extremity cervical radiculopathy associated with residuals of a neck injury, DJD of the cervical spine are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.124a, Diagnostic Code 8510. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active service from June1987 to November 1994, and from February 2003 to November 2003. See DD Forms 214. The Veteran's service includes in the Southwest Asia Theatre during the Persian Gulf War, from April 2003 to July 2003. Additionally, the Veteran served in the Army National Guard from November 1994 to August 2011, and the Army Reserves from August 2011 to November 2013, including periods of active duty for training (ACDUTRA). See August 2015 VA 21-526EZ, Fully Developed Claim; see Information Report. These matters come before the Board of Veterans' Appeals (Board) on appeal from July 2015 (in pertinent part, a headache disability, hypertension, a disability manifested by swelling of the joints, a back disability, a disability manifested by shortness of breath, bilateral foot disability, PTSD, and a cervical disability) and December 2015 (nerve damage of the bilateral lower extremities, a gall bladder disability, and an acquired psychiatric disorder other than PTSD) rating decisions by the Department of Veterans Affairs (VA) Regional Office (RO) in Atlanta, Georgia. See July 2015 Rating Decision-Narrative; see December 2015 Rating Decision- Narrative. In January 2015, the Veteran, in part, filed to reopen the claim for entitlement to service connection for a headache disability, a disability manifested by swelling of the joints, a back disability, and a disability manifested by shortness of breath. See January 2015 VA 21-526EZ, Fully Developed Claim (Compensation). The July 2015 rating decision, in part, denied these claims. See July 2015 Rating Decision-Narrative. Thereafter, in August 2015, the Veteran, in part, submitted an application to reopen these claims, which were again denied in a December 2015 rating decision. See August 2015 VA 21-526EZ, Fully Developed Claim; see December 2015 Rating Decision-Narrative. The Veteran submitted a January 2016 notice of disagreement (NOD), in part, as to these denials. See January 2016 NOD. Although the Veteran specified the January 2016 NOD pertained to the December 2015 rating decision, such was also timely as to the July 2015 rating decision, which is more favorable to the Veteran. Following issuance of a statement of the case (SOC) in August 2016, a substantive appeal was timely received in September 2016, within 60 days. See August 2016 SOC; see September 2016 Form 9. As such, the July 2015 rating decision is the rating decision on appeal for a headache disability, a disability manifested by swelling of the joints, a back disability, and a disability manifested by shortness of breath. In July 2021, the Board reopened the claims of entitlement to service connection for a headache disability, for hypertension, for swelling of the joints, and for nerve damage of the bilateral lower extremities. See July 2021 BVA Decision. In addition, the Board denied the claim for a compensable evaluation for bilateral hearing loss. The Board remanded the claims for service connection for a back disability, for a headache disability, for hypertension, for disability manifested by shortness of breath, for disability manifested by swelling of the joints, for nerve damage of the bilateral lower extremities, for bilateral foot disability, for an acquired psychiatric disorder other than PTSD, and for increased evaluations for PTSD, and for residuals of a neck injury, DJD of the cervical spine. The Board's previous explanation of the procedural history is adopted herein. See July 2021 BVA Decision. To recap, the Veteran's claim for entitlement to service connection for a disability manifested by shortness of breath was denied in a March 2007 unappealed rating decision and was considered on a de novo basis due to subsequently received relevant service treatment records. 38 C.F.R. § 3.156(c)(1); see March 2007 Rating Decision-Narrative. Specifically, in September 2016, the Veteran submitted a July 2003 service record documenting a diagnosis of other dyspnea and respiratory abnormality; and an August 2003 service record, obtained by VA in January 2015, noted chest pain and shortness of breath, both of which arguably supports the Veteran's contention of a chronic in-service disability. See Medical Treatment Record- Government Facility received September 13, 2016; see STR received January 15, 2015. Additionally, and as explained in the July 2021 Board decision, the Veteran was awarded service connection for PTSD; however, in August 2015 he submitted, in part, an application for nervousness as secondary to shortness of breath, which the Board recharacterized as a claim for any acquired psychiatric disability other than PTSD. Clemons v. Shinseki, 23 Vet. App. 1(2009); see August 2015 VA 21-526EZ, Fully Developed Claim. Similarly, and also explained in the July 2021 Board decision, in August 2015 the Veteran submitted, in part, an application for nerve damage both as secondary to back pain and secondary to bilateral foot condition, which was reopened and recharacterized as service connection for nerve damage of the bilateral lower extremities. See August 2015 VA 21-526EZ, Fully Developed Claim. The Board notes that right lower extremity radiculopathy was granted in a June 2022 rating decision, such that it is a full grant and no longer on appeal; however, service connection for left lower extremity radiculopathy remains on appeal. Grantham v. Brown, 114 F.3d 1156, 1158-59 (Fed. Cir. 1997); see June 2022 Rating Decision-Narrative. Further, the Board finds the Veteran's increased rating claim for service-connected cervical disability encompasses a related disability of the upper extremities, and notes that the Veteran was awarded a separate rating for left upper extremity radiculopathy secondary to his cervical spine disability effective January 5, 2015, which is part of the appeal. See October 2021 Rating Decision. As the July 2021 decision noted, a July 2018 rating decision denied entitlement to service connection for erectile dysfunction and continued previous denials for entitlement to service connection for diabetes, a heart disability, and sleep apnea. In August 2018, the Veteran submitted a timely NOD with respect to these denials, and an SOC was issued as to erectile dysfunction and a heart disability in March 2020. See August 2018 NOD; see March 2020 SOC. While the Veteran submitted a VA Form 9 in May 2020, it was not timely. See May 2020 VA Form 9. Thus, the issues of entitlement to reopen previous denials of heart disability and sleep apnea are not on appeal. The Board observes that an SOC was not issued concerning the issue of reopening service connection for diabetes, and as such this must be remanded. As also previously noted, the Veteran appeared at a hearing before a Board Veterans Law Judge (VLJ) in November 2020. See November 2020 Hearing Transcript. A transcript of the hearing is of record. As this VLJ is no longer employed at the Board, the Veteran was offered the opportunity to testify at another hearing by a May 2021 letter. See May 2021 BVA Letter. As the Veteran has not responded, the Board may proceed based on the evidence of record. Considering that the issue of entitlement to service connection for a bilateral foot disability was also remanded in July 2021, the Board notes that it has since been granted by an October 2021 rating decision. See October 2021 Rating Decision-Narrative. This represents a full grant, and the issue is no longer on appeal. Grantham v. Brown, 114 F.3d 1156, 1158-59 (Fed. Cir. 1997). Further the issue of entitlement to service connection for a thoracolumbar spine disability was remanded, and the Board notes that it was granted by an October2021 rating decision. See October 2021 Rating Decision-Narrative. This represents a full grant, and the issue is no longer on appeal. Grantham v. Brown, 114 F.3d 1156, 1158-59 (Fed. Cir. 1997). For the remanded issue of entitlement to an increased rating for PTSD, although the evaluation was increased to 70 percent effective May 11, 2018, this does not represent a full grant, such that it remains on appeal. Grantham v. Brown, 114 F.3d 1156, 1158-59 (Fed. Cir. 1997); see October 2021 Rating Decision. The issues of entitlement to service connection for residuals of removal of the gallbladder, for a headache disability, for hypertension, and for a disability manifested by swelling of the joints were also remanded in July 2021, and an October 2021 Supplemental Statement of the Case in pertinent part addressing these issues was completed. See October 2021 SSOC. Then in December 2021 service connection for hypertension was granted, such that this is a complete grant of benefits for service connection for hypertension, (the appeal for a higher rating is in the AMA). See December 2021 Rating Decision-Narrative. The corresponding December 2021 Rating Codesheet explained that the contentions of swelling of joints, nerve damage of the left lower extremity, gallbladder, shortness of breath and headaches were on the October 2021 SSOC, and were not opted into the AMA via Form 0996, such that they were not accepted for higher level review and remained pending as legacy appeals. See December 2021 Rating Decision-Codesheet; see December 2021 VA Form 20-0996 Request for Higher Level Review. The Board notes that a March 2022 Form 10182 was filed for these issues, and a letter from the AMA indicated that the decision disagreed with was issued before February 19, 2019, and a SOC or SSOC dated on or after February 19, 2019, had not yet been issued, such that the decision was in legacy. See March 2022 VA Form 10182 NOD; see March 2022 AMA Notification Letter. Although the Board notes that the October 2021 SSOC had been issued such that the reasoning given appears to be erroneous, the receipt of the March 2022 NOD was not timely as it was more than 60 days after the October 12, 2021, notice of the SSOC. See 38 C.F.R. § 19.52. As such, the result remains the same, such that the issues of entitlement to service connection for residuals of removal of the gallbladder, for a headache disability, and for a disability manifested by swelling of the joints remain in the legacy system. Pursuant to the July 2021 Board remand instructions, the Veteran was provided VA examinations in August 2021, such that there has been substantial compliance with the remand directives. See Dyment v. West, 13 Vet. App. 141, 146-47 (1999) (remand not required under Stegall v. West, 11 Vet. App. 268 (1998) where there was substantial compliance with Board's remand instructions). The Board notes that VA is required to develop and adjudicate related claims for secondary service connection for disabilities that are reasonably raised during the adjudication of an increased rating claim for the primary disability. See 38 C.F.R. § 3.160; Bailey v. Wilkie, 33 Vet. App. 188 (2021); Kisor v. Wilkie, 139 S. Ct. 2400, 2415 (2019). Here, a June 2015 VA examination report noted that radiculopathy resulted from cervical DJD. As such, the issue of entitlement to service connection for right upper extremity radiculopathy is before the Board on appeal and is properly included in the list of issues before the Board. This appeal has been advanced on the docket. See November 2018 BVA Letter. Service Connection Legal Criteria Service connection may be established for disability due to a disease or injury that was incurred in or aggravated by active military service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303. Service connection may also be granted for any disease initially diagnosed after service, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Service connection may be granted for a disability that is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310(a). In general, in order to prevail on the issue of service connection the evidence must show: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). In the context of Reserve or National Guard service, service connection may only be granted for a disability resulting from disease or injury incurred or aggravated while performing ACDUTRA, or an injury incurred or aggravated while performing INACDUTRA. 38 U.S.C. §§ 101(24); 38 C.F.R. § 3.6. Persian Gulf The Veteran's service includes in the Southwest Asia Theatre during the Persian Gulf War, from April 2003 to July 2003. For veterans who served in the Southwest Asia Theater of Operations during the Persian Gulf War, VA will pay compensation to those who exhibit objective indications of a qualifying chronic disability. 38 C.F.R. § 3.317(a)(1). VA regulation defines a "qualifying chronic disability" as either: (1) an undiagnosed illness or (2) a medically unexplained chronic multisymptom illness that is defined by a cluster of signs or symptoms, such as chronic fatigue syndrome, fibromyalgia, and functional gastrointestinal disorders. 38 C.F.R. § 3.317(a)(2)(i). The term medically unexplained chronic multisymptom illness (MUCMI) means a diagnosed illness without conclusive pathophysiology or etiology, that is characterized by overlapping symptoms and signs and has features such as fatigue, pain, disability out of proportion to physical findings, and inconsistent demonstration of laboratory abnormalities. Chronic multisymptom illnesses of partially understood etiology and pathophysiology, such as diabetes and multiple sclerosis, will not be considered medically unexplained. 38 C.F.R. § 3.317(a)(2)(ii). "Objective indications of chronic disability" include both "signs," in the medical sense of objective evidence perceptible to an examining physician, and other, non-medical indicators that are capable of independent verification. 38 C.F.R. § 3.317(a)(3). For purposes of this section, disabilities that have existed for 6 months or more and disabilities that exhibit intermittent episodes of improvement and worsening over a 6-month period will be considered chronic. The 6-month period of chronicity will be measured from the earliest date on which the pertinent evidence establishes that the signs or symptoms of the disability first became manifest. 38 C.F.R. § 3.317(a)(4). Signs or symptoms which may be manifestations of undiagnosed illness or MUCMI include, but are not limited to: fatigue, signs or symptoms involving the skin, headache, muscle pain, joint pain, neurological signs or symptoms, neuropsychological signs or symptoms, signs or symptoms involving the respiratory system (upper or lower), sleep disturbances, gastrointestinal signs or symptoms, cardiovascular signs or symptoms, abnormal weight loss, and menstrual disorders. 38 C.F.R. §3.317(b). Camp Lejeune Water Contamination A review of the Veteran's DD-214 shows he was stationed at the U.S. Marine Corps Base Camp Lejeune; although his precise length of time at that base has not verified, the record supports that he meets at least the 30-day time frame during the applicable period, as there is a health record showing he was present from February to May 1986 at Camp LeJeune. See Military Personnel Record. In this respect, VA has acknowledged that persons residing or working at the U.S. Marine Corps Base Camp Lejeune between August 1953 and December 1987 were potentially exposed to drinking water contaminated with volatile organic compounds (VOCs). The contaminants included trichloroethylene (TCE) (a metal degreaser), perchloroethylene (PCE) (a dry-cleaning agent), benzene, vinyl chloride, and other VOCs. The National Academy of Sciences' National Research Council (NRC) published its report, "Contaminated Water Supplies at Camp Lejeune, Assessing Potential Health Effects," in 2009. This report included a review of studies addressing exposure to TCE and PCE, as well as a mixture of the two, and a discussion of disease manifestations potentially associated with such exposure. Effective March 14, 2017, VA amended its adjudication regulations regarding presumptive service connection, adding certain diseases associated with contaminants present in the base water supply at U.S. Marine Corps Base Camp Lejeune, North Carolina from August 1, 1953, to December 31, 1987. The final rule establishes that Veterans who served at Camp Lejeune for no less than 30 days during this period, and who have been diagnosed with any of eight associated diseases (adult leukemia, aplastic anemia and other myelodysplastic syndromes, bladder cancer, liver cancer, multiple myeloma, non-Hodgkin's lymphoma, and Parkinson's disease) are presumed to have incurred or aggravated the disease in service for purposes of entitlement to VA benefits. See 38 C.F.R. § 3.309(f). Here, the Veteran is not claiming any of the diseases on the presumptive list. When claimed disabilities are not on the presumptive disability list, the U.S. Court of Appeals for the Federal Circuit has held that direct service connection may nevertheless be established by evidence demonstrating that the disease was in fact "incurred" during service. See Combee v. Brown, 34 F.3d 1039 (Fed. Cir. 1994). An acquired psychiatric disorder other than PTSD The Veteran seeks service connection for an acquired psychiatric disorder other than PTSD, to include as secondary to shortness of breath. Here, the Board notes that it is granting entitlement to service connection for a psychiatric disorder as secondary to PTSD. In this regard, the Board notes that service connection was granted effective August 30, 2010, and shortness of breath was claimed in January 2015, such that there is no harm to the Veteran in deciding the claim now, rather than waiting for the claim of shortness of breath to be decided. The evidence has shown that the Veteran has an acquired psychiatric disorder as secondary to his PTSD. A disability can be service connected on a secondary basis if it is proximately due to or the result of a service-connected condition. 38 C.F.R. § 3.310 (a). In this regard, there is probative medical evidence of record establishing a secondary relationship. 38 C.F.R. § 3.310 (a). Specifically, the Veteran had a June 2015 VA examination for his PTSD in which it was indicated that he maintained sustained remission of his severe alcoholism and continued use of prescribed medications for his depression/mood disorder (associated with PTSD) and medication for nightmares/sleep. See June 2015 VA Examination Review PTSD DBQ. Additionally, the Board notes that his medical record included a depressive disorder in 2011, and diagnosis of depression in 2014, and dysthymia in 2014. See STR; see Albany VA medical Center treatment records received October 2015 in CAPRI; see Albany VA Medical Center treatment records received December 2015 in CAPRI. In January 2015, the Veteran's diagnoses included not only PTSD, but also dysthymia and alcohol dependence. See Carl Vinson VA Medical Center treatment records received October 2015 in CAPRI. Accordingly, service connection for an acquired psychiatric disorder as secondary to PTSD is granted based on the June 2015 VA examiner's definition of his depression/disorder associated with his PTSD. 38 U.S.C. § 5107(b); 38 C.F.R. §§ 3.102, 3.310(a). Nerve damage of the left lower extremity The Veteran claims entitlement to service connection for nerve damage of the left lower extremity, to include as secondary to his back and/or bilateral foot disabilities. Specifically, in August 2015 the Veteran submitted, in part, an application for nerve damage both as secondary to back pain and secondary to bilateral foot condition, which was reopened in the July 2021 Board decision and recharacterized as service connection for nerve damage of the bilateral lower extremities. See August 2015 VA 21-526EZ, Fully Developed Claim; see July 2021 BVA Decision. As noted, the right lower extremity radiculopathy has been separately granted. Relevant Facts In an August 2014 podiatry appointment, the Veteran was told that his nerve symptoms were possibly related to his history of low back pain, as well as to his diabetes. See August 2014 Albany VA Medical Center treatment record received December 2015 in CAPRI. He had tarsal tunnel presentation, with protective sensation and light-touch sensation intact. A September 2014 podiatry consult shows that the podiatrist explained to the Veteran that his nerve symptoms were possibly related to his history of low back pain and diabetes. See Dublin VA Medical Center treatment records received December 2014. An October 2014 treatment note indicated that the Veteran was being treated for tarsal tunnel syndrome bilaterally, and nerve block injections helped a great deal. Id. Again, the notes reference that the nerve symptoms were possibly related to his low back and diabetes. Id. A May 2016 MRI of the lumbar spine indicated that there was a history of low back pain radiating to the legs, right greater than the left, also associated with weakness and instability. See Phoebe Putney Memorial Hospital treatment record received January 2016. The imaging showed the right S1 nerve root may be stretched when weight-bearing and indicated it should be correlated with dermatomal distribution symptoms. In September 2016, the Veteran reported that this MRI showed how his nerve damage was secondary to his back. See Form 9 received September 2016. A June 2017 VA treatment record shows that the Veteran experienced chronic and intense radiating leg pain bilaterally. See Albany CBOC VA treatment record received June 2017. A May 2018 peripheral nerves conditions disability benefits questionnaire endorsed lumbar radiculopathy of the bilateral lower extremities. See May 2018 VA Examination Peripheral Nerves Conditions. There was mild intermittent pain, mild paresthesias and/or dysesthesias, and mild numbness. There was normal muscle strength, and reflexes, but decreased sensation bilaterally at the upper anterior thigh (L2), thigh/knee (L3/4), lower leg/ankle (L4/L5/S1), and foot/toes (L5). There was no atrophy, and no trophic changes. Gait was normal. There was mild incomplete paralysis of the sciatic nerve bilaterally. The lumbar radiculopathy of the bilateral lower extremities functionally impacted work by causing the Veteran pain. A June 2018 treatment record problem list includes lumbar radiculopathy, and neuralgia/neuritis of the lower leg as part of an active problem list. There are multiple lay statements from individuals who served in Iraq with the Veteran reporting that he complained of pain in his feet, knees and low back, and had a difficult time standing in formation or for long periods of time. See June 2018 Buddy/Lay Statements, also received in July 2018. . In February 2021 VA treatment records show that the Veteran had posterior tibial nerve blocks at the level of the tarsal tunnel bilaterally. See Albany CBOC received April 2022. The August 2021 VA examination for the lumbar spine indicated that the Veteran reported sharp pain radiating from his back to the back of his leg and numbness. He reported his right leg gave way once that pain became intense, and for the left lower extremity there was a dull aching/numbing pain. See VA Examination Back (Thoracolumbar Spine) DBQ. As a truck driver for the previous twenty years, the Veteran had to put it on cruise control because of the aching in his lower extremity. The examiner indicated that on examination there was mild right lower extremity constant pain, intermittent pain, paresthesias and or dysesthesias, and numbness, but none of these existed on the left lower extremity. The examiner indicated that the sciatic nerve roots were involved on the right. The May 2022 VA examiner indicated that there was no left lower extremity constant or intermittent pain, paresthesias and or dysesthesias or numbness. Reflexes, sensation, and muscle testing were all normal on the left. See VA Examination Back (Thoracolumbar Spine) Conditions DBQ. Analysis The evidence has shown that the Veteran has left lower extremity radiculopathy as secondary to his service-connected thoracolumbar spine disability. In this regard, the Board notes that service connection was granted effective January 5, 2015, for both his back and his foot disability, and his claim for left lower extremity arose in August 2015, such that there is no harm to the Veteran in deciding the claim now, on the secondary basis to the thoracolumbar spine. A disability can be service connected on a secondary basis if it is proximately due to or the result of a service-connected condition. 38 C.F.R. § 3.310 (a). In this regard, there is probative medical evidence of record establishing a secondary relationship. 38 C.F.R. § 3.310(a). Specifically, the Veteran had a May 2018 VA examination for his peripheral nerves in which it was indicated that he had mild incomplete paralysis of the sciatic nerve bilaterally, and lumbar radiculopathy of the bilateral lower extremities functionally impacted his work. See May 2018 VA Examination Peripheral Nerves Conditions. Even considering the May 2022 VA examiner's determination that there was no left lower extremity pain, paresthesias and/or dysesthesias or numbness, there is at least an equipoise of the evidence in favor of finding the Veteran has left lower extremity radiculopathy as due to his thoracolumbar spine. Accordingly, service connection for left lower extremity radiculopathy as secondary to thoracolumbar spine is granted. 38 U.S.C. § 5107(b); 38 C.F.R. §§ 3.102, 3.310(a). The Board resolves reasonable doubt in the Veteran's favor, and grants service connection for his left lower extremity radiculopathy disability. See Wise v. Shinseki, 26 Vet. App. 517, 531 (2014) ("By requiring only an 'approximate balance of positive and negative evidence'..., the nation, 'in recognition of our debt to our veterans,' has 'taken upon itself the risk of error' in awarding... benefits."). Right upper extremity radiculopathy The Veteran is already in receipt of a 20 percent rating according to DC 8510 since January 5, 2015, for his left upper extremity cervical radiculopathy associated with residuals of a neck injury, DJD of the cervical spine. See June 2022 Rating Decision-Codesheet; see 38 C.F.R. § 4.71a, DC 8510, 38 C.F.R. § 4.124a. Here, as noted in the introduction, the Board is addressing entitlement to service connection for right upper extremity radiculopathy, arising from his claim for an increased rating for his cervical spine. See January 2015 Fully Developed Claim (Compensation). At a June 2015 VA examination for the cervical spine the Veteran reported constant neck pain with numbness in both little fingers. See June 2015 VA Examination Neck (Cervical Spine) Conditions DBQ. He felt that his grip had weakened, such that he could not open bottles. Further, both arms were tingling down to his fingers, and there were intermittent shooting pains down the arms. The examiner indicated that there was radiculopathy with intermittent pain and paresthesias and/or dysesthesias, and numbness of the bilateral upper extremities, characterized as mild. There was not constant pain. The examiner indicated that the C5/6 and C7 nerve roots were involved, with mild severity bilaterally. There were no other neurologic abnormalities. As such, service connection for right upper extremity cervical radiculopathy has been established, as related to the service-connected disability of residuals of a neck injury, DJD of the cervical spine by definition of the June 2015 VA examiner who indicated there was radiculopathy of the bilateral upper extremities. 38 C.F.R. § 3.303, 38 C.F.R. § 3.310. Headache The Veteran seeks service connection for a headache disability, to include as due to contaminated water at Camp LeJeune. See January 2015 Fully Developed Claim (Compensation). Relevant Facts In February 2005 he reported frequent headaches unchecked. See STR. In September 2007 the Veteran reported being involved in a MVA in Iraq, when a vehicle he was traveling in fell in a trench and he jammed his head into the top of the truck, feeling pain in his head and neck, with headaches in the frontal area intermittently since then. See Carl Vinson VA Medical Center treatment record received October 2009 in CAPRI. In September 2007 a neurologist indicated that the Veteran experienced chronic headaches of unknown etiology, but then opined that the headaches were as likely as not related to his history of head trauma in the motor vehicle accident five years earlier. See Albany VA Medical Treatment record received October 2015. A March 2008 VA treatment record provided an impression of chronic headaches and indicated chronic headaches may be related to the Veteran's neck injuries and pain, as well as stress. See Carl Vinson VA Medical Center treatment record received October 2009 in CAPRI. In December 2009 the Veteran continued to report that he had headaches. See STR. In a February 2009 heath questionnaire for dental treatment the Veteran indicated that he experienced frequent headaches. See STR. Again, in a July 2011 health questionnaire the Veteran reported having frequent or severe headaches. See Medical Treatment Record-Government Facility. A June 2018 treatment record included headache as part of an active problem list. In a November 2020 treatment record the Veteran reported experiencing headaches up to four times a week, chronically, and taking Tylenol and pulling over when he was in the truck. See Persian Gulf Registry Exam received October 2021. At his August 2021 VA examination for headaches the Veteran described pressure behind the eyes, and that squeezing the temporal areas of his head made the pain go away. See VA Examination Headaches. He reported noticing this pain after he hit his neck in a vehicle during deployment. The examiner indicated that the Veteran had characteristic prostrating attacks of migraine non-migraine headache pain occurring once monthly. A review of a 20007 brain scan was unremarkable. The VA examiner opined that following examination and review of all available medical evidence, a nexus was not established. See VA Medical Opinion DBQ. The examiner reasoned that progress notes were silent for chronic complaints of headaches, to include the updated VA problem list. The Board observes that this is inaccurate, such that the reasoning for the negative nexus is flawed. See Reonal v. Brown, 5 Vet. App. 458 (1993). The examiner opined that the type of headache the Veteran was describing at the visit was characteristic of sinus headaches instead of headaches associated with cervical injury. This statement makes it unclear whether the Veteran had a headache at the time of the examination which was one involving his sinuses, or whether the examiner was discussing the history of headaches; however, the Board will consider the evidence in the light most favorable to the Veteran, and finds that the description was for that day rather than the history. The examiner emphasized that cervicogenic headaches caused a reduction of range of motion in the neck when they occurred. The examiner also concluded that pain starts on one side of the neck and radiates to the front part of the head or eye, and the Veteran had not provided evidence that the headaches had been aggravated beyond their natural progression by his service-connected disabilities. As such, the examiner opined that it was less likely than not that the claimed condition had secondary service connection, and cited to an article on sinus headaches. Again, the Board finds that based on the evidence of record, this August 2021 VA examination is inadequate. Specifically, the record shows that the Veteran has reported chronic or frequent headaches since approximately 2005, yet the examiner suggested that treatment records were silent for chronic complaints of headaches. See Albany VA Medical Treatment record received October 2015. In March 2022 the Veteran reported having severe migraines since he returned from Iraq. See March 2022 NOD. He indicated such migraines occurred four to five times weekly. Analysis The equipoise of the evidence shows that the Veteran has a headache disability as secondary to his cervical spine disability, incurred in a motor vehicle accident in service. Under the doctrine of law of the case, questions settled on a former appeal of the same case are no longer open for review. See Browder v. Brown, 5 Vet. App. 268, 270 (1993). The "law of the case" doctrine operates to preclude reconsideration of identical issues." Johnson v. Brown, 7 Vet. App. 25, 26 (1994). As such, judicial bodies will not generally review or reconsider issues that already have been decided in a previous appeal. See McCall v. Brown, 6 Vet. App. 215 (1994) (citing Kori Corp. v. Wilco Marsh Buggies & Draglines, 761 F.2d 649, 657 (Fed. Cir. 1985); Browder. Considering the foregoing, under the law of the case doctrine, the Board accepts the Veteran's account of injuring his neck in June 2003 when the truck he was traveling in hit a trench that caused him to fly up and hit the top of the truck with his head and jam his neck. See March 2007 rating decision. Having determined that the Veteran did injure his head and neck in a motor vehicle accident in service, and considering his argument that he experienced headaches as a result, in relation to a September 2007 neurologist's opinion that the Veteran's headaches were as likely as not related to his head trauma in the motor vehicle accident, and the March 2008 treatment record connecting the Veteran's headaches to his neck injury, the Board finds that there is an equipoise of the evidence favoring service connection. 38 C.F.R. § 3.303, 38 C.F.R. § 3.310. Consideration of alternate theories of entitlement is not warranted here, where the Veteran is being granted service connection and alternate theories would not entitle him to an earlier effective date. 38 C.F.R. § 3.400. The Board resolves reasonable doubt in the Veteran's favor, and grants service connection for the Veteran's headache disability. See Wise v. Shinseki, 26 Vet. App. 517, 531 (2014) ("By requiring only an 'approximate balance of positive and negative evidence'..., the nation, 'in recognition of our debt to our veterans,' has 'taken upon itself the risk of error' in awarding... benefits."). Increased Ratings Disability evaluations are determined by evaluating the extent to which a veteran's service-connected disability adversely affects his or her ability to function under the ordinary conditions of daily life, including employment, by comparing his symptomatology with the criteria set forth in the Schedule for Rating Disabilities. The percentage ratings represent as far as can practicably be determined the average impairment in earning capacity resulting from such diseases and injuries and the residual conditions in civilian occupations. Generally, the degrees of disability specified are considered adequate to compensate for considerable loss of working time from exacerbation or illness proportionate to the severity of the several grades of disability. 38 U.S.C. § 1155 (West 2012); 38 C.F.R. § 4.1 (2022). If two evaluations are potentially applicable, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that evaluation; otherwise, the lower evaluation will be assigned. 38 C.F.R. § 4.7. The veteran's entire history is to be considered when making disability evaluations. See generally 38 C.F.R. § 4.1; Schafrath v. Derwinski, 1 Vet. App. 589 (1995). "Staged" ratings are appropriate for any rating claim when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. See Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2008). The evaluation of the same disability under various diagnoses, known as pyramiding, is generally to be avoided. 38 C.F.R. § 4.14. The critical element in permitting the assignment of several ratings under various diagnostic codes is that none of the symptomatology for any one of the disabilities is duplicative or overlapping with the symptomatology of the other disability. See Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994). PTSD The Veteran's PTSD is rated as 50 percent disabling prior to May 11, 2018, and 70 percent since May 11, 2018, under DC 9411, which is rated under the General Rating Formula for Mental Disorders. See June 2022 Rating Decision Codesheet. He has appealed for an increased rating. See July 2015 NOD. In an appeal received January 5, 2015, he requested an increased rating, such that the period of consideration of the evidence begins January 5, 2014. See January 2015 Fully Developed Claim (Compensation). Legal Criteria VA regulations employ a "General Rating Formula for Mental Disorders" such as PTSD with compensable ratings of 10, 30, 50, 70, and 100 percent. 38 C.F.R. § 4.130. A 50 percent rating is assigned for occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; and difficulty in establishing and maintaining effective work and social relationships. A 70 percent rating is assigned for occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately, and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful situations (including work or a work like setting); and inability to establish and maintain effective relationships. A 100 percent rating is in order when there is total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, occupation, or own name. 38 C.F.R. § 4.130. Assessing what particular rating is warranted "requires a two-part analysis." Emerson v. McDonald, 28 Vet. App. 200, 212 (2016). It requires an "initial assessment of the symptoms displayed by the veteran, and if they are of the kind enumerated in the regulation, an assessment of whether those symptoms result in occupational and social impairment with deficiencies in most areas." Id. More generally, the rating analysis for psychiatric disorders is symptom driven. Golden v. Shulkin, 29 Vet. App. 221, 225 (2018); Vazquez-Claudio, 713 F.3d at 116 ("The regulation's plain language highlights its symptom-driven nature."). The symptoms associated with each evaluation under the General Rating Formula do not constitute an exhaustive list, but rather serve as examples of the type and degree of symptoms, or their effects, that would justify a particular rating. Mauerhan v. Principi, 16 Vet. App. 436 (2002). If the evidence demonstrates that the claimant's psychiatric disorder produces symptoms and resulting occupational and social impairment equivalent to that set forth in the criteria for a given rating, then that rating will be assigned. Id. at 443. The symptoms listed do not form an exhaustive list but rather serve as examples of the type and degree of symptoms that would justify the associated rating. See Bankhead v. Shulkin, 29 Vet. App. 10, 1819 (2017). The "'frequency, severity, and duration' of a veteran's symptoms must play an important role in determining his disability level" and the length of remissions, and the claimant's capacity for adjustment during periods of remission must be considered. 38 C.F.R. § 4.126; Vazquez-Claudio, 713 F.3d at 117. While VA considers the level of social impairment, it shall not assign an evaluation based solely on social impairment. Id. In sum, there are two elements that must be met to assign a particular rating under the General Rating Formula: (1) symptoms equivalent in severity, frequency, and duration to the symptoms corresponding to a given rating, and (2) a level of occupational and social impairment corresponding to that rating that results from those symptoms. See Vazquez-Claudio, 713 F.3d at 118. Relevant Facts Consideration of Evidence from January 5, 2014 to May 11, 2018 An April 2014 VA treatment note showed the Veteran dealt with hypervigilance and mild paranoia and was focused on relationship problems. See Albany CBOC treatment records received December 2015. An August 2014 treatment note shows that the Veteran had a history of depression and anxiety but found Celexa helpful for residual symptoms. He tended to isolate when he felt anxious or down and had a history of intrusive thoughts. See Mental Health Outpatient Note treatment note received October 2015 in CAPRI. There was no evidence or indication that his PTSD presented any risk to himself or others or would impair his ability to perform his job for DOT. See Albany CBOC treatment records received December 2015. In October 2014 the Veteran reported an incident in which another trucker confronted him, and although he tried to defuse the situation, he ultimately felt a need to protect himself and laid hands on the individual, prompting building security to become involved. His supervisor watched a video of the incident and was pleased with how the Veteran had attempted to defuse the situation; however, the Veteran reported he had not felt such intense rage for a long time. See Mental Health Outpatient Note received December 2015. Additionally, October 2014 VA treatment notes show that the Veteran had increasing anxiety, verging on paranoia. For instance, he was dressing in the dark in the mornings for fear someone was watching him and might want to shoot him. See Mental Health Outpatient Note received December 2015. A November 2014 therapy note shows that the Veteran had thoughts of self-harm, without intent. He reported that he became frightened when there was fighting going on around (family members fighting in the home). See Albany VA medical Center treatment records received October 2015 in CAPRI. A May 2014 VA treatment record showed that the Veteran dealt with hypervigilance and mild paranoia. For instance, he scanned his car prior to getting in it, and in public places he scanned the crowd and counted how many people were present. The Veteran was encouraged to keep a thought journal to identify what triggered him into angry reactions. In August 2014 the psychologist wrote that he saw no indication that the Veteran's PTSD diagnosis presented a risk to the Veteran or others or would impair his ability to perform his job for DOT. A December 2014 treatment note indicated that the Veteran had been isolating, thinking about former soldiers who were about to deploy to Afghanistan. See Albany CBOC treatment records received December 2015. VA treatment notes show that in February 2015 the Veteran's Zoloft was increased from 50 to 100 milligrams daily. See Albany CBOC treatment records received December 2015. The Veteran also reported that he and his wife had been arguing more so he had agreed to take trucking jobs that lasted all week. Id. In March 2015 the Veteran's mood was depressed. A June 2015 treatment note indicated that the Veteran felt significant anxiety when something was not where he had left it. Id. The Veteran had a June 2015 VA examination for his PTSD in which it was indicated that he maintained sustained remission of his severe alcoholism and continued use of prescribed medications for his depression/mood disorder (associated with PTSD) and medication for nightmares/sleep. See June 2015 VA Examination Review PTSD DBQ. The examiner noted that the Veteran had more than one mental disorder diagnosed, with the diagnoses being independent of each other and resulting from separate etiologies, and the symptoms comprising each disorder being clinically distinct and separate. The examiner opined that there was occupational and social impairment with reduced reliability and productivity due to all mental diagnoses, with the predominant portion of impairment due to the diagnosed PTSD, and mild impairment being due to the Alcohol Use Disorder, in sustained remission. The Veteran reported nightly rituals of checking windows and doors and turning off lights. He said his body told him there was a sniper even if he could not see anyone, and his counselor reminded him that he is in the United States. He endorsed being anxious much of the time, feeling scared and trying to avoid altercations, arguments or heated situations. The Veteran reported that he did not feel comfortable with most people, but especially strangers. He had eliminated guns from his house. When feeling upset his mood would change and he would feel like tearing someone's head off and worried he would wind up in jail. He experienced panic attacks, talked too loudly, and had episodic suicidal thoughts. He avoided loud sounds and isolated himself. Symptoms of PTSD were of depressed mood, anxiety, suspiciousness, panic attacks that occurred weekly or less often, chronic sleep impairment, flattened affect, circumstantial, circumlocutory or stereotyped speech, disturbances of motivation and mood, difficulty in establishing and maintaining effective work and social relationship or adapting to stressful circumstances, including a work like setting, suicidal ideation, and obsessional rituals, which the examiner attributed to the PTSD diagnosis. See June 2015 VA Examination Review PTSD DBQ. Behavioral observation confirmed congruence between the Veteran's verbal report of symptoms and his affect/appearance. The examiner commented that the Veteran had reported a very limited social life and being moody. He gave an example of an incident with another truck driver with whom he argued, and wanted to rip his head off, such that he got scared and angry and had to walk away, but his heart was pumping as if he was high on adrenaline. In July 2015, the Veteran wrote that he had a hard time remembering some common things, was scared to deal with outsiders for fear of hurting someone and questioned why he had been happy years ago but was unable to enjoy life. See July 2015 NOD. VA treatment record from July 2015 shows that the Veteran reported feeling irritable, in part related to his difficulty in getting his primary care needs met. See Albany CBOC treatment records received December 2015. The treatment notes also indicated that the Veteran was not at that time working; however, an August 2015 treatment note indicated that the Veteran was ready to return to work but waiting on medical clearance for diabetes and rotator cuff tear. Id. In August 2015, the Veteran reported that his PTSD had him always on guard, to the point that it was difficult to catch his breath at times. See August 2015 VA 21-4138 Statement In Support of Claim. He reported that it was difficult to make it through a day without blowing his top, hurting someone or himself. Id. He felt unsafe and unable to trust anyone, depressed frustrated and isolated. Id. In a September 2015, VA treatment record the Veteran reported having to leave a friend's funeral because it was too crowded and he "couldn't take it." He reported that his threat system was triggered by people speaking foreign languages, or not being able to see the exit. Id. Additionally, he reported increasing difficulty with communication and feeling as if his wife wanted to argue all the time but desiring to avoid confrontation. See Albany CBOC treatment records received December 2015. The Veteran was taking Zoloft daily along with Remeron at bedtime. In October 2015, the Veteran's mood was dysphoric, with congruent affect. He was oriented, with coherent logical and goal-directed thoughts. See Albany VA Medical Center treatment record received October 2015 in CAPRI. Judgment and insight were good. He denied suicidal or homicidal ideation and no psychotic thought processes were noted. He reported disconnecting from things, increased negative thinking, and spending more time alone. He and his wife were communicating better. A December 2015, VA treatment note shows that the Veteran feared for his family's safety and had brought guns back into his home, which caused relational problems with his wife, such that he no longer had the guns. See Mental Health Outpatient Note received July 2016. The Veteran endorsed hypervigilance and negative cognitions about himself and the world. Id. A February 2016 VA treatment note shows that the Veteran had a difficult interaction with his supervisor who threatened to decrease his pay, which caused him to become so angry that he was scared he would do something and removed himself from the situation to gain control of himself. See Mental Health Outpatient Note received July 2016. A March 2016 VA treatment note shows that the Veteran was having difficulty dealing with the way his boss interacted with him, finding it to be harsh, degrading and harassing, which in turn made him feel emotionally unstable. Id. His counselor, and boss's boss were helping him to communicate his stressors and resolve his problems at work. Id. His chronic PTSD and dysthymia were under good control, and there were no suicidal or homicidal ideations or evidence of psychosis. Id. In June 2016, the Veteran was triggered while driving and experienced a flashback of his time in Iraq and was so bothered by the experience he had to pull off the interstate and get out of his truck and use his calming breathing. See Albany CBOC received July 2016. Other VA treatment records show that the Veteran had a history of violent episodes towards his wife and had not had a severe violent episode since he stopped drinking five years earlier but did continue to have aggressive behavior (about 7 months prior). See Albany CBOC VA treatment record received June 2017. The Veteran expressed difficulty with irritability and requested an increase in his Zoloft, which was at that time 100 milligrams daily. Id. His Zoloft was increased to 100 milligrams twice a day, and Remeron 30 milligrams at bedtime. Id. VA treatment notes from 2018 show that the Veteran had a marked reduction of outbursts, with no recent aggressive behavior, and his mood and insight had improved considerably, although he continued to struggle with memory loss. See Albany CBOC VA treatment record received April 2018. The Veteran, however, reported obsessive lock checking and checking his truck for sabotage, such that he had to arrive to work an hour early. The Veteran's anger and anxiety were triggered by his work environment and his pain intensified his PTSD and depression symptoms. From May 11, 2018 The Veteran had a PTSD examination on May 11, 2018, in which the examiner indicated that there was no more than one mental disorder diagnosed. See VA Examination Review PTSD DBQ received April 2022. The examiner found there was occupational and social impairment with reduced reliability and productivity. The Veteran indicated that his PTSD symptoms had worsened since an examination in August 2010, demonstrated by increased depressed mood, anxiety, memories of trauma, dreams of traumatic experiences, flashbacks, anger, irritability, problems with concentration, sleep problems, and problems with social and interpersonal relationship. The Veteran's symptoms were depressed mood, anxiety, suspiciousness, panic attacks more than once weekly, chronic sleep impairment, mild memory loss, disturbances of motivation and mood, difficulty in establishing and maintaining effective work and social relationships, difficulty in adapting to stressful circumstances, including work or a worklike setting, inability to establish and maintain effective relationships, and obsessional rituals which interfere with routine activities. There was no suicidal or homicidal ideation. There were no psychotic thoughts, and the Veteran was oriented to person, place and time. Thinking was logical and goal directed, and cognitive function suggested average capacity in domains of memory and executive function. Speech was normal. Mood was dysthymic with congruent affect. The examiner opined that the current continuation and progression of the Veteran's symptom patterns with increased impairment in occupational and social function was more likely than not due to exacerbation of his PTSD. In December 2018 the Veteran reported almost having an accident in his work truck, which triggered his PTSD significantly, and feeling like he was on an emotional roller coaster since the near-accident. See Albany CBOC VA treatment notes received April 2022. A January 2019 VA treatment note indicated that the Veteran had ongoing irritable mood, and an increase in flashbacks recently due to increased worry about being able to do his job and provide for his family. See Albany CBOC VA treatment notes received April 2022. An August 2019 treatment note showed that the Veteran presented for follow up of chronic PTSD and dysthymia and reported taking on other people's stressors (his wife and daughter's problems) and having pain under poor control, which affected his sleep and moods. He was reexperiencing the trauma with nightmares, flashbacks, and intrusive thoughts approximately every other night. He was hypervigilant, describing himself as being more on guard. He demonstrated avoidance, trying to avoid crowds. Emotionally, he was numb or detached, and this had worsened over the past few months. Interests and motivation were lacking. He felt worthless, helpless or hopeless due to pain. His energy was lacking. His mood was sad, with a flat affect. A September 2019 note indicated that the Veteran was experiencing uncontrolled symptoms of PTSD and depression despite adequate therapeutic trial of sertraline. As such, a trial of Prazosin for nightmares and tapering off Sertraline was discussed by the clinical pharmacy specialist. A July 2020 treatment note indicated that the Veteran experienced a flashback triggered by hearing someone talk a foreign language. See Albany CBOC treatment record received October 2021. Additionally, he had to use deep breathing in the back of his truck with curtains closed for a couple of hours to calm himself. His mood was anxious, frustrated and angry. He continued to suffer from surreal flashbacks and nightmares. An August 2020 VA treatment record shows the Veteran was having more difficulty with sleep, and that his medications were managing his mood and irritability. At his November 2020 Board hearing, the Veteran described always being nervous, thinking others were plotting against him; having difficulty being with family and large groups or hearing other languages spoken. See Board Hearing Transcript. He reported his PTSD interfered with his family, social and work life. He explained how he was worried about being trailed and found himself counting cars or worried his mind might tell him to run someone off the road when a car passes him more than twice. He explained that he sometimes had to park on an exit ramp to calm himself, which slowed his arrival to appointments and interfered with his timeliness. In addition, his wife said he was anti-social and preferred to be by himself or with his grandkids. The Veteran reported his wife felt nervous by his authoritarian voice, which she would describe as him yelling, and that she was considering a divorce such that they were in marital counseling. In addition, the Veteran indicated that he had difficulty sleeping, and nightmares. He described being in the middle of a conversation and ducking down because he felt it was necessary to get low because he lost count of the people moving around him. Such instances caused others to think he was "crazy" and interfered with his interactions with others. VA treatment records from December 2020 show that the Veteran was anxious, frustrated and angry, and had partner-relationships problems and chronic PTSD. See Albany CBOC treatment record received October 2021. He was continuing to work on marriage issues. VA treatment records show that in October 2021 the Veteran found his wife to trigger or provoke him to revert in his behaviors, and he wanted a divorce. See Mental Health Outpatient VA treatment note received November 2021. Analysis Based on the foregoing evidence, the Board finds that for the entire period on appeal the Veteran's PTSD most nearly approximates the criteria for a 70 percent rating. The Board has considered the Veteran's symptoms, to include depressed mood, anxiety, suspiciousness, flattened affect difficulty in establishing and maintaining effective work and social relationships, and impaired impulse control, such as unprovoked irritability, which he endorsed in the June 2015 VA examination. See June 2015 VA Examination Review PTSD DBQ. In addition, the Board has considered the Veteran's increasing dosages of medication. See Albany CBOC VA treatment record received June 2017. Indeed, the Veteran experienced episodic suicidal thoughts, and thoughts of tearing someone's head off in June 2015. See June 2015 VA Examination Review PTSD DBQ. Based on the evidence of record, the Board finds that the Veteran's overall PTSD symptoms are productive of occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking or mood. Therefore, the criteria for a 70-percent rating have been satisfied. As to the next higher rating of 100 percent, the Board is mindful of the Court's holding in Vasquez-Claudio which explained that analysis of psychiatric disorders is "symptom driven" and a veteran may only qualify for a given disability rating by demonstrating the particular symptoms associated with that percentage, or others of similar severity, frequency, and duration. 713 F.3d at 118. A maximum 100 percent rating is not warranted as the Veteran did not exhibit symptoms of or such as grossly inappropriate behavior, persistent delusions or hallucinations, persistent danger of hurting himself or others, intermittent inability to perform daily living, disorientation to time, living or place, memory loss of close relatives, own occupation or own name. In February 2016 the Veteran reported that he became so angry he was worried that he would hurt someone, suggesting that he gets irritated easily. See Mental Health Outpatient Note received July 2016. He reported having occasional thoughts of hurting people, but denied intention and plan and, denied suicidal or homicidal intentions or plans. See VA Examination Review PTSD DBQ received April 2022; see Mental Health Outpatient Note received July 2016. Even so, the Board finds the Veteran is not in persistent danger of hurting himself or others. Id. Also, there was some paranoia and intrusive thoughts. See November 2015 VA Examination Review PTSD DBQ. The Veteran has undergone marital counseling, and appears to be in the beginning stages of seeking divorce; however, the Veteran has been able to maintain some social relationships, such as with his stepchildren and wife, and maintained employment as a truck driver, such that the Veteran's overall PTSD symptoms are not productive of total occupational and social impairment. See Mental Health Outpatient VA treatment note received November 2021; see Mental Health Outpatient Note received December 2015 (showing supervisor's approval of how he handled a stressful situation at work) . The Veteran's statements that he is generally entitled to a higher rating are not competent evidence as to a specific level of disability according to the appropriate diagnostic codes. See Robinson v. Shinseki, 557 F.3d 1355 (2009). As discussed above, the Board has considered the Veteran's lay statements describing his PTSD symptomatology as both competent and credible. The examination findings, along with the Veteran's competent reports, discuss his symptoms as well as their frequency, severity and duration. For example, the Veteran experienced "intense rage" in October 2014, "significant anxiety" in June 2015, and "nightly rituals" in June 2015. See Mental Health Outpatient Note received December 2015; see Albany CBOC treatment records received December 2015; see June 2015 VA Examination Review PTSD DBQ. The evidence has shown symptoms of the severity, frequency or duration to be productive of social and occupational impairment with deficiencies in most areas; however, the symptoms are not resulting in total occupational and social impairment. Based on the aforementioned evidence, the Board finds that the evidence supports a 70 percent rating for the entire period on appeal. The weight of the evidence is, however, against a rating in excess of 70 percent for the Veteran's service-connected PTSD. Cervical Spine The Veteran is in receipt of a 20 percent rating under DCs 5010-5242 for his residuals of a neck injury, DJD of the cervical spine. See June 2022 Rating January 5, 2014. See January 2015 Fully Developed Claim (Compensation). Legal Criteria When evaluating disabilities of the joints, the Rating Schedule provides for consideration of additional functional impairment due to pain, weakness, fatigue, incoordination, and lack of endurance when assigning evaluations. 38 C.F.R. §§ 4.40, 4.45, 4.59 (2021); see DeLuca v. Brown, 8 Vet. App. 202 (1995); see also Mitchell v. Shinseki, 25 Vet. App. 32, 44 (2011); see Burton v. Shinseki, 25 Vet. App. 1 (2011). Nonetheless, even when the background factors listed in § 4.40 or 4.45 are relevant when evaluating a disability, the rating is assigned based on the extent to which motion is limited, pursuant to 38 C.F.R. § 4.71a; a separate or higher rating under § 4.40 or 4.45 itself is not appropriate. See Thompson v. McDonald, 815 F.3d 781, 785 (Fed. Cir. 2016) ("[I]t is clear that the guidance of § 4.40 is intended to be used in understanding the nature of the veteran's disability, after which a rating is determined based on the § 4.71a criteria."). Additionally, in Correia v. McDonald, 28 Vet. App. 158 (2016), the Court held that, when possible, examiners must include range of motion testing on active and passive motion and in weight-bearing and non-weight-bearing conditions and, if possible, with range of motion measurements of the opposite undamaged joint." The spine has no opposite joint. In Sharp v. Shulkin, 29 Vet. App. 26, 34-36 (2017), the Court held that VA examiners must obtain information about the severity, frequency, duration, precipitating and alleviating factors, and extent of functional impairment of flares from the veterans themselves, when a flare-up is not observable at the time of examination. Changes to the rating schedule for musculoskeletal disabilities became effective February 7, 2021. The amended rating criteria, if favorable to the Veteran's claim, can be applied only for periods from the effective date of the regulatory change. However, the old regulations will be considered for the periods both before and after the change was made. See VAOPGCPREC 3-2000, 65 Fed. Reg. 33,422 (2000); Kuzma v. Principi, 341 F.3d 1327 (Fed. Cir. 2003). The changes effective February 7, 2021, under 38 C.F.R. § 4.71a, DC 5242 and 5243 were not to the rating schedule itself but added instruction to classify disabilities associated with IVDS under DC 5243 and all other intervertebral disc disabilities under 5242. As such, DC 5242 now reflects "Degenerative arthritis, degenerative disc disease other than intervertebral disc syndrome (also, see either DC 5003 or 5010);" DC 5243 now reflects "Intervertebral disc syndrome: Assign this diagnostic code only when there is disc herniation with compression and/or irritation of the adjacent nerve route; assign diagnostic code 5242 for all other disc diagnoses." As such, the changes do not impact the general rating formula and evaluation of the disability under the pre-and post-February 7, 2021, regulations is not required. Disabilities of the spine are rated under the General Rating Formula for Diseases and Injuries of the Spine (General Rating Formula). Ratings under the General Rating Formula are made with or without symptoms such as pain (whether or not it radiates), stiffness, or aching in the area of the spine affected by residuals of injury or disease. The Veteran's cervical DDD and spondylosis is rated under 38 C.F.R. § 4.71a, Diagnostic Code 5242. The General Rating Formula provides that as to ratings for the cervical spine, a 20 percent rating is warranted for forward flexion of the cervical spine greater than 15 degrees but not greater than 30 degrees, or the combined range of motion of the cervical spine not greater than 170 degrees, or muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. A 30 percent rating is assigned when forward flexion of the cervical spine is 15 degrees or less; or there is favorable ankylosis of the entire cervical spine. A 40 percent rating is assigned if there is unfavorable ankylosis of the entire cervical spine. A 100 percent rating may be assigned if there is unfavorable ankylosis of the entire spine. Relevant Facts A March 2007 rating decision granted entitlement to service connection for a cervical spine disability rated as 10 percent disabling effective November 1, 2005. See March 2007 Rating Decision. A January 2010 rating decision increased the Veteran's rating for residuals of neck injury, degenerative joint disease of the cervical spine to 20 percent effective April 15, 2009. See January 2010 Rating Decision-Narrative. The Veteran appealed for an increased rating for his cervical spine January 5, 2015, such that the period of consideration of the evidence begins January 5, 2014. See January 2015 Fully Developed Claim (Compensation). In February 2014 the Veteran reported having neck pain, and that it was difficult to turn his head to the left. See Albany VA Medical Center treatment records received October 2015. At a June 2015 VA examination for the cervical spine the Veteran reported constant neck pain with numbness in both little fingers. See June 2015 VA Examination Neck (Cervical Spine) Conditions DBQ. He felt that his grip had weakened, such that he could not open bottles. Further, both arms were tingling down to his fingers, and there were intermittent shooting pains down the arms. He used a muscle relaxer for neck spasms, which helped. The Veteran did not report that flare-ups impacted the function of his cervical spine. Range of motion testing showed that following repetitions, forward flexion was to 40 degrees, with extension to 15 degrees. See June 2015 VA Examination Neck (Cervical Spine) Conditions DBQ. Right lateral flexion was to 35 degrees, and left lateral flexion was to 30 degrees. Right and left lateral rotation were to 20 degrees each. For each of these measurements, objective evidence of painful motion began at the degree where the movement ended. See June 2015 VA Examination Neck (Cervical Spine) Conditions DBQ. Following three repetitions, the range of motion remained the same; and yet, the examiner indicated that there was additional limitation in range of motion following repetitive use testing, such that the Board interprets this as corresponding to functional loss, which was identified as less movement than normal, and pain on movement. There was no localized tenderness or pain to palpation for joints of the cervical spine. There was guarding or muscle spasm, but not so severe that it resulted in abnormal gait or spinal contour. The examiner opined that it was not possible to determine without resorting to mere speculation if additional limitation of motion was present due to pain during flare-ups or when joint was used repeatedly over a period of time, because there was no conceptual or empirical basis for making such a determination without directly observing function under these conditions. Muscle strength testing on the right revealed active movement against some resistance at elbow flexion and wrist extension on the right but was otherwise of normal strength for elbow and wrist flexion and extension bilaterally and finger flexion and abduction bilaterally. See June 2015 VA Examination Neck (Cervical Spine) Conditions DBQ. Muscle atrophy was not present. Reflex examination was normal. Sensory examination showed sensation to light touch was decreased on the right inner-outer forearm (C6/T1), but otherwise normal. Considering radiculopathy, there was intermittent pain and paresthesias and/or dysesthesias, and numbness of the bilateral upper extremities, characterized as mild. There was not constant pain. The examiner indicated that the C5/6 and C7 nerve roots were involved, with mild severity bilaterally. There were no other neurologic abnormalities. The Veteran did not have intervertebral disc syndrome (IVDS) and incapacitating episodes. See June 2015 VA Examination Neck (Cervical Spine) Conditions DBQ. The Veteran did not use assistive devices for his cervical spine. In July 2015 the Veteran asserted that he lost feeling in his hands bilaterally, and experienced muscle spasms in his neck. See July 2015 NOD. An October 2015 treatment records shows that the Veteran reported neck pain with numbness to his hands, and the pain was described as a 7, characterized by tight muscles. See Albany VA Medical Center treatment record received October 2015 in CAPRI. He reported his muscle relaxers were no longer working. In November 2015 the Veteran reported that he experienced neck pain, and his neck muscles were tightening, and muscle relaxers no longer worked, and requested a consult with a neurologist. See Albany CBOC treatment record received July 2016. A November 2015 MRI showed moderate lower predominant in anterior spondylosis with left sided upper to mid predominant facet arthrosis of the cervical spine. See Radiology Outpatient Clinic VA treatment record received June 2017. A January 2016 MRI of the cervical spine showed mild multilevel DDD and spondylosis, small disc osteophyte complexes at multiple levels without a large disc protrusion, or canal stenosis; slight flattening of the left ventral cord at C6-7; multilevel foraminal stenosis; multilevel facet osteoarthritis. See Open MRI of Tifton received June 2016. VA treatment note from August 2016 shows that the Veteran was prescribed anti-inflammatory medication for the nerve radiation pain, and muscle relaxers for his cervical radiculopathy, meaning the nerve in his neck was being compressed by inflammation, his discs or both. See Albany CBOC VA treatment record received June 2017. A June 2018 physical therapy note shows that the Veteran had neck adjustments and therapeutic exercises, and improved his range of motion overall, although he continued to experience flare-ups with pain in his cervical spine. See Albany CBOC VA treatment records received April 2022. In November 2020 at his Board hearing the Veteran described how his neck stiffened to the point that it was difficult to move. See Board Hearing Transcript. As a truck driver he needed to turn his head, but the back of his neck locked up at times causing difficulty driving. In addition, his neck was stiff when he awoke requiring him to massage it in order to loosen it enough for him to begin functioning. The neck pain necessitated that he takes medications for muscle spasms, but the medication caused drowsiness. In all he reported experiencing decreased motion, pain and stiffness. The Veteran had a VA examination for his cervical spine in August 2021. See VA Examination Neck (Cervical Spine) Conditions. The Veteran did not report flare-ups of the cervical spine, although he had functional impairment from the pain with rotating his head. His range of motion was abnormal due to pain with rotation of his head. Active and passive ranges of motion were as follows: forward flexion to 30 degrees, extension endpoint to 20 degrees; right lateral flexion endpoint to 30 degrees; left lateral flexion endpoint ot 40 degrees; right lateral rotation endpoint to 50 degrees; and left lateral rotation endpoint to 70 degrees. Pain was present with forward flexion, extension, right lateral flexion and right lateral rotation. There was not objective evidence of crepitus. There was tenderness on palpation of the left side of the neck. The Veteran was able to perform repetitive use testing with at least three repetitions, and no additional loss of function or range of motion. Considering where there was pain, fatigability, weakness, lack of endurance or incoordination which significantly limited functional ability with repeated use the examiner indicated that pain caused functional loss. Specifically, right lateral flexion endpoint was at 20 degrees with pain (all other ranges of motion remained the same). The examiner indicated that there was localized tenderness, guarding or muscle spasms of the cervical spine, not resulting in abnormal gait or abnormal spinal contour, but tender on palpation to the left side of the neck due to DJD. There were not muscle spasms or guarding. Additional factors contributing to disability were less movement than normal. Muscle strength testing was normal. Reflexes were normal. There was no ankylosis of the spine. There were no other neurologic abnormalities, and there was not intervertebral disc syndrome. Review of imaging from 2018 did not show loss of 50 percent or more of height. The Veteran's cervical spine limited his rotation of the head, which affected him occupationally. The examiner commented that there was a progression of cervical DJD with left upper extremity radiculopathy and additional diagnosis of spinal stenosis. Analysis Based on the evidence of record, the Board finds that the Veteran's cervical spine disability manifested as loss in forward flexion to 30 degrees, at worst, with combined ROM to 160 degrees, at worst, and with no evidence of ankylosis or IVDS. See August 2021 VA Examination Neck (Cervical Spine) Conditions; see June 2015 VA Examination Neck (Cervical Spine) Conditions DBQ. Limitation of motion due to pain. tenderness, guarding and muscle spasms was considered in the August 2021 VA examination. Id. The symptomatology of the Veteran's cervical spine disability is more nearly approximated by the rating criteria for 20 percent. The persuasive evidence is against finding the necessary criteria for a 30 percent rating for the cervical spine are met. Specifically, the evidence does not approximate forward flexion limited to 15 degrees or less or ankylosis of the spine. 38 C.F.R. § 4.71A. Indeed, the August 2021 examiner indicated that there was no ankylosis of the spine, and no intervertebral disc syndrome. See August 2021 VA Examination Neck (Cervical Spine) Conditions. Therefore, the Board finds that even when considering functional limitations due to pain and the other factors identified in 38 C.F.R. §§ 4.40, 4.45, 4.59 as well as the criteria in DeLuca and Mitchell, the Veteran's functional loss does not equate to the criteria required for a 20 percent rating. The Veteran has reported difficulty moving his neck when it stiffens, or instances when it locks up causing difficulty driving. Even so, the August 2021 examiner indicated that there is not ankylosis, and the Board finds that the Veteran's reports are similar to reporting limitations of motion rather than an absence of motion. Indeed, there is no indication the Veteran suffered from such restricted range of motion of the cervical spine that it may be considered the functional equivalent of ankylosis. See Chavis v. McDonough, 34 Vet. App. 1, 10 (2021). There is also no medical or lay evidence indicating that the Veteran has had any incapacitating episodes due to IVDS during the period on appeal. See August 2021 VA Examination Neck (Cervical Spine) Conditions For the foregoing reasons, the evidence of record persuasively weighs against a rating greater than 20 percent for the cervical spine. As the evidence of record persuasively weighs against a greater rating, the benefit-of-the-doubt rule does not apply. 38 U.S.C. § 5107 (b); 38 C.F.R. §§ 4.3, 4.7; Lynch v. McDonough, 21 F.4th 776 (Fed. Cir. 2021). Left Upper Extremity Cervical Radiculopathy The Veteran is in receipt of a 20 percent rating according to DC 8510 since January 5, 2015, for his left upper extremity cervical radiculopathy associated with residuals of a neck injury, DJD of the cervical spine. See June 2022 Rating Decision-Codesheet; see 38 C.F.R. § 4.71a, DC 8510, 38 C.F.R. § 4.124a. Here, the Board is addressing entitlement to a rating greater than 20 percent since January 5, 2015, for left upper extremity radiculopathy. His claim arises from his claim for an increased rating for his cervical spine, such that the period under consideration is from January 5, 2014. See January 2015 Fully Developed Claim (Compensation). Legal Criteria As a foundational matter, ratings based on functional impairment of the upper extremities are predicated upon which extremity is the major extremity, with only one extremity being considered major. 38 C.F.R. § 4.69. The Veteran is right-hand dominant. Consistent with the regulations, the Board finds the Veteran's left upper extremity to be the non-dominant, minor, extremity for rating purposes. Id. As previously noted, the term "incomplete paralysis" indicates a degree of lost or impaired function substantially less than the type pictured for complete paralysis given with each nerve, whether due to varied level of the nerve lesion or to partial regeneration. See 38 C.F.R. § 4.124a, Diseases of the Peripheral Nerves. When the involvement is wholly sensory, the rating should be for the mild, or at most the moderate degree. Id. The ratings for the peripheral nerves are for unilateral involvement; when bilateral, combine with application of the bilateral factor. Under diagnostic code 8510, considering the minor joint, a rating of 20 percent is warranted for mild incomplete paralysis, a 30 percent rating is warranted for moderate incomplete paralysis, and a 40 percent rating is warranted for severe incomplete paralysis of the minor joint upper radicular group. A rating of 60 percent is warranted for complete paralysis of the minor joint upper radicular group with all shoulder and elbow movement lost or severely affected and hand and wrist movements not affected. See 38 C.F.R. § 4.124A. The Board observes that the terms "mild" "moderate" "moderately severe" and "severe" are not defined in the Rating Schedule. Thus, rather than applying a mechanical formula, the Board must evaluate all of the evidence to the end that its decisions are "equitable and just." 38 C.F.R. § 4.6. Relevant Facts As noted, at a June 2015 VA examination for the cervical spine the Veteran reported constant neck pain with numbness in both little fingers. See June 2015 VA Examination Neck (Cervical Spine) Conditions DBQ. He felt that his grip had weakened, such that he could not open bottles. Further, both arms were tingling down to his fingers, and there were intermittent shooting pains down the arms. Considering radiculopathy, there was intermittent pain and paresthesias and/or dysesthesias, and numbness of the bilateral upper extremities, characterized as mild. There was not constant pain. The examiner indicated that the C5/6 and C7 nerve roots were involved, with mild severity bilaterally. There were no other neurologic abnormalities. In July 2017 the Veteran was afforded a VA examination for peripheral nerves conditions. See July 2017 VA Examination Peripheral Nerves. He was diagnosed as having bilateral upper extremity neuropathy (median nerve and/or ulnar nerve). The recorded history indicated that he retired from Guard active duty in 2011. The Veteran again reported that this condition began when he jammed his neck in 2003 motor vehicle accident in service, and he reported beginning to lose his grip in the left hand by 2004. He reported that he had a right arm EMG in 2007, and a bilateral arm EMG in 2016, and was told he had damaged nerves in both wrists. The Veteran wore a brace on the left side and awaited a brace for his right side. See July 2017 VA Examination Peripheral Nerves. His current symptoms were of numbness, and poor grip bilaterally (although the left side was worse than the right side). The Veteran was right-hand dominant. He used a muscle relaxer, Diclofenac. Bilaterally, there was moderate intermittent pain; moderate paresthesias and/or dysesthesias and moderate numbness. Muscle strength testing was normal. There was no atrophy. Reflexes were normal. There were no trophic changes. The radial nerves were normal. Considering the medial nerve, Phalen's and Tinel's signs were positive. There was mild incomplete paralysis of the right and left median nerve, and of the ulnar nerve. The musculocutaneous, circumflex, upper radicular group, middle and lower radicular group nerves were normal. Functional impairment was not such that the Veteran would be equally well served with amputation and prosthesis. There were no other pertinent physical findings, complications, conditions, signs or symptoms, or related scars. The Veteran reported that EMG had been abnormal. Functionally, the Veteran needed to avoid repetitive activities and heavy lifting. The examiner indicated that the history and exam made it appear that the Veteran had carpal tunnel and or ulnar nerve neuropathy, and the EMG studies would need to be reviewed in order to rule out radiculopathy. A June 2018 physical therapy note shows that as the Veteran focused on therapeutic exercises for his cervical spine, he experienced tingling in his left hand, and reported normally having numbness there, although he was encouraged that it was decreasing with his exercises. See Albany CBOC VA treatment record received April 2022. A September 2018 VA treatment record shows that the Veteran experienced chronic with acute bilateral arm and wrist pain, worse in the left wrist, and unbearable into the elbow. There was tenderness and increased intermittent pain. Capsaicin cream was ordered for his neuropathy. At his VA examination for his cervical spine in August 2021 the Veteran reported experiencing pain from his neck to his left arm, and that his left arm lost feeling and strength. See VA Examination Neck (Cervical Spine) Conditions. He reported constant pain up and down his neck to the point where it irritated him to sleep. His symptoms were of numbness, pain that was sharp and intermittent radiating to the left shoulder, with Capsaicin as an alleviating factor and rotating his head or making a quick movement of his neck as an aggravating factor. In addition, repetitive activities such as rotating his head as a truck driver aggravated his condition. Testing showed radicular constant pain, intermittent pain, paresthesias and/or dysesthesias, and numbness that was mild for the left upper extremity. The left upper radiculopathy nerve roots were involved. Analysis Here, the Board has considered the lay and medical evidence of record. The Veteran had moderate intermittent pain, numbness and paresthesias and or dysesthesias in July 2017; however, the examiner indicated there was mild incomplete paralysis of the left median nerve and the ulnar nerve, and there was no muscle atrophy and muscle, and reflex exams were normal. See July 2017 VA Examination Peripheral Nerves. Still, the Veteran described difficulty with continued numbness, pain and tenderness. See Albany CBOC VA treatment record received April 2022. Further testing showed radicular constant pain, intermittent pain, paresthesias and /or dysesthesias and numbness, and numbness, involving the left upper radiculopathy. See August 2021 VA Examination Neck (Cervical Spine) Conditions. Considering the totality of the evidence, however, the Board finds that the Veteran's radiculopathy symptomatology does not approximate the next higher rating of 30 percent which requires moderate severity of the incomplete paralysis of the minor upper extremity. Rather, here, the numbness and pain, with some functional limitations, to include losing feeling and strength in his left arm, remains at most mild in degree of severity. For the foregoing reasons, the evidence of record persuasively weighs against the Veteran's claim for a rating greater than 20 percent for left upper extremity radiculopathy. As the evidence of record persuasively weighs against a rating in excess of 20 percent, the benefit-of-the-doubt rule does not apply. 38 U.S.C. § 5107(b); 38 C.F.R. §§ 4.3, 4.7; Lynch v. McDonough, 21 F.4th 776 (Fed. Cir. 2021). REASONS FOR REMAND Diabetes mellitus As the July 2021 Board decision noted, a July 2018 rating decision continued previous denials, in pertinent to include for entitlement to service connection for diabetes. In August 2018, the Veteran submitted a timely NOD with respect to these denials, however an SOC as to the issue of reopening diabetes mellitus was not provided. See August 2018 NOD; see March 2020 SOC. While the Veteran submitted a VA Form 9 in May 2020, it was not timely. See May 2020 VA Form 9. Under Manlincon v. West, 12 Vet. App. 238, 240 (1999), the Board must instruct the RO that the issue of reopening the claim for service connection for diabetes mellitus remains pending in appellate status and requires further action. See 38 U.S.C. § 7105; 38 C.F.R. § 19.26. In this regard, it is noteworthy that this claim is not before the Board at this time and will only be before the Board if the Veteran files a timely substantive appeal. As such, this must be remanded. All Others A medical examination is necessary when there is (1) competent evidence of a current disability or persistent or recurrent symptoms of a disability, (2) evidence establishing an in-service event, injury, or disease, and (3) an indication that the disability or symptoms may be associated with service or with another service-connected disability, but (4) insufficient medical evidence of record for the Secretary to make a decision on the claim. See McLendon v. Nicholson, 20 Vet. App. 79 (2006). For the reasons discussed below remand is necessary to afford the Veteran with an examination regarding the nature and etiology of his claimed disabilities. See 38 U.S.C. § 5103A(f). A disability manifested by shortness of breath The Veteran seeks service connection for a disability manifested by shortness of breath, to include as due to environmental exposures in the Persian Gulf, to include burn pits. Here there have been symptoms of shortness of breath, to include descriptions of difficulty breathing, and a November 2020 VA treatment record that the Veteran had symptoms of dyspnea. See Persian Gulf Registry Exam received October 2021; see Albany CBOC treatment record received October 2021. In May 2018 the Veteran was afforded a Gulf War examination that indicated there were no additional signs and or symptoms not addressed through completion of DBQs. See May 2018 Gulf War General Medical Examination (Including Burn Pits) DBQ. There was, however, functional impact of additional signs and or symptoms that may represent an undiagnosed illness or diagnosed medically unexplained chronic multisymptom illness. Id. The examiner then opined that the Veteran's shortness of breath was less likely than not proximately due to or the result of the Veteran's service-connected condition. Id. She reasoned that based on examination and all available documentation the Veteran had normal respiratory examination, which was a disease with a clear and specific etiology and diagnosis. Id. As such, a claimed shortness of breath condition was not corroborated as being related to a specific exposure event to the Veteran's Southwest Asia service. Id. The Board notes on the examination portion, the examiner marked the box indicating that yes there was another pulmonary condition, pertinent physical finding or scar due to pulmonary condition, yet ENT was unremarkable, lungs were clear, and heart had no murmurs or gallops, and regular rate and rhythm. See May 2018 VA Examination Respiratory Condition. Here, the most recent VA examination in May 2018 concluded that the examination for respiratory conditions was normal, and therefore did not give a nexus opinion. See May 2018 VA Examination Respiratory Conditions DBQ. Since then, the November 2020 VA treating provider indicated there were symptoms of dyspnea, and the Veteran has reported persistent shortness of breath. As such, and considering the contradictory May 2018 VA gulf war examination, it appears that the Veteran should be afforded another VA examination for his claimed shortness of breath, and an opinion as to whether the dyspnea is related to his service, to include service in the Persian Gulf, or near the burn pits. Remand is therefore necessary to obtain a VA opinion regarding the Veteran's disability claimed as shortness of breath. See McLendon v. Nicholson, 20 Vet. App. 79 (2006). Residuals of gallbladder removal The Veteran contends that he is entitled to service connection for residuals of gallbladder removal surgery to include as secondary to contaminated water exposure at Camp Lejeune. Here, the record shows that the Veteran's gallbladder was removed in May 2011. Specifically, he was diagnosed with cholelithiasis with chronic cholecystitis in May 2011 and underwent a laparoscopic cholecystectomy (gallbladder removal) with intraoperative cholangiogram. Discharge diagnosis was of gallstone pancreatitis. See Phoebe Putney Memorial Hospital records received November 2013. Although the Veteran reported in part, that while on orders for the U.S. Army National Guard he received hospital treatment to have his gallbladder removed, the personnel records have been obtained and do not show that he was on active duty or active duty for training at the time of his May 2011 operation. See VA Form 10182 Notice of Disagreement. Even so, given that the Veteran's exposure to contaminated water would have occurred while he was on active duty, and there is no question that he has had his gallbladder removed and reports residuals, the Board finds that a medical opinion is necessary to determine whether such exposure to contaminated water is at least as likely as not to have caused the eventual removal of his gallbladder and residual symptoms. See McLendon v. Nicholson, 20 Vet. App. 79 (2006). The issue is medically complex, as it requires specialized medical education and the ability to interpret diagnostic tests. Jandreau v. Nicholson, 492 F.3d 1372, 1377, 1377 n.4 (Fed. Cir. 2007). As such, this is the type of etiological opinion for which the Board requires a VA examiner to opine as to the nature and etiology of the Veteran's claimed gallbladder removal residuals, and whether they were caused by contaminated water while in service. A disability manifested by swelling of the joints The Veteran seeks service connection for a disability manifested by swelling of the joints. In January 2015 the Veteran filed his claim for entitlement to service connection for a disability manifested by swelling of the joints. See January 2015 Fully Developed Claim (Compensation). In August 2016 the Veteran reported that his disability was due to exposure to environmental hazards during the Gulf War. In March 2022 the Veteran indicated that his swollen joints began during deployment to Iraq and had been an ongoing condition since then. See March 2022 NOD. In November 2005, the Veteran reported that he had joint swelling, and had been placed on medication. See November 2005 VA 21-526EZ Veterans Application for Compensation or Pension. In December 2009 the Veteran reported that he had neck and back joint pain and headaches. See STR. In August 2009 the Veteran endorsed taking medication for joint pain. See STR. In a July 2011 report of medical history, he endorsed swollen or painful joints. See Medical Treatment Record- Government Facility. In this regard, a May 2018 Gulf War General Medical Examination disability benefits questionnaire was obtained and did not find any diagnosed illnesses for which no etiology was established. The Board observes that the Veteran's cervical and thoracolumbar spine disabilities are separately service-connected, and his headaches are also service connected in this decision. Even so, the examiner marked a box indicating that yes there is a functional impact of additional signs and/or symptoms that may represent an "undiagnosed illness" or "diagnosed medically unexplained chronic multisymptom illness" but no remarks were provided. As such, the Board finds that the May 2018 VA examination is inadequate in that it is unclear whether there is an undiagnosed illness or MUCMI due to environmental exposure in the Persian Gulf. The matters are REMANDED for the following actions: 1. Issue an SOC to the Veteran addressing the issue of whether the claim for service connection for diabetes mellitus can be reopened. The Veteran must be advised of the time limit for filing a substantive appeal. 38 C.F.R. § 20.302(b). Then, only if the appeal is timely perfected, this issue is to be returned to the Board for further appellate consideration. 2. Request all outstanding service personnel records, to include those from the Veteran's Army National Guard Service. Please note that the Veteran has reported that he was with the National Guard in 2011 when he had his gallbladder removed and attempt to verify his orders at the time of his operation. 3. Schedule the Veteran for VA examinations with appropriate examiners to address the nature and etiology of his disability characterized by shortness of breath, residuals of gallbladder removal and disability manifested by swelling of the joints. The entire claims file must be provided to, and reviewed by, the examiner. The examiner should obtain the Veteran's detailed lay history, including onset and progression symptomatology. (a) The examiner should state whether it is at least as likely as not that the Veteran's disability manifested by shortness of breath, to include dyspnea i) Was incurred in service or is related to an in-service injury, event, or disease, to include exposure to contaminated water at Camp LeJeune, or exposure to environmental hazards, to include burn pits, in Iraq ii) Whether it is at least as likely as not his symptoms are due to an undiagnosed illness or medically unexplained chronic multi-symptom illness resulting from service in Southwest Asia during the Persian Gulf War. The examiner is asked to opine as to the etiology and pathophysiology of the shortness of breath. The examiner is asked to determine whether the Veteran's shortness of breath is a medically unexplained chronic multi symptom illness with an etiology or pathophysiology that is inconclusive. If so, the examiner should also comment on the severity of the symptomatology and report all signs and symptoms necessary for evaluating the illness under the rating criteria. (b) The examiner should state whether it is at least as likely as not that the Veteran's residuals of gallbladder removal i) Was incurred in service or is related to an in-service injury, event, or disease, to include exposure to contaminated water at Camp LeJeune or exposure to environmental hazards, to include burn pits, in Iraq (c) The examiner should state whether it is at least as likely as not that the Veteran's disability manifested by swelling of the joints i) Was incurred in service or is related to an in-service injury, event, or disease, to include exposure to contaminated water at Camp LeJeune, or exposure to environmental hazards, to include burn pits, in Iraq. The examiner is asked to directly address the Veteran's statement that he experienced joint pain in service in Southwest Asia and has had it ever since. If multiple etiologies are identified as the cause of the joint pain and swelling, the examiner is asked to identify each and to discuss the significance to the specific details and history in the Veteran's case. In other words, if the examiner identifies known causes and risk factors for the condition in general, he/she must explain how these identifies apply in this case. ii) Whether it is at least as likely as not his symptoms are due to an undiagnosed illness or medically unexplained chronic multi-symptom illness resulting from service in Southwest Asia during the Persian Gulf War. The examiner is asked to opine as to the etiology and pathophysiology of the swelling of the joints. The examiner is asked to determine whether the Veteran's swelling of the joints is a medically unexplained chronic multi symptom illness with an etiology or pathophysiology that is inconclusive. If so, the examiner should also comment on the severity of the symptomatology and report all signs and symptoms necessary for evaluating the illness under the rating criteria. Provide a complete rationale for all opinions expressed. In providing the requested opinion, consider the Veteran's description of his in-service injury and symptoms as well as his post-service symptoms. If there is any medical reason to accept or reject the proposition that the Veteran's reported injury and symptoms in service and thereafter represented the onset of his current disability, this should be noted. Stated another way, do the Veteran's reports about his symptoms align with how the currently diagnosed disability is known to develop or are the Veteran's reports generally inconsistent with medical knowledge or implausible? The term at least as likely as not does not mean within the realm of medical possibility. Rather, it means that the weight of the medical evidence both for and against a conclusion is so evenly divided that it is as medically sound to find in favor of the conclusion (e.g., etiology) as it is to find against the conclusion. Any opinion expressed by the examiner should be accompanied by a complete rationale. If medical literature is relied upon in rendering a determination, the examiner should identify and specifically cite each reference material utilized. If the examiner is unable to offer an opinion without resort to speculation, a thorough explanation as to why an opinion cannot be rendered should be provided. The examiner is reminded that the Veteran is competent to report symptoms, treatment, and injuries, and that his reports must be considered in formulating the requested opinions. The examiner is further reminded that the mere absence of in-service evidence of a particular condition as the sole basis for forming a negative nexus opinion, without additional explanation, will not be adequate. 4. The AOJ must review the claims file and ensure that the foregoing development action has been completed in full. If any development is incomplete, appropriate corrective action must be implemented. If any report does not include adequate responses to the specific opinions requested, it must be returned to the providing examiner for corrective action. YVETTE R. WHITE Veterans Law Judge Board of Veterans' Appeals Attorney for the Board A. Barner, 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.