Entitlement to a 40 percent disability rating from an earlier effective date of March 2, 2014, but not higher or earlier, for lumbosacral strain with degenerative disc disease (DDD) and intervertebral disc syndrome…

Citation Nr: 26001390 Decision Date: 01/30/26 Archive Date: 01/30/26 DOCKET NO. 15-30 368 DATE: January 30, 2026 ORDER Entitlement to a 40 percent disability rating from an earlier effective date of March 2, 2014, but not higher or earlier, for lumbosacral strain with degenerative disc disease (DDD) and intervertebral disc syndrome (IVDS) is granted. Entitlement to special monthly compensation (SMC) based on the need for regular aid and attendance pursuant to 38 U.S.C. § 1114(l) is granted. FINDINGS OF FACT 1. Resolving reasonable doubt in favor of the Veteran, from March 2, 2014, forward flexion of his thoracolumbar spine was limited to 30 degrees or less, or he had the functional equivalent of favorable ankylosis of the entire thoracolumbar spine. 2. The evidence of record is persuasively weighs against the finding that the Veteran's service-connected lumbar spine disability was manifested by forward flexion of thoracolumbar spine limited to 30 degrees or less, or favorable ankylosis of the entire thoracolumbar spine prior to March 2, 2014; or had an incapacitating episode, or unfavorable ankylosis of the entire thoracolumbar spine throughout the rating period on appeal. 3. The Veteran requires regular aid and attendance due to his service-connected disabilities, specifically due to the service-connected lumbar spine disability and associated radiculopathy of bilateral lower extremities. CONCLUSIONS OF LAW 1. The criteria for entitlement to a 40 percent disability rating from an earlier effective date of March 2, 2014, but not higher or earlier, for lumbosacral strain with DDD and IVDS have been met. 38 U.S.C. §§ 1155, 5107, 5110; 38 C.F.R. §§ 3.102, 3.400, 4.1, 4.3, 4.7, 4.14, 4.25, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5003, 5010, 5237, 5243. 2. The criteria for entitlement to SMC based on the need for regular aid and attendance have been met. 38 U.S.C. §§ 1114, 5107; 38 C.F.R. §§ 3.102, 3.350, 3.351, 3.352. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the United States Army from September 1986 to March 1994. This case comes before the Board of Veterans' Appeals (Board) on appeal from a May 2011 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO). The Veteran subsequently testified at a November 2018 Board hearing before a Veterans Law Judge (VLJ). A transcript of the hearing is associated with the record. Since that time, the VLJ who presided over the November 2018 Board hearing retired from the Board. In an October 2021 letter, the Board advised the Veteran of the VLJ's retirement, and that the Veteran had the option to testify at another hearing before a different VLJ. The Veteran did not request another Board hearing and, as such, the Board may proceed with consideration of the appeal. Addressing the relevant procedural history, in an October 2020 decision, the Board denied, in relevant part, entitlement to a disability rating in excess of 20 percent for lumbosacral strain with DDD prior to June 20, 2018, and granted a 40 percent rating from June 20, 2018. The Veteran appealed the October 2020 Board decision to the United States Court of Appeals for Veterans Claims (Court). The Veteran did not appeal the denial of entitlement to a disability rating in excess of 40 percent for lumbosacral strain with DDD from June 20, 2018. In October 2021, the Court granted a Joint Motion for Partial Remand (JMPR) based on agreed-upon assertions submitted by the parties (the Veteran and the Secretary of VA). Pursuant to the JMPR, in October 2021, the Court vacated, in relevant part, the Board's denial of a rating in excess of 20 percent for lumbosacral strain with DDD prior to June 20, 2018. Thereafter, the Board remanded this case in March 2022. In the March 2022 remand, the Board found that issues of entitlement to service connection for gastritis and gastroesophageal reflux disease (GERD) as secondary to the service-connected lumbosacral strain with DDD and/or radiculopathy of the right and left lower extremities were raised by the record, and that VA has a duty to assist the Veteran in the development of these claims. Therefore, the Board remanded the matters of the increased rating claim for lumbar spine disability and service connection for GERD to the RO for further development. Afterwards, in an August 2022 rating decision, the RO granted entitlement to service connection for GERD, but denied entitlement to service connection for viral gastroenteritis. The RO also issued an August 2022 Supplemental Statement of the Case (SSOC) denying entitlement to service connection for gastritis as secondary to lumbosacral strain with DDD and/or radiculopathy of the right and left lower extremities, entitlement to a disability rating in excess of 20 percent for lumbosacral strain with DDD for the period prior to June 20, 2018, and entitlement to a total disability rating based on individual unemployability (TDIU) for the period prior to April 18, 2013. Subsequently, in October 2022, the Board remanded these matters again for additional development. Thereafter, in an August 2023 decision, the Board denied entitlement to service connection for a gastrointestinal disorder other than GERD, claimed as gastritis secondary to lumbosacral strain with DDD and/or radiculopathy of the right and left lower extremities; entitlement to a disability rating in excess of 20 percent for lumbosacral strain with DDD for the period prior to June 20, 2018; and entitlement to a TDIU for the period prior to April 18, 2013. The Veteran appealed the August 2023 Board decision to the Court. The Veteran only appealed the denial of entitlement to service connection for a gastrointestinal disorder other than GERD, claimed as gastritis secondary to lumbosacral strain with DDD and/or radiculopathy of the right and left lower extremities; and entitlement to a disability rating in excess of 20 percent for lumbosacral strain with DDD for the period prior to June 20, 2018. The Veteran did not appeal the denial of entitlement to a TDIU for the period prior to April 18, 2013. In March 2024, the Court granted a JMPR based on agreed-upon assertions submitted by the parties (the Veteran and the Secretary of VA). Pursuant to the JMPR, in March 2024, the Court vacated, in relevant part, the Board's denial of entitlement to service connection for a gastrointestinal disorder other than GERD, claimed as gastritis secondary to lumbosacral strain with DDD and/or radiculopathy of the right and left lower extremities; and entitlement to a disability rating in excess of 20 percent for lumbosacral strain with DDD for the period prior to June 20, 2018; and remanded these matters to the Board for adjudication consistent with the terms of the March 2024 JMPR. Pursuant to the March 2024 Court order, in August 2024, the Board remanded the issues of entitlement to service connection for a gastrointestinal disorder other than GERD, claimed as gastritis secondary to the service-connected lumbosacral strain with DDD and/or radiculopathy of the right and left lower extremities; and entitlement to a disability rating in excess of 20 percent for lumbosacral strain with DDD for the period prior to June 20, 2018. Additionally, in the August 2024 remand, the Board found that the issue of entitlement to SMC based on the need for regular aid and attendance had been raised as a part and parcel of the increased rating claim for the service-connected lumbar spine disability, and also remanded this matter for RO to adjudicate the claim at first instance. Thereafter, in a December 2024 rating decision, the RO granted entitlement to service connection for a gastrointestinal disorder other than GERD, claimed as gastritis. Therefore, this matter is not on appeal anymore. The RO also issued a December 2024 SSOC denying entitlement to a disability rating in excess of 20 percent for lumbosacral strain with DDD for the period prior to June 20, 2018, and returned this matter back to the Board. Thereafter, in March 2025, the Board remanded the issue of entitlement to a disability rating in excess of 20 percent for lumbosacral strain with DDD for the period prior to June 20, 2018, along with the issue of entitlement to SMC based on the need for regular aid and attendance as part of increased rating claim for lumbar spine disability for additional development. After completing the additional development, the RO issued a December 2025 SSOC denying entitlement to a disability rating in excess of 20 percent for lumbosacral strain with DDD for the period prior to June 20, 2018; and entitlement to SMC based on the need to regular aid and attendance; and returned these matter back to the Board for appellate review. Since the Veteran also has the diagnosis of IVDS of lumbar spine, the Board has recharacterized the issue of increased rating for the lumbar spine disability as "lumbosacral strain with DDD and IVDS." INCREASED RATING Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities, found in 38 C.F.R., Part 4. The percentage ratings are based on the average impairment of earning capacity as a result of a service-connected disability, and separate diagnostic codes identify the various disabilities and the criteria for specific ratings. See 38 U.S.C. § 1155; 38 C.F.R. § 4.1. If two disability evaluations are potentially applicable, the higher evaluation is assigned if the disability picture more nearly approximates the criteria for that rating; otherwise, the lower rating is assigned. 38 C.F.R. § 4.7. Any reasonable doubt regarding the degree of a disability is resolved in favor of the Veteran. See 38 U.S.C. § 5107; 38 C.F.R. §§ 3.102, 4.3. The Veteran's entire history is to be considered when assigning disability rating. Schafrath v. Derwinski, 1 Vet. App. 589, 594 (1991); 38 C.F.R. § 4.1. The Board will consider entitlement to staged ratings to compensate for times since filing the claim when the disability may have been more severe than at other times during the period of claim on appeal. Hart v. Mansfield, 21 Vet. App. 505, 509-510 (2007); Fenderson v. West, 12 Vet. App. 119, 126 (1999). 1. Entitlement to a 40 percent disability rating from an earlier effective date of March 2, 2014, but not higher or earlier, for lumbosacral strain with DDD and IVDS is granted. The Veteran seeks entitlement to a disability rating in excess of 20 percent for his lumbar spine disability for the period prior to June 20, 2018. Initially, the Board finds that the applicable rating period on appeal for the service-connected lumbar spine disability begins from September 17, 2009, one year prior to the receipt of the increased rating claim for the service-connected lumbar spine disability, if it is factually ascertainable that the increase in disability occurred on that date; otherwise, it is the date of receipt of increased rating claim, which is September 17, 2010. See 38 C.F.R. § 3.400(o)(2). Where evidence demonstrates a factually ascertainable increase in disability during the one-year period preceding the date of receipt of a claim for increased compensation, the law provides that the effective date of the award "shall be the earliest date as of which it is ascertainable that an increase in disability had occurred, if application is received within one year from such date." 38 U.S.C. § 5110(b)(2); Harper v. Brown, 10 Vet. App. 125, 126 (1997); 38 C.F.R. § 3.400(o)(2). Therefore, three possible dates may be assigned depending on the facts of a case: (1) if an increase in disability occurs after the claim is filed, the date that the increase is shown to have occurred (date entitlement arose) (38 C.F.R. § 3.400(o)(1)); (2) if an increase in disability precedes the claim by a year or less, the date that the increase is shown to have occurred (factually ascertainable), otherwise; (3) date of receipt of claim. See Harper, 10 Vet. App. at 126; 38 C.F.R. § 3.400(o)(2). Thus, the appeal period begins from September 17, 2009, one year prior to the receipt of the increased rating claim for the service-connected lumbar spine disability, if it is factually ascertainable that the increase in disability occurred on that date; otherwise, it is the date of receipt of the claim, which is September 17, 2010. See 38 C.F.R. § 3.400(o)(2). The Veteran is in receipt of 10 percent disability rating from December 4, 1995; 20 percent disability rating from August 29, 2003; temporary 100 percent disability rating from April 2, 2004 to June 1, 2004; 20 percent disability rating from June 1, 2004; and 40 percent disability rating from June 20, 2018. As noted above, in the August 2023 decision, the Board denied entitlement to a disability rating in excess of 20 percent for lumbosacral strain with DDD for the period prior to June 20, 2018. The Veteran appealed the August 2023 Board decision to the Court. The Veteran appealed the denial of entitlement to a disability rating in excess of 20 percent for lumbosacral strain with DDD for the period prior to June 20, 2018. Thus, the Veteran is in receipt of 20 percent disability rating from beginning of the rating period on appeal, September 17, 2009 to June 20, 2018. Accordingly, the question for the Board is whether the Veteran is entitled to a disability rating in excess of 20 percent prior to June 20, 2018. For the following reasons and after resolving reasonable doubt in favor of the Veteran, the Board finds that entitlement to a 40 percent disability rating from an earlier effective date of March 2, 2014, but not earlier, for the lumbar spine disability is warranted. Disability of the musculoskeletal system is primarily the inability, due to damage or infection in parts of the system, to perform the normal working movements of the body with normal excursion, strength, speed, coordination, and endurance. Functional loss may be due to the absence or deformity of structures or other pathology, or it may be due to pain, supported by adequate pathology and evidenced by the visible behavior in undertaking the motion. Weakness is as important as limitation of motion, and a part that becomes painful on use must be regarded as seriously disabled. See 38 C.F.R. § 4.40. When evaluating musculoskeletal disabilities based on limitation of motion, 38 C.F.R. § 4.40 requires consideration of functional loss caused by pain or other factors listed in that section that could occur during flare-ups or after repeated use and, therefore, not be reflected on range-of-motion testing. With respect to joints, in particular, the factors of disability reside in reductions of normal excursion of movements in different planes. 38 C.F.R. § 4.45 requires consideration also be given to less movement than normal, more movement than normal, weakened movement, excess fatigability, incoordination, and pain on movement. See DeLuca v. Brown, 8 Vet. App. 202 (1995); see also Mitchell v. Shinseki, 25 Vet. App. 32, 44 (2011). Nonetheless, even when the background factors listed in § 4.40 or 4.45 are relevant when evaluating a disability, the rating is assigned based on the extent to which motion is limited, pursuant to 38 C.F.R. § 4.71a; a separate or higher rating under § 4.40 or 4.45 itself is not appropriate. See Thompson v. McDonald, 815 F.3d 781, 785 (Fed. Cir. 2016) ("[I]t is clear that the guidance of § 4.40 is intended to be used in understanding the nature of the veteran's disability, after which a rating is determined based on the § 4.71a criteria."). In Correia v. McDonald, 28 Vet. App. 158 (2016), the Court specified additional requirements that VA examiners should address when assessing musculoskeletal disabilities, holding specifically, that the joints involved should be tested for pain on both active and passive motion, in weight-bearing and non-weight-bearing and, if possible, with the range of the opposite undamaged joint. In addition, assignment of a disability rating should consider limitation of functional ability during flare-ups or when a joint is used repeatedly over a period of time. See DeLuca 8 Vet. App. 202. Specifically, in Sharp v. Shulkin, 29 Vet. App. 26 (2017), the Court stated that flare-ups must be considered in providing an estimate of additional functional loss based on range of motion. In Mitchell, 25 Vet. App. 32, 38 (2011), the Court held that, although pain may cause a functional loss, "pain itself does not rise to the level of functional loss as contemplated by VA regulations applicable to the musculoskeletal system." Rather, pain may result in functional loss, but only if it limits the ability "to perform the normal working movements of the body with normal excursion, strength, speed, coordination, or endurance." Mitchell, 25 Vet. App. at 38. (quoting 38 C.F.R. § 4.40). Under 38 C.F.R. § 4.59, painful motion is a factor to be considered with any form of arthritis; and joints that are actually painful, unstable, or malaligned due to healed injury should be entitled to at least the minimum compensable rating for the joint. However, 38 C.F.R. § 4.59 is not limited to disabilities involving arthritis. See Burton v. Shinseki, 25 Vet. App. 1, 5 (2011). The Veteran's lumbar spine disability is rated under diagnostic code 5243, which rates IVDS. 38 C.F.R. § 4.71a, Diagnostic Code 5243. Since the Veteran also has lumbosacral strain with DDD, diagnostic code 5237 that rates lumbosacral strain and diagnostic code 5242 that rates degenerative arthritis and degenerative disc disease of spine are also applicable. 38 C.F.R. § 4.71a, Diagnostic Code 5237, 5242. Diagnostic code 5242 also instructs to consider diagnostic code 5003 that rates degenerative arthritis and diagnostic code 5010 that rates post-traumatic arthritis. 38 C.F.R. § 4.71a, Diagnostic Code 5003, 5010, 5242. The Rating Schedule provides that disabilities rated under diagnostic codes 5235 to 5243 should be evaluated under the General Rating Formula for Diseases and Injuries of the Spine (General Formula), unless diagnostic code 5243 is evaluated under the Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes. 38 C.F.R. § 4.71a, Diagnostic Code 5242, 5243, General Rating Formula for Diseases and Injuries of the Spine. In regard to the General Formula as applied to the lumbar spine disability, a 10 percent rating is warranted for forward flexion of the thoracolumbar spine greater than 60 degrees but not greater than 85 degrees; or, combined range of motion of the thoracolumbar spine greater than 120 degrees but not greater than 235 degrees; or, muscle spasm, guarding, or localized tenderness not resulting in abnormal gait or abnormal spinal contour; or, vertebral body fracture with loss of 50 percent or more of the height. 38 C.F.R. § 4.71a, General Rating Formula for Diseases and Injuries of the Spine. A 20 percent rating is warranted for forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees; or, the combined range of motion of the thoracolumbar spine not greater than 120 degrees; or, muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. Id. A 40 percent rating is warranted for forward flexion of the thoracolumbar spine 30 degrees or less; or, favorable ankylosis of the entire thoracolumbar spine. Id. A 50 percent rating is warranted for unfavorable ankylosis of the entire thoracolumbar spine. Id. A 100 percent evaluation is warranted for unfavorable ankylosis of the entire spine. Id. For VA compensation purposes, normal forward flexion of the thoracolumbar spine is zero to 90 degrees, extension is zero to 30 degrees, left and right lateral flexion are zero to 30 degrees, and left and right lateral rotation are zero to 30 degrees. The combined range of motion refers to the sum of the range of forward flexion, extension, left and right lateral flexion, and left and right rotation. The normal combined range of motion of the thoracolumbar spine is 240 degrees. The normal ranges of motion for each component of spinal motion provided here are the maximum that can be used for calculation of the combined range of motion. 38 C.F.R. § 4.71a, General Rating Formula for Diseases and Injuries of the Spine, Note (2). Any associated objective neurologic abnormalities, including, but not limited to bowel or bladder impairment, should be evaluated separately under an appropriate diagnostic code. 38 C.F.R. § 4.71a, General Rating Formula for Diseases and Injuries of the Spine, Note (1). For VA compensation purposes, unfavorable ankylosis is a condition in which the entire cervical spine, the entire thoracolumbar spine, or the entire spine is fixed in flexion or extension, and the ankylosis results in one or more of the following: difficulty walking because of a limited line of vision; restricted opening of the mouth and chewing; breathing limited to diaphragmatic respiration; gastrointestinal symptoms due to pressure of the costal margin on the abdomen; dyspnea or dysphagia; atlantoaxial or cervical subluxation or dislocation; or neurologic symptoms due to nerve root stretching. Fixation of a spinal segment in neutral position (zero degrees) always represents favorable ankylosis. 38 C.F.R. § 4.71a, General Rating Formula for Diseases and Injuries of the Spine, Note (5). The Board notes that effective February 7, 2021, certain parts of 38 C.F.R. § 4.71a, which provides the ratings schedule for disabilities of the musculoskeletal system, were revised. 85 Fed. Reg. 230 (Nov. 30, 2020). These amendments revised select diagnostic codes "to ensure that this portion of the rating schedule uses current medical terminology and provides detailed and updated criteria for the evaluation of musculoskeletal disabilities." Id. If a law or regulation changes during the course of a claim or an appeal, the version more favorable to the Veteran will apply, to the extent permitted by any stated effective date in the amendment in question. 38 U.S.C. § 5110(g). If the revised version of the regulation is more favorable, the implementation of that regulation under 38 U.S.C. § 5110(g) can be no earlier than the effective date of that change. If the former version is more favorable, VA can apply the earlier version of the regulation for the period prior to, and from, the effective date of the change. Therefore, the Board will consider the Veteran's claim under the old criteria prior to February 7, 2021, and both the old and new rating criteria from February 7, 2021. The criteria that is more favorable to the Veteran will be applied from February 7, 2021. The Board notes that in the February 2021 regulatory change, diagnostic code 5237 was not amended. 38 C.F.R. § 4.71a, Diagnostic Code 5237. The Board also notes that in the February 2021 regulatory change, the diagnostic code 5242 was amended. The regulatory change reworded the diagnostic code 5242 from "Degenerative arthritis of the spine (see also diagnostic code 5003)" to "Degenerative arthritis, degenerative disc disease other than intervertebral disc syndrome (also, see either 5003 or 5010);" however, there is no change in rating criteria under this diagnostic code. 38 C.F.R. § 4.71a, Diagnostic Code 5242 (2021). As diagnostic code 5242 also directs to consider diagnostic code 5003 for evaluating degenerative arthritis of the spine, the Board notes that the regulatory change reworded the diagnostic code 5003 from "Arthritis, degenerative (hypertrophic or osteoarthritis)" to "Degenerative arthritis, other than post traumatic", but did not change the actual criteria for rating disabilities under the diagnostic code. 38 C.F.R. § 4.71a, Diagnostic Code 5003 (2021). Under diagnostic code 5003 (under both old and new criteria) degenerative arthritis, when established by X-ray findings is rated on the basis of limitation of motion under the appropriate diagnostic codes for the specific joint or joints involved. 38 C.F.R. § 4.71a, Diagnostic Code 5003 (2020, 2021). When however, the limitation of motion of the specific joint or joints involved is noncompensable under the appropriate diagnostic codes, a rating of 10 percent is for application for each such major joint or group of minor joints affected by limitation of motion, to be combined, not added under diagnostic code 5003. Id. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. Id. In the absence of limitation of motion, a 20 percent evaluation is warranted with X-ray evidence of involvement of two or more major joints or two or more minor joint groups, with occasional incapacitating exacerbations. Id. A 10 percent evaluation is warranted with X-ray evidence of involvement of two or more major joints or two or more minor joint groups. Id. As of February 7, 2021, diagnostic code 5242 also directs to consider diagnostic code 5010 for evaluating degenerative arthritis of the spine. In this regard, the Board notes that the diagnostic code 5010 was amended effective February 7, 2021. The regulatory change reworded the diagnostic code 5010 from "Arthritis, due to trauma, substantiated by X-ray findings" to "Post-traumatic arthritis". Prior to the regulatory change, diagnostic code 5010 directed that the disability (arthritis due to trauma) be rated as degenerative arthritis under diagnostic code 5003. 38 C.F.R. § 4.71a, Diagnostic Code 5010 (2020). As of February 7, 2021, under the amended criteria, diagnostic code 5010 directs that the disability (post-traumatic arthritis) be rated as limitation of motion, dislocation, or other specified instability under the affected joint. 38 C.F.R. § 4.71a, Diagnostic Code 5010 (2021). If there are 2 or more joints affected, each rating is to be combined in accordance with 38 C.F.R. § 4.25. Id. As noted above, the Veteran's lumbar spine disability is rated under diagnostic code 5243, which rates IVDS because the Veteran has the diagnosis of IVDS. 38 C.F.R. § 4.71a, Diagnostic Code 5243. Besides rating under General Formula, IVDS can also be evaluated under the Formula for IVDS Based on Incapacitating Episodes. The Board notes that prior to and after the February 2021 regulatory change, the diagnostic code 5243 directs to evaluate IVDS (preoperatively or postoperatively) either under the General Rating Formula for Diseases and Injuries of the Spine or under the Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes, whichever method results in the higher evaluation when all disabilities are combined under § 4.25. However, as of February 7, 2021, diagnostic code 5243 additionally directs to assign this diagnostic code only when there is disc herniation with compression and/or irritation of the adjacent nerve root; assign diagnostic code 5242 for all other diagnoses. 38 C.F.R. § 4.71a, Diagnostic Code 5243 (2020, 2021). However, the actual rating criteria is unchanged under this diagnostic code. Under diagnostic code 5243, a 10 percent rating is assigned for IVDS with incapacitating episodes having a total duration of at least one week but less than 2 weeks during the past 12 months. 38 C.F.R. § 4.71a, Diagnostic Code 5243. A 20 percent rating is assigned for IVDS with incapacitating episodes having a total duration of at least 2 weeks but less than 4 weeks during the past 12 months. Id. A 40 percent rating is assigned for IVDS with incapacitating episodes having a total duration of at least 4 weeks but less than 6 weeks during the past 12 months. Id. A 60 percent rating is assigned for IVDS with incapacitating episodes having a total duration of at least 6 weeks during the past 12 months. Id. For purposes of ratings under diagnostic code 5243, an incapacitating episode is a period of acute signs and symptoms due to intervertebral disc syndrome that requires bed rest prescribed by a physician and treatment by a physician. Id. Note (1). The Board has reviewed the relevant evidence of record from the beginning of the rating period on appeal. In a September 2010 statement in support of claim, the Veteran asserted that his back pain was getting worse, but he was still able to work. In an October 2010 statement in support of claim, the Veteran asserted that he injured his back while in service, and he went to sick call every other day and was continuously told that he had muscle strain. The Veteran also asserted that his lower back would pop while walking. He had spinal injections, and finally had a lower back surgery. He asserted that he had continuous pain in back since active service. The Veteran underwent a VA spine examination in November 2010. The examiner noted the diagnosis of lumbar strain with DDD/degenerative joint disease with S1 radiculopathy left lower extremity, classified as mild, postoperative discectomy. The examiner noted that the back condition had gotten slightly worse since his last VA examination in 2007. The Veteran complained of chronic moderate lower back pain with some loss of motion. He did not indicate that he was having additional weakness, instability, or loss of motion of the back with flare-ups. Functional restrictions included limitations involving standing, walking, and lifting. The examiner noted that the Veteran was not using cane or brace for the condition, nor had he been incapacitated in the previous 12 months due to lower back condition. Upon examination, findings included radiculopathy symptoms in the left leg with radiating down the left posterolateral leg and foot on a frequent basis. It was further reported that the Veteran had persistent paresthesias along the nerve distribution of the left leg, but there was no dysesthesia, incontinence, dyscoordination, or braces. The orthopedic portion of the examination noted mild spasms and tenderness to palpation. Range of motion was measured as forward flexion limited to 70 degrees; posterior flexion limited to 10 degrees; lateral flexion limited to 20 degrees bilaterally; and rotary flexion limited to 35 degrees bilaterally. Pain was reported at the extreme range of motion in all directions. The examiner further reported that there was additional weakness, fatigability, dyscoordination, restricted range of motion, and some functional impairment following repetitive stress testing. However, the Veteran had a normal gait and his motor strength was 5/5. A November 2010 VA X-ray report for the Veteran's back noted degenerative changes in the Veteran's lumbar spine. In a September 2011 statement, the Veteran asserted that due to his lower back disability, he was limited on lifting, standing, or sitting for long periods of time. In a September 2012 private treatment record, the clinician noted that the Veteran has progressively increasing back pain and symptoms had been ongoing for six months to a year. In an October 2012 private treatment record, the clinician noted that the Veteran had a lumbar epidural steroid injection. The clinician noted that the MRI showed a subligamentous disc herniation at L4-5 and an inferior extruded disc herniation at L5-S1. In a November 2012 private treatment record, the clinician noted that the Veteran was doing better after post-redo diskectomy. His motor strength was 5/5, and straight leg raise test was negative. In a February 2013 private treatment record, the clinician noted back pain and increase in muscle spasms in lower spine, and the motor strength was 5/5. A March 2013 private treatment record noted lumbar spine surgery. Pre- and postoperative diagnosis was noted as lumbar spondylosis and facet arthropathy. In a June 2013 private treatment record, the clinician noted tenderness to digital palpation and muscle tension on both sides of the lumbar spine. There was muscle spasm on both sides of the lumbar spine. The clinician noted that the Veteran had reduced range of motion, but did not note in term of degrees. In another June 2013 private treatment record, the clinician noted that the Veteran was in a car accident, but he had the back pain prior to the accident, and the accident aggravated the condition, resulting in increased back pain and hip pain with intermittent left leg pain. In an August 2013 private treatment record, the clinician noted that the Veteran had lower back pain with tenderness and muscle spasm. The clinician noted reduced flexion, lateral bending bilaterally, and rotation on the right. In a March 2, 2014 statement, the Veteran's spouse asserted that the Veteran's lower back condition had worsen severely. The Veteran had trouble getting dressed, she stated that she usually puts his socks/pants on. The Veteran was unstable on feet and had fallen numerous times walking on level surfaces. Due to instability, the Veteran only bathes when wife can assist him. The Veteran could not sleep more than three to four hours. The Veteran could not lay, sit, or stand for any length of time. The Veteran could not lift anything over 5 pounds, and nothing over his head. The Veteran's spouse stated that the Veteran could not twist/bend at the waist and was in unbearable pain, and sexual relations were non-existent due to pain. An April 2014 Social Security Administration (SSA) record noted that the Veteran was unable to dress himself, and needed assistance with bathing, and had difficulty using arms/hands/fingers. He had difficulty completing tasks, and was unable to bend/stoop. In a January 2015 VA examination report for back (thoracolumbar spine) conditions, the examiner noted the Veteran's reports that he was not experiencing flare-ups. Range of motion testing was noted as forward flexion limited to 55 degrees, extension limited to 15 degrees, right and left lateral flexion limited to 15 degrees each, right lateral rotation limited to 20 degrees, and left lateral rotation limited to 25 degrees. While pain was noted that same pain was not resulting in or causing functional loss. The examiner noted that there was no additional loss of range of motion on repeated use over a period of time. There was some guarding which produced an abnormal gait. However, no muscle spasm or localized tenderness was noted. Muscle strength was 5/5 with no atrophy or ankylosis. The Veteran did state that, on occasion, he used a brace on his back. It was noted that the Veteran had complaints of pain with throbbing, and a decreased ability to walk or stand for extended periods of time, and had decreased motion and stiffness. Nevertheless, when examined, the examiner indicated that there were no additional functional limitations based on pain. Radiculopathy was noted with involvement of sciatic nerve in left lower extremity. The examiner noted arthritis of lower back. In a March 2017 private treatment record, the clinician noted that the Veteran had very limited range of motion of lower back, and forward flexion was limited to 20 degrees. In a March 2018 private treatment record, the clinician noted that the Veteran's forward flexion of lumbar spine was limited to 20 degrees. In the November 2018 Board hearing, the Veteran testified that he did not have a lot of range of motion and had constant pain, and his wife had to put his socks on in the morning. In a January 2020 VA examination report for back (thoracolumbar spine) conditions, the examiner noted the diagnosis of lumbar strain, IVDS, DDD, and radiculopathy of bilateral lower extremities. The examiner noted the Veteran's reports of experiencing flare-ups, as described as dull aches in the lower back; and experiencing functional loss/impairment, described as the inability to bend down or climb stairs. Upon examination, the Veteran's range of motion testing showed forward flexion of 0 to 60 degrees, extension of 0 to 15 degrees, right and left lateral flexion of 0 to 15 degrees, and right and left lateral rotation of 0 to 15 degrees; with range of motion itself contributing to a functional loss. Pain was noted on examination and caused functional loss, with objective evidence of localized tenderness and pain with weight-bearing shown. The Veteran was not able to perform repetitive-use testing, as he expressed pain during attempts; however, pain, fatigue, weakness, and lack of endurance significantly limits functional ability with repeated use, as described in terms of range of motion as forward flexion of 0 to 60 degrees, extension of 0 to 15 degrees, right and left lateral flexion of 0 to 15 degrees, and right and left lateral rotation of 0 to 15 degrees. The examination was not conducted during a flare-up; however, pain, fatigue, weakness, and lack of endurance significantly limited functional ability with flare-ups, as described in terms of range of motion as forward flexion of 0 to 60 degrees, extension of 0 to 15 degrees, right and left lateral flexion of 0 to 15 degrees, and right and left lateral rotation of 0 to 15 degrees. There was no guarding, muscle spasms, muscle atrophy, or ankylosis present. Additionally, the examiner noted that there was objective evidence of pain when the back is used in non-weight bearing and passive range of motion, with passive range of motion being the same as active. The examiner noted the diagnosis of IVDS, but did not note any episodes of acute signs and symptoms due to IVDS that required bed rest prescribed by a physician and treatment by a physician in the past 12 months. In an October 2020 decision, the Board granted entitlement to an increased disability rating of 40 percent, but not higher or earlier, for service-connected lumbosacral strain with degenerative disc disease (lumbar spine disability), beginning June 20, 2018. The Veteran appealed the October 2020 Board decision to the Court. In an October 2021 JMPR, the parties agreed that in assigning the date of June 20, 2018 for 40 percent rating for the Veteran's lumbar spine disability, the Board did not address the Veteran's statement challenging the adequacy of the prior VA examination of January 2015 because the Veteran alleged that when he could not bend his back due to pain, the examiner grabbed him and forced him to bend in the direction she wanted. Therefore, the Court remanded the matter to the Board for additional development. Thereafter, the Board remanded the matter for additional development in March 2022 and October 2022. Specifically, in the October 2022 remand, the Board directed the RO to obtain a retrospective opinion on the severity of the Veteran's service-connected lower back disability, including to determine whether the Veteran exhibited objective evidence of pain with active range of motion testing, passive range of motion testing and/or non-weight-bearing testing during the January 2015 VA examination. In a January 2023 VA retrospective medical opinion, the examiner stated that in spite of the lay statements of record including assertions made at his Board hearing, and the January 2015 examination, there is no objective evidence of pain with either active range of motion testing, passive range of motion testing, or nonweight bearing testing. Thereafter, in the August 2023 decision, the Board denied entitlement to a disability rating in excess of 20 percent for lumbosacral strain with DDD for the period prior to June 20, 2018. The Veteran appealed the August 2023 Board decision to the Court. In March 2024, the Court granted a JMPR based on agreed-upon assertions submitted by the parties (the Veteran and the Secretary of VA). Pursuant to the JMPR, in March 2024, the Court vacated, in relevant part, the Board's denial of entitlement to a disability rating in excess of 20 percent for lumbosacral strain with DDD for the period prior to June 20, 2018; and remanded this matter to the Board for adjudication consistent with the terms of the March 2024 JMPR. In the March 2024 JMPR, the parties agreed that in denying entitlement to a disability rating in excess of 20 percent for lumbosacral strain with DDD for the period prior to June 20, 2018, in the August 2023 decision, the Board did not address a March 2017 private treatment record that noted the Veteran's lumbar spine flexion was limited to 20 degrees, and a March 2014 statement in support of claim that indicates that the Veteran could not bend at the waist. Furthermore, the parties agreed that a January 2023 retrospective opinion did not comply with the previous Board remand and did not elaborate on the January 2015 VA examination report that noted pain during initial range of motion (ROM) testing, however, there is no indication that the non-weight-bearing and passive planes were tested. Accordingly, pursuant to the March 2024 JMPR, in August 2024, the Board remanded the matter to obtain a new medical opinion, including a retrospective opinion from September 2009 (one year prior to the filing of increased rating claim for back condition) to June 2018 on the severity of the Veteran's service-connected lower back disability that addresses the above noted lay and medical evidence of record. Pursuant to the August 2024 Board remand, the RO obtained a VA medical opinion in August 2024, in which the examiner stated that the Veteran's lumbar strain had shown significant progression over the years. The examiner stated that the Veteran had had several surgical interventions for the lumbar pathology, and there are several findings that show severely decreased ROM per the referenced medical records. Thereafter, the examiner referred to the March 2015 [which is actually January 2015], January 2020, and June 2022 VA disability benefits questionnaires (DBQs), and included verbatim findings form these DBQs without providing any retrospective opinion on the severity of the Veteran's lumbar spine disability. The examiner did not address the January 2015 VA examination report that noted pain during initial ROM testing, however, there is no indication that the non-weight-bearing and passive planes were tested. Furthermore, the examiner did not address the March 2014 statement from the Veteran's wife claiming that the Veteran cannot twist/bend at the waist due to lower back disability; and the March 2017 private treatment record noting that the Veteran's lumbar spine flexion was limited to 20 degrees, and extension to erect but not beyond. Therefore, in March 2025, the Board remanded the matter again to obtain a new medical opinion, including a retrospective opinion from September 2009 to June 2018 on the severity of the Veteran's service-connected lower back disability that addresses the above noted lay and medical evidence of record. Pursuant to the Board remand, in March 2025, the RO requested a medical opinion from a VA examiner. However, in a March 2025 response, the examiner stated that she could not provide opinion because she did not have the previous VA examination reports for review. Thereafter, the same examiner provided medical opinions in October 2025 and November 2025. In the October 2025 VA medical opinion, the examiner included verbatim findings from the previous VA medical opinions without providing any retrospective opinion on the severity of the Veteran's lumbar spine disability, and merely stated that examination report from November 2010 noted reduced ROM with repetitive use, however, examination reports from October 2010 and January 2025 noted no reduced ROM with repetitive use, and further commentary would resort to speculation. Similarly, in the November 2025 VA medical opinion, the examiner repeated the same information from the October 2025 medical opinion, and additionally stated that the March 2017 private treatment record noted that the Veteran's lumbar spine flexion was limited to 20 degrees, and extension to erect, but not beyond. Furthermore, the examiner stated that it is not possible to estimate further [range of motion] without resorting to mere speculation. The Board finds the October and November 2025 VA medical opinions inadequate because the examiner did not provide retrospective medical opinion estimating additional loss of range of motion on repeated use over time, and merely stated that it is not possible to estimate further loss of ROM without resorting to mere speculation. However, the examiner did not provide an explanation of why that is so and state whether the need to speculate is due to a deficiency in the state of general medical knowledge (no one could respond given medical science and the known facts), a deficiency in the record (additional facts are required), or a deficiency in the examiner's knowledge (the examiner does not have the required knowledge or training). The Board notes that the Veteran's claim has been remanded several times but no adequate retrospective medical opinion could not obtained. Instead of remanding the Veteran's claim again, the Board would decide the matter based on the evidence of record. Thus, based on the above described evidence of record and after resolving reasonable doubt in favor of the Veteran, the Board finds that entitlement to a 40 percent disability rating from an earlier effective date of March 2, 2014, but not higher or earlier, for lumbosacral strain with DDD and IVDS is warranted. As noted above, in the March 2, 2014 statement, the Veteran's spouse stated that the Veteran could not twist/bend at the waist and was in unbearable pain. Similarly, the April 2014 SSA record noted that the Veteran was unable to bend/stoop. Furthermore, in the March 2017 and March 2018 private treatment records, the clinicians noted that the Veteran had very limited range of motion of lower back, and forward flexion was limited to 20 degrees. Accordingly, the Board finds that a 40 percent rating is warranted from March 2, 2014 under 38 C.F.R. § 4.71a, General Rating Formula for Diseases and Injuries of the Spine because forward flexion of the Veteran's thoracolumbar spine was limited to 30 degrees or less, or he had the functional equivalent of favorable ankylosis of the entire thoracolumbar spine because in the March 2014 statement, the Veteran's wife stated that the Veteran could not twist/bend at the waist and the April 2014 SSA record noted that the Veteran was unable to bend/stoop. However, a disability rating in excess of 20 percent prior to March 2, 2014 is not warranted because the evidence of record does not reflect that forward flexion of the Veteran's thoracolumbar spine was limited to 30 degrees or less, or he had favorable ankylosis of the entire thoracolumbar spine prior to March 2014. As noted above, in the November 2010 VA examination report, the examiner noted that the forward flexion of the Veteran's thoracolumbar spine was limited to 70 degrees, and he had a normal gait and his motor strength was 5/5. Thus, a disability rating in excess of 20 percent prior to March 2, 2014 under 38 C.F.R. § 4.71a, General Rating Formula for Diseases and Injuries of the Spine is not warranted for the Veteran's lumbar spine disability. Also, a disability rating in excess of 40 percent is not warranted throughout the rating period on appeal under 38 C.F.R. § 4.71a, General Rating Formula for Diseases and Injuries of the Spine because the Veteran has not have unfavorable ankylosis of the entire thoracolumbar spine throughout the rating period on appeal. To give the Veteran every consideration in connection with the matter on appeal, the Board is required to consider all other potentially applicable diagnostic codes under 38 C.F.R. § 4.71a pertaining to the lumbar spine condition during the appeal period. See Butts v. Brown, 5 Vet. App. 532, 538 (1993) (the assignment of a particular diagnostic code is "completely dependent on the facts of a particular case"). Other disability ratings may be assigned only if the symptomatology for a disability is not duplicative or overlapping with the symptomatology of any other disability. See Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994); see also Lyles v. Shulkin, 29 Vet. App. 107, 118 (2017) (holding that 38 C.F.R. § 4.14 prohibits paying compensation twice for the same symptoms or functional impairment). Therefore, the Board has considered whether a separate or increased rating is warranted under different diagnostic code or rating criteria besides 38 C.F.R. § 4.71a, General Rating Formula for Diseases and Injuries of the Spine. In this regard, the Board finds that a disability rating in excess of 20 percent prior to March 2, 2014 and in excess of 40 percent thereafter for the Veteran's lumbar spine disability is not warranted under 38 C.F.R. § 4.71a Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes because the Veteran's lumbar spine disability has not manifested by incapacitating episodes having a total duration of at least 2 weeks but less than 4 weeks during a given 12 months period. As noted above, in the January 2020 VA examination report, the examiner noted the diagnosis of IVDS, but did not note any episodes of acute signs and symptoms due to IVDS that required bed rest prescribed by a physician and treatment by a physician in the past 12 months. Additionally, there was no indication in VA examination reports or private or VA treatment records that the Veteran has not been able to get out of bed. Also, he has not been prescribed bed rest at any time during the appeal period. As noted above, the Veteran has arthritis of lumbar spine, therefore, diagnostic code 5242 is applicable in this case. Besides evaluating under General Rating Formula for Diseases and Injuries of the Spine, diagnostic code 5242 also directs to consider diagnostic code 5003 or 5010 for evaluating degenerative arthritis of the spine. As noted above, before regulatory change, diagnostic code 5010 instructed to rate post-traumatic arthritis as degenerative arthritis under diagnostic code 5003. 38 C.F.R. § 4.71a, Diagnostic Code 5010 (2020). After the February 7, 2021, regulatory change, diagnostic code 5010 instructs to rate post-traumatic arthritis as limitation of motion, dislocation, or other specified instability under the affected joint. 38 C.F.R. § 4.71a, Diagnostic Code 5003 (2021). If there are 2 or more joints affected, each rating shall be combined in accordance with 38 C.F.R. § 4.25. Id. The Veteran has arthritis/degenerative disease of the lumbar spine; therefore, diagnostic code 5003 can be applied to the Veteran's lumbar spine disability. Since the Veteran had painful and limited motion throughout the appeal period, the arthritis/DDD of the lumbar spine can be rated under range of motion throughout the appeal period, including the period before and after the regulatory change. Older as well new diagnostic code 5003 warrants at least 10 percent rating if limitation of motion is non-compensable. 38 C.F.R. § 4.71a, Diagnostic Code 5003 (2021). However, the Veteran has been receiving at least 20 percent rating throughout the appeal period based on limitation of motion or painful motion under 5243, therefore, a separate or higher rating is not available under diagnostic code 5003. 38 C.F.R. § 4.71a, Diagnostic Code 5003, 5010, 5243 (2020, 2021). Regarding neurological impairment, the Board notes that the Veteran is already service connected for left and right lower extremity radiculopathy, and is receiving separate ratings for radiculopathy of the left and right lower extremities, and the Veteran has not appealed the rating of these disabilities, and therefore, these are not before the Board. The Court has held that once radiculopathy is recognized and adjudicated in a VA decision as a distinct service-connected disability with its own rating criteria, it does not remain part and parcel of the underlying spine claim. De Hart v. McDonough, 37 Vet. App. 371, 383-384 (2024). Furthermore, there are no other neurological impairments noted in the medical evidence of record other than the bilateral lower extremity radiculopathy, such as bowel or bladder dysfunction. As such, separate ratings for additional neurological impairments are not warranted at this time. The Board notes that the Veteran demonstrated painful lower back motion throughout the appeal period. Since the Veteran is already in receipt of at least 20 percent disability rating for the lower back disability based on limitation of range of motion and painful motion under diagnostic code 5243 throughout the appeal period, a separate compensable rating under 38 C.F.R. § 4.59 for painful motion would be inappropriate. See Esteban, 6 Vet. App. at 261-62; see also Lyles, 29 Vet. App. at 118 (holding that 38 C.F.R. § 4.14 prohibits paying compensation twice for the same symptoms or functional impairment). Thus, the Board finds that from March 2, 2014, forward flexion of the Veteran's thoracolumbar spine was limited to 30 degrees or less, or he had favorable ankylosis of the entire thoracolumbar spine. However, the evidence of record is persuasively weighs against the finding that the Veteran's service-connected lumbar spine disability was manifested by forward flexion of thoracolumbar spine limited to 30 degrees or less, or favorable ankylosis of the entire thoracolumbar spine prior to March 2, 2014; or had an incapacitating episode, or unfavorable ankylosis of the entire thoracolumbar spine throughout the rating period on appeal. 38 C.F.R. § 4.71a, General Rating Formula for Diseases and Injuries of the Spine. Accordingly, entitlement to a 40 percent disability rating from an earlier effective date of March 2, 2014, but not higher or earlier, for lumbosacral strain with DDD and IVDS is granted. 2. Entitlement to SMC based on the need for regular aid and attendance pursuant to 38 U.S.C. § 1114(l) is granted. In the August 2024 remand, the Board found that the issue of entitlement to SMC based on the need for regular aid and attendance had been raised as a part and parcel of the increased rating claim for the service-connected lumbar spine disability, and remanded this matter for RO to adjudicate the claim at first instance. Thereafter, in March 2025, the Board remanded the issue of entitlement to SMC again as part of increased rating claim for lumbar spine disability and because the RO had not completed the adjudication of the issue of entitlement to SMC. After completing the adjudication, the RO issued a December 2025 SSOC denying entitlement to SMC based on the need for regular aid and attendance, and returned this matter back to the Board for appellate review. For the following reasons, the Board finds that entitlement to SMC based on the need for regular aid and attendance is warranted. The Veteran contends that he requires the regular aid and attendance of another person due to his service-connected disabilities, specifically due to the service-connected lumbar spine disability and associated bilateral lower extremity radiculopathy. In particular, in a March 2014 statement, the Veteran's wife asserted that the Veteran's lower back condition had worsen severely, and he had trouble getting dressed. She has been helping him dress. He is unstable on feet and has fallen numerous times walking on level surfaces. Due to the Veteran's instability, he only bathes when wife can assist him. He cannot sleep more than 3 to 4 hours, and cannot lay/sit/stand for any length of time. He cannot lift anything over 5lbs, and nothing over his head. He cannot twist/bend at the waist and is in unbearable pain. The Board notes that the Veteran is already in receipt of a total disability rating based on individual unemployability (TDIU) due to his service connected disabilities with an effective date of April 18, 2013. Under 38 U.S.C. § 1114(s), SMC is warranted if a veteran has a service-connected disability rated as total, and (1) has additional service-connected disability or disabilities independently ratable at 60 percent or more, or, (2) by reason of such veteran's service-connected disability or disabilities, the veteran is permanently housebound. 38 U.S.C. § 1114(s). The requirement of "permanently housebound" will be considered to have been met when the veteran is substantially confined to such veteran's house (ward or clinical areas, if institutionalized) or immediate premises due to a service-connected disability or disabilities which it is reasonably certain will remain throughout such veteran's lifetime. Id; See Buie v. Shinseki, 24 Vet. App. 242, 250-51 (2011); 38 C.F.R. § 3.350(i). The total rating for the single disability for SMC purposes may be schedular, or may be based on a TDIU, so long as TDIU is warranted solely because of that single disability. The Veteran has the following service-connected disabilities: lumbosacral strain with DDD rated as 10 percent disabling from December 4, 1995, 20 percent from August 29, 2003, temporarily 100 percent disabling from April 2, 2004 to June 1, 2004, 20 percent disabling from June 1, 2004, and 40 percent disabling from March 2, 2014; radiculopathy of the left lower extremity affecting the sciatic nerve associated with lumbosacral strain with DDD rated as 10 percent disabling from October 25, 2010, and 20 percent disabling from October 16, 2015; radiculopathy of the right lower extremity affecting the sciatic nerve associated with lumbosacral strain with DDD rated as 10 percent disabling from October 25, 2010, and 20 percent disabling from November 14, 2018; radiculopathy of the left lower extremity affecting the femoral nerve associated with lumbosacral strain with DDD rated as 20 percent disabling from January 4, 2020; radiculopathy of the right lower extremity affecting the femoral nerve associated with lumbosacral strain with DDD rated as 20 percent disabling from January 4, 2020; tinea versicolor rated as 0 percent disabling from December 4, 1995, and 10 percent disabling from August 29, 2003; left hip strain with impairment of the thigh rated as 10 percent disabling from October 25, 2010; right hip strain with impairment of the thigh rated as 10 percent disabling from October 25, 2010; GERD including viral gastroenteritis associated with lumbosacral strain with DDD rated as 10 percent disabling from December 28, 2021; lumbar scar, s/p surgeries associated with lumbosacral strain with DDD rated as zero percent disabling from April 2, 2004; right hip strain with limitation of extension rated as zero percent disabling from October 25, 2010; left hip strain with limitation of extension rated as zero percent disabling from October 25, 2010; left hip strain with limitation of flexion rated as zero percent disabling from October 25, 2010; and right hip strain with limitation of flexion rated as zero percent disabling from October 25, 2010. The Veteran's combined schedular rating is 90 percent. In the April 2020 rating decision, the RO granted entitlement to a TDIU due to all of the Veteran's service-connected disabilities, and not based on a single disability. Even if a TDIU is solely granted based on the Veteran's lower back disability and associated bilateral lower extremity radiculopathy or other disabilities associated with lower back disability, the Veteran does not have additional service-connected disability or disabilities independently ratable at 60 percent or more. Thus, the Veteran does not meet the schedular criteria for SMC at the housebound rate. However, SMC based on the need for regular aid and attendance can still be granted, which is a greater benefit than SMC at the housebound rate. SMC at the aid and attendance rate ("SMC(l)") is payable when a veteran, due to a service-connected disability or disabilities, has suffered the anatomical loss or loss of use of both feet or one hand and one foot, or is blind in both eyes, or is permanently bedridden or with such significant disabilities as to be in need for regular aid and attendance of another person. 38 U.S.C. § 1114(l); 38 C.F.R. §§ 3.350(b), 3.351(c), 3.352(a). The criteria for determining that a claimant needs "regular aid and attendance" are contained in 38 C.F.R. § 3.352(a). Those criteria include: (1) Inability of the claimant to dress or undress him or herself or to keep him or herself ordinarily clean and presentable; (2) Frequent need of adjustment of any special prosthetic or orthopedic appliances which by reason of the particular disability cannot be done without assistance; (3) Inability of the claimant to feed him or herself through loss of coordination of upper extremities or through extreme weakness; (4) Inability to attend to the wants of nature; or (5) Incapacity, either physical or mental, that requires care or assistance on a regular basis to protect the claimant from hazards or dangers incident to his or her daily environment. 38 C.F.R. § 3.352(a). It is not required that all of the disabling conditions enumerated in the provisions of 38 C.F.R. § 3.352(a) be found to exist to establish eligibility for aid and attendance and that such eligibility required at least one of the enumerated factors be present. The particular personal function which a veteran was unable to perform should be considered in connection with his or her condition as a whole and that it was only necessary that the evidence establish that a veteran is so helpless as to need regular aid and attendance, not that there be a constant need. Turco v. Brown, 9 Vet. App. 222, 224 (1996). Being "bedridden" will also be a proper basis for finding that a veteran needs regular aid and attendance. 38 C.F.R. § 3.352(a). The term "bedridden" means a condition which, through its essential character, actually requires that the claimant remain in bed. Id. However, the fact that someone has voluntarily taken to bed or that a physician has prescribed rest in bed for the greater or lesser part of the day to promote convalescence or cure is not sufficient. Id. When, after careful consideration of all procurable and assembled data, a reasonable doubt arises regarding service origin, the degree of disability, or any other point, such doubt should be resolved in favor of the claimant. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. The Board has reviewed the relevant evidence of record. At the November 2018 Board hearing, the Veteran stated that he does not have lot of range of motion of lower back, and his wife puts his socks on in the morning because he has constant pain. He also reported that he has tingling and numbness in his legs, and his left leg has completely given out due to which he fell down. In a January 2025 VA opinion on SMC based on the need for regular aid and attendance, the VA examiner noted that the Veteran has poor balance and limited ability to perform self-care activities due to lumbar conditions affecting the spine's structural integrity, muscle strength, and flexibility. The examiner noted that the Veteran walks with stooped posture, and that he needs assistance with bathing due to instability and peripheral neuropathy in right and left lower extremity, causing numbness and limited mobility. In a February 2025 administrative review and memorandum, the RO requested the Executive Director of Compensation Service for advisory opinion; however, the RO recommended the grant of entitlement to SMC based on the need for aid and attendance. The RO noted that the Veteran does not have a single service connected disability which is totally disabling; however, entitlement to service connection is in effect for lumbosacral strain with DDD evaluated as 40 percent from June 20, 2018, left lower extremity sciatic radiculopathy evaluation as 20 percent from October 16, 2015, right lower extremity sciatic radiculopathy evaluated as 20 percent from November 14, 2018, left lower extremity femoral radiculopathy evaluated as 20 percent from January 4, 2020, right lower extremity femoral radiculopathy evaluated as 20 percent from January 4, 2020. It was noted that the service-connected disability related to the back and secondary radiculopathies is indeed severe. It was also noted that VA examiner noted that the Veteran experiences "poor balance and limited ability to perform self-care activities due to lumbar conditions affecting the spine's structural integrity, muscle strength, and flexibility, walking with stooped posture. Needing assistance with bathing due to instability and peripheral neuropathy in right and left lower extremity, causing numbness and limited mobili[t]y." The RO noted that the clinician, a nurse practitioner, is competent to provide this opinion that the Veteran requires aid and attendance due to service connected conditions. Therefore, the RO recommended that SMC based on the need for aid and attendance should be granted. In the March 2025 advisory opinion, the Executive Director Compensation Service stated that in February 2025, the RO submitted a memorandum requesting extraschedular consideration of Aid and Attendance. The Executive Director noted that the Veteran does not have a single service-connected disability evaluated as 100 percent disabling. The Veteran's combined evaluation is 90 percent. A single disability evaluated as 100-percent disabling under a schedular evaluation is generally a prerequisite for entitlement to aid and attendance and housebound benefits. Thus, the claim has been referred for an advisory opinion. VA Form 21-2680 dated January 13, 2025 notes a combination of the Veteran's back condition and resulting left and right lower radiculopathies which restrict functions. The claimant was not shown to be confined to bed. The examiner noted that the Veteran can feed himself, prepare his own meals, does not need assistance bathing or tending to other hygiene needs, is not legally blind, and does not require nursing home care. The examiner noted that the Veteran does require medication management. The examiner noted the Veteran has the mental capacity to manage his benefits. Examination showed stooped posture, with functional limitations due to stiffness and limited range of motion causing balance disturbance. There were no upper extremity restrictions noted. The Veteran was noted to walk with a cane. The examiner noted that the Veteran leaves his house once a week for shopping or doctor's appointments. Notably, the examiner stated in remarks that the Veteran had "poor balance and limited ability to perform self-care activities due to lumbar conditions affecting the spine's structural integrity, muscle strength, and flexibility, walking with stooped posture. Needing assistance with bathing due to instability and peripheral neuropathy in right and left lower extremity, causing numbness and limited mobility." After including the above noted criteria for determining that a claimant needs "regular aid and attendance" under 38 C.F.R. § 3.352(a), the Executive Director stated that after review of the available evidence, a finding of Aid and Attendance/Housebound is not supported, and such must be denied. While some of the medical evidence presented suggests that the Veteran's service-connected disabilities result in the inability to perform certain activities of daily living, mainly bathing, the evidence as a whole does not support a finding of such an exceptional disability picture as to render the schedular criteria for Aid and Attendance/Housebound impractical. Therefore, the executive directed concluded that entitlement to Aid and Attendance/Housebound on an extraschedular basis is denied. Thus, the Executive Director Compensation Service provided an opinion against the claim for SMC. However, based on the above noted evidence of record, including the January 2025 VA medical opinion on SMC, and after resolving reasonable doubt in favor of the Veteran, the Board finds that the Veteran requires regular aid and attendance of another person due to his service-connected disabilities, including the service-connected lumbar spine disability and associated bilateral lower extremity radiculopathy. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. Particularly, the Veteran's bilateral lower extremity radiculopathy is severe and has resulted in falls. Due to lower back disability, he cannot lift heavy objects and has difficulty bending over. His wife helps him in bathing and changing clothes and keeping him clean. The Veteran has been having issues with his balance due to his bilateral lower extremity radiculopathy. Thus, the Board finds that due to severe lower back disability and bilateral lower extremity radiculopathy, the Veteran has at least two factors to establish eligibility for aid and attendance as enumerated in 38 C.F.R. § 3.352(a), because the Veteran has inability to dress or undress him or to keep him ordinarily clean and presentable, and he has physical incapacity that requires care or assistance on a regular basis to protect the Veteran from hazards or dangers incident to his daily environment, which includes getting hurt from falls. (Continued on the next page) ? Thus, evidence of record establishes that the Veteran's condition as a whole necessitates regular aid and attendance, even though he might not need a constant aid and attendance. Turco, 9 Vet. App. at 224. Accordingly, entitlement to SMC based on the need for regular aid and attendance pursuant to 38 U.S.C. § 1114(l) is granted. MICHAEL MARTIN Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Nadeem Tariq, 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.