Citation Nr: 1600450 Decision Date: 01/06/16 Archive Date: 01/21/16 DOCKET NO. 09-32 556 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Winston-Salem, North Carolina THE ISSUE Entitlement to an initial disability rating (or evaluation) in excess of 10 percent for hypothyroidism. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL The Veteran (Appellant) ATTORNEY FOR THE BOARD B. J. Dempsey, Associate Counsel INTRODUCTION The Veteran, who is the appellant, served on active duty from May 1987 to May 2007. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a November 2007 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Winston-Salem, North Carolina, which granted service connection for hypothyroidism and assigned an initial 10 percent disability rating, effective June 1, 2007 (the day following service separation). In January 2010, the Veteran testified at a RO hearing held before a Decision Review Officer (DRO). A transcript of the hearing is associated with the record. In a February 2013 decision, the Board denied an initial disability rating in excess of 10 percent for hypothyroidism. The Veteran appealed the February 2013 decision on the issue of a higher initial rating for hypothyroidism to the United States Court of Appeals for Veterans Claims (Court). The Board's February 2013 decision was partially vacated pursuant to an August 2013 Joint Motion for Partial Remand (JMR) on the basis that a new VA compensation examination was warranted to assess the current severity of the hypothyroidism disability. In January 2014, the Board remanded the issue of entitlement to an initial disability rating in excess of 10 percent for hypothyroidism for another VA examination to help ascertain the current nature and severity of the service-connected hypothyroidism, and for subsequent readjudication of the appeal. After reviewing the ensuing March 2014 VA examination report, the Board remanded the matter again in September 2014 to attempt to obtain private treatment records related to the service-connected hypothyroidism. In an April 2015 decision, the Board denied an initial disability rating in excess of 10 percent for hypothyroidism. The Veteran appealed the April 2015 decision to the Court. Pursuant to a November 2015 JMR, the Court vacated and remanded the April 2015 Board decision. The November 2015 JMR instructed the Board to consider whether the hypothyroidism symptoms more nearly approximated the criteria for a higher rating pursuant to 38 C.F.R. § 4.7 (2015). The Board has reviewed the electronic files on "Virtual VA" and the Veterans Benefits Management System (VBMS) to ensure a complete review of the evidence in this case. FINDING OF FACT For the entire initial rating period from June 1, 2007, the service-connected hypothyroidism has been manifested by fatigability and required continuous medication for control. CONCLUSION OF LAW For the entire initial rating period from June 1, 2007, the criteria for an initial disability rating in excess of 10 percent for hypothyroidism have not been met or more nearly approximated. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1-4.7, 4.119, Diagnostic Code 7903 (2015). REASONS AND BASES FOR FINDING AND CONCLUSION Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA) enhanced VA's duties to notify and assist claimants in substantiating their claims for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2014); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2015). Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant and the representative of any information, and any medical or lay evidence, that is necessary to substantiate the claim. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b). As the appeal for a higher initial rating for hypothyroidism arises from disagreement with the initial rating following the grant of service connection, no additional notice is required. The United States Court of Appeals for the Federal Circuit (Federal Circuit) and the Court have held that, once service connection is granted, the claim is substantiated, additional notice is not required, and any defect in notice is not prejudicial. Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007); Dunlap v. Nicholson, 21 Vet. App. 112 (2007); 38 C.F.R. § 3.159(b)(3)(i) (no duty to provide VCAA notice upon receipt of a notice of disagreement); VAOPGCPREC 8-2003 (in which the VA General Counsel interpreted that separate notification is not required for "downstream" issues following a service connection grant, such as initial rating and effective date). The Board concludes that VA has satisfied its duties to assist the Veteran. VA has made reasonable efforts to obtain relevant records and evidence. Specifically, the information and evidence that has been associated with the claims file includes the Veteran's service treatment records, post-service VA and private treatment records, VA examination reports, the January 2010 DRO hearing transcript, and lay statements from the Veteran and his wife. VA most recently examined the service-connected hypothyroidism disability in March 2014. The March 2014 VA examiner interviewed the Veteran regarding past and present symptomatology, physically examined the Veteran, and provided clinical observations pertinent to the rating criteria. The March 2014 VA examiner indicated that the Veteran's primary care physician should evaluate the Veteran to provide an opinion on the underlying etiology of certain symptoms. VA obtained private medical records from the Veteran's private physicians and associated those treatment records with the claims file. An undated letter from the private physician treating the hypothyroidism was received by VA after the March 2014 VA examination and suggests an authorship date in 2013 or 2014 (noting "6-7 years of medical records" dating back to June 2007). The Board finds that the March 2014 VA examination report, when considered alongside the subsequently obtained private treatment records and private physician letter, is adequate to assist in determining the severity of the service-connected hypothyroidism, and that no further examination or opinion is needed. See Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). In light of the foregoing, the Board finds that VA has provided the Veteran with every opportunity to submit evidence and arguments in support of the claim, and to respond to VA notices. The Veteran and representative have not identified any outstanding evidence that needs to be obtained. For these reasons, the Board finds that VA has fulfilled the duties to notify and assist the Veteran. Disability Rating Criteria Disability ratings are determined by applying the criteria set forth in VA's Schedule for Rating Disabilities. The percentage ratings are based on the average impairment of earning capacity and individual disabilities are assigned separate diagnostic codes. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. In determining the disability rating, VA has a duty to acknowledge and consider all regulations that are potentially applicable through the assertions and issues raised in the record, and to explain the reasons and bases for its conclusions. Schafrath v. Derwinski, 1 Vet. App. 589, 594 (1991). If two ratings are potentially applicable, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that rating; otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. Any reasonable doubt regarding a degree of disability will be resolved in favor of the veteran. 38 C.F.R. § 4.3. The Court has indicated that a distinction must be made between a veteran's dissatisfaction with original ratings and dissatisfaction with determinations on later filed claims for increased ratings. Fenderson v. West, 12 Vet. App. 119, 125-26 (1999). In initial rating cases, separate ratings can be assigned for separate periods of time based on the facts found, a practice known as "staged" ratings. Id.; 38 C.F.R. § 4.2. In rendering a decision on appeal the Board must analyze the credibility and probative value of the evidence, account for the evidence which it finds to be persuasive or unpersuasive, and provide the reasons for its rejection of any material evidence favorable to the claimant. Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994); Gilbert v. Derwinski, 1 Vet. App. 49, 57 (1990). Competency of evidence differs from weight and credibility. Competency is a legal concept determining whether testimony may be heard and considered by the trier of fact, while credibility is a factual determination going to the probative value of the evidence to be made after the evidence has been admitted. Rucker v. Brown, 10 Vet. App. 67, 74 (1997); Layno v. Brown, 6 Vet. App. 465, 469 (1994); see also Cartright v. Derwinski, 2 Vet. App. 24, 25 (1991) ("although interest may affect the credibility of testimony, it does not affect competency to testify"). A veteran is competent to report symptoms because this requires only personal knowledge, not medical expertise, as it comes to him through his senses. See Layno, 6 Vet. App. 465. Lay testimony is competent to establish the presence of observable symptomatology, where the determination is not medical in nature and is capable of lay observation. Barr, 21 Vet. App. at 312. Lay evidence may establish a diagnosis of a simple medical condition, a contemporaneous medical diagnosis, or symptoms that later support a diagnosis by a medical professional. Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). A veteran as a lay person is competent to offer an opinion on a simple medical condition. Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009) (citing Jandreau, 492 F.3d at 1372). When all the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the claimant prevailing in either event, or whether a preponderance of the evidence is against the claim, in which case, the claim is denied. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102. Initial Rating for Hypothyroidism In November 2007, the RO granted service connection for hypothyroidism and assigned an initial 10 percent disability rating, effective June 1, 2007. The Veteran contends that an initial disability rating in excess of 10 percent is warranted based on symptoms including constipation, hair loss, fatigability, muscular aching and weakness, weight gain, emotional instability, and required use of medication to manage these symptoms. See, e.g., June 2014 Veteran letter. For the entire initial rating period from June 1, 2007, the service-connected hypothyroidism has been rated at 10 percent disabling under 38 C.F.R. § 4.119, Diagnostic Code 7903. Under Diagnostic Code 7903, a 10 percent disability rating is warranted for fatigability or continuous medication required for control. A 30 percent disability rating is warranted for fatigability, constipation, and mental sluggishness. A 60 percent disability rating is warranted for muscular weakness, mental disturbance, and weight gain. A 100 percent disability rating is warranted for cold intolerance, muscular weakness, cardiovascular involvement, mental disturbance (dementia, slowing of thought, depression), bradycardia (less than 60 heart beats per minute), and sleepiness. On review of all the evidence, lay and medical, the Board finds that, for the entire initial rating period from June 1, 2007, the service-connected hypothyroidism has been manifested by fatigability and required continuous medication for control. For the reasons discussed below, the Board finds that the hypothyroidism symptoms are consistent with a 10 percent disability rating and do not meet or more nearly approximate the criteria for a higher 30 percent initial disability rating under DC 7903. During the final in-service examination in February 2007, the service medical examiner noted current hypothyroidism that was under control and not considered disabling. Contemporaneous treatment records from October 2006 reflect that the hypothyroidism was being managed with a 100 microgram (mcg.) dose of Synthroid twice per day (for a total daily dose of 200 mcg.), which began as early as September 2004, but which was first prescribed at 100 mcg. per day in November 2003 for symptoms including constipation and fatigability. See August 2004 treatment record. The Veteran had been self-prescribing increases from 100 mcg. since the initial prescription in November 2003. In a contemporaneous February 2007 medical history report, the Veteran disclosed a history of hypothyroidism, but noted good control with Synthroid and denied any recent unexplained weight gain or loss, intestinal trouble, or frequent trouble sleeping. Similarly, the Veteran provided detailed explanations of current health trouble, but did not indicate symptoms such as weight gain, constipation, or fatigue. VA conducted a Compensation and Pension (C&P) examination in August 2007 for several claimed disorders including hypothyroidism. The Veteran provided a medical history significant for worsening of hypothyroidism symptoms over the previous nine months (approximately December 2006). Specifically, the Veteran reported gaining 25 pounds during that nine month period. The August 2007 VA examiner opined that the hypothyroidism may have been playing a small role in daytime fatigue and shortness of breath, and suspected that the hypothyroidism had only mild effects on the Veteran's endurance. VA, through QTC Medical Services, examined the hypothyroidism in September 2007. The September 2007 VA examination report indicates that the Veteran denied current symptoms, but that when active, symptoms included weight gain, emotional irritability, and memory loss. The September 2007 VA examiner stated that the Veteran used daily treatment with good results and no side effects. Upon physical examination, the September 2007 VA examiner noted no signs of physical malaise or eye symptoms indicative of active hypothyroidism. The September 2007 VA examiner also noted that thyroid function studies were within normal limits with the exception of minimal elevation of the T4 index, which was still in the upper limits of normal. Private treatment records from Dr. K. begin in December 2007 and reflect that the Veteran was prescribed a daily 200 mcg. dose of Synthroid, which had been prescribed for "a few years." The Veteran initially sought care from Dr. K. for back pain, but did not discuss any recent hypothyroidism disability symptoms. The initial December 2007 treatment record does not otherwise indicate any current hypothyroidism disability symptoms, and the Veteran's prescription level did not change. The private treatment records do not show any complaints relating to the hypothyroidism disability until October 2009, when the Veteran reported 60 pounds of weight gain over the "past couple of years." The daily dose of Synthroid was not changed and remains at 200 mcg. as of the July 2014 receipt of an undated letter from Dr. K. Follow-up from thyroid labs in October 2010 shows that the hypothyroidism disability was being well controlled by the current medication despite complaints of fatigue, insomnia, constipation, and weight gain. During the January 2010 DRO hearing, the Veteran testified that hypothyroidism was causing fatigue, poor memory, emotional instability, depression, slowing of thought, and depression. In February 2013, the Veteran's wife reported that the Veteran had symptoms of fatigue, uncontrolled weight gain, hair loss, and uncontrolled mood swings. VA examined the hypothyroidism again in March 2014. The Veteran reported that hypothyroidism was currently being managed with a daily 200 mcg. dose of Synthroid, which had been the dosage for two years. The March 2014 VA examiner indicated that the Veteran had current symptoms of fatigability, slowing of thought, and weight gain. The March 2014 VA examiner reported that thyroid lab results were normal and opined that it is less likely than not that fatigue, weight gain, and mental slowness are caused by the hypothyroidism. The March 2014 VA examiner further opined that there are likely other factors, such as sleep apnea, involved in the claimed fatigue, weight gain, and mental slowness. In an undated letter received by VA in July 2014, Dr. K. noted that the Veteran has occasionally run out of thyroid medication for a short period of time. During such times, the Veteran has reported experiencing lack of energy, emotional instability, memory loss, constipation, and gaining weight. When medication is resumed, the Veteran reported that the symptoms subside. Dr. K. provided this narrative illustrating a correlation between the appearance of certain symptoms and the lack of medication over short periods of time (noted to be as little as a week); however, Dr. K. did not directly attribute lack of energy, emotional instability, memory loss, constipation, or weight gain to the service-connected hypothyroidism. In sum, the evidence demonstrates that the Veteran has used a daily 200 mcg. dose of Synthroid to control hypothyroid symptoms since as early as September 2004. Lab results from October 2010 (Dr. K.) and March 2014 (VA examination) showed normal results, as interpreted by the medical examiners. The September 2007 VA examination report also reflects thyroid function studies within normal limits, with the exception of the free T4 reading which was on the high end of normal. The August 2007 VA examiner opined that the hypothyroidism may have been playing a small role in daytime fatigue and shortness of breath; however, neither the September 2007 VA examiner, the March 2014 VA examiner, nor Dr. K. have directly attributed any symptoms to the hypothyroid disability, and have generally indicated that any such symptoms have been controlled by the 200 mcg. Synthroid dose that has been prescribed since as early as September 2004. The Board has also considered the Veteran's self-reported hypothyroidism symptoms, as well as the statements of the Veteran's wife, made in various lay statements during the initial rating period from June 1, 2007. Both the Veteran and the Veteran's wife have attributed symptoms such as constipation, hair loss, muscular aching and weakness, weight gain, and emotional instability to hypothyroidism. The Veteran and his wife are competent to report symptoms such as constipation, hair loss, muscular aching and weakness, weight gain, and emotional instability, as each of these symptoms may be detected by the Veteran's own senses or his wife's observations and reports to her by the Veteran. See Layno, 6 Vet. App. 465. The Board finds, however, that neither the Veteran nor the Veteran's wife are competent to link any of these symptoms to hypothyroidism. See 38 C.F.R. § 3.159(a)(1); Clyburn v. West, 12 Vet. App. 296, 301 (1999) (medical evidence is not required to demonstrate chronic knee symptoms in service and continuity of symptoms after service; but a lay veteran is not competent to relate currently diagnosed chondromalacia patellae or degenerative joint disease to the continuous post-service knee symptoms); King v. Shinseki, 700 F.3d 1339, 1345 (Fed. Cir. 2009) (holding that it was not erroneous for the Board to find that a lay veteran claiming service connection for a back disorder and his wife lacked the "requisite medical training, expertise, or credentials needed to render a diagnosis" and that their testimony "could not establish medical causation nor was it a competent opinion as to medical causation"). In this case, attributing symptoms to a complex disease such as hypothyroidism requires detailed understanding of the thyroid gland and endocrine system, experience in identifying hypothyroidism symptoms, and the ability to identify and differentiate potential causes for symptoms such as constipation, hair loss, muscular aching and weakness, weight gain, and emotional instability, all of which may be affected by different factors and body systems. As neither the Veteran nor the Veteran's wife is shown to have such knowledge, experience, or ability, their statements relating symptoms such as constipation, hair loss, muscular aching and weakness, weight gain, and emotional instability to hypothyroidism are not afforded probative weight. The Board has also considered the Veteran's statements questioning the adequacy and accuracy of VA examinations. As to the September 2007 VA (QTC) examination, the Veteran has asserted that the September 2007 VA examiner did not accurately record the self-reported medical history. The Veteran has specifically denied reporting that hypothyroidism was in remission and, as proof, referenced the QTC medical questionnaire wherein he affirmed active hypothyroidism and reported constipation as a symptom. The Veteran also stated that he told the September 2007 VA examiner that he experienced mental sluggishness, difficulties in concentration, and anger issues due to difficulties in finding the appropriate dosage of medication to manage the hypothyroidism. See November 2008 VA Form 21-4138. Upon review of the September 2007 VA examination report, the Board notes that the September 2007 VA examiner specifically wrote that the history for hypothyroidism was obtained from the Veteran. The Board also observes that the medical history noted by the examiner is essentially consistent with other evidence of record. Specifically, the Veteran's service treatment records reflect that the Veteran began treatment for hypothyroidism in 2003 and was noted to be asymptomatic on 200 mcg. of Synthroid daily in July 2005. In September 2005, it was noted that the most recent lab results for hypothyroidism were within normal limits. At the time of the February 2007 service retirement examination, hypothyroidism was noted to be under good control with medication and the Veteran articulated no complaints of any symptomatology believed to be related to hypothyroidism, as stated above. At the August 2007 VA medical examination, the Veteran reported treatment with Synthroid 100 mcg. two tablets daily (200 mcg.) with no side effects. The service medical evidence, as well as the evidence shortly after service, indicates that hypothyroidism had existed since 2003 and was currently being controlled adequately with medication without any symptoms or side effects. As the noted medical history is consistent with other evidence of record and would not have been obtained by a source other than the Veteran, the Board does not find the Veteran's assertion that the September 2007 VA examiner misreported the symptomatology at the time of the medical examination to be credible. Although the Veteran reported having certain symptomatology on the September 2007 QTC questionnaire that he believed was attributable to hypothyroidism, the Board finds that the Veteran, in fact, provided a different account of the symptomatology believed to be experienced due to hypothyroidism at the September 2007 VA examination. There is no indication that the medical examination is not adequate despite the inconsistent statements from the Veteran regarding his experienced symptomatology (or lack thereof). Significantly, the September 2007 VA examiner based the conclusion that the Veteran's hypothyroidism was in remission on physical examination of the Veteran and laboratory findings, in addition to the Veteran's reported history. There were no objective findings to show current symptoms of hypothyroidism. Furthermore, the Board finds the September 2007 VA examination report, which was based on both subjective and objective factors and does not support the Veteran's assertion that he experienced current hypothyroidism symptomatology such as fatigue, constipation, and mental sluggishness/disturbance, to be more credible, so affords it far greater probative weight than the Veteran's inconsistent lay account regarding purported symptoms he believes are attributable to hypothyroidism. As discussed above, the Veteran and his wife, while competent to report his symptomatology, are not competent to attribute that symptomatology to the diagnosis of hypothyroidism. The Veteran's inconsistent accounts of hypothyroidism symptomatology undermine the credibility of such reported histories and symptoms that were made for compensation purposes. Furthermore, the Board notes that the May 2008 statement submitted from the treating medical provider (V.K., CNP) supports the currently assigned disability rating of 10 percent for hypothyroidism. While the private nurse noted that the Veteran's hypothyroidism was a lifelong health malady and will never be in remission, which appeared to contradict the September 2007 VA examiner's finding above to some degree, the nurse also wrote that the Veteran's hypothyroidism was "controlled by medication with biannual monitoring." As the currently assigned 10 percent rating already contemplates that continuous medication for hypothyroidism is needed for control, the private medical provider's statement provides further evidence against the appeal seeking a higher initial rating. At the DRO hearing, the Veteran indicated that he and his private medical provider were still trying to "nail down" the exact dosage to better manage symptoms and side effects associated with the hypothyroidism. See January 2010 DRO hearing transcript at 5. However, the August 2007 VA examination report and the September 2007 VA examination report both show that the Veteran denied having any side effects associated with the medication used to treat hypothyroidism at those times. While the Veteran has reported having current symptoms such as fatigue, constipation, mental sluggishness and/or disturbance, and weight gain that he believes are attributable to hypothyroidism, he has offered inconsistent statements regarding his experience of symptomatology, and the evidence submitted does not support a rating in excess of 10 percent. The Veteran's own treating medical provider (V.K., CNP) noted that the hypothyroidism was controlled with continuous medication and only required biannual monitoring without mention of any problems or symptoms attributable to hypothyroidism, despite acknowledging that the letter was submitted in response to the September 2007 VA examination report. It is likely that V.K., CNP, would have mentioned any problems that the Veteran was then suffering from hypothyroidism, particularly when providing a statement to contradict the findings of the September 2007 VA examiner. The fact that V.K., CNP, did not identify any symptoms related to hypothyroidism and only stated that it was controlled by medication is significant and weighs against the Veteran's assertions of having symptoms other than fatigability made pursuant to the appeal for a higher initial rating. For these reasons, the Board does not find the Veteran's hearing testimony alleging that hypothyroidism is not adequately controlled by medication to be credible. The Veteran most recently asserted that the March 2014 VA examiner mischaracterized the self-reported medical history. See June 2014 letter. Specifically, the Veteran asserts that the March 2014 VA examiner either misunderstood or misinterpreted how often the Veteran has failed to take the prescribed daily hypothyroidism medication. The Veteran did not point out, however, that the March 2014 VA examiner clearly noted that the basis for the medical opinion was normal thyroid labs despite current complaints of fatigability, slowing of thought, and weight gain, which suggests that those symptoms were not present due to abnormal thyroid levels. The March 2014 VA examiner also noted that medication had generally been consistently taken over the previous two years. In sum, the evidence demonstrates that, for the entire initial rating period from June 1, 2007, the service-connected hypothyroidism has been controlled by daily medication, with the possible exception of mild fatigability, as suggested by the August 2007 VA examiner. As the August 2007 VA examiner opined that hypothyroidism might be playing a "small role" in fatigue, the Board resolves reasonable doubt in the Veteran's favor to find that fatigability is a symptom of hypothyroidism. While symptoms such as constipation, hair loss, muscular aching and weakness, weight gain, and emotional instability have appeared at times during the initial rating period, the evidence does not demonstrate that these symptoms have been constant or resulted in changes to the hypothyroidism medication dosage during the initial rating period from June 1, 2007. In addition, the evidence does not include any competent medical evidence linking the symptoms of constipation, hair loss, muscular aching and weakness, weight gain, and emotional instability to the service-connected hypothyroidism. In consideration of the foregoing, the Board finds that the manifestations of the Veteran's hypothyroidism do not meet or more nearly approximate the schedular criteria for a higher initial rating of 30 percent under Diagnostic Code 7903. The most credible and probative evidence shows that the hypothyroidism is controlled with continuous medication throughout the rating period from June 1, 2007, which is contemplated in the 10 percent schedular rating. With regard to the August 2007 VA examiner's opinion that fatigability may persist in the face of continuous medication, fatigability is a symptom consistent with a 10 percent disability rating. In order for fatigability to warrant a 30 percent disability rating, the hypothyroidism disability must also manifest additional symptoms like or similar to "constipation and mental sluggishness," which is not shown in this case. 38 C.F.R. § 4.119, Diagnostic Code 7903. The assertion by the Veteran and his wife that he experiences symptoms such as constipation, mental sluggishness/disturbance, and weight gain due to hypothyroidism is inconsistent with other, more credible evidence of record, to include the statements made by the Veteran at the time of the service retirement examination. For these reasons, the Board finds that, for the entire initial rating period from June 1, 2007, the service-connected hypothyroidism disability symptoms do not meet or more nearly approximate the criteria for a higher initial disability rating of 30 percent. The Board finds that the weight of the evidence is against the assignment of a higher initial rating for hypothyroidism on a schedular basis. 38 C.F.R. §§ 4.3, 4.7. Extraschedular Consideration The Board has considered whether referral for extraschedular consideration is warranted. An extraschedular disability rating is warranted based upon a finding that the case presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization that would render impractical the application of the regular schedular standards. 38 C.F.R. § 3.321(b)(1) (2015); see Fanning v. Brown, 4 Vet. App. 225, 229 (1993). Under Thun v. Peake, 22 Vet App 111 (2008), there is a three-step inquiry for determining whether a veteran is entitled to an extraschedular rating. First, the Board must determine whether the evidence presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. Second, if the schedular evaluation does not contemplate the claimant's level of disability and symptomatology and is found inadequate, the Board must determine whether the claimant's disability picture exhibits other related factors such as those provided by the regulation as "governing norms." Third, if the rating schedule is inadequate to evaluate a veteran's disability picture and that picture has attendant thereto related factors such as marked interference with employment or frequent periods of hospitalization, then the case must be referred to the VA Under Secretary for Benefits or the Director of the Compensation and Pension Service to determine whether the veteran's disability picture requires the assignment of an extraschedular rating. Turning to the first step of the extraschedular analysis, the Board finds that all the symptomatology and impairment caused by the service-connected hypothyroidism disability are specifically contemplated by the schedular rating criteria, and no referral for extraschedular consideration is required. As stated above, the Veteran's hypothyroidism is controlled by continuous medication. The 10 percent rating under Diagnostic Code 7903 specifically considers hypothyroidism that requires continuous medication for control and manifests fatigability; therefore, the Board finds that manifestations of the Veteran's disability are fully contemplated in the currently assigned 10 percent rating under Diagnostic Code 7903. For these reasons, the Board finds that the schedular criteria are not inadequate to rate the Veteran's hypothyroidism, and referral for consideration of extraschedular rating is not necessary. Under Johnson v. McDonald, 762 F.3d 1362 (Fed. Cir. 2014), a veteran may be awarded an extraschedular rating based upon the combined effect of multiple conditions in an exceptional circumstance where the rating of the individual conditions fails to capture all the service-connected disabilities experienced; however, in case, neither has the Veteran asserted, nor has the evidence of record suggested, any such combined effect of multiple service-connected disabilities to create such an exceptional circumstance. The other service-connected disabilities in this case are obstructive sleep apnea, bilateral clavicle degenerative joint disease, bilateral knee degenerative joint disease, gastroesophageal reflux disease, lumbar spine degenerative disc disease, bilateral restless leg syndrome, traumatic cataract right eye, iridodialysis left eye, right foot status post ganglion cyst removal, and residual contracture status post-operative repair right fifth digit. For these reasons, the Board finds that the schedular rating criteria are adequate to rate the service-connected hypothyroidism, and referral for consideration of extraschedular rating is not required. The schedule is intended to compensate for average impairments in earning capacity resulting from service-connected disability in civil occupations. 38 U.S.C.A. § 1155. "Generally, the degrees of disability specified [in the rating schedule] are considered adequate to compensate for considerable loss of working time from exacerbations or illnesses proportionate to the severity of the several grades of disability." 38 C.F.R. § 4.1 (2015). In this case, the problems reported by the Veteran are specifically contemplated by the criteria discussed above, including the effects on daily life. In the absence of exceptional factors associated with the hypothyroidism, the Board finds that the criteria for submission for assignment of an extraschedular rating pursuant to 38 C.F.R. § 3.321(b)(1) are not met. See Bagwell v. Brown, 9 Vet. App. 337 (1996); Shipwash v. Brown, 8 Vet. App. 218, 227 (1995). Moreover, the Board has considered whether the issue of entitlement to a total disability rating based on individual unemployability due to service-connected disabilities (TDIU) was reasonably raised by the record in this case. In this case, neither the Veteran nor the evidence suggests unemployability due to service-connected disability. Rice v. Shinseki, 22 Vet. App. 447 (2009). The Veteran has not asserted that he was totally unemployable as the result of the service-connected hypothyroidism, and the evidence indicates that the Veteran has continued to work full-time during the pendency of the appeal. Accordingly, the Board concludes that a claim for entitlement to a TDIU has not been raised by the record. ORDER For the entire initial rating period from June 1, 2007, an initial disability rating in excess of 10 percent for hypothyroidism is denied. ____________________________________________ J. PARKER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs