Citation Nr: 1301282 Decision Date: 01/11/13 Archive Date: 01/16/13 DOCKET NO. 09-45 074 ) DATE ) ) On appeal from the Department of Veterans Affairs (VA) Regional Office (RO) in New York, New York THE ISSUES 1. Entitlement to an increased disability rating for a lumbar strain, currently rated as 20 percent disabling. 2. Entitlement to an increased disability rating for radiculopathy of the right lower extremity (previously rated as lumbosacral strain with radiculopathy), currently rated as 20 percent disabling. 3. Entitlement to an increased disability rating for radiculopathy of the left lower extremity (previously rated as lumbosacral strain with radiculopathy), currently rated as 20 percent disabling. 4. Entitlement to an increased disability rating for bilateral hearing loss. 5. Entitlement to an increased disability rating for a pilonidal cyst with residual scar, status post removal of pilonidal cyst. 6. Entitlement to a total disability rating based on individual unemployability (TDIU). REPRESENTATION Veteran represented by: New York State Division of Veterans' Affairs ATTORNEY FOR THE BOARD L. Durham, Counsel INTRODUCTION The Veteran served on active duty from August 1971 to August 1975. These matters come before the Board of Veterans' Appeals (Board) on appeal from a December 2008 rating decision issued by the VA RO in New York, New York, which continued a 40 percent disability rating for a lumbar strain with radiculopathy, continued a noncompensable evaluation for bilateral hearing loss, continued a noncompensable evaluation for a pilonidal cyst, and denied entitlement to TDIU. Pursuant to his request, the Veteran was scheduled to appear at a hearing before the Board, sitting at the RO, in April 2011. Prior to its occurrence, however, the Veteran cancelled his request for a Board hearing in writing. No other request for a hearing remains pending in this case. These issues were remanded by the Board for further development July 2011. The Board notes that the issue of entitlement to an increased rating for service-connected lumbar strain was previously characterized as entitlement to a rating in excess of 40 percent for a lumbar strain with radiculopathy. However, in an August 2012 supplemental statement of the case (SSOC), the RO recharacterized this issue, as of July 30, 2010, as entitlement to an evaluation in excess of 20 percent for a lumbar strain, entitlement to an evaluation in excess of 20 percent for radiculopathy of the right lower extremity, and entitlement to an evaluation in excess of 20 percent for radiculopathy of the left lower extremity. As such, the Board has recharacterized these issues accordingly in this determination. In so doing, however, the Board will consider the greatest potential benefit available to the Veteran based upon that recharacterization for the entire rating period under appeal, and not just that period from July 30, 2010. Additionally, in an October 2012 rating decision, the RO granted entitlement to service connection for residual scar, status post removal of pilonidal cyst, and assigned an evaluation of 10 percent, effective August 22, 2011. The Board notes that the Veteran did not appeal this rating decision to the Board. However, the Board finds that the rating of the residual scar associated with the Veteran's pilonidal cyst is inextricably intertwined with the rating of the pilonidal cyst, as both disabilities are rated under the diagnostic criteria for evaluating disabilities of skin due to the fact that the pilonidal cyst has been removed and the residual scar is the disability actually being evaluated. Therefore, the Board has recharacterized the disability on appeal as a pilonidal cyst with residual scar, status post removal of pilonidal cyst. In so doing, however, the Board will consider the greatest potential benefit available to the Veteran based upon that recharacterization for the entire rating period under appeal, and not just that period from August 22, 2011. The Board notes that the Veteran's representative did not submit argument in the form of a Statement of Accredited Representative in Appealed Case after the July 2011 remand. However, in an August 28, 2012, letter attached to the most recent SSOC, the Veteran and his representative were advised that he had 30 days from the date of this letter to respond. As 30 days have since passed, the Board will proceed to the merits of the claims. In an August 2012 statement, the Appeals Management Center (AMC) noted the Veteran's contention that he has developed a shoulder disability as a result of his service-connected lumbar strain and right and left lower extremity radiculopathy disabilities. This issue has not been adjudicated and is referred to the RO for appropriate action, to include its initial adjudication. The issue of entitlement to TDIU is addressed in the REMAND portion of the decision below and is REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. FINDINGS OF FACT 1. The Veteran's service-connected lumbar strain is manifested by complaints of pain, stiffness, weakness, spasm, and limitation of motion, with no evidence of ankylosis of any kind, or limitation of flexion to 30 degrees or less, or incapacitating episodes due to the lumbar spine disability. 2. The Veteran's service-connected radiculopathy of the right lower extremity is manifested by no more than complaints of numbness, tingling, and pain. 3. The Veteran's service-connected radiculopathy of the left lower extremity is manifested by no more than complaints of numbness, tingling, and pain. 4. The Veteran's bilateral hearing loss disability is manifested by no more than a Level I hearing acuity bilaterally. 5. The Veteran's service-connected pilonidal cyst with residual scar, status post removal of pilonidal cyst is manifested by no more than complaints of pain, tenderness, and aching. CONCLUSIONS OF LAW 1. For the period of December 28, 2007, to July 29, 2010, the criteria for a disability rating of 20 percent, but no more, for service-connected lumbar strain have been met. See 38 U.S.C.A. §§ 1155, 5102, 5103, 5103A, 5107 (West 2002 & Supp. 2009); 38 C.F.R. §§ 3.159, 3.321, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5237 (2012). 2. For the period of July 30, 2010, to the present, the criteria for a disability rating in excess of 20 percent for service-connected lumbar strain have not been met or approximated. See 38 U.S.C.A. §§ 1155, 5102, 5103, 5103A, 5107 (West 2002 & Supp. 2009); 38 C.F.R. §§ 3.159, 3.321, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5237 (2012). 3. For the period of December 28, 2007, to July 29, 2010, the criteria for a disability rating of 20 percent, but no more, for service-connected radiculopathy of the right lower extremity have been met. See 38 U.S.C.A. §§ 1155, 5102, 5103, 5103A, 5107 (West 2002 & Supp. 2009); 38 C.F.R. §§ 3.159, 3.321, 4.124a, Diagnostic Code 8720 (2012). 4. For the period of July 30, 2010, to the present, the criteria for a disability rating in excess of 20 percent for service-connected radiculopathy of the right lower extremity have not been met or approximated. See 38 U.S.C.A. §§ 1155, 5102, 5103, 5103A, 5107 (West 2002 & Supp. 2009); 38 C.F.R. §§ 3.159, 3.321, 4.124a, Diagnostic Code 8720 (2012). 5. For the period of December 28, 2007, to July 29, 2010, the criteria for a disability rating of 20 percent, but no more, for service-connected radiculopathy of the left lower extremity have been met. See 38 U.S.C.A. §§ 1155, 5102, 5103, 5103A, 5107 (West 2002 & Supp. 2009); 38 C.F.R. §§ 3.159, 3.321, 4.124a, Diagnostic Code 8720 (2012). 6. For the period of July 30, 2010, to the present, the criteria for a disability rating in excess of 20 percent for service-connected radiculopathy of the left lower extremity have not been met or approximated. See 38 U.S.C.A. §§ 1155, 5102, 5103, 5103A, 5107 (West 2002 & Supp. 2009); 38 C.F.R. §§ 3.159, 3.321, 4.124a, Diagnostic Code 8720 (2012). 7. The criteria for a compensable evaluation for service-connected bilateral hearing loss have not been met or approximated. See 38 U.S.C.A. § 1155, 5102, 5103, 5103A, 5107 (West 2002 & Supp. 2009); 38 C.F.R. §§ 3.159, 3.321, 4.85, 4.86 (2012). 8. For the period of December 28, 2007, to August 21, 2011, the criteria for a disability rating of 10 percent, but no higher, for a pilonidal cyst with residual scar, status post removal of pilonidal cyst have been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2009); 38 C.F.R. §§ 3.159, 3.321, 4.118, Diagnostic Codes 7804, 7805 (2008, 2012). 9. For the period of August 22, 2011, to the present, the criteria for a disability rating in excess of 10 percent for a pilonidal cyst with residual scar, status post removal of pilonidal cyst have not been met or approximated. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2009); 38 C.F.R. §§ 3.159, 3.321, 4.118, Diagnostic Codes 7804, 7805 (2008, 2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Veterans Claims Assistance Act of 2000 (VCAA) With respect to the Veteran's claims, VA has met all statutory and regulatory notice and duty to assist provisions. See 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126 (West 2002 & Supp. 2009); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326 (2012). Under the VCAA, when VA receives a complete or substantially complete application for benefits, it is required to notify the claimant and his or her representative, if any, of any information and medical or lay evidence that is necessary to substantiate the claim. 38 U.S.C.A. § 5103(a) (West 2002); 38 C.F.R. § 3.159(b) (2012); Quartuccio v. Principi, 16 Vet. App. 183 (2002). In Pelegrini v. Principi, 18 Vet. App. 112, 120-21 (2004) (Pelegrini II), the United States Court of Appeals for Veterans Claims (Court) held that VA must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. VCAA letters dated in March 2008, April 2009, and July 2009 fully satisfied the duty to notify provisions. See 38 U.S.C.A. § 5103(a) (West 2002 & Supp. 2009); 38 C.F.R. § 3.159(b)(1) (2012); Quartuccio, at 187. The Veteran was aware that it was ultimately his responsibility to give VA any evidence pertaining to the claims. These letters informed him that additional information or evidence was needed to support his claims, and asked him to send the information or evidence to VA. See Pelegrini II, at 120-121. Additionally, these letters described how appropriate disability ratings and effective dates were assigned. The Board also concludes VA's duty to assist has been satisfied. The Veteran's available service treatment records and relevant VA and private medical records are in the file. The Board finds that all available records identified by the Veteran as relating to these claims have been obtained, to the extent possible. The record contains sufficient evidence to make a decision on the claims. VA has fulfilled its duty to assist. With respect to claims for increased ratings, the duty to assist includes, when appropriate, the duty to conduct a thorough and contemporaneous examination of the Veteran. See Green v. Derwinski, 1 Vet. App. 121 (1991). In addition, where the evidence of record does not reflect the current state of the Veteran's disability, a VA examination must be conducted. See Schafrath v. Derwinski, 1 Vet. App. 589 (1991); 38 C.F.R. § 3.327(a) (2012). The RO provided the Veteran with examinations for his hearing loss claim most recently in August 2011 and September 2011. The RO provided the Veteran with examinations for his pilonidal cyst claim and his lumbar spine with radiculopathy claims most recently in August 2011. There is no objective evidence indicating that there has been a material change in the severity of these service-connected disabilities since he was last examined. See 38 C.F.R. § 3.327(a) (2012). The duty to assist does not require that a claim be remanded solely because of the passage of time since an otherwise adequate examination was conducted. See VAOPGCPREC 11-95. The examiners reviewed the claims files, conducted the appropriate diagnostic tests and studies, and considered the Veteran's assertions. The Board finds these examination reports to be thorough and consistent with contemporaneous medical records. Thus, the Board concludes that the examinations in this case are adequate upon which to base a decision with regard to these claims. As there is no indication that any failure on the part of VA to provide additional notice or assistance reasonably affects the outcome of this case, the Board finds that any such failure is harmless. See Mayfield v. Nicholson, 19 Vet. App. 103 (2005), rev'd on other grounds, Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). II. Analysis The Board must assess the credibility and weight of all evidence, including the medical evidence, to determine its probative value, accounting for evidence which it finds to be persuasive or unpersuasive, and providing reasons for rejecting any evidence favorable to the claimant. Equal weight is not accorded to each piece of evidence contained in the record; every item of evidence does not have the same probative value. When all the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the Veteran prevailing in either event, or whether a preponderance of the evidence is against the claim, in which case, the claim is denied. See Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Disability evaluations are determined by evaluating the extent to which a Veteran's service-connected disability adversely affects his or her ability to function under the ordinary conditions of daily life, including employment, by comparing his or her symptomatology with the criteria set forth in the Schedule for Rating Disabilities. The percentage ratings represent as far as can practicably be determined the average impairment in earning capacity resulting from such diseases and injuries and the residual conditions in civilian occupations. Generally, the degree of disabilities specified are considered adequate to compensate for considerable loss of working time from exacerbation or illness proportionate to the severity of the several grades of disability. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. § 4.1 (2012). Separate diagnostic codes identify the various disabilities and the criteria for specific ratings. If two disability evaluations are potentially applicable, the higher evaluation will be assigned to the disability picture that more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7 (2012). Any reasonable doubt regarding the degree of disability will be resolved in favor of the Veteran. 38 C.F.R. § 4.3 (2012). The Veteran's entire history is reviewed when making a disability determination. See 38 C.F.R. § 4.1 (2012). Where the Veteran timely appealed the rating initially assigned for the service-connected disability within one year of the notice of the establishment of service connection for it, VA must consider whether the Veteran is entitled to "staged" ratings to compensate him for times since filing his claim when his disability may have been more severe than at other times during the course of his appeal. See Fenderson v. West, 12 Vet. App. 119 (1999). But where service connection has already been established, and increase in the disability rating is at issue, it is the present level of the disability that is of primary concern. See Francisco v. Brown, 7 Vet. App. 55 (1994). However, in such cases, when the factual findings show distinct time periods during which a claimant exhibits symptoms of the disability at issue and such symptoms warrant different evaluations, staged evaluations may also be assigned. Hart v. Mansfield, 21 Vet. App. 505 (2007). The evaluation of the same disability under various diagnoses, known as pyramiding, is generally to be avoided. 38 C.F.R. § 4.14 (2012). The critical element in permitting the assignment of several ratings under various diagnostic codes is that none of the symptomatology for any one of the disabilities is duplicative or overlapping with the symptomatology of the other disability. See Esteban v. Brown, 6 Vet. App. 259, 261- 62 (1994). 1. Entitlement to increased disability ratings for a lumbar strain and radiculopathy of the right and the left lower extremities. In a December 2008 rating decision, the RO continued a 40 percent evaluation for service-connected lumbosacral strain with radiculopathy under Diagnostic Code 5237. In an August 2012 SSOC, the RO assigned a 20 percent evaluation, effective July 30, 2010, for the Veteran's service-connected lumbosacral strain under Diagnostic Code 5237 and separate 20 percent evaluations, effective July 30, 2010, for radiculopathy of the right and the left lower extremities under Diagnostic Code 8720. The Veteran is seeking higher ratings. As an initial matter, the Board notes that the assignment of a particular diagnostic code is "completely dependent on the facts of a particular case." See Butts v. Brown, 5 Vet. App. 532, 538 (1993). One diagnostic code may be more appropriate than another based on such factors as an individual's relevant medical history, the diagnosis and demonstrated symptomatology. Any change in a diagnostic code by a VA adjudicator must be specifically explained. See Pernorio v. Derwinski, 2 Vet. App. 625, 629 (1992). Furthermore, while service-connected disabilities and ratings in effect for 20 years or more are protected, and ratings in effect for shorter periods are also afforded some protections against reduction, the selection of diagnostic codes or applicable rating criteria are not protected and may be appropriately revised if the action does not result in the reduction of compensation payments. See 38 C.F.R. §§ 3.951, 3.957 (2006); See Butts, 5 Vet. App. 532; VAOPGCPREC 71-91 (Nov. 7, 1991). The Board notes that, in this case, as the assignment of a 20 percent evaluation for the Veteran's lumbosacral strain under Diagnostic Code 5237 and separate 20 percent evaluations for radiculopathy of the right and the left lower extremities under Diagnostic Code 8720 results in a total higher evaluation than the Veteran's previously assigned 40 percent rating for lumbosacral strain with radiculopathy, the recharacterization of this issue did not result in any overall reduction. The schedule for rating spine disabilities was changed, effective September 26, 2003, to provide for the evaluation of all spine disabilities under a new General Rating Formula for Diseases and Injuries of the Spine, unless the disability is rated under the Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes (renumbered as Diagnostic Code 5243). Diagnostic codes for all diseases and injuries to the spine were renumbered. As the Veteran's claim was received on December 28, 2007, only the current rating formula must be considered and any regulation changes made prior to the September 26, 2003, changes are irrelevant for the purposes of this claim. Under the current General Rating Formula for Diseases and Injuries of the Spine, a 10 percent rating is for application with forward flexion of the thoracolumbar spine greater than 60 degrees but not greater than 85 degrees; or, forward flexion of the cervical spine greater than 30 degrees but not greater than 40 degrees; or, combined range of motion of the thoracolumbar spine greater than 120 degrees but not greater than 235 degrees; or combined range of motion of the cervical spine greater than 170 degrees but not greater than 335 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. A 20 percent rating is warranted for forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees; or, forward flexion of the cervical spine greater than 15 degrees but not greater than 30 degrees; or combined range of motion of the thoracolumbar spine not greater than 120 degrees; or, combined range of motion of the cervical spine not greater than 170 degrees; or muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. A 30 percent evaluation is assigned for forward flexion of the cervical spine at 15 degrees or less; or favorable ankylosis of the entire cervical spine. A 40 percent evaluation is warranted for unfavorable ankylosis of the entire cervical spine; or, forward flexion of the thoracolumbar spine of 30 degrees or less; or, favorable ankylosis of the entire thoracolumbar spine. A 50 percent evaluation is warranted for unfavorable ankylosis of the entire thoracolumbar spine. A 100 percent evaluation is warranted for unfavorable ankylosis of the entire spine. 38 C.F.R. § 4.71a, Diagnostic Codes 5235 to 5243 (2012). For VA compensation purposes, normal forward flexion of the lumbar spine is 0 to 90 degrees, extension is 0 to 30 degrees, left and right lateral flexion are 0 to 30 degrees, and left and right lateral rotation are 0 to 30 degrees. 38 C.F.R. § 4.71a, Diagnostic Codes 5235 to 5243, Note (2) (2012). 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. Id. The normal combined range of motion of the thoracolumbar spine is 240 degrees. Id. The normal ranges of motion for each component of spinal motion provided in this note are the maximum that can be used for calculation of the combined range of motion. Id. Under Note (1), any associated objective neurologic abnormalities, including, but not limited to, bowel or bladder impairment, must be evaluated separately under the appropriate diagnostic code. Under the Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes, a 10 percent evaluation is assigned for intervertebral disc syndrome with incapacitating episodes having a total duration of at least 1 week but less than 2 weeks during the past 12 months; a 20 percent evaluation is assigned for incapacitating episodes having a total duration of at least 2 weeks but less than 4 weeks during the past 12 months; a 40 percent evaluation is assigned with incapacitating episodes having a total duration of at least 4 weeks but less than 6 weeks during the past 12 months; and a 60 percent evaluation is assigned with incapacitating episodes having a total duration of at least 6 weeks during the past 12 months. 38 C.F.R. § 4.71a, Diagnostic Code 5243 (2012). For purposes of evaluations under the Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes, 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. at Note (1). If intervertebral disc syndrome is present in more than one spinal segment, provided that the effects in each spinal segment are clearly distinct, evaluate each segment on the basis of incapacitating episodes or under the General Rating Formula for Diseases and Injuries of the Spine, whichever method results in a higher evaluation for that segment. Id. at Note (2). When evaluating disabilities of the musculoskeletal system, 38 C.F.R. § 4.40 allows for consideration of functional loss due to pain and weakness causing additional disability beyond that reflected on range of motion measurements. See DeLuca v. Brown, 8 Vet. App. 202 (1995). Further, 38 C.F.R. § 4.45 provides that consideration also be given to weakened movement, excess fatigability and incoordination. The Board notes that the Veteran underwent a VA examination in April 2008. The Veteran reported an ache in the central lumbosacral area on a constant basis and an aching numbness on the left posterior leg to the heel. He reported that both his back and left leg symptoms have been constant for the last 3 or 4 years. The Veteran reported no incapacitating episodes in the last 12 months. He retired from the U.S. Customs in 1998 on disability retirement, which was mainly because of his heart. However, he was put in a desk job, and he could not handle that because of his low back. Inspection of the spine revealed normal symmetry. There was tenderness over the lower lumbar midline but not at any other spinal level. There was no soft tissue, spasm, or tenderness in the cervical, thoracic, or lumbar areas. Straight leg raising induced low back pain at 20 degrees bilaterally with more severe pain on the left than the right. He had a slow antalgic gait without his cane in the examination room, favoring his left lower extremity. Range of motion of the lumbar spine was recorded at 60 degrees of flexion, 25 degrees of left and right lateral flexion, 10 degrees of extension, and 40 degrees of left and right rotation. He complained of discomfort at the extremes of each of these movements, and no change with repetitive examination. Deep tendon reflexes were all 2+ diffusely. Motor examination revealed 4.5/5 weakness in all muscle groups of the left lower extremity and normal strength in the right lower extremity. He reported decreased strength to pinprick mildly in the left lateral thigh and the left posterior and medial calf compared to the right. The Veteran was diagnosed with lumbar spine degenerative disc disease. The examiner noted that, because of his service-connected condition of lumbar degenerative disc disease, the Veteran would be limited to sedentary work and very light activity. The Board notes that the Veteran underwent a VA examination most recently in August 2011. The examiner reviewed the claims file. The Veteran reported constant lumbar spine pain. The Veteran denied a history of fatigue. The Veteran reported a history of decreased motion, stiffness, weakness, spasm, and spine pain which radiated into his legs. The Veteran used a cane and a brace and was unable to walk more than a few yards. His posture, gait, and head position were normal, and he had symmetry in appearance of the spine. He had no gibbus, kyphosis, lumbar lordosis, lumbar flattening, reverse lordosis, list, scoliosis, or lumbar spine ankylosis. The examiner noted no weakness, tenderness, pain with motion, guarding, atrophy, or spasms bilaterally with regard to the lumbar sacrospinalis. With regard to range of motion, the Veteran's flexion was recorded at 0 to 45 degrees, extension at 0 to 15 degrees, left lateral flexion at 0 to 20 degrees, right lateral flexion at 0 to 20 degrees, left lateral rotation at 0 to 20 degrees, and right lateral rotation at 0 to 20 degrees. The examiner noted that there was objective evidence of pain on active range of motion or following repetitive motion. There were no additional limitations after 3 repetitions of range of motion. Reflex examination findings were noted as normal bilaterally with the exception of the right ankle jerk, which was noted as absent. Sensory findings were noted as normal with regard to the bilateral lower extremities as to vibration, position sense, pain or pinprick, and light touch. Additionally, there was no dysesthesias noted. Motor examination revealed that the Veteran had active movement against full resistance bilaterally as to hip flexion and hip tension. The Veteran had active movement against some resistance as to knee flexion, knee extension, ankle dorsiflexion, ankle plantar flexion, and great toe extension. Muscle tone was normal, and there was no muscle atrophy. The Board also reviewed relevant private and VA treatment records. In a March 2007 private treatment record from Great North Woods Medical, the Veteran was noted as having chronic back pain with sciatica. In an April 2008 private treatment record from this facility, it was noted that the Veteran was 100 percent disabled from his job with Customs due to his back pain. It was noted that he had severe left leg discomfort with radicular quality. In a separate April 2008 letter from this facility, it was noted that the Veteran always has severe left leg pain, representing a radiculopathy. In a July 2008 private treatment record from this facility, the Veteran complained of an exacerbation of chronic back pain with left radiculopathy a few days prior to his stent placement. He had to resort to using a walker and a cane but was noted at this time as being now down to just the cane occasionally. The exacerbation caused a bilateral radiculopathy but that resolved and he was noted as currently just having his usual left leg symptoms of paresthesias, weakness, and pain. In a July 30, 2010, VA treatment record, the Veteran complained of bilateral leg weakness and restless legs that were symptomatic mainly at night. The Veteran reported that his symptoms began 3 years ago but had progressed over the last 2 years. He reported tingling and numbness that radiated from his back along his medial legs to his toes. In a November 2010 VA treatment record, the Veteran complained of lower back pain and bilateral leg weakness, with the left greater than the right. It was noted that motor strength was limited in the bilateral lower extremities secondary to pain, roughly 5 out of 5 but it gave way secondary to pain. Sensation was grossly intact to light touch and pinprick. Deep tendon reflexes were 2+ throughout. In a December 2010 VA treatment record, range of motion of the lumbar spine was recorded as a flexion of 40 degrees, an extension of 5 degrees, lateral bending of 10 degrees, and rotation of 30 degrees. In an August 2011 VA treatment record, it was noted that the Veteran had neurogenic claudication that limited his walking to 100 yards or less. In an April 2008 letter, an acquaintance of the Veteran asserted that the Veteran could hardly walk or drive or do anything because his back caused him so much pain. As discussed, for the period of time on appeal prior to July 30, 2010, the Veteran's lumbosacral strain with radiculopathy was assigned a 40 percent evaluation. The RO recharacterized the issue and assigned separate 20 percent evaluations for radiculopathy of each leg as of July 30, 2010, due to a July 30, 2010, VA treatment record, in which the Veteran complained of bilateral leg weakness, tingling, and numbness, and the Veteran's symptoms were noted as consistent with neurogenic claudication. However, the Board notes that the Veteran specifically indicated in the July 30, 2010, VA treatment record that his symptoms began 3 years ago and had progressed over the last 2 years. Therefore, as it appears that the Veteran began experiencing more significant radicular symptoms approximately 2 to 3 years prior to July 30, 2010, the Board finds that the recharacterization of this issue and the award of separate 20 percent evaluations for radiculopathy of each lower extremity should be assigned the date that the claim was received, on December 28, 2007. As such, the Board finds the Veteran should be assigned a 20 percent evaluation for his service-connected lumbosacral strain under Diagnostic Code 5237, effective December 28, 2007, and separate 20 percent evaluations for radiculopathy of the right and the left lower extremities under Diagnostic Code 8720, effective December 28, 2007. The Board has considered whether an effective date could be awarded prior to December 28, 2007. In this regard, the Board notes that an effective date of an evaluation and award of compensation based on an original claim, a claim reopened after final disallowance, or a claim for increase will be the date of receipt of the claim or the date entitlement arose, whichever is the later. 38 U.S.C. § 5110(a) (West 2002); 38 C.F.R. § 3.400 (2012). An exception to that rule applies, however, under circumstances where evidence demonstrates that a factually ascertainable increase in disability occurred within the one-year period preceding the date of receipt of a claim for increased compensation. In such an instance, 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.A. § 5110(b)(2) (West 2002); see also 38 C.F.R. § 3.400(o)(2) (2012); Harper v. Brown, 10 Vet. App. 125 (1997). In this, case the Board notes that it is not factually ascertainable by the medical evidence of record for the year prior to December 28, 2007, that the Veteran experienced bilateral radiculopathy so severe as to be compensable separately from his lumbar spine disability. While the Veteran reported in the VA treatment record that his symptoms began 3 years prior to July 30, 2010, he also reported that these symptoms began worsening as of 2 years prior. Further, although a March 2007 private treatment record noted chronic back pain with sciatica, there was no indication as to the extent of that symptomatology. With no clinical evidence explicitly demonstrating that the Veteran's radiculopathy symptoms were significant enough to warrant separate compensable evaluations prior to December 28, 2007, the Board finds that December 28, 2007, the date that the claim was received, is the appropriate effective date. With regard to assigning an evaluation in excess of 20 percent for any period of time on appeal for the Veteran's lumbar spine disability under the General Rating Formula for Diseases and Injuries of the Spine, the Board notes that there is no evidence of record reflecting that the Veteran had favorable or unfavorable ankylosis of the entire spine or of the thoracolumbar spine, or a forward flexion of the thoracolumbar spine of 30 degrees or less at any time during the period on appeal. As such, an evaluation in excess of 20 percent is not warranted for the Veteran's service-connected lumbar spine disability for any period of time on appeal under the General Rating Formula for Diseases and Injuries of the Spine. With regard to applying the Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes, the Board finds no medical or lay evidence in the record reflecting that the Veteran has been prescribed bedrest by a physician for his service-connected lumbar spine disability for any period of time on appeal. As such, an increased rating cannot be assigned under this criteria. The Board also notes that, according to Note (1), any associated objective neurologic abnormalities, including, but not limited to, bowel or bladder impairment, must be evaluated separately under the appropriate diagnostic code. The Board notes that the Veteran's radiculopathy of the left and right lower extremities have already been awarded separate compensable evaluations, which will be discussed below. With regard to assigning a higher disability rating according to 38 C.F.R. § 4.40 and 4.45, the Board has considered the Veteran's complaints of pain, stiffness, and weakness. However, the medical evidence of record does not reflect that these symptoms, or any other symptoms elicited upon repetitive testing, limit the Veteran's range of motion so as to meet the criteria for a higher evaluation. As such, the Board concludes that the greater weight of evidence is against assigning an evaluation in excess of 20 percent for the Veteran's lumbar strain for any period of time on appeal, as contemplated by the holding in Deluca. With regard to assigning evaluations in excess of 20 percent each for the Veteran's radiculopathy of the right and left lower extremities for any period of time on appeal, the Board notes that the Veteran's radiculopathy is rated under Diagnostic Code 8720. Diagnostic Codes 8520, 8620, and 8720 provide ratings for paralysis, neuritis, and neuralgia of the sciatic nerve. 38 C.F.R. § 4.124a. Disability ratings of 10, 20, and 40 are warranted, respectively, for mild, moderate, and moderately severe incomplete paralysis of the sciatic nerve. 38 C.F.R. § 4.124a, Diagnostic Code 8720 (2012). A disability rating of 60 percent is warranted for severe incomplete paralysis with marked muscle atrophy. Id. An 80 percent rating is warranted with complete paralysis of the sciatic nerve. Id. The Board notes that in rating diseases of the peripheral nerves, the term "incomplete paralysis" indicates a degree of lost or impaired function substantially less than the type picture for complete paralysis given with each nerve, whether due to varied level of the nerve lesion or to partial regeneration. 38 C.F.R. § 4.124a. When the involvement is wholly sensory, the rating should be for the mild, or at most, the moderate degree. Id. With regard to assigning an evaluation in excess of 20 percent for either lower extremity under Diagnostic Code 8720, the Board has considered the Veteran's complaints of significant pain related to his radiculopathy of the bilateral lower extremities and notes that the evidence does reflect that he indeed has symptoms related to radiculopathy. However, the Board finds that the clinical evidence of record simply does not reflect that the Veteran's radiculopathy of either lower extremity is moderately severe in degree so as to warrant a 40 percent evaluation. Specifically, at the April 2008 VA examination, deep tendon reflexes were all noted as 2+ diffusely or normal. Motor examination revealed 4.5/5 weakness in all muscle groups of the left lower extremity and normal strength in the right lower extremity. The Veteran reported decreased strength to pinprick mildly in the left lateral thigh and the left posterior and medial calf compared to the right. In a November 2010 VA treatment record, it was noted that motor strength was limited in the bilateral lower extremities secondary to pain, roughly 5 out of 5, but it gave way secondary to pain. Sensation was grossly intact to light touch and pinprick, and deep tendon reflexes were 2+ throughout. In the August 2011 VA examination report, reflex examination findings were noted as normal bilaterally with the exception of the right ankle jerk, which was noted as absent. Sensory findings were noted as normal with regard to the bilateral lower extremities as to vibration, position sense, pain or pinprick, and light touch. Additionally, there was no dysesthesias noted. Motor examination revealed that the Veteran had active movement against full resistance bilaterally as to hip flexion and hip tension. The Veteran had active movement against some resistance as to knee flexion, knee extension, ankle dorsiflexion, ankle plantar flexion, and great toe extension. Therefore, in light of the fact that the medical evidence reflects that, most recently, the Veteran's sensory findings were noted as normal, his reflexes were noted as normal with a single exception, and he had either active movement against full resistance or active movement against some resistance, the Board finds that the Veteran's radiculopathy of each lower extremity is appropriately rated as being moderate in severity. As such, separate evaluations in excess of 20 percent are not warranted for the Veteran's radiculopathy of either lower extremity under Diagnostic Code 8720. The Board has reviewed the remaining diagnostic codes relating to diseases of the peripheral nerves, but finds that they are inapplicable in this case. See 38 C.F.R. § 4.124a (2012). The Board has also considered the potential application of other various provisions, including 38 C.F.R. § 3.321(b)(1), for exceptional cases where scheduler evaluations are found to be inadequate. See Schafrath v. Derwinski, 1 Vet. App. 589 (1991). 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 first 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 Veteran's level of disability and symptomatology and is found inadequate, the Board must determine whether the Veteran'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 Under Secretary for Benefits or the Director of the Compensation and Pension Service to determine whether, to accord justice, the Veteran's disability picture requires the assignment of an extraschedular rating. With respect to the first prong of Thun, the evidence in this case does not show such an exceptional disability picture that the available schedular evaluation for the Veteran's service-connected lumbar strain or his service-connected radiculopathy of the right lower extremity or left lower extremity is inadequate. A comparison between the level of severity and symptomatology of the Veteran's disabilities with the established criteria shows that the rating criteria reasonably describe the Veteran's disability level and symptomatology. There is no evidence in the medical records of an exceptional or unusual clinical picture. The Board, therefore, has determined that referral of this case for extra-schedular consideration pursuant to 38 C.F.R. 3.321(b)(1) is not warranted. In summary, the Board concludes that the evidence supports a rating of 20 percent for the Veteran's service-connected lumbosacral strain for the period of December 28, 2007, to the present, and separate 20 percent evaluations for radiculopathy of the right and the left lower extremities for the period of December 28, 2007, to the present. The Board further concludes that the preponderance of the evidence is against the claims for separate ratings higher than 20 percent for these disabilities for any period of time on appeal from December 28, 2007, to the present. The benefit of the doubt rule enunciated in 38 U.S.C.A. § 5107(b) is not for application as there is not an approximate balance of evidence. See generally Gilbert, supra; Ortiz v. Principi, 274 F. 3d 1361 (Fed. Cir. 2001). Assignment of staged ratings has been considered and is not for application. See Hart, supra. 2. Entitlement to an increased disability rating for bilateral hearing loss. In a December 2008 rating decision, the RO continued a noncompensable evaluation for bilateral hearing loss. The Veteran is seeking a higher rating. A rating for hearing loss is determined by a mechanical application of the rating schedule to the numeric designations assigned based on audiometric test results. See Lendenmann v. Principi, 3 Vet. App. 345 (1992). Evaluations of bilateral defective hearing range from noncompensable to 100 percent. The basic method of rating hearing loss involves audiological test results of organic impairment of hearing acuity as measured by the results of controlled speech discrimination tests (Maryland CNC), together with the average hearing threshold level as measured by pure tone audiometry tests in the frequencies of 1000, 2000, 3000, and 4000 Hertz. To evaluate the degree of disability of service-connected hearing loss, the rating schedule establishes eleven auditory acuity levels ranging from numeric level I for essentially normal acuity, through numeric level XI for profound deafness. See 38 C.F.R. § 4.85 (2012). The current rating criteria include an alternate method of rating exceptional patterns of hearing as defined in 38 C.F.R. § 4.86 (puretone threshold of 55 decibels or more at 1000, 2000, 3000, and 4000 Hertz; puretone threshold of 30 decibels or less at 1000 Hertz and 70 decibels or more at 2000 Hertz). The Veteran underwent a VA audiological examination in April 2008. This audiological summary report of examination for organic hearing loss reflected puretone thresholds as follows: HERTZ 1000 2000 3000 4000 RIGHT 35 30 25 30 LEFT 30 50 45 50 As such, the average decibel loss was 30 for the right ear and 43.75 for the left ear. Speech recognition ability was 96 percent for the right ear and 92 percent for the left ear. This examination report specifically indicated that speech recognition scores were obtained using the Maryland CNC test. According to Table VI of 38 C.F.R. § 4.85, this examination results in the assignment of a hearing acuity of Level I bilaterally. This warrants a 0 percent rating. More recently, the Veteran underwent a VA audiological examination in August 2011. This audiological summary report of examination for organic hearing loss reflected puretone thresholds as follows: HERTZ 1000 2000 3000 4000 RIGHT 45 30 30 35 LEFT 45 35 40 45 As such, the average decibel loss was 35 for the right ear and 41.25 for the left ear. Speech recognition ability was 100 percent bilaterally. This examination report specifically indicated that speech recognition scores were obtained using the Maryland CNC test. According to Table VI of 38 C.F.R. § 4.85, this examination results in the assignment of a hearing acuity of Level I bilaterally. This warrants a 0 percent rating. The Board notes that the claims file contains a September 2011 VA examination report as well. However, the audiological results from this examination are identical to the results recorded at the August 2011 VA examination. The claims file also contains VA and private treatment records. However, these treatment records do not record the Veteran's hearing impairment in terms of the specific hearing thresholds or reflect that recorded word recognition scores were obtained using the Maryland CNC test. In summary, upon review of all relevant medical evidence of record, the Board does not find that the Veteran's hearing loss meets the criteria of a compensable evaluation. Therefore, an increased rating is not warranted. While the Board notes the difficulties the Veteran experiences as a result of his disability, his claim primarily hinges on a mechanical application of specifically defined regulatory standards. The Board is bound by the very precise nature of the laws governing evaluations of hearing loss disability. The Board has also considered the potential application of other various provisions, including 38 C.F.R. § 3.321(b)(1), for exceptional cases where scheduler evaluations are found to be inadequate. See Schafrath, 1 Vet. App. 589. The Board notes the Veteran's assertions that he has difficulty hearing people, especially females. In this regard, the Board notes that the rating criteria for hearing loss were last revised, effective June 10, 1999. See 64 Fed. Reg. 25,200 (May 11, 1999). In forming these revisions, VA sought the assistance of the Veteran's Health Administration (VHA) in developing criteria that contemplated situations in which a Veteran's hearing loss was of such a type that speech discrimination tests may not reflect the severity of communicative functioning these Veterans experienced or that was otherwise an extreme handicap in the presence of any environmental noise, even with the use of hearing aids. VHA had found through clinical studies of Veterans with hearing loss that when certain patterns of impairment are present, a speech discrimination test conducted in a quiet room with amplification of the sounds does not always reflect the extent of impairment experienced in the ordinary environment. Id. The decibel threshold requirements for application of Table VIA were based on the findings and recommendations of VHA. The intended effect of the revision was to fairly and accurately assess the hearing disabilities of Veterans as reflected in a real life industrial setting. 59 Fed. Reg. 17,295 (April 12, 1994). Accordingly, the Board finds that functional impairment due to hearing loss that is compounded by background or environmental noise is a disability picture that is considered in the current schedular rating criteria. Therefore, the Veteran's struggle to comprehend verbal conversations is a factor contemplated in the regulations and rating criteria as defined. Accordingly, the Board determines that the Veteran's complaints of hearing difficulty have been considered under the numerical criteria set forth in the rating schedule. Thus, the Board determines that the schedular rating criteria adequately contemplate the Veteran's symptomatology, and that the requirements for an extraschedular evaluation under 38 C.F.R. § 3.321(b)(1) have not been met. Bagwell v. Brown, 9 Vet. App. 337 (1996); Shipwash v. Brown, 8 Vet. App. 218 (1995). In summary, the Board concludes that the preponderance of the evidence is against the claim for a compensable evaluation for bilateral hearing loss. The benefit of the doubt rule enunciated in 38 U.S.C.A. § 5107(b) is not for application as there is not an approximate balance of evidence. See generally Gilbert, supra; Ortiz v. Principi, 274 F. 3d 1361 (Fed. Cir. 2001). Assignment of staged ratings has been considered and is not for application. See Hart, supra. 3. Entitlement to an increased disability rating for a pilonidal cyst with residual scar, status post removal of pilonidal cyst. In a December 2008 rating decision, the RO continued a noncompensable evaluation for a pilonidal cyst under Diagnostic Code 7805. In an October 2012 rating decision, the RO granted service connection for residual scar, status post removal of pilonidal cyst, and assigned an evaluation of 10 percent under Diagnostic Code 7804, effective August 22, 2011. The Veteran is seeking a higher evaluation for this disability. The Board notes that the schedule for rating disabilities of the skin was changed, effective August 30, 2002. As the Veteran's claim for an increased evaluation was received in December 28, 2007, any regulation changes made prior to the August 30, 2002, changes are irrelevant for the purposes of this claim. However, the Board also acknowledges that, during the pendency of this appeal, 38 C.F.R. § 4.118, Diagnostic Codes 7800-7805 were amended, effective October 23, 2008. As such, the Board will consider the criteria in effect both prior to and after October 23, 2008. The Veteran underwent a VA examination in April 2008. At this examination, the Veteran reported that he was diagnosed with a pilonidal cyst in service and believed it was drained on 1 occasion. He had surgery to remove the cyst in 2004. He reported that the scar was tender at times, and it would ache at times when he sits too long, but his back pain limited his sitting more than the scar. Examination of the scar revealed a 2.5 inch scar in the buttocks crease. The scar was not inflamed and nontender. There was no adherence to the underlying tissue. Skin texture was normal. The scar was not unstable. There was no elevation or depression of the scar, and it was superficial, not deep. There was no inflammation or keloid. Color of the scar was normal compared to surrounding skin. There was no induration of the scar, and there was no limitation of motion because of the scar. The Veteran was diagnosed with pilonidal cyst excision - no effect on functioning. The Veteran underwent a VA examination most recently in August 2011. The examiner reviewed the claims file and noted that the Veteran had a pilonidal cyst that was removed in 2004 after the cyst became enlarged and tender. The area where the cyst existed was still sore and hurt with sitting and driving a car. The Veteran had received no skin disease treatment in the past 12 months. The Veteran was diagnosed with status post surgical removal of pilonidal cyst with residual tenderness in the area from which it was removed. The examiner noted that there was mild impairment of travel due to pain, and there was mild impairment of leisure as he had pain when he sits for more than 20 minutes. There was no limitation of motion. The Board has also reviewed the VA and private medical evidence of record. In an April 2008 private treatment record from Great North Woods Medical, the Veteran reported that he occasionally had mild discomfort related to his history of pilonidal cyst. It was noted that examination of the past surgical site for pilonidal sinus excision and marsupialization shows a well-healed proximal gluteal cleft scar with no fluctuance, erythema, tenderness, or sinus tract. In an April 2008 letter from this facility, it was noted that, since his surgery, the Veteran had just occasional discomfort and no drainage from the site. With regard to the criteria in effect prior to the October 23, 2008, amendment, the Board notes that Diagnostic Code 7800 evaluates disfigurement of the head, face, or neck. 38 C.F.R. § 4.118, Diagnostic Code 7800 (2008). As the Veteran's service-connected scar is related to a pilonidal cyst, this diagnostic code is inapplicable. Diagnostic Code 7801 evaluates scars that are not located on the head, face, or neck, that are deep or that cause limited motion. 38 C.F.R. § 4.118, Diagnostic Code 7801 (2008). The evidence of record does not reflect that the Veteran's scar is deep or causes limited motion. As such, this diagnostic code in inapplicable. Diagnostic Code 7802 assigns a 10 percent rating for scars covering an area or areas of 144 square inches (929 square centimeters) or greater that are not located on the head, face, or neck, that are superficial and that do not cause limited motion. 38 C.F.R. § 4.118, Diagnostic Code 7802 (2008). As the Veteran's scar has been noted as being 2.5 inches in length, this diagnostic code is inapplicable. Diagnostic Code 7803 awards a 10 percent rating for superficial, unstable scars. 38 C.F.R. § 4.118, Diagnostic Code 7803 (2008). According to Note (1) of this diagnostic code, an unstable scar is one where, for any reason, there is frequent loss of covering of skin over the scar. As there is no indication that the Veteran's scar is unstable, this diagnostic code is also inapplicable. Diagnostic Code 7804 awards a 10 percent evaluation for a superficial scar that is painful upon examination. 38 C.F.R. § 4.118, Diagnostic Code 7804 (2008). The April 2008 VA examiner noted that the scar was tender at times, and that it would ache at times when the Veteran sat too long. Therefore, due to the Veteran's complaints of tenderness and aching when he sits too long, the Board finds that the Veteran's pilonidal cyst should be assigned a 10 percent evaluation under the criteria in effect prior to October 23, 2008, for the period of December 28, 2007, the date the Veteran submitted his claim for an increased rating, to August 21, 2011. This is the maximum evaluation available under the Diagnostic Code 7804 criteria in effect prior to October 28, 2008. The Board has considered whether a 10 percent evaluation could be assigned prior to December 28, 2007. However, it is simply not factually ascertainable by the medical evidence of record for the year prior to December 28, 2007, that the Veteran met the criteria for an increased rating at that point. As such, the Board finds that December 28, 2007, the date that the claim was received, is the appropriate effective date for this increase. Finally, the Board notes that Diagnostic Code 7805 evaluates scars, other, based upon limitation of function of the affected part. 38 C.F.R. § 4.118, Diagnostic Code 7805 (2008). As there is no indication that the Veteran's scar results in limitation of function, this diagnostic code is inapplicable. The Board notes that there are no other relevant skin diagnostic code sections for consideration in rating the severity of the Veteran's pilonidal cyst scar under the criteria in effect prior to October 23, 2008. As such, an increased evaluation for the Veteran's service-connected pilonidal cyst scar is not warranted under these criteria. With regard to the criteria in effect as of October 23, 2008, the Board notes that Diagnostic Code 7800 evaluates disfigurement of the head, face, or neck. 38 C.F.R. § 4.118, Diagnostic Code 7800 (2012). As the Veteran's service-connected scar is related to a pilonidal cyst, this diagnostic code is inapplicable. Diagnostic Code 7801 evaluates scars based upon their size that are not located on the head, face, or neck, and that are deep and nonlinear. 38 C.F.R. § 4.118, Diagnostic Code 7801 (2012). As the evidence of record does not reflect that the Veteran's scar is at least 6 square inches, a compensable evaluation is not warranted under this diagnostic code. Diagnostic Code 7802 assigns a 10 percent rating for scars covering an area or areas of 144 square inches (929 square centimeters) or greater that are not located on the head, face, or neck, that are superficial and nonlinear. 38 C.F.R. § 4.118, Diagnostic Code 7802 (2012). As the Veteran's scar has been noted as being 2.5 inches in length, this diagnostic code is inapplicable. Diagnostic Code 7803 was removed from the diagnostic criteria as of October 23, 2008. Diagnostic Code 7804 evaluate painful or unstable scars. A 10 percent evaluation is awarded for one or two scars that are unstable or painful. A 20 percent evaluation is awarded for 3 or 4 scars that are unstable or painful. A 30 percent evaluation is awarded for 5 or more scars that are unstable or painful. 38 C.F.R. § 4.118, Diagnostic Code 7804 (2012). As the Veteran is already awarded a 10 percent evaluation for 1 scar that is painful for the entire period of time on appeal, and the Veteran does not have multiple scars related to his pilonidal cyst, an evaluation in excess of 10 percent is not warranted under Diagnostic Code 7804. Finally, Diagnostic Code 7805 evaluates scars, other (including linear scars) and other effects of scars evaluated under Diagnostic Codes 7800, 7801, 7802, and 7804. This diagnostic code notes that any disabling effect(s) not considered in a rating provided under diagnostic codes 7800-4, should be evaluated under an appropriate diagnostic code. As discussed above, the provided diagnostic codes have been considered. The Board notes that there are no other relevant skin diagnostic code sections for consideration in rating the severity of the Veteran's pilonidal cyst scar. Additionally, there are no other diagnostic criteria apart from the skin diagnostic codes under which the Veteran could obtain an evaluation in excess of 10 percent or a separate compensable evaluation for his service-connected pilonidal cyst with residual scar, status post removal of pilonidal cyst. As such, an evaluation in excess of 10 percent is not warranted for the Veteran's service-connected pilonidal cyst with residual scar, status post removal of pilonidal cyst for any period of time on appeal. The Board has also considered the potential application of other various provisions, including 38 C.F.R. § 3.321(b)(1), for exceptional cases where scheduler evaluations are found to be inadequate. See Schafrath v. Derwinski, 1 Vet. App. 589 (1991). 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 first 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 Veteran's level of disability and symptomatology and is found inadequate, the Board must determine whether the Veteran'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 Under Secretary for Benefits or the Director of the Compensation and Pension Service to determine whether, to accord justice, the Veteran's disability picture requires the assignment of an extraschedular rating. With respect to the first prong of Thun, the evidence in this case does not show such an exceptional disability picture that the available schedular evaluation for the Veteran's service-connected pilonidal cyst with residual scar, status post removal of pilonidal cyst is inadequate. A comparison between the level of severity and symptomatology of the Veteran's disability with the established criteria shows that the rating criteria reasonably describe the Veteran's disability level and symptomatology. There is no evidence in the medical records of an exceptional or unusual clinical picture. The Board, therefore, has determined that referral of this case for extra-schedular consideration pursuant to 38 C.F.R. 3.321(b)(1) is not warranted. In summary, the Board concludes that the evidence supports a rating of 10 percent for the Veteran's service-connected pilonidal cyst with residual scar, status post removal of pilonidal cyst for the period of December 28, 2007, to August 21, 2011. The Board further concludes that the preponderance of the evidence is against the claim for a rating higher than 10 percent for this disability for any period of time on appeal from December 28, 2007, to the present. The benefit of the doubt rule enunciated in 38 U.S.C.A. § 5107(b) is not for application as there is not an approximate balance of evidence. See generally Gilbert, supra; Ortiz v. Principi, 274 F. 3d 1361 (Fed. Cir. 2001). Assignment of staged ratings has been considered and is not for application. See Hart, supra. ORDER Entitlement to an evaluation of 20 percent, but no more, for service-connected lumbar strain for the period of December 28, 2007, to July 29, 2010, is granted. Entitlement to an evaluation in excess of 20 percent for service-connected lumbar strain for the period of July 30, 2010, to the present, is denied. Entitlement to an evaluation of 20 percent, but no more, for service-connected radiculopathy of the right lower extremity for the period of December 28, 2007, to July 29, 2010, is granted. Entitlement to an evaluation in excess of 20 percent for service-connected radiculopathy of the right lower extremity for the period of July 30, 2010, to the present, is denied. Entitlement to an evaluation of 20 percent, but no more, for service-connected radiculopathy of the left lower extremity for the period of December 28, 2007, to July 29, 2010, is granted. Entitlement to an evaluation in excess of 20 percent for service-connected radiculopathy of the left lower extremity for the period of July 30, 2010, to the present, is denied. Entitlement to a disability rating in excess of 0 percent for bilateral hearing loss is denied. Entitlement to an evaluation of 10 percent, but no more, for service-connected pilonidal cyst with residual scar, status post removal of pilonidal cyst for the period of December 28, 2007, to August 21, 2011, is granted. Entitlement to an evaluation in excess of 10 percent for service-connected pilonidal cyst with residual scar, status post removal of pilonidal cyst for the period of August 22, 2011, to the present, is denied. REMAND After a thorough review of the Veteran's file, the Board has determined that additional development is necessary prior to the adjudication of the claim for entitlement to TDIU. The Board notes that VA will grant a total rating for compensation purposes based on unemployability when the evidence shows that the Veteran is precluded, by reason of service-connected disabilities, from obtaining and maintaining any form of gainful employment consistent with his or her education and occupational experience. 38 C.F.R. §§ 3.340, 3.341, 4.16 (2012). Under the applicable regulations, benefits based on individual unemployability are granted only when it is established that the service-connected disabilities are so severe, standing alone, as to prevent the retaining of gainful employment. Under 38 C.F.R. § 4.16, if there is only one such disability, it must be rated at least 60 percent disabling to qualify for benefits based on individual unemployability. If there are two or more such disabilities, there shall be at least one disability ratable at 40 percent or more, and sufficient additional disability to bring the combined rating to 70 percent or more. 38 C.F.R. § 4.16(a) (2012). Disabilities resulting from a common etiology or from a single accident are considered one disability. Id. In addition, disabilities of one or both upper extremities, or one or both lower extremities, including the bilateral factor, are considered one disability under this section. Id. Where these percentage requirements are not met, entitlement to benefits on an extraschedular basis may be considered when the Veteran is unable to secure and follow a substantially gainful occupation by reason of service-connected disabilities, and consideration is given to the Veteran's background including his or her employment and educational history. 38 C.F.R. §4.16(b) (2012). The Board does not have the authority to assign an extraschedular total disability rating for compensation purposes based on individual unemployability in the first instance. Bowling v. Principi, 15 Vet. App. 1 (2001). In determining whether unemployability exists, consideration may be given to the Veteran's level of education, special training, and previous work experience, but it may not be given to his or her age or to any impairment caused by nonservice-connected disabilities. 38 C.F.R. §§ 3.341, 4.16, 4.19 (2012). In this case, service connection is in effect for the following disabilities: lumbar strain (20 percent), right lower extremity radiculopathy (20 percent), left lower extremity radiculopathy (20 percent), pilonidal cyst with residual scar, status post removal of pilonidal cyst (10 percent), tinnitus (10 percent), and bilateral hearing loss (0 percent). With regard to the Veteran's employability, the Board acknowledges that a May 1999 letter from Lake Champlain Cardiology Associates, LLP. noted that, at that time, because of coronary artery disease, the Veteran was disabled and unable to work. It was noted that he was able to ambulate and capable of mild activities, but he was not capable of hard, strenuous exercise, such as heavy lifting, etc., which his job would entail. In a May 1999 letter from Kaiser Permanente, a physician stated that, since his cardiac procedures, the Veteran had not been cleared to return to work, and the cardiologist who cared for him felt that he was unable to work at that time. In a June 2000 letter from a physician at Lake Champlain Cardiology Associates, LLP., it was noted that the Veteran had significant cardiac problems which prohibited him from returning to work because of his intermittent need for significant amounts of Nitroglycerine. In a May 2001 VA treatment record, the Veteran reported that he was retired on disability from U.S. Customs. In April 2008, the Veteran underwent a VA general examination. It was noted that the Veteran retired from U.S. Customs in 1998 on disability retirement. That was mainly, the Veteran reported, because of his heart, but then he was put in a desk job, and he could not handle that because of his low back. The examiner concluded by stating that, because of his service-connected condition of lumbar degenerative disc disease, he would be limited to sedentary and very light activity, with no repetitive bending and no climbing. He would need to be able to change positions from sitting to standing on an as-needed basis. He needed a cane to ambulate other than very short distances. In April 2008, the Veteran also underwent a VA audiological examination. It was noted that the Veteran was a police officer for 15 years and retired in 1998 from U.S. Customs. The examiner noted that, regarding occupational functioning, persons who are deaf or hard of hearing can perform the majority of jobs available. However, there are factors that create communication barriers that can limit their participation in the workplace. With few exceptions, persons who are deaf or hard of hearing, if given appropriate training and accommodations, have the same range of job options as any other person. The employer may be required by the Americans with Disabilities Act to provide the needed accommodation. In an April 2008 letter, an acquaintance of the Veteran asserted that the Veteran always had a severe back problem that has hampered his physical movement and that he assisted the Veteran in acquiring disability retirement from U.S. Customs in 1998 for a development and ongoing progressive degenerative heart condition. An August 2008 response from the U.S. Customs and Border Protection indicated the Veteran retired due to disability in August 1998. The employer or supervisor noted that, after the Veteran's heart problems, back trouble, and neck surgery, an attempt was made for desk duty. However, the back would not allow it due to pain and discomfort. In an August 2011 VA skin examination report, it was noted that the Veteran experienced mild impairment of travel due to pain and mild impairment of leisure, as he had pain when he sits for more than 20 minutes, due to his pilonidal cyst scar. It was noted that there was no limitation of motion. In an August 2011 VA spine examination report, it was noted that the Veteran retired in August 1998 from his occupation as a customs agent due to back pain and arteriosclerotic heart disease with angina. It was noted that the Veteran's degenerative disc disease of the cervical spine and lumbosacral spine resulted in his being assigned different duties, increased tardiness, and increased absenteeism. The claims file also contains VA audiological compensation and pension reports from August and September 2011. In these reports, it was noted that the Veteran's hearing loss impacts his ordinary conditions of daily life, including his ability to work. Specifically, it was noted that that the Veteran had difficulty hearing female speakers. It was also noted that the Veteran's tinnitus impacts his ordinary conditions of daily life, including his ability to work, in that it is constant. In this case, the Veteran and his representative have asserted that the Veteran is unable to maintain employment due to his service-connected disabilities. However, it is unclear from the medical evidence of record whether the Veteran is unemployable as a result of his service-connected disabilities or whether he is unemployable as a result of a nonservice-connected cardiac condition. Therefore, the Board will afford the Veteran a new VA examination for the proper assessment of this claim. 38 U.S.C.A. § 5103A (West 2002). As such, this issue must be remanded in order to schedule the Veteran for a VA examination to determine whether he is precluded, by reason of service-connected disabilities from obtaining and maintaining any form of substantial gainful employment consistent with his education and occupational experience. Colvin v. Derwinski, 1 Vet. App. 171, 175 (1991) (if the medical evidence of record is insufficient, the Board is free to supplement the record by seeking an advisory opinion or ordering a medical examination). Finally, upon remand, any outstanding VA treatment records relating to the claim on appeal that have not yet been associated with the claims file should be obtained. Accordingly, the case is REMANDED for the following action: 1. Obtain any and all relevant VA treatment records that have not yet been associated with the claims file. 2. Schedule the Veteran for an appropriate VA examination for his claim for entitlement to TDIU. The claims file should be provided to the appropriate examiner for review, and the examiner should note that it has been reviewed. The examiner should elicit a history from the Veteran regarding his recent employment and examine the Veteran thoroughly. After reviewing the file, noting the Veteran's reported history, and examining the Veteran, the examiner should render an opinion as to whether the Veteran is at least as likely as not (50 percent or greater probability) precluded solely by reason of his service-connected disabilities from obtaining and maintaining any form of substantial gainful employment consistent with his education and occupational experience. The examiner is advised that only symptoms related to the Veteran's service-connected disabilities should be considered in determining whether the Veteran is precluded from obtaining and maintaining employment. Symptoms related to nonservice-connected disabilities or circumstances should be not be considered in this determination. The examiner should explain the reasons behind any opinions provided. 3. Then, readjudicate the claim. In particular, review all the evidence that was submitted since the most recent SSOC was issued. If the benefit sought remains denied, the Veteran and his representative should be provided a SSOC. After the Veteran and his representative have been given the applicable time to submit additional argument, the claim should be returned to the Board for further review. The Veteran has the right to submit additional evidence and argument on the matter or matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). No further action is required of the Veteran until further notice. However, the Board takes this opportunity to advise the Veteran that the conduct of the efforts as directed in this remand, as well as any other development deemed necessary, is needed for comprehensive and correct adjudication of his claim. His cooperation in VA's efforts to develop his claim, including reporting for any scheduled VA examination, is both critical and appreciated. The Veteran is also advised that failure to report for any scheduled examination may result in the denial of a claim. See 38 C.F.R. § 3.655 (2012). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board or by the Court for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2012). ______________________________________________ MICHAEL A. PAPPAS Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs