Citation Nr: 1305663 Decision Date: 02/15/13 Archive Date: 02/21/13 DOCKET NO. 08-27 076 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in North Little Rock, Arkansas THE ISSUES 1. Entitlement to an increased rating for a low back disability, in excess of 20 percent prior to February 11, 2012 and in excess of 40 percent from February 11, 2012. 2. Entitlement to a total disability rating based on individual unemployability (TDIU). REPRESENTATION Appellant represented by: The American Legion WITNESSES AT HEARING ON APPEAL The Veteran; the Veteran's spouse ATTORNEY FOR THE BOARD T. M. Gillett, Counsel INTRODUCTION The Veteran served on active duty from July 1984 to April 1992. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a January 2008 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in North Little Rock, Arkansas, which denied the Veteran's claims for service connection for cancer of the kidney and bladder, an increased rating in excess of 20 percent for a low back disability, and entitlement to TDIU, and an application to reopen service connection for a right arm ulnar nerve disorder. In August 2009, the Veteran and the Veteran's spouse presented sworn testimony before the undersigned Veterans Law Judge, seated at the RO (Travel Board hearing). A transcript of the hearing has been associated with the Veteran's VA claims folder. At the August 2009 hearing, the Veteran submitted additional evidence directly to the Board. At that time, the Veteran also submitted a written waiver of local consideration of this evidence. This waiver is contained in the Veteran's claims folder. See 38 C.F.R. §§ 19.9, 20.1304(c) (2012). In August 2009, the Board received notification from the Veteran indicating that he wished to withdraw his application to reopen service connection for a right arm ulnar nerve disability. In a June 2011 Withdrawal and Remand, the Board dismissed the Veteran's application to reopen service connection for a right arm ulnar nerve disability in accordance with his wishes. In June 2011, the Board remanded the Veteran's claims for service connection for cancer of the kidney and bladder, an increased rating in excess of 20 percent for a low back disability, and entitlement to TDIU to the Appeals Management Center (AMC) for the procurement of additional treatment records and Social Security Administration (SSA) records, and the provision of VA medical examinations. As will be explained thoroughly below, the Board finds that the AMC complied with the June 2011 Remand directives. See Stegall v. West, 11 Vet. App. 268, 271 (1998) (noting the Board's duty to "insure [the RO's] compliance" with the terms of its remand orders). In a December 2012 rating decision, the AMC granted service connection for cancer of the kidney and bladder, granting respective separate ratings for status post left nephroureterectomy (left kidney removal) and multiple turbst; and lower urinary tract symptoms with history of hematuria. As the December 2012 rating decision acted as a full grant of the Veteran's claim for service connection for cancer of the kidney and bladder, the issue of service connection for cancer of the kidney and bladder is not in appellate status and is not before the Board. 38 U.S.C.A. § 7105 (West 2002 & Supp. 2012). In a September 2012 rating decision, the RO partially granted the Veteran's claim for an increased rating in excess of 20 percent for a low back disability, evaluating the disability as 40 percent disabling from February 11, 2012, and granting a separate 10 percent rating for radiculopathy of the left lower extremity related to the low back disability, also effective February 11, 2012. In a September 2012 statement, the Veteran requested that the 40 percent rating assigned for his low back disability from February 11, 2012 be made effective at the date of his claim for an increased rating. The Veteran wrote that it was his understanding that increased ratings were supposed to be effective on the date of the claim. Moreover, the Veteran stated that he wished for a rating in excess of 10 percent for the radiculopathy related to his low back disability and wished to have that increased rating made effective as of the date of his claim as well. As the Veteran is seeking a claim for an increased rating for a low back disability, the Board will review the evidence regarding the severity of the Veteran's back disability over the entirety of the increased rating period under appeal. See Francisco v. Brown, 7 Vet. App. 55 (1994). In doing so, the Board is tasked by VA to determine the level of the Veteran's disability during that period and to consider the application of staged ratings. See Hart v. Mansfield, 21 Vet. App. 505 (2007). Staged ratings are assigned when a disorder increases in severity during the increased rating period. Such ratings are effective on the date that the increase in severity becomes factually ascertainable. Therefore, the Board will review the evidence regarding the severity of the Veteran's low back disability for the entire rating period under appeal, to include the periods both prior to and from February 11, 2012, and will assign either a single rating or staged ratings accordingly. As the separate rating for radiculopathy was assigned due to symptoms related to the Veteran's low back disability, in theory, the Board will also consider the severity of the Veteran's radiculopathy disability over the entirety of the increased rating period. 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. For the increased rating period prior to February 11, 2012, the Veteran's low back disability was not manifested by symptomatology more nearly approximating forward flexion of the thoracolumbar spine limited to 30 degrees or less or favorable ankylosis of the entire thoracolumbar spine. 2. For the increased rating period prior to February 11, 2012, the Veteran did not have radiculopathy of either lower extremity. 3. For the increased rating period from February 11, 2012, the Veteran's low back disability was not manifested by symptomatology more nearly approximating unfavorable ankylosis of the entire thoracolumbar spine. 4. For the increased rating period from February 11, 2012, the Veteran's radiculopathy of the left lower extremity has not been manifested by symptomatology more nearly approximating moderate neuritis of the sciatic nerve. 5. For the increased rating period from February 11, 2012, the Veteran has not had radiculopathy of the right lower extremity related to a service-connected low back disability. CONCLUSIONS OF LAW 1. For the increased rating period prior to February 11, 2012, the criteria for an increased rating in excess of 20 percent for a low back disability have not been met. 38 U.S.C.A. §§ 1155, 5103A (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 4.3, 4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5242 (2012). 2. For the increased rating period from February 11, 2012, the criteria for an increased rating in excess of 40 percent for a low back disability have not been met. 38 U.S.C.A. §§ 1155, 5103A (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 4.3, 4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5242 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA) and implementing regulations impose obligations on VA to provide claimants with notice and assistance. 38 U.S.C.A. §§ 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2012). VA has a duty to notify a veteran of any information and evidence needed to substantiate and complete a claim. 38 U.S.C.A. §§ 5102, 5103. In order to meet the requirements of 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b), VCAA notice must (1) inform the veteran about the information and evidence necessary to substantiate the claim; (2) inform the veteran about the information and evidence that VA will seek to provide; and (3) inform the veteran about the information and evidence the veteran is expected to provide. VCAA notice should be provided to a veteran before the initial unfavorable agency of original jurisdiction (AOJ) decision on a claim. See Pelegrini v. Principi, 18 Vet. App. 112 (2004). In a claim for an increased rating, the VCAA requires only generic notice as to the type of evidence needed to substantiate the claim, namely, evidence demonstrating a worsening or increase in severity of the disability and the effect that worsening has on employment, as well as general notice regarding how disability ratings and effective dates are assigned. Vazquez-Flores v. Shinseki, 580 F.3d 1270 (Fed. Cir. 2009). In this case, a VCAA notice letter sent in May 2008 satisfied the provisions of 38 U.S.C.A. § 5103(a). In this letter, VA informed the Veteran about the information and evidence not of record that was necessary to substantiate the claim; the information and evidence that VA would seek to provide; the information and evidence the Veteran was expected to provide; and the information required by Vazquez-Flores. This notice was issued after the issuance of the rating decision from which the Veteran's claim arises. In Pelegrini, 18 Vet. App. at 112 (Pelegrini II), the Court held, in part, that a VCAA notice, as required by 38 U.S.C. § 5103(a), must be provided to a claimant before the initial unfavorable agency of original jurisdiction (AOJ) decision on a claim for VA benefits. This was not done in this case; however, subsequent to the issuance of the aforementioned notice letter, the RO readjudicated the Veteran's claim, as demonstrated by the August 2008 Statement of the Case (SOC). See Prickett v. Nicholson, 20 Vet. App. 370, 376-78 (2006) (validating the remedial measures of issuing a fully compliant VCAA notification and re-adjudicating the claim in the form of a statement of the case to cure timing of notification defect); Mayfield v. Nicholson, 20 Vet. App. 537, 541-42 (2006) (Mayfield III) (holding that a statement of the case that complies with all applicable due process and notification requirements constitutes a re-adjudication decision). As the SOC complied with the applicable due process and notification requirements for a decision, it constitutes a readjudication decision. Accordingly, the provision of adequate notice followed by a readjudication "cures" any timing problem associated with notice or the lack of notice prior to an initial adjudication. Mayfield III, 20 Vet. App. at 541-42, citing Mayfield v. Nicholson, 444 F.3d 1328, 1333-34 (Fed. Cir. 2006) (Mayfield II). The Board finds that all necessary assistance has been provided to the Veteran. VA has acquired the Veteran's VA and SSA records to assist the Veteran with the claim, and the Board is not aware of any additional relevant evidence which is available, but has not been obtained. For this claim, VA provided the Veteran with two VA medical examinations, in December 2007 and February 2012, respectively, to determine the severity of the Veteran's low back disability. In a September 2008 statement included with his Substantive Appeal to the Board, the Veteran wrote that the "doctors from Memphis," purportedly to include the December 2007 VA examiner, were "not accurate in their reports." In a September 2012 statement, the Veteran wrote that the February 2012 VA examiner's conclusions regarding the severity of his low back and radiculopathy disabilities were not credible because the VA examiner only met with him once for 15 minutes. The Veteran stated that such a small amount of time was inadequate to allow for the February 2012 VA examiner to determine the severity of his low back disability. The Board finds that the Veteran's September 2008 and September 2012 statements, indicating that the VA medical examinations provided during the pendency of this appeal were inadequate, both lack credibility and are insufficient to overcome the presumption of regularity applying to government officials, such as VA examiners conducting compensation examinations. See Madden v. Gober, 125 F.3d 1477, 1481 (Fed. Cir. 1997) (holding that the Board has the duty to assess the credibility and weight to be given to the evidence); Ashley v. Derwinski, 2 Vet. App. 307, 308-09 (1992). The United States Court of Appeals for Veterans Claims (Court) has held that "there is a presumption of regularity which holds that government officials are presumed to have properly discharged their official duties." Ashley, 2 Vet. App. at 308-09 (quoting United States v. Chemical Foundation, Inc., 272 U.S. 1, 14-15, 71 (1926)). The presumption of regularity attaches to "all manner of VA processes and procedures." See Woods v. Gober, 14 Vet. App. 214, 220 (2000). Thus, it follows that the presumption is applicable to the December 2007 and February 2012 VA examiners' provisions of VA medical examinations. Absent clear evidence to the contrary, VA is entitled to the presumption that the respective VA examiners properly performed the examinations necessary to determine the severity of the Veteran's service-connected low back disability as of the date of the examination. In addition, the VA examiners are entitled to the presumption that the medical examinations provided were of sufficient length to provide findings regarding the severity of the Veteran's disability. The Board notes that the September 2007 and February 2012 VA medical examination reports were written by a medical doctor and a resident physician, respectively, who were fully qualified to provide medical examinations. See Cox v. Nicholson, 20 Vet. App. 563, 568-69 (2007) (holding that medical examinations may be conducted by licensed healthcare professionals competent to provide diagnoses, statements, or opinions). The September 2007 and February 2012 VA medical examination reports contain no indication that the respective VA examiners performed improper examinations, as both VA examiners indicated performing thorough physical examinations. The Board notes that both VA medical examination reports are thorough and contain the required findings regarding the Veteran's low back disability; therefore, the Veteran's complaints indicating that the December 2007 and February 2012 VA examiners were either inaccurate or did not spend an adequate amount of time performing the examination are not credible. See Madden, 125 F.3d at 1481 (holding that the Board has the duty to assess the credibility and weight to be given to the evidence); Ashley, at 308-09; Sickels v. Shinseki, 643 F.3d 1362 (Fed. Cir. 2011) (holding that the Board is entitled to presume the competence of a VA examiner and the adequacy of his or her opinion); Butler v. Principi, 244 F.3d. 1337, 1340 (Fed. Cir. 2001) (stating that the presumption of regularity allows courts to presume that what appears regular is regular, the burden shifting to the claimant to show the contrary). As the VA medical examination reports were written after interviews with the Veteran, physical examinations of the Veteran, and contain sufficient findings to allow for the rating of the Veteran's low back disability, the Board finds that the December 2007 and February 2012 VA medical examination reports are adequate for VA purposes. Under these circumstances, there is no duty to provide an additional medical examination or opinion. 38 U.S.C.A. § 5103A(d); 38 C.F.R. § 3.159(c)(4); see also McLendon v. Nicholson, 20 Vet. App. 79, 83 (2006). As noted in the Introduction, in the June 2011 Remand, the Board requested that the AMC procure additional treatment records and Social Security Administration (SSA) records, and provide the Veteran with a medical examination to determine the current severity of his low back disability. As the AMC procured the records as requested in the Remand and provided the Veteran with the February 2012 VA medical examination, which was adequate for VA purposes, the Board finds that the AMC complied with the June 2011 Remand directives. See Stegall, 11 Vet. App. at 271 (1998). In view of the foregoing, the Board finds that VA has fulfilled its duties to notify and assist the Veteran in the claim under consideration. Adjudication of the claim at this juncture, without directing or accomplishing any additional notification and/or development action, poses no risk of prejudice to the Veteran. Bernard v. Brown, 4 Vet. App. 384, 394 (1993). Disability Rating Criteria Disability evaluations are determined by the application of a schedule of ratings that is based on average impairment of earning capacity. 38 U.S.C.A. § 1155. Percentage evaluations are determined by comparing the manifestations of a particular disorder with the requirements contained in VA's Schedule for Rating Disabilities (Rating Schedule), 38 C.F.R. Part 4 (2012). The percentage ratings contained in the Rating Schedule represent, as far as can practically be determined, the average impairment in earning capacity resulting from such disease or injury and their residual conditions in civilian occupations. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1 (2012). If two disability ratings are potentially applicable, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that evaluation. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. In view of the number of atypical instances, it is not expected, especially with the more fully described grades of disabilities, that all cases will show all the findings specified. 38 C.F.R. § 4.21 (2012). It is the defined and consistently applied policy of VA to administer the law under a broad interpretation, consistent, however, with the facts shown in every case. Any reasonable doubt regarding the degree of disability is resolved in favor of the veteran. 38 C.F.R. §§ 3.102, 4.3. While a veteran's entire history is reviewed when assigning a disability evaluation, where service connection has already been established and an increase in the rating is at issue, it is the present level of disability that is of primary concern. Francisco, 7 Vet. App. at 55. In determining the present level of a disability for any increased evaluation claim, the Board must consider the application of staged ratings. See Hart, 21 Vet. App. at 505. Disabilities of the spine usually are rated under the General Rating Formula for Diseases and Injuries of the Spine (Diagnostic Codes 5235 to 5243). 38 C.F.R. § 4.71a. Ratings under the General Rating Formula for Diseases and Injuries of the Spine are made with regard to the presence or non-presence of symptoms such as pain (whether or not it radiates), stiffness, or aching in the area of the spine affected by residuals of injury or disease. The General Rating Formula for Diseases and Injuries of the Spine provides a 10 percent disability rating for forward flexion of the thoracolumbar spine greater than 60 degrees but not greater than 85 degrees; combined range of motion of the thoracolumbar spine greater than 120 degrees but not greater than 235 degrees; 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 disability rating is assigned for forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees; or combined range of motion of the thoracolumbar spine not greater than 120 degrees; or muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. A 40 percent disability rating is assigned for forward flexion of the thoracolumbar spine limited to 30 degrees or less, or favorable ankylosis of the entire thoracolumbar spine. A 50 percent disability rating is assigned for unfavorable ankylosis of the entire thoracolumbar spine. A 100 percent disability rating is assigned for unfavorable ankylosis of the entire spine. Id. Note (2) provides that, for VA compensation purposes, normal forward flexion of the thoracolumbar spine is zero to 90 degrees, extension is zero to 30 degrees, left and right lateral flexion are zero to 30 degrees, and left and right lateral rotation are zero to 30 degrees. The normal combined range of motion of the thoracolumbar spine is 240 degrees. See also Plate V, 38 C.F.R. § 4.71a. The Formula for Rating Intervertebral Disc Syndrome (IVDS) Based on Incapacitating Episodes provides a 20 percent disability rating for IVDS with incapacitating episodes having a total duration of at least two weeks, but less than four weeks, during the past 12 months; a 40 percent disability rating for IVDS with incapacitating episodes having a total duration of at least four weeks, but less than six weeks, during the past 12 months; and a 60 percent disability rating for IVDS with incapacitating episodes having a total duration of at least six weeks during the past 12 months. 38 C.F.R. § 4.71a. Note (1) to DC 5243 defines an incapacitating episode as a period of acute signs and symptoms due to IVDS that requires bed rest prescribed by a physician and treatment by a physician. Id. Regardless of the criteria, when assigning a disability rating for an orthopedic disorder, it is necessary to consider functional loss due to flare-ups, fatigability, incoordination, and pain on movement. See DeLuca v. Brown, 8 Vet. App. 202, 206-07 (1995). Under 38 C.F.R. §§ 4.40 and 4.45, the rating for an orthopedic disorder must reflect functional limitation which is due to pain, as supported by adequate pathology and evidenced by the visible behavior of the claimant undertaking the motion. Weakness is also as important as limitation of motion, and a part which becomes painful on use must be regarded as seriously disabled. A little used part of the musculoskeletal system may be expected to show evidence of disuse, either through atrophy, the condition of the skin, absence of normal callosity, or the like. Pursuant to 38 C.F.R. § 4.59, painful motion should be considered limited motion, even though a range of motion may be possible beyond the point when pain sets in. See Powell v. West, 13 Vet. App. 31, 34 (1999); Hicks v. Brown, 8 Vet. App. 417, 421 (1995). When 38 C.F.R. § 4.59 is raised by the claimant or reasonably raised by the record, even in non-arthritis contexts, the Board should address its applicability. See Burton v. Shinseki, 25 Vet. App. 1 (2011) (holding that the Board had failed to address painful motion and the applicability of 38 C.F.R. § 4.59 to an initial disability rating for residuals of a left shoulder injury with surgical repair). Nonetheless, a higher rating is not assignable under any diagnostic code relating to range of motion where pain does not cause a compensable functional loss. The "pain must affect some aspect of 'the normal working movements of the body' such as 'excursion, strength, speed, coordination, and endurance,'" as defined in 38 C.F.R. § 4.40, before a higher rating may be assigned. This is because "pain alone does not constitute a functional loss under the VA regulations that evaluate disability based upon range-of-motion loss." Mitchell v. Shinseki, 25 Vet. App. 32, 33, 43 (2011). The Board notes for sake of reference that ankylosis is "immobility and consolidation of a joint due to disease, injury, or surgical procedure." See Lewis v. Derwinski, 3 Vet. App. 259 (1992) (citing Saunders Encyclopedia and Dictionary of Medicine, Nursing, and Allied Health at 69 (4th ed. 1997)). Moreover, for VA compensation purposes, unfavorable ankylosis is a condition in which the entire cervical spine, the entire thoracolumbar spine, or the entire spine is fixed in flexion or extension, and the ankylosis results in one or more of the following: difficulty walking because of a limited line of vision; restricted opening of the mouth and chewing; breathing limited to diaphragmatic respiration; gastrointestinal symptoms due to pressure of the costal margin on the abdomen; dyspnea or dysphagia; atlantoaxial or cervical subluxation or dislocation; or neurologic symptoms due to nerve root stretching. Significant to this appeal, fixation of a spinal segment in neutral position (zero degrees) always represents favorable ankylosis. See 38 C.F.R. § 4.71a, General Rating Formula for Diseases and Injuries of the Spine, Note (1). Radiculopathy, if it is found to be due to a service-connected low back disability, is rated under the criteria for paralysis of the sciatic nerve, found at 38 C.F.R. § 4.124a, Diagnostic Code 8620 (2012). Under these criteria, mild symptomatology of paralysis of the sciatic nerve warrants a 10 percent evaluation, moderate symptomatology warrants a 20 percent rating, moderately severe symptomatology warrants a 40 percent rating, and severe incomplete paralysis, with marked muscular atrophy, warrants a 60 percent rating. 38 C.F.R. § 4.124a. The Board has reviewed all of the lay and medical evidence in the Veteran's claims folder. The Board finds that the Veteran is competent to report the symptoms and impairments associated with his low back disability. See Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009); Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007) (holding that lay statements may serve to support a claim by supporting the occurrence of lay-observable events or the presence of disability or symptoms of disability that are susceptible of lay observation). The Board has not discounted lay evidence regarding the severity of the Veteran's low back disability because it is lay evidence or because it was reported by the Veteran. See Kowalski v. Nicholson, 19 Vet. App. 171 (2005). That being said, the Board has an obligation to determine the credibility of all evidence, lay and medical. See Madden, at 1481 (holding that the Board has the duty to assess the credibility and weight to be given to the evidence). The Board has considered all evidence of record as it bears on the question of an increased rating. See 38 U.S.C.A. § 7104(a) (West 2002 & Supp. 2012) ("Decisions of the Board shall be based on the entire record in the proceeding and upon consideration of all evidence and material of record"); 38 U.S.C.A. § 5107(b) ("Secretary shall consider all information and lay and medical evidence of record in a case"). Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, the extensive evidence of record. The United States Court of Appeals for the Federal Circuit (Federal Circuit) has held that the Board must review the entire record, but does not have to discuss each piece of evidence. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000). Therefore, the Board will summarize the relevant evidence where appropriate, and the Board's analysis below will focus specifically on what the evidence shows, or fails to show, as to the Veteran's appeal. Increased Rating for Low Back Disability The Veteran essentially contends that his low back disability warrants higher ratings under 38 C.F.R. § 4.97, Diagnostic Code 5242 than the 20 percent rating assigned for the increased rating period prior to February 11, 2012; and the 40 percent rating assigned from February 11, 2012. Specifically, the Veteran reports that his low back disability has been manifested by pain and symptomatology at least equivalent to that required for a 40 percent rating during the entire increased rating period under appeal. As noted above, in a September 2012 rating decision, the AMC granted a separate 10 percent rating for radiculopathy of the left lower extremity, supposedly related to the Veteran's low back disability, effective February 11, 2012. The Veteran contends that he experienced radiculopathy in both lower extremities related to his low back disability during the entire initial rating period under appeal and also that his radiculopathy of the left lower extremity symptoms, by themselves, merit an increased rating than the 10 percent rating currently assigned. Prior to February 11, 2012 Having reviewed the record of evidence, both lay and medical, for the period prior to February 11, 2012, the Board finds that the Veteran's low back disability symptomatology did not meet or more nearly approximate the criteria for a next higher 40 percent rating under any of the applicable diagnostic codes. 38 C.F.R. § 4.71a. For the period prior to February 11, 2012, the Board finds that the Veteran's low back disability was not manifested by limitation of forward flexion of the thoracolumbar spine more nearly approximating 30 degrees or less due to pain or favorable ankylosis of the entire thoracolumbar spine. The Board notes that the Veteran was granted service connection in August 1992 for a diagnosed lumbar strain that the Veteran incurred during service. The Veteran was not diagnosed as having any degenerative disease of the spine at the time of the granting of service connection. Reviewing the evidence for the increased rating period prior to February 11, 2012, in a December 2007 VA medical examination report, the Veteran reported experiencing stiffness in his lower back since an in-service accident. The Veteran indicated that his main complaint was an inability to sleep due to back pain. The Veteran reported that the pain would be eased if he flexed his knees at night. The Veteran stated that the pain was roughly the same every day and that he did not experience any true flare-ups of pain. The Veteran indicated that his low back pain generally was about a seven on a scale of 10, but could vary from a six to a nine on a scale of 10. The Veteran indicated that his pain would be worsened by increased activity. The Veteran reported taking pain medication for relief and using heating pads with limited success. The Veteran stated that he had not tried either physical therapy or surgery. The Veteran specifically denied experiencing any radicular symptoms, bowel or bladder dysfunction, or fevers. The Veteran indicated that he did not wear any orthotics or use a cane or crutch, but stated that he would occasionally use a back brace. The Veteran indicated that the brace in question was not prescribed by any doctor. The Veteran denied experiencing any incapacitating episodes or being prescribed bed rest within the past year. The Veteran indicated that he could walk a block if necessary. The Veteran indicated that he had been unemployed since 2007. The Veteran indicated that he worked last as a welder, but left the job because his back "bothered him." The Veteran denied being fired or laid off. Upon examination, the VA examiner noted that the Veteran exhibited forward flexion of the thoracolumbar spine to 60 degrees, with pain at 45 degrees. The VA examiner indicated that the Veteran was very hesitant and resistant to performing the examination. The VA examiner noted no limitation of motion due to repetitive use due to fatigue, weakness, lack of endurance, or incoordination. The VA examiner noted that a review of lumbar X-ray and CT scans showed no fracture, no dislocation, no bony abnormalities, normal alignment, and normal disc space maintenance. The VA examiner noted that the Veteran had negative flip and straight leg raise tests bilaterally for radicular symptoms. The VA examiner reported that the Veteran had some tightness in the hamstrings when performing the straight leg test that started to bother him at about 60 degrees of flexion of the legs bilaterally. The examiner noted five out of five strength to EHL, TA, GS, quad, hamstring, and hip flexors. The VA examiner also indicated normal sensation to light touch L4 through S1. DP and PT pulses were present. The VA examiner reported negative Babinski and clonus tests. The VA examiner indicated that he could not elicit deep tendon reflexes bilaterally. The VA examiner diagnosed a lumbar strain and tight hamstrings. The VA examiner reported that the Veteran had some limited motion upon examination of the lumbar spine, but stated that this was partially explained by the Veteran's being resistant to examination. The examiner also stated that the Veteran had tight hamstring and lower lumbar muscles, and suggested that the Veteran be provided with therapy. Regarding DeLuca, the VA examiner noted that the Veteran experienced pain on range of motion testing. The VA examiner opined that it was conceivable that the pain could further limit the Veteran's function as described, particularly after being on his feet or after lifting heavy objects all day. The VA examiner stated that it was not feasible, however, to attempt to express any of this in terms of additional limitation of motion as those matters could not be determined with any degree of medical certainty. In a January 2008 SSA record, specifically an adult function report, the Veteran stated that, due to his injuries, he could not lift heavy objects, weld, or repair cars and trucks. The Veteran stated that he could perform activities of daily living, to include shopping and driving a car. When asked which activities his disabilities affected, the Veteran replied, in pertinent part, lifting, standing, walking, sitting, stair climbing, kneeling, squatting, reaching, and bending. In a work history report, dated January 5, 2008, the Veteran reported working at only one job over the past 15 years, specifically as a converter assembler. In a January 2008 SSA report on his pain, the Veteran stated that he experienced constant stiffness in his back and arm, along with numbness. The Veteran stated that the pain was constant but increased in severity at times. The Veteran stated that such symptoms could be caused by standing or walking from 10 to 15 minutes, or sitting from 30 to 40 minutes. In a February 2008 work history report, the Veteran reported working 10 different jobs over the previous fifteen years. Of note, the Veteran reported working as a welder only for approximately two and a quarter years, with his last such employment ending in 2001. Since that time, the Veteran reported working as a conveyor manufacturer, a fast food cook, and, for one week in 2007, on a factory assembly line in an unnamed position. In a February 2008 physical capacity evaluation, a SSA examiner indicated that the Veteran's primary diagnosis was right carpal tunnel syndrome status post surgery, and his secondary diagnosis was non-invasive renal carcinoma. After examining the Veteran, the SSA examiner found that the Veteran could occasionally lift 20 pounds, frequently lift 10 pounds, stand and/or walk about six hours in an eight-hour workday, sit with normal breaks about six hours in an eight-hour workday, and push or pull an unlimited amount. The SSA examiner indicated that the Veteran would experience no postural limitations, such as climbing stairs or ramps, balancing, stooping, kneeling, crouching, or crawling. In a February 2008 VA treatment record, a VA examiner noted that the Veteran ambulated without assistance. Upon examination, the VA examiner noted that both the Veteran's musculoskeletal and neurological systems were normal. In an August 2009 VA MRI of the lumbar spine report, a VA examiner noted degenerative changes involving the lumbar spine, to include a diffuse disc bulge with a suspicious subtle annular tear at L5-S1 with a tiny central protrusion, mild indentation of the underlying thecal sac, and mild narrowing of the left neural foramina; and a diffuse disc bulge at L4-L5 with mild indentation of the underlying thecal sac and mild to moderate narrowing of the bilateral neural foramina. At the August 2009 Travel Board hearing, the Veteran testified that he had problems with bending of the low back that had worsened. The Veteran stated that he could not sleep at night, could not lift, or go for long walks. The Veteran stated that he was also experiencing neurological disorders, to include "a little bit of drop foot." The Veteran indicated that his foot was constantly falling asleep. The Veteran's spouse testified that the Veteran could not drive often because his back would begin to hurt. She also stated that the Veteran's back would go out. In a December 2010 VA primary care note, a VA examiner reported that the Veteran did not experience any musculoskeletal disorders. A neurological examination indicated that motor strength was five out of five throughout, sensory nerves were intact to light touch, deep tendon reflexes were 2+ throughout, and gait and balance were normal. In a September 2012 statement, the Veteran indicated that his low back disability should have been rated higher than 20 percent for the period prior to February 11, 2012. The Veteran stated that his low back disability worsened years prior to February 2012. The Veteran stated that he struggled everyday with walking, sitting, laying down, and cramping. The Veteran also indicated that he had experienced numbness in his hips and legs. Having reviewed the evidence, the Board finds that the Veteran's low back disability symptomatology for the increased rating period prior to February 11, 2012 did not more nearly approximate the limitation of motion listed in the criteria for the next higher 40 percent rating under the General Rating Formula for Diseases and Injuries of the Spine. 38 C.F.R. § 4.71a, Diagnostic Code 5242. For the increased rating period prior to February 11, 2012, the preponderance of the evidence indicates that the Veteran's low back disability was manifested, at worse, by limitation of motion of the thoracolumbar spine to 45 degrees, which is greater than the limitation of flexion to 30 degrees which is the minimum requirement for a 40 percent rating based on limitation of forward flexion under the General Rating Formula for Diseases and Injuries of the Spine. As noted above, a 40 percent rating under the aforementioned formula may be awarded if forward flexion of the thoracolumbar spine is limited to 30 degrees or less due to a low back disorder. As such, in order to qualify for a next higher 40 percent rating for limitation of forward flexion, a veteran must show symptomatology more nearly approximating forward flexion of the spine limited to at least 30 degrees. In the December 2007 VA medical examination report, a VA examiner noted that the Veteran's motion of the spine was limited to 45 degrees due to pain. The VA examiner opined that the Veteran could experience additional limitation of function of the spine, particularly after being on his feet or after lifting heavy objects all day, but did not indicate that such limitations would more nearly approximate the limitation of forward flexion of the thoracolumbar spine to 30 degrees required for a 40 percent rating. Subsequent VA treatment records do not contain any notation indicating limitation of motion of the spine. In fact, subsequent medical records note that the Veteran lacked any low back disability symptomatology. Therefore, the medical evidence of record does not indicate low back disability symptomatology more nearly approximating limitation of forward flexion of the thoracolumbar spine to 30 degrees as required for a next higher 40 percent rating under Diagnostic Code 5242. See id. Reviewing the lay statements of record, the Veteran has reported experiencing limitation of motion of spine in his lay statements. However, in his statements regarding his symptomatology of the spine for the increased rating period prior to February 11, 2012, the Veteran did not indicate experiencing limitation of motion of the spine more nearly approximating the limitation of forward flexion of the thoracolumbar spine to 30 degrees required for a 40 percent rating. Although the Veteran reported experiencing pain of the spine, he did not report that such pain caused limitation of forward flexion of the low back to 30 degrees, as required for a next higher rating. Therefore, the Board finds that the evidence, both lay and medical, for the increased rating period prior to February 11, 2012 does not indicate functional loss of the thoracolumbar spine, to include due to flare-ups, fatigability, incoordination, and pain on movement, such as to approximate limitation of forward flexion of the thoracolumbar spine to 30 degrees required for a 40 percent rating. See id.; see also DeLuca, 8 Vet. App. at 206-07 (1995). The record also contains no evidence, lay or medical, indicating favorable ankylosis of the entire thoracolumbar spine. Although the Veteran reported experiencing limitation of motion of the spine during the period prior to February 11, 2012, the Veteran did not report symptoms so severe as to more nearly approximate a complete loss of forward flexion or extension of the lumbar spine. Moreover, the medical records in evidence contain no notation or diagnosis indicating favorable ankylosis. As such, for the increased rating period prior to February 11, 2012, the Veteran's low back disability symptomatology does not more nearly approximate the favorable ankylosis of the spine required for the next higher 40 percent rating under the General Rating Formula for Diseases and Injuries of the Spine. 38 C.F.R. § 4.71a, Diagnostic Code 5242. As noted above, the Veteran was originally service connected for a lumbar strain. In the December 2007 VA medical examination report, a VA examiner again diagnosed the Veteran as having a lumbar strain. In an August 2009 VA lumbar spine MRI report, a VA examiner diagnosed the Veteran as having degenerative changes of the lumbar spine. As will be explained more thoroughly below, in a February 2012 VA medical examination report, a VA examiner opined that the Veteran's current degenerative joint disease was less likely than not related to the service-connected lumbar strain. As the Board finds that the February 2012 VA medical examination report has probative value in this matter, the Board notes that the need to determine whether the Veteran's low back disability symptomatology more nearly met that required for a 40 percent rating under the Formula for Rating IVDS Based on Incapacitating Episodes under Diagnostic Code 5243 is questionable, at best. 38 C.F.R. § 4.71a, Diagnostic Code 5243. However, in reviewing the evidence, the Board notes that for the period prior to February 11, 2012, the record contains no evidence, lay or medical, indicating that the Veteran's low back disability caused symptomatology of such severity that he underwent bed rest prescribed by a physician of at least four weeks during any 12-month period. Therefore, for the period prior to February 11, 2012, the Veteran's low back disability symptomatology did not more nearly approximate that required for a 40 percent rating under the Formula for Rating IVDS Based on Incapacitating Episodes under Diagnostic Code 5243. 38 C.F.R. § 4.71a, Diagnostic Code 5243. The Board notes that the medical evidence of record contains no notation or diagnosis for radiculopathy prior to February 11, 2012. In lay statements made in support of his claim for an increased rating for that period, the Veteran claimed to have experienced radiculopathy. Specifically, at the August 2009 Travel Board hearing, the Veteran testified that he experienced a feeling as if his foot were asleep. However, the Board finds that the Veteran's reports of radiculopathy during this period are not credible as they are inconsistent with the other evidence of record, to include the Veteran's own statements. See Caluza v. Brown, 7 Vet. App. 498 (1995) (holding that, in weighing credibility of lay evidence, even that recorded in a medical record, VA may consider such elements as interest, bias, inconsistent statements, bad character, internal inconsistency, facial plausibility, self interest, consistency with other evidence of record, malingering, desire for monetary gain, and demeanor of the witness). As noted above, in the December 2007 VA medical examination report, the Veteran specifically denied experiencing radiculopathy. In a February 2008 VA treatment record, a VA examiner noted that the Veteran's neurological system was normal. In a January 2008 SSA record, when asked which activities his disabilities affected, the Veteran replied, in pertinent part, lifting, standing, walking, sitting, stair climbing, kneeling, squatting, reaching, and bending. Yet, in a February 2008 physical capacity evaluation, a SSA examiner indicated that the Veteran would experience no postural limitations, such as climbing stairs or ramps, balancing, stooping, kneeling, crouching, or crawling. Of note, the February 2008 SSA examiner, having examined the Veteran, did not indicate that the Veteran's low back disability was either a primary or secondary disability affecting his ability to work. At the August 2009 Travel Board hearing, the Veteran testified that his foot would fall asleep and even suggested that he would drag it at times. Yet, in a December 2010 VA primary care note, written after the August 2009 Travel Board hearing, a VA examiner indicated that neurological testing, to include motor strength, sensory nerve, deep tendon reflex, and gait and balance testing were normal. The Board notes that the Veteran contends that he experienced great difficulty with radiculopathy during the period prior to February 11, 2012. However, the medical evidence contains no diagnosis for radiculopathy prior to February 11, 2012. In fact, at all examinations performed during the period prior to February 11, 2012, VA examiners indicated that the Veteran did not have a neurological disorder of the lower extremities. Moreover, although the Veteran now claims that he experienced radiculopathy symptoms for years, in the December 2007 VA medical examination report, the Veteran himself specifically denied experiencing any radiculopathy symptomatology. Therefore, the Board finds that the Veteran's lay reports indicating that he experienced radiculopathy symptomatology prior to February 11, 2012 are not credible as they are inconsistent with both the specific medical evidence of record and the Veteran's own December 2007 denial of radiculopathy symptoms. See id. For the reasons stated above, for the increased rating period prior to February 11, 2012, the Board finds that the preponderance of the evidence weighs against the grant of a rating in excess of 20 percent under 38 C.F.R. § 4.71a, Diagnostic Code 5242; therefore, the benefit of the doubt doctrine does not apply to this aspect of the appeal. 38 U.S.C.A. § 5107(b); 38 C.F.R. §§ 4.3, 4.7. From February 11, 2012 Having reviewed the record of evidence, both lay and medical, for the increased rating period from February 11, 2012, the Board finds that the Veteran's low back disability symptomatology did not meet or more nearly approximate the criteria for a next higher rating under any of the applicable diagnostic codes. 38 C.F.R. § 4.71a. Specifically for the period from February 11, 2012, the Board finds that the Veteran's low back disability was not manifested by symptomatology more nearly approximating unfavorable ankylosis of the entire thoracolumbar spine. Reviewing the evidence for the increased rating period from February 11, 2012, in a February 2012 VA medical examination report, the Veteran reported experiencing pain in his back, shooting down his left and occasionally his right leg. The Veteran stated that his left leg had been numb for about two weeks and that he limped as a result. The Veteran stated that his low back would flare-up with activities and certain movements on a daily basis. The Veteran stated that he was unable to work during a flare-up. Upon physical examination, the VA examiner noted that thoracolumbar spine range of motion was limited, with onset of pain beginning at ten degrees of flexion, zero degrees of extension, ten degrees of bilateral lateral flexion, and ten degrees of bilateral rotation. The VA examiner stated that the Veteran would experience additional limitation of range of motion of the back upon repetitive use, including less movement than normal, pain on movement, disturbance of locomotion, and interference with sitting, standing, and/or weight-bearing. However, in recording his results, the VA examiner noted that the Veteran's range of motion upon three repetitive attempts were the same as upon initial testing. The VA examiner noted that the Veteran had normal strength in the lower extremities and no indication of muscle atrophy. The VA examiner indicated that deep tendon reflexes were normal. Upon sensory examination, the VA examiner reported that sensation to light touch was normal in the right lower extremity and left upper anterior thigh, but decreased in the left thigh/knee, lower leg/ankle, and foot/toes. Straight leg testing was negative on the right, but positive on the left, suggesting left lower extremity radiculopathy. The VA examiner noted that the Veteran experienced mild pain, paresthesias and/or dysesthesias, and numbness in the left lower extremity, but no such symptoms in the right extremity. The VA examiner diagnosed the Veteran as having mild left lower extremity radiculopathy involving the L4-L5 nerve, but no radiculopathy of the right lower extremity. The VA examiner stated that the Veteran did not have IVDS. The VA examiner noted that the Veteran used a back brace regularly. The VA examiner noted that the Veteran had arthritis documented by X-ray evidence. After interviewing the Veteran, performing a physical examination, and reviewing the claims file, the February 2012 VA examiner diagnosed the Veteran as having degenerative disc disease with a sign of radiculopathy. The VA examiner stated that this disability would not allow the Veteran to perform work that required heavy lifting or prolonged standing/walking. However, the VA examiner indicated that the Veteran would be fit to perform sedentary work. Having reviewed all evidence of record, the VA examiner further opined that the Veteran's current degenerative disc disease was not related to the service-connected lumbar strain. The VA examiner indicated that there was no medical evidence to suggest that a lumbar strain would lead to either radiculopathy or degenerative disc disease. In a September 2012 lay statement, the Veteran stated that the disability ratings assigned for his respective low back and radiculopathy disabilities from February 11, 2012 did not take into account his everyday struggles with walking, sitting, laying down, cramping, and numbness in his legs and hips. Having reviewed the evidence, the Board finds that the Veteran's low back disability symptomatology for the period from February 11, 2012 has not more nearly approximated the unfavorable ankylosis of the entire thoracolumbar spine required for the next higher 50 percent rating under the General Rating Formula for Diseases and Injuries of the Spine. See id. In order to support a finding of unfavorable ankylosis of the entire thoracolumbar spine, the evidence must indicate the Veteran's lumbosacral spine is fixed in flexion or extension, and that the anklyosis itself has resulted in one or more of the following: difficulty walking because of a limited line of vision; restricted opening of the mouth and chewing; breathing limited to diaphragmatic respiration; gastrointestinal symptoms due to pressure of the costal margin on the abdomen; dyspnea or dysphagia; atlantoaxial or cervical subluxation or dislocation; or neurologic symptoms due to nerve root stretching. See 38 C.F.R. § 4.71a, General Rating Formula, Note (1). Here, the Veteran has not been diagnosed with anklyosis despite a thorough examination of the thoracolumbar spine. The Board notes that the February 2012 VA examiner reported that the Veteran experienced pain beginning at zero degrees of extension, suggesting symptoms more nearly approximating ankylosis, a fixation of extension of the spine. However, the evidence of record does not indicate that the Veteran's fixation of extension spine has caused difficulty walking because of a limited line of vision; restricted opening of the mouth and chewing; breathing limited to diaphragmatic respiration; gastrointestinal symptoms due to pressure of the costal margin on the abdomen; dyspnea or dysphagia; atlantoaxial or cervical subluxation or dislocation; or neurologic symptoms due to nerve root stretching. Therefore the evidence indicates the Veteran's low back disability does not meet the criteria required for the next higher 50 percent rating under 38 C.F.R. § 4.71a, Diagnostic Code 5242. The Board notes that the Veteran was reported to experience additional loss of motion of the spine upon repetitive use. However, the evidence does not indicate that such limitation would cause functional loss of the thoracolumbar spine, to include due to flare-ups, fatigability, incoordination, and pain on movement, such as to approximate unfavorable ankylosis of the thoracolumbar spine with any of the additional symptoms required for a next higher 50 percent rating. See id.; see also DeLuca, 8 Vet. App. at 206-07 (1995). The Board notes that the February 2012 VA examiner reported that the Veteran did not have IVDS. However, even if the Veteran's current low back disability were to be evaluated under the Formula for Rating IVDS Based on Incapacitating Episodes under 38 C.F.R. § 4.71a, Diagnostic Code 5243 for the period from February 11, 2012, the Board notes that the record contains no evidence, lay or medical, indicating that the Veteran's low back disability caused symptomatology of such severity that he experienced incapacitating episodes having a total duration of at least six weeks during any 12 month period. Therefore, for the period from February 11, 2012, the Veteran's low back disability symptomatology did not more nearly approximate that required for a 60 percent rating under the Formula for Rating IVDS Based on Incapacitating Episodes under Diagnostic Code 5243. 38 C.F.R. § 4.71a, Diagnostic Code 5243. The Board also finds that the Veteran's radiculopathy of the left lower extremity symptomatology did not more nearly approximate the moderate symptomatology required for a next higher 10 percent rating for the period from February 11, 2012. Moreover, the Board finds that the Veteran does not have radiculopathy of the right lower extremity related to his service-connected low back disability. In the February 2012 VA medical examination report, the Veteran reported experiencing numbness of the left lower extremity for the previous two weeks, suggesting greater symptomatology than mild symptoms. The Veteran also stated that he back pain shooting up both his left and right legs. Moreover, in the September 2012 statement, the Veteran indicated that he also had radiculopathy of the right lower extremity. In this instance, the Board finds that the Veteran's report of greater than mild radiculopathy related to his service-connected low back disability is outweighed by the probative medical evidence of record. See Madden, at 1481. In this instance, the VA examiner specifically noted that the Veteran's lower extremity strength was normal and that deep tendon reflex testing was also normal. Further testing, to include sensory tests, indicated mild radiculopathy symptoms. Therefore, the medical evidence contains no indication that the Veteran's radiculopathy caused any symptoms of a moderate nature. In addition, the VA examiner specifically found that the Veteran did not have diagnosable radiculopathy of the right lower extremity. Moreover, the Board notes that the evidence of record indicates that the Veteran has radiculopathy, related to diagnosed degenerative disc disease. However, the evidence also indicates that the degenerative disc disease is less likely than not related to the Veteran's service-connected low back disability, specifically a lumbar strain. See Mittleider v. West, 11 Vet. App. 181, 182 (1998) (indicating that the Board may distinguish between symptoms related to separate disorders if there is competent and credible evidence which would allow for such action). In this instance, the February 2012 VA medical examiner noted interviewing the Veteran, performing an exhaustive physical examination, and reviewing the claims file. Having diagnosed the Veteran as having both degenerative disc disease and radiculopathy related to that disorder, the VA examiner opined that the degenerative disc disease was less likely than not related to the Veteran's service-connected lumbar strain. In explaining this finding, the VA examiner, based on the evidence of record and his professional knowledge, stated that there was no medical evidence to suggest that a lumbar strain would lead to either radiculopathy or degenerative disc disease. As the February 2012 VA medical examination report was written after an interview with the Veteran, a medical examination, a review of the claims file, and contains specific findings based on all evidence of record, the Board finds that the February 2012 VA medical examination report is of great probative value in determining the etiology of the Veteran's diagnosed degenerative disc disease. See Prejean v. West, 13 Vet. App. 444, 448 (2000) (indicating that the Board may determine the probative value of medical opinions based on their detail, the persuasiveness of their opinions, and the physicians' access to a veteran's medical records). Therefore, the Board notes that the Veteran's reports of greater than mild radiculopathy symptomatology in the left lower extremity and radiculopathy in the right lower extremity are outweighed by the specific and objective medical findings regarding the nature of the Veteran's radiculopathy symptoms found in the February 2012 VA medical examination report. See Madden, at 1481. Moreover, although the Board will not take any action to either decrease or eliminate the 10 percent rating currently assigned for radiculopathy of the left lower extremity, the only probative opinion of record, specifically the February 2012 VA medical opinion, indicates that the Veteran's radiculopathy symptoms are not related to his service-connected lumbar strain. Therefore, the preponderance of the evidence weighs against any grant of an additional rating for right extremity radiculopathy or an increased rating for left lower extremity radiculopathy. For the reasons stated above, for the increased rating period from February 11, 2012, the Board finds that the preponderance of the evidence weighs against the grant of a rating in excess of 40 percent under 38 C.F.R. § 4.71a, Diagnostic Code 5242. Therefore, the benefit of the doubt doctrine does not apply to this aspect of the appeal. 38 U.S.C.A. § 5107(b); 38 C.F.R. §§ 4.3, 4.7. Extraschedular Consideration The Board has considered whether referral for consideration of an extraschedular evaluation is warranted for the Veteran's claim for an increased rating for a low back disability, to include radiculopathy. In exceptional cases, an extraschedular rating may be provided. 38 C.F.R. § 3.321 (2012). The threshold factor for extraschedular consideration is a finding that the evidence before VA presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. Therefore, initially, there must be a comparison between the level of severity and symptomatology of a veteran's service-connected disability with the established criteria found in the Rating Schedule for that disability. Thun v. Peake, 22 Vet. App. 111 (2008). Under the approach prescribed by VA, if the criteria reasonably describe a veteran's disability level and symptomatology, then the veteran's disability picture is contemplated by the Rating Schedule, the assigned schedular evaluation is, therefore, adequate, and no referral is required. In the second step of the inquiry, however, if the schedular evaluation does not contemplate a veteran's level of disability and symptomatology and is found inadequate, the RO or Board must determine whether the veteran's exceptional disability picture exhibits other related factors such as those provided by the regulation as "governing norms." 38 C.F.R. § 3.321(b)(1) (stating that related factors include "marked interference with employment" and "frequent periods of hospitalization"). When the Rating Schedule is inadequate to evaluate a veteran's disability picture, and that picture has 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 for completion of the third step-a determination of whether, to accord justice, the claimant's disability picture requires the assignment of an extraschedular rating. Id. Regarding the Veteran's service-connected low back disability with radiculopathy, turning to the first step of the extraschedular analysis, the Board finds that the symptomatology and impairment caused by the Veteran's low back disability, with radiculopathy, is specifically contemplated by the schedular rating criteria (38 C.F.R. § 4.71a, Diagnostic Code 5242; 38 C.F.R. § 4.124a, Diagnostic Code 8620), and no referral for extraschedular consideration is required. The schedular rating criteria at Diagnostic Code 5242 specifically provide for disability ratings based on a combination of history, symptoms, and clinical findings. The schedular rating criteria specifically provide for ratings based on limitation of motion, including due to flare-ups, fatigability, incoordination, and pain on movement. See 38 C.F.R. §§ 4.40, 4.45, 4.59; see also DeLuca. In this case, considering the lay and medical evidence for the increased rating period prior to February 11, 2012, the Veteran's low back disability was manifested by limitation of forward flexion of the thoracolumbar spine to 45 degrees. Moreover, for the increased rating period from February 11, 2012, the Veteran's low back disability was manifested by limitation of forward flexion to 10 degrees and limitation of extension to zero degrees. The schedular rating criteria specifically allow for ratings based on the severity of the limitations of motion of the low back. Regarding the separately rated radiculopathy disorder, the evidence indicates that the Veteran did not have such a disorder prior to February 11, 2012. Considering the lay and medical evidence for the increased rating period from February 11, 2012, the Board has found that the Veteran's radiculopathy of the left lower extremity disability was manifested by mild sensory numbness and pain. The schedular rating criteria specifically allow for ratings based on the severity of neurological symptomatology. As the schedular evaluation contemplate the Veteran's level of disability and symptomatology of the left back disability, to include radiculopathy, the Board need not determine whether there is an exceptional disability picture that exhibits other related factors such as those provided by the regulation as "governing norms." 38 C.F.R. 3.321(b)(1). In the absence of evidence that the schedular rating criteria is inadequate to rate the symptoms of the Veteran's low back disability, to include radiculopathy, the Board is not required to remand the issue of a higher initial rating for a low back disability to the RO for the procedural actions outlined in 38 C.F.R. § 3.321(b)(1). See Bagwell v. Brown, 9 Vet. App. 337 (1996); Shipwash v. Brown, 8 Vet. App. 218, 227 (1995). ORDER An increased rating for a low back disability, in excess of 20 percent prior to February 11, 2012; and in excess of 40 percent from February 11, 2012, is denied. REMAND The Board finds that additional development is required regarding the issue of TDIU prior to Board adjudication. 38 C.F.R. § 19.9 (2012). The Veteran is currently service-connected for a low back disability (rated as 40 percent disabling), radiculopathy of the left lower extremity (rated as 10 percent disabling), and cancer of the kidney and urinary bladder status post left kidney removal and multiple turbst (rated as 20 percent disabling) and residuals of cancer of the bladder and kidney, lower urinary tract symptoms with history of hematuria (rated as 30 percent disabling). As the Veteran's combined disability rating is 70 percent and one disability is rated as 40 percent disabling, the Veteran meets the percentage requirements for consideration of TDIU on a schedular basis under 38 C.F.R. § 4.16(a). The Veteran essentially contends that his service-connected disabilities preclude his potential employment. During the pendency of the appeal, VA has not procured an opinion as to whether the Veteran's service-connected disabilities rendered the Veteran unable to obtain and maintain employment consistent with his education and occupational experience. The Court has held that a TDIU claim may not be denied without producing evidence, as distinguished from mere conjecture, that a veteran's disability does not prevent him or her from performing work that would produce sufficient income to be other than marginal. Friscia v. Brown, 7 Vet. App. 294 (1995), citing Beaty v. Brown, 6 Vet. App. 532, 537 (1994). In Friscia, the Court specifically stated that VA has a duty to supplement the record by obtaining an examination, which includes an opinion on what effect the appellant's service-connected disabilities have on the ability to work. Friscia, 7 Vet. App. at 297 (citing 38 U.S.C.A. § 5107(a) (West 2002 & Supp. 2012)); 38 C.F.R. §§ 3.103(a), 3.326, 3.327, 4.16(a) (2011); Beaty, 6 Vet. App. at 537; Obert v. Brown, 5 Vet. App. 30, 33 (1993). In light of the foregoing, the Board finds that the Veteran requires a VA examination to ascertain whether the Veteran is unemployable due to his service-connected disabilities, specifically a low back disability, radiculopathy of the left lower extremity, and residuals of cancer of the kidney and urinary bladder. Accordingly, the case is REMANDED for the following action: 1. After the above development is completed, the AMC/RO should afford the Veteran a VA examination to determine the combined impact of all service-connected disabilities, specifically the Veteran's low back disability, radiculopathy of the left lower extremity, and separate symptoms of residuals of cancer of the kidney and urinary bladder (specifically status post left kidney removal and multiple turbst; and lower urinary tract symptoms with history of hematuria). All indicated tests and studies should be performed. In conjunction with the examination, the relevant evidence from the claims folder should be made available to the VA examiner. Following the review of the relevant evidence in the claims file, a clinical evaluation, and any diagnostic tests and/or additional examinations that are deemed necessary, the VA examiner should answer the following question: Whether the Veteran's service-connected disabilities, either singly or together, render him incapable of securing and maintaining substantially gainful employment consistent with his educational and occupational experience? A rationale should be given for any opinion provided. If an opinion cannot be provided without resort to pure speculation, the VA examiner should explain why speculation would be required in this case (e.g., if the requested determination is beyond the scope of current medical knowledge, actual causation cannot be selected from multiple potential causes, etc). The VA examiner should identify the relevant testing or other information needed to provide the requested opinion. If development is required, the development should be conducted and the claims file returned to the VA examiner. 2. After the completion of the above, the AMC/RO should re-adjudicate the issue of entitlement to TDIU. If the benefit sought on appeal is not granted, the Veteran and the representative should be provided with a Supplemental Statement of the Case (SSOC). An appropriate period of time should then be allowed for a response, before the record is returned to the Board for further review. The Veteran is advised to appear and participate in any scheduled VA examination, as failure to do so may result in denial of this claim. See 38 C.F.R. § 3.655 (2012). The Veteran and the representative have the right to submit additional evidence and argument on the matter the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims 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). ______________________________________________ JOHN Z. JONES Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs