Citation Nr: 1312646 Decision Date: 04/16/13 Archive Date: 05/02/13 DOCKET NO. 07-00 032 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Houston, Texas THE ISSUES 1. Entitlement to service connection for Bell's palsy. 2. Entitlement to service connection for a bilateral hand disorder, including arthritis. 3. Entitlement to initial rating higher than 10 percent for lumbosacral strain from July 2, 2004, to November 30, 3008, and to a rating higher than 20 percent since December 1, 2008. REPRESENTATION Appellant represented by: Texas Veterans Commission WITNESS AT HEARING ON APPEAL The Appellant-Veteran ATTORNEY FOR THE BOARD D. Bredehorst INTRODUCTION The Veteran served on active duty from May 1990 to April 2000 and from September 2000 to July 2004. This appeal to the Board of Veterans' Appeals (Board/BVA) from an October 2005 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) that granted service connection for lumbosacral strain and assigned an initial 10 percent rating for this low back disability retroactively effective from July 2, 2004, the first day after the Veteran's separation from service when he returned to life as a civilian. The RO also, however, denied his claims for service connection for arthritis of his hands and for Bell's palsy. As concerning his lumbosacral strain, he appealed for a higher initial rating for this low back disability. See Fenderson v. West, 12 Vet. App. 119, 125-26 (1999) (When a Veteran appeals an initial rating, VA adjudicators must consider whether to "stage" the rating, meaning assign different ratings at different times since the effective date of the award, if there have been occasions when the disability has been more severe than at others). Another RO decision since issued in March 2009, during the pendency of this appeal, granted service connection for patellofemoral pain syndrome of both knees, so right and left, and assigned separate 10 percent ratings retroactively effective from May 9, 2008. The Veteran contested these ratings, as well. Yet another RO decision in July 2009 increased the rating for his lumbosacral strain from 10 to 20 percent as of December 1, 2008. He continued to appeal for an even higher rating. See AB v. Brown, 6 Vet. App. 35, 38-39 (1993) (It is presumed he is seeking the highest possible rating for this disability unless he expressly indicates otherwise). So this claim now concerns whether he was entitled to an initial rating higher than 10 percent from July 2, 2004, to November 30, 3008, and whether he has been entitled to a rating higher than 20 percent since December 1, 2008. In July 2012, as support for his claims, the Veteran testified at a hearing at the RO before the undersigned Veterans Law Judge of the Board. This type of hearing is often and more commonly referred to as a Travel Board hearing. A transcript of the hearing is of record in the claims file. The Board issued a decision in September 2012 denying the claims for initial ratings higher than 10 percent for the patellofemoral pain syndrome affecting the right and left knees. Because, however, the remaining claims required further development before being decided on appeal, the Board remanded them to the RO via the Appeals Management Center (AMC) in Washington, DC. Still further development is needed concerning the claim of entitlement to service connection for a bilateral hand disorder, including arthritis, so the Board is again remanding this claim to the RO via the AMC. But the Board, instead, is going ahead and deciding the claims for service connection for Bell's palsy and for higher ratings for the lumbosacral strain. FINDINGS OF FACT 1. There is no competent and credible evidence confirming the Veteran has Bell's palsy or residuals of this disorder at any time since the filing of this claim. 2. From July 2, 2004 to November 30, 2008, his service-connected low back disability was manifested by pain, forward flexion limited to no worse than 65 degrees, discomfort and flare-ups with extended sitting or standing, and a combined range of thoracic and lumbar (thoracolumbar) spine motion greater than 120 degrees; there was no muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour; he did not have incapacitating episodes; and there was no evidence of ankylosis of his thoracolumbar spine, either favorable or unfavorable. 3. Since December 1, 2008, this service-connected low back disability has been manifested by pain, forward flexion limited to no worse than 45 degrees after repetitive motion, and complaints of stiffness, weakness, fatigue, and lack of endurance; there has been no evidence of incapacitating episodes or ankylosis, favorable or unfavorable, or of objective evidence that function has been additionally limited by pain, fatigue, weakness, incoordination, or lack of endurance. CONCLUSIONS OF LAW 1. It is not shown the Veteran has Bell's palsy due to disease or injury incurred in or aggravated by his active military service. 38 U.S.C.A. §§ 1110, 1131, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.303 (2012). 2. The criteria are not met for initial rating higher than 10 percent for the low back disability from July 2, 2004 to November 30, 2008, or for a rating higher than 20 percent since December 1, 2008. 38 U.S.C.A. §§ 1155, 5107(b) (West 2002); 38 C.F.R. §§ 3.102, 4.1, 4.3, 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes (DCs) 5235-5243 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA) enhanced VA's duties to notify and assist claimants with their claims for VA benefits upon receipt of a complete or substantially complete application. The VCAA was codified by statutes at 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, and 5126 (West 2002 & Supp. 2012), and the implementing VA regulations were codified, as amended, at 38 C.F.R. §§ 3.102, 3.156(a), 3.159, and 3.326(a) (2012). To this end, VA must: (1) inform the claimant of the information and evidence not of record that is necessary to substantiate the claim; (2) inform him of the information and evidence that VA will obtain; and (3) inform him of the information and evidence he is expected to provide. See also Quartuccio v. Principi, 16 Vet. App. 183, 187 (2002). When the claim is for service connection, the notice should address all five elements of the claim: (1) Veteran status, (2) existence of a disability, (3) relationship between the disability and service, (4) disability rating, and (5) effective date. See Dingess v. Nicholson, 19 Vet. App. 473, 486 (2006); aff'd sub nom. Hartman v. Nicholson, 483 F.3d 1311 (2007). The United States Court of Appeals for Veterans Claims (Court/CAVC) held in Pelegrini v. Principi, 18 Vet. App. 112 (2004), that, to the extent possible, the VCAA notice also should be provided to the claimant before an initial unfavorable decision on the claim. Pelegrini at 119-20. If, however, for whatever reason it was not, or the notice provided was inadequate or incomplete, this timing error can be effectively rectified ("cured") by providing any necessary VCAA notice and then readjudicating the claim - such as in a statement of the case (SOC) or supplemental SOC (SSOC), such that the intended purpose of the notice is not frustrated, rather preserved, and the Veteran is given an opportunity to participate effectively in the adjudication of the claim. See Mayfield v. Nicholson, 499 F.3d 1317, 1323 (Fed. Cir. 2007); Prickett v. Nicholson, 20 Vet. App. 370, 376 (2006). VCAA notice errors, even when shown to have occurred, are not presumptively prejudicial, rather, must be judged on a case-by-case basis. And as the pleading party attacking the agency's decision, the Veteran, not VA, has this burden of proof of not only establishing error, but, above and beyond that, showing how it is unduly prejudicial, meaning outcome determinative of the claim. Shinseki v. Sanders, 129 S. Ct. 1696 (2009). Here, an April 2005 pre-decisional letter provided the Veteran the required notice of the evidence and information necessary to substantiate his claims, the information required of him to enable VA to obtain evidence, and the assistance that VA would provide in obtaining supporting evidence. Although he has not received notice regarding the "downstream" disability rating and effective date elements as concerning his claim of entitlement to service connection for Bell's palsy, these "downstream" elements of this claim are ultimately moot inasmuch as the Board is denying the underlying claim for service connection. Moreover, regarding his claim for a higher initial rating for his low back disability, his appeal of this claim arose from the RO's October 2005 rating decision granting service connection for this disability and assigning the initial 10 percent rating, and his appeal since has continued even since the receipt of the higher 20 percent rating. In this circumstance, once a notice of disagreement (NOD) has been filed, for example contesting a "downstream" issue such as the initial rating assigned for the disability, the notice requirements of 38 U.S.C. §§ 5104 and 7105 regarding a rating decision and SOC control as to the further communications with the appellant, including as to what evidence is necessary to establish a more favorable decision with respect to the downstream element of the claim. Goodwin v. Peake, 22 Vet. App. 128 (2008). See also Dunlap v. Nicholson, 21 Vet. App. 112 (2007); and VAOPGCPREC 8-2003, 69 Fed. Reg. 25180 (May 5, 2004). He was provided this required SOC in December 2006 citing the applicable statutes and regulations and discussing the reasons and bases for not assigning a higher initial rating for this disability. Indeed, he also since has been provided SSOCs concerning this claim in April 2009 and February 2013, including discussing the reasons and bases for not increasing his rating beyond the 20-percent level (up from the initial 10 percent). He therefore has received all required notice concerning this claim. VA also has made reasonable efforts to assist him in obtaining evidence necessary to substantiate his claims. His service treatment records (STRs) are in his claims file, and VA has obtained all pertinent/identified post-service records that could be obtained. He additionally had a Travel Board hearing before the undersigned Veterans Law Judge of the Board. According to 38 C.F.R. § 3.103(c)(2) (2012), it is the responsibility of the presiding hearing officer to explain fully the issues and suggest the submission of evidence which the claimant may have overlooked and which would be advantageous to his position. In Bryant v. Shinseki, 23 Vet. App. 488 (2010), the Court held that the hearing officer's duties under section 3.103(c)(2) are twofold. First, the hearing officer must explain fully the issues still outstanding that are relevant and material to substantiating the claim by explicitly identifying them for the claimant. Id., at 496. Second, the hearing officer must suggest that a claimant submit evidence on an issue material to substantiating the claim when such evidence is missing from the record or when the testimony at the hearing raises an issue for which there is no evidence in the record. Id., at 496-97. Here, the undersigned identified the issues on appeal and during the course of the hearing engaged in a discussion of evidence that would be relevant to the appeal such as VA examinations, nexus opinions, and post-service treatment records. Moreover, the Veteran did not raise any new issues pertaining to these claims during the course of his hearing. See Bryant, 23 Vet. App. at 497-98. Thus, the Board finds that the presiding judge's two-fold duty to inform the Veteran of the outstanding issues relevant and material to the claim and to suggest the submission of evidence when such evidence is missing or has been overlooked has been satisfied. See id. at 496-97. The Veteran has not alleged there were any deficiencies in the conducting of his Board hearing related to the hearing officer's duties under section 3.103(c)(2). See Bryant, 23 Vet. App. at 497-98. Moreover, even assuming there were such a deficiency, the Board finds that it did not prejudice his claims. In Bryant, 23 Vet. App. at 498-99, the Court held that although the hearing officer did not explicitly lay out the material issues of medical nexus and current disability, the purpose of 38 C.F.R. § 3.103(c)(2) had been fulfilled because the record reflected that these issues were developed by VA, and there was no indication the appellant had any additional information to submit. In this case, including as reflected in his hearing testimony, the Veteran evidenced his actual knowledge of the type of evidence and information still needed to substantiate his claims, both insofar as establishing his entitlement to service connection for Bell's palsy and to higher ratings for his service-connected low back disability. See Vazquez-Flores v. Peake, 22 Vet. App. 37, 48 (2008), overruled on other grounds in Vazquez-Flores v. Shinseki, 580 F.3d 1270 (Fed. Cir. 2009), ("Actual knowledge is established by statements or actions by the claimant or the claimant's representative that demonstrates an awareness of what was necessary to substantiate his or her claim.") (citing Dalton v. Nicholson, 21 Vet. App. 23, 30-31 (2007)). Given the development of the Veteran's claims by the RO and the Board in the September 2012 remand, the Board finds that any deficiency in the July 2012 Board hearing was non-prejudicial. See id. Development directed by the Board's September 2012 remand was completed and all evidence, including constructively of record, has been obtained. As the findings related to the low back disability were fully reported and an adequate opinion and rationale provided regarding Bell's palsy, there was compliance with these remand directives. See Stegall v. West, 11 Vet. App. 268, 271 (1998) (A Veteran is entitled to compliance with remand directives, and the Board itself commits error, as a matter of law, in failing to ensure compliance). But see also D'Aries v. Peake, 22 Vet. App. 97, 105 (2008); and Dyment v. West, 13 Vet. App. 141, 146-4 (1999) (indicating situations when it is acceptable to have "substantial", even if not "exact" or "total", compliance with remand directives). The Board therefore is proceeding with the adjudication of these claims. Legal Criteria and Analysis In deciding these claims, the Board has reviewed all of the evidence in the Veteran's claims file, both his physical claims file and electronic ("Virtual VA") claims file. Although the Board has an obligation to provide adequate reasons and bases supporting this decision, there is no requirement that the evidence submitted by him or obtained on his behalf be discussed in exhaustive detail. Rather, the Board's analysis below will focus specifically on what evidence is needed to substantiate the claims and what the evidence in the claims file shows, or fails to show, with respect to the claims. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) and Timberlake v. Gober, 14 Vet. App. 122, 128-30 (2000). A. Service Connection for Bell's Palsy Service connection is granted if it is shown the Veteran suffers from disability resulting from an injury sustained or a disease contracted in the line of duty during his active military service or for aggravation during service of a pre-existing condition beyond its natural progression. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303(a). Direct service connection requires competent and credible evidence showing: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a relevant disease or an injury; and (3) a causal relationship or nexus between the present disability and the disease or injury incurred or aggravated during service. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004); see also Caluza v. Brown, 7 Vet. App. 498 (1995). For the showing of chronic disease in service there is required a combination of manifestations sufficient to identify the disease entity and sufficient observation to establish chronicity at the time, as distinguished from merely isolated findings or diagnosis including the word "chronic." Continuity of symptomatology is required where the condition noted during service is not, in fact, shown to be chronic or when the diagnosis of chronicity may be legitimately questioned. When the fact of chronicity in service is not adequately supported then a showing of continuity after discharge is required to support the claim. 38 C.F.R. § 3.303(b) (2012). But to establish entitlement to service connection based on continuity of symptomatology, the claimant must have one of the chronic diseases specifically enumerated in 38 C.F.R. § 3.309(a). Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). The Board must assess the credibility and weight of all the evidence, so including both the medical and lay evidence, to determine its probative value, accounting for evidence that it finds persuasive or unpersuasive and providing reasons or bases for rejecting any evidence favorable to the claimant. See Masors v. Derwinski, 2 Vet. App. 181 (1992); Wilson v. Derwinski, 2 Vet. App. 614, 618 (1992); Hatlestad v. Derwinski, 1 Vet. App. 164 (1991); Gilbert v. Derwinski, 1 Vet. App. 49 1990). 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. The evaluation of evidence generally involves a three-step inquiry. First, the Board must determine whether the evidence comes from a "competent" source. The Board must then determine if the evidence is credible, or worthy of belief. See Barr v. Nicholson,21 Vet. App. 303 (2007) (the Board must determine whether such evidence is also credible). The third step of this inquiry requires the Board to weigh the probative value of the proffered evidence in light of the entirety of the record. Competent lay evidence means any evidence not requiring that the proponent have specialized education, training, or experience. Lay evidence is competent if it is provided by a person who has knowledge of facts or circumstances and conveys matters that can be observed and described by a lay person. 38 C.F.R. § 3.159(a). Lay evidence may be competent and sufficient to establish a diagnosis of a condition when: (1) a layperson is competent to identify the medical condition (i.e., when the layperson will be competent to identify the condition where the condition is simple, for example a broken leg, and sometimes not, for example, a form of cancer); (2) the layperson is reporting a contemporaneous medical diagnosis, or; (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007); see also Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009) (where widow seeking service connection for cause of death of her husband, the Veteran, the Court holding that medical opinion not required to prove nexus between service-connected mental disorder and drowning which caused Veteran's death). In ascertaining the competency of lay evidence, lay persons are competent to provide opinions on some medical issues; their competency depends entirely on the specific disability at issue. See Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011). Specifically, lay evidence has been found to be competent with regards to a disease with "unique and readily identifiable features" that is "capable of lay observation." See, e.g., Barr, supra; see also Jandreau, supra; Charles v. Principi, 16 Vet. App. 370 (2002) (tinnitus); Falzone v. Brown, 8 Vet. App. 398 (1995) (flatfeet). However, laypersons also have been found not competent to provide evidence in more complex medical situations. See Woehlaert v. Nicholson, 21 Vet. App. 456 (2007) (concerning rheumatic fever). See also Colantonio v. Shinseki, 606 F.3d 1378, 1382 (Fed. Cir. 2010) (recognizing that in some cases lay testimony "falls short" in proving an issue that requires expert medical knowledge); Waters v. Shinseki, 601 F.3d 1274, 1278 (Fed. Cir. 2010) (concluding that a Veteran's lay belief that his schizophrenia had aggravated his diabetes and hypertension was not of sufficient weight to trigger the Secretary's duty to seek a medical opinion on the issue). The standard of proof to be applied in decisions on claims for Veterans' benefits is set forth in 38 U.S.C.A. § 5107 (West 2002). A claimant is entitled to the benefit of the doubt when there is an approximate balance of positive and negative evidence. See also 38 C.F.R. § 3.102. When a claimant seeks benefits and the evidence is in relative equipoise, he prevails. See Gilbert, supra. The preponderance of the evidence must be against the claim for benefits to be denied. Alemany v. Brown, 9 Vet. App. 518 (1996). The Veteran contends that he had Bell's Palsy in service and that he still does. In July 2012, he testified during his hearing before the Board that he was first told he had Bell's palsy in 2002 while receiving treatment for his back. The doctor had noticed a droopiness of the Veteran's face and resultantly recommended that he see an outside physician concerning this. The second physician also observed the droopiness. See hearing transcript, page 5. The Veteran's STRs dated in March 2002 confirm that a clinical consultation was requested on account of him having a right-sided facial "droop" when compared to the left side. There was no history of then recent herpes zoster or other virus or of trauma to his face or head (the Board sees that he had had an injury to his face but it was 7 years earlier, in March 1995, and resulted in a nasal fracture with deformity). The provisional diagnosis was possible Bell's palsy right face, rule out brain neoplasm). He underwent a neurological evaluation that same month, and the examiner noted the Veteran did not complain of drooling or weakness. He did have asymmetry of expression with normal eye closure and synchronized eye blink. The assessment was physiological (non pathologic) asymmetry of expression. No other records, including the report of his separation examination, show any abnormality of his face involving asymmetry or droopiness. His military service ended in July 2004. During a June 2005 VA compensation examination, so about a year later, the claims file was not reviewed, but the Veteran reported receiving a diagnosis of Bell's palsy in 2002, while in the military. The neurological examination was normal and there was no definite motor weakness of his face, but the examiner observed the Veteran had some very minimal asymmetry of nasolabial fold on the right when compared with the left side. The diagnosis was an apparent diagnosis of mild Bell's palsy by the Veteran's report. Since the Board determined that June 2005 VA examination was inadequate, the Veteran underwent another VA compensation examination in December 2012 that included a review of his claims file. Review of STRs and other evidence is not always required or necessarily determinative of an opinion's probative value, but it is helpful when an examiner reviews a claimant's prior medical records when this review is necessary to ensure a fully informed examination or to provide an adequate basis for the examiner's findings and conclusions. VAOGCPREC 20-95 (July 14, 1995). See also Neives-Rodriguez v. Peake, 22 Vet. App. 295 (2008). According to the holdings in Neives Rodriguez, when determining the probative value to be assigned to a medical opinion, the Board must consider three factors. The initial inquiry in determining probative value is to assess whether a medical expert was fully informed of the pertinent factual premises (i.e., medical history) of the case. A review of the claims file is not required since a medical professional can also become aware of the relevant medical history by having treated a Veteran for a long period of time or through a factually accurate medical history reported by a Veteran. See id. at 303-04. The second inquiry involves consideration of whether the medical expert provided a fully articulated opinion. See Id. A medical opinion that is equivocal in nature or expressed in speculative language does not provide the degree of certainty required for medical nexus evidence. See McLendon v. Nicholson, 20 Vet. App. 79 (2006). The third and final factor in determining the probative value of an opinion involves consideration of whether the opinion is supported by a reasoned analysis. The most probative value of a medical opinion comes from its reasoning. Therefore, a medical opinion containing only data and conclusions is not entitled to any weight. In fact, a review of the claims file does not substitute for a lack of a reasoned analysis. See Nieves-Rodriguez, 22 Vet. App. at 304; see also Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007) ("[A] medical opinion ... must support its conclusion with an analysis that the Board can consider and weigh against contrary opinions."). A medical opinion that contains only data and conclusions is not entitled to any weight and a review of the claims file cannot compensate for lack of the reasoned analysis required in a medical opinion. See Hernandez-Toyens v. West, 11 Vet. App. 379, 382 (1998) (indicating the failure of the commenting physician to provide a basis for his or her opinion goes to the weight or credibility of the evidence); Murphy v. Derwinski, 1 Vet. App. 78, 81 (1990) (wherein the Court further recognized that a mere statement of opinion, without more, does not provide an opportunity to explore the basis of the opinion). All of that said, in Kowalski v. Nicholson, 19 Vet. App. 171 (2005), the Court also clarified that the Board may not disregard a favorable medical opinion solely on the rationale that it was based on a history given by the Veteran. Rather, as the Court explained further in Coburn v. Nicholson, 19 Vet. App. 427 (2006), reliance on a Veteran's statements renders a medical report not credible only if the Board rejects the statements of the Veteran as lacking credibility. When deciding claims, the Board has to make an express credibility finding regarding lay evidence, such as testimony and statements the Veteran proffers. See Dalton v. Nicholson, 21 Vet. App. 23 (2007). Here, though, because it remained uncertain whether the Veteran actually had Bell's palsy and residuals of it, to in turn establish the required etiological linkage between this condition and his military service, the Board's September 2012 remand was to have him undergo the additional VA compensation examination for this necessary clarification, which, as mentioned, he subsequently had in December 2012. In Mariano v. Principi, 17 Vet. App. 305(2003), the Court indicated it "would not be permissible for VA to undertake such additional development if a purpose was to obtain evidence against an appellant's case." Mariano, at 312. In Douglas v. Shinseki, 23 Vet. App. 19 (2009), however, the Court distinguished its holding in Mariano. In Douglas, the Court acknowledged its decision in Mariano, but held that VA may undertake the development of additional evidence if it is necessary to render an informed decision on the claim. Douglas, at 26. During this additionally requested VA compensation examination in December 2012, the Veteran reported that he experienced drooling on the right side of his mouth, but muscle strength and sensory testing of the cranial nerves were normal. The examiner's summary evaluation shows that cranial nerve VII, which involves the face, was unaffected. Overall, the examiner found there were no objective signs of Bell's palsy or other cranial nerve abnormality. Although the Veteran asserts that he was actually diagnosed with Bell's palsy during his military service and that he since has continued to experience its effects, the medical evidence of record, including his STRs, does not support this contention. His STRs instead show that Bell's palsy was a provisional diagnosis, so merely suspected, and that initial suspicion was not predicated on the results of a neurological evaluation, hence, the reason this further clinical evaluation and workup was determined necessary. And, ultimately, once neurological evaluation was completed, Bell's palsy was not the final diagnosis. Instead, it appears to have been ruled out. The Veteran testified that his symptoms have continued since service and that his wife has told him that, in certain situations, such as one that is confrontational, his face droops and his words slur. See hearing transcript, page 6. He is competent to report what he experiences or observable symptoms, but the fact of the matter remains that the evidence simply does not show he has ever received a definitive or confirmed diagnosis of Bell's palsy. His post-service VA treatment records from October 2005 to April 2011 do not mention this diagnosis or contain findings of the symptoms he has described. Furthermore, the December 2012 VA compensation examiner did not diagnose Bell's palsy nor find any residuals of this disorder. The June 2005 VA examination only noted a diagnosis based on what the Veteran had reported and, as has already been discussed, despite his claim to the contrary, there was no actual diagnosis of Bell's palsy during his service, only, again, initial suspicion he had this condition, which ultimately was determined not in fact to have been the case. So the June 2005 VA examiner's reliance on a history of this diagnosis, as reported by the Veteran, which, turns out, is an inaccurate history, in turn undermines the probative value of that earlier VA examiner's diagnosis. A medical opinion based on an inaccurate factual premise has no probative value. See Reonal v. Brown, 5 Vet. App. 458, 460-61 (1993). The threshold requirement for any claim for service connection is that the Veteran first establish he has the claimed disability or show that he at least has since the filing of his claim. See Boyer v. West, 210 F.3d 1351, 1353 (Fed. Cir. 2000); see also Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992) (indicating service connection presupposes a current diagnosis of the condition claimed, to at least confirm the Veteran has it, and that, without this threshold minimum level of proof, there can be no valid claim because there is no disability to relate or attribute to his military service). See also Rabideau v. Derwinski, 2 Vet. App. 141, 143 (1992); Gilpin v. Brown, 155 F.3d 1353 (Fed. Cir. 1998) [service connection may not be granted unless a current disability exists]. A current disability means a disability shown by competent and credible evidence to exist. Chelte v. Brown, 10 Vet. App. 268 (1997). VA compensation only may be awarded to an applicant who has disability existing on the date of application, not for past disability. See Degmetich v. Brown, 8 Vet. App. 208 (1995); 104 F.3d 1328, 1332 (1997). In McClain v. Nicholson, 21 Vet. App. 319, 321 (2007), the U.S. Court of Appeals for the Federal Circuit (Federal Circuit Court) reiterated that this requirement of current disability is satisfied when the claimant has the disability at the time the claim or application for VA disability compensation is filed or during the pendency of the claim, and that a claimant may be granted service connection even though the disability resolves prior to VA's adjudication of the claim. Here, though, competent and credible evidence has not been presented establishing the Veteran actually has or ever actually has had Bell's palsy. And since, for this reason, the preponderance of the evidence is against his claim, the benefit-of-the-doubt doctrine does not apply and his claim must be denied. 38 C.F.R. § 3.102; Gilber, supra; Alemany, supra. B. Higher Ratings for the Low Back Disability Disability evaluations are determined by the application of VA's Schedule for Rating Disabilities. Separate diagnostic codes identify the various disabilities. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4. When rating a service-connected disability, the entire history must be borne in mind. Schafrath v. Derwinski, 1 Vet. App. 589 (1991). However, in a claim for increased rating, the most recent evidence is generally the most relevant, as the present level of disability is of primary concern. Francisco v. Brown, 7 Vet. App. 55 (1994). That being said, a disability may have undergone varying and distinct levels of severity throughout the entire time period that the increased-rating claim has been pending. In those instances, it is appropriate to "stage" the rating. See Hart v. Mansfield, 21 Vet. App. 505 (2007) and Fenderson v. West, 12 Vet. App. 119, 125-26 (1999) (employing this practice irrespective of whether the rating being contested in an established or initial rating). Regulations require that, where there is a question as to which of two evaluations is to be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. All reasonable doubt material to the determination is resolved in the Veteran's favor. 38 C.F.R. § 4.3. In rating musculoskeletal disabilities, it is appropriate to consider additional limitation of function due to factors such as pain, weakness, incoordination and fatigability of the joint. See 38 C.F.R. §§ 4.40 and 4.45 and DeLuca v. Brown, 8 Vet. App. 202, 206-07 (1995). Although § 4.40 does not require a separate rating for pain, it does provide guidance for determining ratings under other diagnostic codes assessing musculoskeletal function. Painful motion is an important factor of disability, and it is the intention of the Rating Schedule to recognize actually painful, unstable, or malaligned joints, due to healed injury, as entitled to at least the minimum compensable rating for the joint. See 38 CF.R. § 4.59; Burton v. Shinseki, 25 Vet. App. 1 (2011) (indicating § 4.59 is for consideration even when the Veteran does not have arthritis). Functional loss due to pain is rated at the same level as functional loss where motion is impeded. See Schafrath v. Derwinski, 1 Vet. App. 589, 592 (1991). Pursuant to § 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). A finding of functional loss due to pain, however, must be supported by adequate pathology and evidenced by the visible behavior of the Veteran. 38 C.F.R. § 4.40; Johnston v. Brown, 10 Vet. App. 80, 85 (1997). Moreover, although pain may cause a functional loss, pain itself does not constitute functional loss. Mitchell v. Shinseki, 25 Vet. App. 32, 38-43 (2011). Rather, pain must affect some aspect of "the normal working movements of the body" such as "excursion, strength, speed, coordination, and endurance," in order to constitute functional loss. Id.; see 38 C.F.R. § 4.40. Degenerative or traumatic arthritis established by X-ray findings will be rated on the basis of limitation of motion under the appropriate diagnostic codes for the specific joints or joint involved. When there is arthritis and at least some limitation of motion, but the limitation of motion would be rated noncompensable under a limitation of motion code, a 10 percent rating may be assigned for each affected major joint. 38 C.F.R. § 4.71a, Codes 5003 and 5010. This is because, read together, Code 5003 and 38 C.F.R. § 4.59 provide that painful motion due to degenerative arthritis, which is established by X-ray, is deemed to be limitation of motion and warrants the minimum rating for a joint, even if there is no actual limitation of motion. See Lichtenfels v. Derwinski, 1 Vet. App. 484, 488 (1991). Descriptive terms such as "slight", "moderate", "severe" and "marked", etc., are in certain instances not specifically defined in the Rating Schedule. Rather than applying a mechanical formula, the Board must evaluate all of the evidence to the end that its decisions are "equitable and just." 38 C.F.R. §§ 4.2, 4.6. The service-connected lumbosacral strain was rated as 10-percent disabling from July 2, 2004 to November 30, 2008, and has been rated as 20-percent disabling effectively since December 1, 2008, pursuant to Code 5237. Under the General Rating Formula for Diseases and Injuries of the Spine (General Formula), 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 height warrants a 10 percent disability rating. 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, the combined range of motion of the thoracolumbar spine not greater than 120 degrees; or, the combined range of motion of the cervical spine not greater than 170 degrees; or, muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis warrants a 20 percent disability rating. Forward flexion of the cervical spine 15 degrees or less; or favorable ankylosis of the entire cervical spine warrants a 30 percent disability rating. Unfavorable ankylosis of the entire cervical spine; or, forward flexion of the thoracolumbar spine 30 degrees or less; or favorable ankylosis of the entire thoracolumbar spine warrants a 40 percent disability rating. Unfavorable ankylosis of the entire thoracolumbar spine warrants a 50 percent disability rating. Unfavorable ankylosis of the entire spine warrants a 100 percent disability rating. 38 C.F.R. § 4.71a. Ankylosis is stiffening or fixation of the joint as the result of a disease process, with fibrous or bony union across the joint. See Dinsay v. Brown, 9 Vet. App. 79, 81 (1996), citing Dorland's Illustrated Medical Dictionary at 86 (27th ed. 1988) (Ankylosis is "immobility and consolidation of a joint due to disease, injury, or surgical procedure."); see also Coyalong v. West, 12 Vet. App. 524, 528 (1999); Lewis v. Derwinski, 3 Vet. App. 259 (1992). Note (5) in Codes 5235-5242 provides that, for VA compensation purposes, unfavorable ankylosis is a condition in which the entire cervical spine, the entire thoracolumbar spine, or the entire spine is fixed in flexion or extension, and the ankylosis results in one or more of the following: difficulty walking because of a limited line of vision; restricted opening of the mouth and chewing; breathing limited to diaphragmatic respiration; gastrointestinal symptoms due to pressure of the costal margin on the abdomen; dyspnea or dysphagia; atlantoaxial or cervical subluxation or dislocation; or neurologic symptoms due to nerve root stretching. Fixation of a spinal segment in neutral position (zero degrees) always represents favorable ankylosis. Any associated objective abnormalities such as bowel or bladder impairment are to be rated separately under an appropriate Diagnostic Code. See Note (1) of General Rating Formula. Note (2) (see also Plate V) explains that, for VA compensation purposes, normal flexion of the thoracolumbar spine is from zero to 90 degrees, extension from 0 to 30 degrees, left and right lateral flexion from zero to 30 degrees, and left and right lateral rotation from zero to 30 degrees. The normal combined range of motion, then, is 240 degrees and refers to the sum of the range of forward flexion, extension, left and right lateral flexion, and left and right rotation. Because the General Formula is identical for all Diagnostic Codes pertaining to the spine other than for intervertebral disc syndrome (IVDS), consideration of other relevant diagnostic codes pertaining to the spine is not required. See 38 C.F.R. § 4.71a, Codes 5235, 5236, 5238, 5239, 5240, 5241, 5242 (2012); see also Schafrath v. Derwinski, 1 Vet. App. 589, 595 (1991). IVDS should be evaluated either under the General Formula or under the Formula for Rating IVDS Based on Incapacitating Episodes, whichever method results in the higher evaluation when all disabilities are combined under § 4.25 (VA's combined ratings table). In general, all disabilities, including those arising from a single disease entity, are rated separately, and all disability ratings are then combined in accordance with 38 C.F.R. § 4.25. However, the evaluation of the same "disability" or the same "manifestations" under various diagnoses is not allowed - else, it would violate VA' anti-pyramiding regulation. See 38 C.F.R. § 4.14. A claimant may not be compensated twice for the same symptomatology as "such a result would overcompensate the claimant for the actual impairment of his earning capacity." Brady v. Brown, 4 Vet. App. 203, 206 (1993) (interpreting 38 U.S.C.A. § 1155). However, if a Veteran has separate and distinct manifestations attributable to the same injury, they should be compensated under different diagnostic codes. See Esteban v. Brown, 6 Vet. App. 259 (1994); Fanning v. Brown, 4 Vet. App. 225, 230 (1993). Under the Formula for Rating IVDS based on Incapacitating Episodes, a 10 percent disability evaluation is warranted for incapacitating episodes having a total duration of at least one week but less than two weeks during the past 12 months; a 20 percent disability evaluation is warranted for 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 evaluation is warranted for 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 evaluation is warranted for incapacitating episodes having a total duration of at least six weeks during the past 12 months. Note (1) in Code 5243 for IVDS defines an incapacitating episode as a period of acute signs and symptoms due to IVDS requiring bed rest prescribed by a physician and treatment by a physician. From July 2, 2004 to November 30, 2008 During June and August 2005 VA compensation examinations, it was noted that the Veteran had a spinal cord stimulator implanted in his lumbosacral region during service in 2004. He complained of constant lumbar pain that was 5/10 in intensity and increased during flare-ups that occurred when sitting for longer than one hour or standing more than four hours. Low back symptoms were not exacerbated by stair climbing, twisting, turning, bending, lifting, or other activities of daily living. There were no lower extremity radicular symptoms, or bowel or bladder changes associated specifically with back complaints. No additional periods of work were lost during the past year due to back complaints. On objective physical examination, his posture and gait were good and without a limp. Thoracic and lumbar curves were preserved. There was an 11 cm left superior gluteal transverse surgical scar with a palpable implanted SCS and a second 6 cm midline longitudinal surgical scar at L1 with a palpable implant to the left of midline. The scars were not adherent or tender. There was tenderness to palpation inferior to the lumbar implant, to the lumbosacral junction, and to the paravertebral musculature, although there was no paravertebral muscle spasm to palpation. Active range of motion revealed forward flexion to 65 degrees, extension to 25 degrees, and bilateral rotation and bilateral lateral bending from 0 to 25 degrees. He experienced lumbar discomfort at all extremes of motion and with repetition. Heel/toe walking was intact, and straight leg raising, Goldthwait, pelvic rock, and Laseugue's tests were negative. Lower extremity active range of motion was intact as was motor strength (5/5), and deep tendon reflexes (2+). Based on the limited available evidence during this period, a rating higher than 10 percent is not warranted. Range of motion studies show that forward flexion of the lumbosacral spine was to 65 degrees, the combined range of motion of the lumbosacral spine well exceeded 120 degrees, his gait was normal, and there was no evidence of muscle spams or abnormal spinal contour found on examination. Even considering his subjective complaints of pain on range of motion studies, the medical evidence of record does not demonstrate additional limitation of motion in response to repetitive motion that would support an increased evaluation. See DeLuca, supra; 38 C.F.R. § 4.40; see also 38 C.F.R. §§ 4.45, 4.59 (2012). As for separate evaluations of the chronic orthopedic and neurologic manifestations associated with his low back disability, there are no additional described neurologic manifestations that would warrant a compensable rating if evaluated separately. The neurological evaluation was essentially unremarkable during the VA examinations, including for such relevant things as associated bowel or bladder dysfunction or lower extremity radiculopathy or sciatic neuropathy, and indeed, even the Veteran himself denied having any associated neurological complaints. Thus, an additional separate neurological rating is not warranted. 38 C.F.R. §§ 4.71a, General Rating Formula for Diseases and Injuries of the Spine, Note (1); 4.124a, Code 8520. Since December 1, 2008 During an additional VA compensation examination in December 2008, the Veteran complained of pain, stiffness, weakness, fatigue, and lack of endurance as a result of his lumbar spine disability. He also reported having significant morning stiffness and that his spinal stimulator had not been working for the past several months, which had led to a worsening of his low back condition. Since the stimulator had stopped working, he also reportedly had experienced daily muscle spasms, chronic and constant discomfort, and daily pain throughout the day. No other treatment had had much effect other than his medication. Precipitating factors were activities of daily living (ADLs) such as standing, sitting, walking, hills, inclines, stairs, uneven ground, and ladders. He denied having numbness, bladder or bowel complaints, or erectile dysfunction (ED) due to his low back disability. He did not use any assistive devices and he was not unsteady. He was unable to sit, stand, or walk longer than 20 minutes due to his low back disability, but he was able to perform ADLs. His usual occupation as an auditor involved sitting, standing, and walking, and he was able to walk for minimal periods of time with frequent rest. He denied having radiculopathy, but he noted one episode of foot numbness months earlier that had lasted during the course of a weekend. Range-of-motion testing of his lumbosacral spine revealed forward flexion to 60 degrees, left rotation from 0 to 30 degrees, right rotation from 0 to 20 degrees, and extension and bilateral lateral flexion from 0 to 20 degrees. He complained of pain on motion with all range of motion maneuvers, especially with forward flexion. There was a loss of lordosis of the thoracolumbar spine, but there was no increased kyphosis and no scoliosis. An 8-mm scar transversed his left hip where the stimulator had been implanted. The scar was nontender, well-healed, and nonindurated. A 6-mm scar was in the midline in the L1 and T12 level, which was also nontender, well-healed, and nonindurated. There were palpable and visible spasms of the paraspinous musculature in the low thoracic and high lumbar region bilaterally. His gait was normal and straight leg raises were negative. Deep tendon reflexes were equal in his lower extremities; muscle strength testing was 5/5; and neurosensory was intact to all digits in the lower extremities. Regarding DeLuca criteria, the examiner found no objective clinical evidence that function was additionally limited by pain, fatigue, weakness, incoordination, or lack or endurance (such as with repetitive motion). Subjective pain appeared to have the greatest functional impact. The Veteran had not had any physician-directed bed rest during the past 12 months on account of his low back disability. In September 2009, his spinal cord stimulator implant was replaced. In June 2010, he sought VA treatment and reported having right-sided back pain that was aggravated 3 months earlier when he bent over to tie his shoes. During a November 2011 VA compensation examination, it was noted that he had diagnoses of chronic low back strain and lumbosacral osteoarthritis. He denied having flare-ups that impacted the functioning of his thoracolumbar spine. Range-of-motion testing of his thoracolumbar spine revealed forward flexion to 90 degrees or greater with pain beginning at 65 degrees; extension and bilateral lateral flexion to 20 degrees with pain beginning at 20 degrees; and bilateral rotation to 25 degrees with no pain demonstrated on right rotation but beginning at 25 degrees of left rotation. He did not perform repetitive motion testing due to his concern regarding pain. He had functional loss, functional impairment and/or additional limitation of range of motion of the thoracolumbar spine after repetitive use due to less movement than normal, weakness, and pain on movement. There was localized tenderness or pain to palpation, and guarding or muscle spasm that was severe enough to produced an abnormal gait. There was no atrophy and muscle strength, sensation, and reflexes in the lower extremities were normal. The straight leg test was negative, but he had radicular pain or other signs or symptoms due to radiculopathy that consisted of paresthesias and/or dysesthesias in his right lower extremity. No nerve roots were found to be involved and there were no other neurological abnormalities or findings related to his thoracolumbar spine disorder (such as bowel or bladder problems). The examiner indicated the Veteran had IVDS, but that he had had no incapacitating episodes during the past 12 months due to this disorder. He did not use any assistive devices. Although he worked full-time, his back pain caused problems with prolonged sitting or walking. In July 2012, the Veteran testified that, since his job involved a lot of walking and going up or down stairs, he had a lot of pain - estimating he could walk about 200 feet before having to stop briefly. Bending over and sitting for long periods of time also hurt. He was unable to carry things and did only a limited amount of yard work. He also complained of pain and numbness in his legs. See hearing transcript, pages 8-9. During his additional VA compensation examination since held in December 2012, he complained of continued low back pain and reported that the spinal cord stimulator had stopped working again. Although he reported having radiculopathy symptoms, the examiner observed that throughout all of the available VA treatment records there were no reports of radiculopathy symptoms. The Veteran reported having flare-ups occurring 5 to 6 times a month and lasting 2 days at a time at a pain level of 10/10. Range-of-motion testing of his thoracolumbar spine revealed forward flexion to 60 degrees with pain at 60 degrees (so at the endpoint); extension to 25 degrees with pain at 25 degrees (so also at the endpoint); right lateral flexion to 10 degrees with pain at 10 degrees (endpoint); left lateral flexion to 15 degrees with pain at 15 degrees (endpoint); and bilateral rotation to 20 degrees with pain at 20 degrees (again, at the endpoint). The Veteran performed repetitive motion demonstrating forward flexion to 45 degrees, extension to 25 degrees, bilateral lateral flexion to 10 degrees, right rotation to 15 degrees and left rotation to 20 degrees. He had functional loss and/or functional impairment of the thoracolumbar spine after repetitive motion due to less movement and pain on movement. There was no guarding or muscle spasms of the thoracolumbar spine. There was no evidence of atrophy and muscle strength, sensory, and reflex testing in the bilateral lower extremities was normal. The straight leg test was negative and the signs or symptoms of radiculopathy consisted of bilateral lower extremity numbness. He reported having a left foot drop, but the examiner noted there was no indication of nerve root involvement. The Veteran reported numbness and pain down the medial leg past his knees, but these symptoms did not conform to any known dermatome pattern. The examiner indicated the Veteran did not have IVDS and did not use any assistive devices. The disability's impact on him included being unable picking up or play with his children, reduced sexual functioning during periods of pain, an inability to sit longer than 40 to 45 minutes, and being limited to walking continuously for 1 hour. The examiner commented that the Veteran was able to easily perform forward bending to 90 degrees when he was not doing the range-of-motion testing and that his radiculopathy symptoms were all subjective. Furthermore, his self report of foot drop was not evident; while ambulating his gait was relatively normal. During the peripheral nerve portion of the examination, the Veteran had some bilateral paresthesias and/or dysesthesias related to a peripheral nerve condition and slight decreased strength in right ankle plantar flexion muscle strength. There was no muscle atrophy or abnormality in sensory or reflex testing. His gait was normal and electromyogram (EMG) studies of his lower extremities were normal. The examiner opined that there was no present impairment noted objectively stemming from the Veteran's lumbar spine; therefore, his lower extremity symptoms are not neurological in origin and not due to his military service. Based on this collective body of evidence for this succeeding period at issue since December 1, 2008, a rating higher than 20 percent cannot be assigned. The next higher rating of 40 percent requires forward flexion of the thoracolumbar (thoracic and lumbar) spine limited to 30 degrees or less or favorable ankylosis of the entire thoracolumbar spine. Although range-of-motion findings have varied during the several VA compensation examinations, at no time was forward flexion of the thoracolumbar spine to 30 degrees or less, even when considering the extent of the Veteran's pain and during repetitive-motion testing. At worse, it was limited to 45 degrees and this was demonstrated after repetitive motion in December 2012. Moreover, he does not have ankylosis, either favorable or unfavorable, of his thoracolumbar spine. Thus, even with consideration of the DeLuca factors, the criteria for a higher rating are not met. Although the rating criteria for the spine allow for separate neurological evaluation(s) if the spine rating is assigned based on limitation of motion, the record does not establish that any neurological impairment has been shown in relation to the Veteran's service-connected low back disability. Indeed, to the contrary, the December 2012 VA compensation examiner found no objective signs or symptoms of neurological impairment; instead, the record overall only reflects subjective complaints of this, which the December 2012 VA compensation neurological examiner found to be unrelated to the service-connected low back disability. Other examiners have concluded similarly, pointing out the subjective complaints were not objectively confirmed, despite specific diagnostic testing for this, and that they do not follow the typical or expected dermatome pattern suggestive of as being associated with the low back disability. The Veteran resultantly cannot rely on his subjective complaints, alone, as reason or justification for assigning a separate rating or granting additional compensation inasmuch as he has not shown he has the required objective neurological impairment associated with his service-connected low back disability. In fact, it has been expressly concluded he does not, so this has been ruled out. See Mittleider v. West, 11 Vet. App. 181, 182 (1998). There is conflicting evidence regarding whether he has IVDS. See the November 2011 and December 2012 VA compensation examination reports. Regardless of whether he has IVDS, he still is not shown to have experienced any actual incapacitating episodes on account of his service-connected low back disability, which, to reiterate, mean bed rest prescribed by a physician, that is, in addition to treatment by a physician. Absent this, he necessarily has not, by definition, had any incapacitating episodes. Thus, a higher rating cannot be assigned on the basis of incapacitating episodes. A preponderance of the evidence is against assignment of a higher rating; therefore, the benefit-of-the-doubt doctrine is inapplicable and the claim must be denied. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 4.3; see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). There equally is no inferred claim for a total disability rating based on individual unemployability (TDIU) under Rice v. Shinseki, 22 Vet. App. 447 (2009) and its progeny since the Veteran maintains substantially gainful employment. Extra-schedular Consideration In exceptional cases where schedular evaluations are found to be inadequate, the RO or Board may refer a claim to the Under Secretary for Benefits or to the Director of Compensation and Pension (C&P) Service for consideration of an extra-schedular evaluation commensurate with the average earning capacity impairment due exclusively to the service-connected disability or disabilities. 38 C.F.R. § 3.321(b)(1) (2012). The governing norm in these exceptional cases is a finding that the case presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization as to render impractical the application of the regular schedular standards. Id. The Court has clarified the analytical steps necessary to determine whether referral for extra-schedular consideration is warranted. See Thun v. Peake, 22 Vet. App. 111 (2008). First, there must be a determination of whether the evidence presents such an exceptional disability picture that the available schedular evaluation for that service-connected disability is inadequate. Second, if the schedular evaluation does not contemplate the Veteran's level of disability and symptomatology and is found inadequate, there must be a determination of whether the Veteran's exceptional 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 extra-schedular rating under 38 C.F.R. § 3.321(b)(1). Here, the Board finds that the Veteran's symptomatology and limitation in occupational functioning for the low back disability are reasonably contemplated by the rating schedule under the first prong of the analysis. His primary complaints regarding his low back involve such symptoms as persistent pain and consequent inability to stand or walk for prolonged periods, which are all contemplated by the schedular rating criteria. Consequently, the Board finds that his symptomatology and limitation in occupational functioning attributable to his low back disability is reasonably contemplated by the Rating Schedule under the first prong of the Thun analysis. The level of the disability is also contemplated in the various diagnostic codes and correspond to the overall disability picture presented. Furthermore, no examiner has reported an exceptional disability picture with symptoms not represented in the rating schedule. In sum, there is no indication that the average industrial impairment from this disability exceeds that contemplated by the assigned ratings. 38 C.F.R. § 4.1. Accordingly, the Board finds that referral of this case for extra-schedular consideration is unwarranted. ORDER The claim for entitlement to service connection for Bell's palsy is denied. The claim for an initial rating higher than 10 percent for the low back disability from July 2, 2004, to November 30, 2008, and for higher than 20 percent since December 1, 2008, also is denied. REMAND The Veteran is also claiming entitlement to service connection for a bilateral (right and left) hand disorder, including in the way of arthritis, but still additional development of this remaining claim is required. The Veteran, through his representative at that time, initially claimed his disability involved arthritis of his hands. See March 2005 statement. In the notice of disagreement (NOD), he reported having pain in his hands from his wrists through the end of his fingers. Although no object evidence of hand arthritis was found during his August 2005 VA compensation examination, the examiner diagnosed early osteoarthritis. Arthritis must be objectively confirmed by X-ray. 38 C.F.R. § 4.71a, DC 5003. See also DC 5010, indicating the same even for arthritis due to trauma, i.e., post-traumatic arthritis. An October 2005 VA treatment record also notes bilateral (so right and left) carpel tunnel syndrome (CTS). In September 2012, the Board resultantly remanded this claim to schedule a VA compensation examination for a medical opinion. Although the remand noted possible diagnoses of arthritis and CTS and requested opinions regarding any current disability affecting the Veteran's hands, the examiner only addressed the etiology of left thumb arthritis, which was found on X-ray. No opinion was offered regarding the CTS. Given these separate diagnoses, both of arthritis and CTS, the claim encompasses both. The Court (CAVC) has held that the scope of a claim for service connection includes any disability that reasonably may be encompassed by the claimant's description of the claim, reported symptoms, and the other information of record. Clemons v. Shinseki, 23 Vet. App. 1, 5-6 (2009); see also Brokowski v. Shinseki, 23 Vet. App. 79, 85 (2009) (A claimant's identification of the benefit sought does not require any technical precision), citing Ingram v. Nicholson, 21 Vet. App. 232, 256-57 (2007) (It is the pro se claimant who knows what symptoms he is experiencing and that are causing him disability); see, too, Robinson v. Nicholson, 21 Vet. App. 545, 552 (2008) (The Board is required to consider all issues raised either by the claimant or the evidence of record). For this reason, the examination is inadequate and not substantially in compliance with the Board's remand directives. See Stegall v. West, 11 Vet. App. 268 (1998); Dyment v. West, 13 Vet. App. 141, 146-47 (1999). Once VA undertakes the effort to provide an examination for a service-connection claim, even if not statutorily obligated to do so, it must provide an adequate one or, at a minimum, notify the claimant why one will not or cannot be provided. See Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). The additional medical comment mentioned is needed to assist in deciding this claim. The AMC also must take this opportunity to obtain ongoing treatment records. Accordingly, this remaining claim is REMANDED for the following additional development and consideration: 1. Obtain and associate with the claims file for consideration the Veteran's VA treatment records since August 2011 concerning his bilateral CTS. If no such records are available or the search for them yields negative results and it is determined that further attempts to obtain these records would be futile, then this should be clearly documented in the claims file and the Veteran appropriately notified. See 38 C.F.R. § 3.159(c)(2), (c)(3) and (e)(1). 2. Schedule the Veteran for a VA neurological compensation examination to determine the etiology of his claimed bilateral hand disorder. The examiner must review the claims file, including a copy of this remand, and obtain a complete history from the Veteran. a) Taking into consideration the examination findings, review of the claims file, and the Veteran's reported history and contentions, the examiner must comment on the likelihood (very likely, as likely as not, or unlikely) the Veteran's bilateral CTS incepted during his military service from May 1990 to April 2000 and from September 2000 to July 2004 or is otherwise related or attributable to his service or dates back to his service. b) The examiner must discuss the underlying reasoning supporting his or her opinion and, if necessary, cite to specific evidence in the record. *The VA compensation examiner that previously evaluated the Veteran following and as a result of the Board's prior remand only commented on the etiology of arthritis (not also the CTS), and only to the extent there is arthritis affecting the left thumb, so this additional medical comment is needed concerning the apparent affect of the CTS on the wrists and hands, but especially in terms of whether related or attributable to the Veteran's military service or, instead, due to other unrelated factors or causes 3. Then readjudicate this remaining claim for service connection for a bilateral hand disorder in light of this and all other additional evidence. If this claim is not granted to the Veteran's satisfaction, send him and his representative a Supplemental Statement of the Case (SSOC) and give them an opportunity to submit additional evidence and/or argument in response before returning this claim to the Board for further appellate consideration. The Veteran has the right to submit additional evidence and argument concerning this claim Board is remanding. 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). ______________________________________________ KEITH W. ALLEN Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs