Citation Nr: 1315029 Decision Date: 05/07/13 Archive Date: 05/15/13 DOCKET NO. 06-14 247A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Muskogee, Oklahoma THE ISSUES 1. Entitlement to secondary service connection for osteoporosis, to include as secondary to service-connected disabilities. 2. Entitlement to secondary service connection for recurrent fractures, to include as secondary to service-connected disabilities. 3. Entitlement to an increased rating for Hashimoto's disease with hypothyroidism, currently evaluated as 10 percent disabling. 4. Entitlement to an increased rating for asthma, currently evaluated as 30 percent disabling. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESSES AT HEARING ON APPEAL The Veteran and his spouse ATTORNEY FOR THE BOARD J. Murray, Associate Counsel INTRODUCTION The Veteran served on active duty in the United States Navy from August 1980 to February 1984. This case comes before the Board of Veteran's Appeals (Board) on appeal from an October 2004 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Muskogee, Oklahoma. The Veteran and his spouse testified at a hearing before the undersigned Acting Veterans Law Judge at the RO in November 2009. The Veteran was provided an opportunity to set forth his contentions at the hearing. The record reflects that at this hearing the undersigned set forth the issues to be discussed at the hearing, focused on the elements necessary to substantiate the claims, and sought to identify any further development that was required to help substantiate the claims. These actions satisfied the duties a Veterans Law Judge has to explain fully the issue and to suggest the submission of evidence that may have been overlooked. See Bryant v. Shinseki, 23 Vet. App. 488, 492 (2010) (holding that the requirements of 38 C.F.R. § 3.103(c)(2) apply to a hearing before the Board). A transcript of the hearing is of record. The Board remanded the current matters on appeal in March 2010 and in November 2011 to the RO (via the Appeals Management Center (AMC)) for further actions. At the outset, the Board observes that all directed development on remand was completed. For reasons explained below, the Board finds that further remand is not required. See Stegall v. West, 11 Vet. App. 268, 270-71 (1998). The record reflects that the Veteran is unable to work because of the symptomatology associated with his service-connected diabetes mellitus and its complications. See the Veteran's wife's April 2006 statement in support of the claims. As the Veteran has not asserted, and the record does not indicate, that his inability to work is due to either his service-connected asthma or Hashimoto's disease with hypothyroidism, an issue of entitlement to a total disability rating due to individual unemployability (TDIU) is not part, and parcel, to the claims currently on appeal. See Rice v. Shinseki, 22 Vet. App. 447 (2009) (a request for TDIU, whether expressly raised by a veteran or reasonably raised by the record, is not a separate claim for benefits, but is rather part of the adjudication of a claim for increased compensation). As such, a claim for TDIU is referred back to the agency of original jurisdiction for appropriate action. The issue of increased rating for asthma is addressed in the REMAND portion of the decision below and is REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. FINDINGS OF FACT 1. The preponderance of the competent lay and medical evidence is against a finding that the Veteran's osteoporosis is related to his period of service, to include as proximately related to by his service-connected disabilities. 2. The preponderance of the competent lay and medical evidence is against a finding that the Veteran's recurrent fractures is related to his period of service, to include as proximately related by his service-connected disabilities. 3. Throughout the entire period under appeal, the Veteran's Hashimoto's disease with hypothyroidism has been productive of fatigability and weight gain and requires continuous medication. CONCLUSIONS OF LAW 1. The criteria for service connection for osteoporosis are not met. 38 U.S.C.A. §§ 1110, 1112, 1131, 1137, 5107 (West 2002); 38 C.F.R. §§ 3.303, 3.307, 3.309, 3.310 (2012). 2. The criteria for service connection residuals of recurrent fractures are not met. 38 U.S.C.A. §§ 1110, 1112, 1131, 1137, 5107 (West 2002); 38 C.F.R. §§ 3.303, 3.307, 3.309, 3.310 (2012). 3. The criteria for an evaluation of 30 percent, and not higher, for Hashimoto's disease with hypothyroidism are met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. § 4.119, Diagnostic Code 7903 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. VA's Duties to Notify and Assist As provided for by the Veterans Claims Assistance Act of 2000 (VCAA), VA has a duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a). Proper notice from VA must inform the claimant of any information and medical or lay evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. Quartuccio v. Principi, 16 Vet. App. 183 (2002). This notice must be provided prior to an initial unfavorable decision on a claim by the RO. Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004). In addition, the notice requirements of the VCAA apply to all five elements of a service-connection claim, including: (1) Veteran status; (2) existence of a disability; (3) a connection between the Veteran's service and the disability; (4) degree of disability; and (5) effective date of the disability. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). Further, this notice must include information that a disability rating and an effective date for the award of benefits will be assigned if service connection is awarded. Id. at 486. Here, the Veteran was provided with proper notification in June 2004 and August 2004, prior to the adjudication of his claims in October 2004 rating decision, in which he was informed of what was necessary to substantiate the claim, and what evidence VA and the Veteran were required to provide. In a November 2009 letter, VA provided the Veteran with the notice required under the VCAA and under Dingess. The Board found that the Veteran had not been properly notified about the requirements to substantiate a claim on a secondary basis and remanded the claim in November 2011 to correct this deficiency. In November 2011 the Veteran was sent a letter that fully addressed all notice elements of direct and secondary service connection. Although not all the notice was not provided prior to the initial adjudication of the claim, the claim was readjudicated in an October 2012 supplemental statement of the case. Under these circumstances, the Board finds that the notification requirements of the VCAA have been satisfied. Pelegrini, 18 Vet. App. at 122; see also Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Prickett v. Nicholson, 20 Vet. App. 370, 376 (2006); 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b). The Board also concludes VA's duty to assist has been satisfied. The Veteran's service treatment and service personnel records were previously obtained. Available VA treatment records dated through 2010 were obtained pursuant to the March 2010 remand. The Veteran has submitted copies of his treatment records from his private medical providers. However, the Veteran declined to provide release of records so that VA may obtain them in response to the March 2010 and November 2011 requests. Therefore, other identified records could not be obtained. Also pursuant to the March 2010 remand, VA examination was offered to the Veteran in June 2010, in order to obtain medical opinions on whether the Veteran's osteoporosis and residual recurrent fractures were etiologically related to his period of service. The report shows that the examiner considered the medical evidence of record and the findings from clinical examination in support of his medical opinion. Pursuant to the November 2011, the June 2010 VA examiner provided a supplemental VA medical opinion in March 2012 that addressed whether the Veteran's osteoporosis and residual recurrent fractures were proximately caused by any of his service-connected disabilities. The Board finds that the VA examination report and supplemental VA medical opinion are adequate for VA purposes. See Barr v. Nicholson, 21 Vet. App. 303, 311 (2007) (Where VA provides the veteran with an examination in a service connection claim, the examination must be adequate.) Given the foregoing, the Board finds that VA has complied with the Board's prior remand as to the issue herein decided. See Stegall v. West, 11 Vet. App. 268 (1998). No further notification or development action is necessary on the issue now being decided. Neither the Veteran nor his representative has argued otherwise. II. Service Connection Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303(a). Service connection may also be granted for any disease diagnosed after discharge when all of the evidence establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). 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. If a condition noted during service is not shown to be chronic, then generally, a showing of continuity of symptoms after service is required for service connection. See 38 C.F.R. § 3.303(b). The chronicity provision of 38 U.S.C.A. § 3.303(b) is applicable where the evidence, regardless of its date, shows that the Veteran had a chronic condition in service or during an applicable presumption period and still has such condition. Regulations also provide that service connection may be granted for a disability diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disability is due to disease or injury which was incurred in or aggravated by service. 38 C.F.R. § 3.303(d). Certain chronic diseases, although not shown in service, may be presumed to have incurred in or aggravated by service if they become manifested to a compensable degree within one year of separation from active duty. 38 U.S.C.A. §§ 1101, 1112, 1113; 38 C.F.R. §§ 3.307, 3.309. To prevail on the issue of service connection, there must be (1) medical evidence of a current disability; (2) medical, or in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and (3) medical evidence of a nexus between the claimed in-service disease or injury and the current disability. See Hickson v. West, 12 Vet. App. 247, 253 (1999). The determination as to whether the requirements for service connection are met is based on an analysis of all the evidence of record and the evaluation of its credibility and probative value. 38 U.S.C.A. § 7104(a); Baldwin v. West, 13 Vet. App. 1 (1999); 38 C.F.R. § 3.303(a). If there is at least an approximate balance of positive and negative evidence regarding any issue material to the claim, the claimant shall be given the benefit of the doubt in resolving each such issue. 38 U.S.C.A. § 5107; Ortiz v. Principi, 274 F.3d 1361, 1364 (Fed. Cir. 2001); 38 C.F.R. §§ 3.102. On the other hand, if the Board determines that the preponderance of the evidence is against the claim, it has necessarily found that the evidence is not in approximate balance, and the benefit of the doubt rule is not applicable. Ortiz, 274 F.3d at 1365. The Veteran seeks entitlement to service connection for osteoporosis and residuals of recurrent fractures. He contends that his current diagnosed osteoporosis and residuals of recurrent fractures are related to his period of service when he received steroid therapy to treat his asthma symptomatology. In the alternative, the Veteran asserts that his osteoporosis and residuals of recurrent fractures is secondary to his service-connected disabilities. The record clearly demonstrates that the Veteran has current diagnoses of osteoporosis and recurrent fractures. See a May 2004 private bone density report; see also the report of a June 2010 VA examination. There is evidence of current disability for each claim. See Hickson, 12 Vet. App. at 253. With respect to the second element, in-service incurrence or aggravation of a disease or injury, the Board will address the matter of a disease and injury separately. The Board first turns to the question of an in-service incurrence of the disease. There is no indication in the service treatment records that the Veteran was treated for, or diagnosed with, osteoporosis or recurrent fractures during his period of service. The post-service medical evidence shows that the Veteran began receive treatment for recurrent fractures in 2004, and he was first diagnosed with osteoporosis in May 2004 based on the findings from a private bone density scan. There was no indication of any bone pathology problems during the Veteran's period of service. See 38 C.F.R. § 3.303. Moreover, the subsequent medical evidence does not show that the Veteran was diagnosed with osteoporosis until two decades after his separation from service. See 38 C.F.R. §§ 3.307, 3.309. With respect to in-service injury, the Board observes that the Veteran's service treatment records confirm that the Veteran was prescribed oral steroid medication, such as Prednisone, to treat his asthma attack. He was also prescribed a Vanceril inhalator (inhaled steroids). Accordingly, element (2), in-service injury from steroid treatment for his asthma, is satisfied as well. Also, the record reflects that the Veteran continued to receive oral steroid treatment (Prednisone) in the first couple of years following his separation from service and he continues to use inhaled steroid therapy until recently. A January 1985 health summary from the Tinker Air Force Base Hospital to VA Hospital Administration Services shows that the Veteran began receiving treatment there for his asthma in May 1984. Clinical evaluation showed that the Veteran had acute asthma poorly controlled on medication and diagnostic testing revealed adverse thyroid profile. As part of his treatment, he was started on Prednisone that was approximately 60 milligrams (mg) per day and gradually tapered off of the Prednisone when he responded well. It was noted that the Veteran had been off Predispose for several months at the time of the January 1985 summary. During a February 1986 Decision Review Officer Hearing, the Veteran testified that he was been treated twice since 1984 with Prednisone because of the severity of his asthma attacks. The report of an April 1987 VA examination to evaluate the Veteran's asthma disability shows that the Veteran's prescribed treatment included the use of a Vanceril inhalator three to four times a day. A VA respiratory examination in March 1997 shows he continued to use inhaled steroid-type (Azmacort inhaler) medication to treat his asthma. A subsequent March 2001 VA respiratory examination no longer showed that the Veteran reported use of any inhaled steroid-type medication; however, a July 2004 and June 2010 VA examination reports shows the Veteran reported using Advair to treat his asthma symptomatology. The Veteran is also in receipt of service connection for asthma, Hashimoto's disease with hypothyroidism, a right knee disability, and diabetes mellitus with secondary complications of coronary artery disease, peripheral neuropathy, retinopathy, and erectile dysfunction. The remaining questions on appeal are whether the evidence of record is at least in approximate balance that the Veteran's osteoporosis and recurrent fractures is related to his in-service steroid use or a proximately caused by his service-connected disabilities, to include treatment for his service-connected asthma. The Veteran was afforded a VA examination in June 2010 in conjunction with his claim. The examination report shows diagnoses of osteoporosis and status post fracture of the right hip, postoperative open reduction and internal fixation. Based on a review of the medical evidence, the VA examiner opined that it was less likely than not that the osteoporosis and recurrent fracture pathology are in any way related to the Veteran's service. The examiner noted that osteoporosis can be caused by prolonged and chronic steroid use. However, service treatment records only show the Veteran had intermittent steroid use to treat his asthma and he did not continue to have prolonged steroid use during service or in the years after service. The examiner also opined that the Veteran's osteoporosis was not related to his service-connected Hashimoto disease with hypothyroidism. Pursuant to the Board's November 2011 remand directives, the June 2010 VA examiner provided clarifications in a March 2012 addendum on whether the Veteran's osteoporosis and recurrent fracture was incurred in service or is otherwise the result of his active duty service, to include as secondary to a service-connected disability. Based on a review of the claims folding, including the June 2010 VA examination report, the examiner opined that the Veteran's osteoporosis and recurrent fractures were less likely than not incurred in or otherwise caused by the Veteran's period of service, to include as proximately due to or the result of the Veteran's service-connected disabilities. In support of the medical conclusion, the VA examiner noted that the service treatment records did not indicate any incident of recurrent fractures or a diagnosis of osteoporosis. Again, the examiner noted that while osteoporosis can be caused by prolonged or chronic steroid use, the Veteran's steroid use for treatment of his asthma was intermittent during his period of service and since service. The examiner further stated that the medical literature has not associated osteoporosis with coronary artery disease, peripheral neuropathy, retinopathy, erectile dysfunction, or right knee disability. The examiner also noted that the majority of studies of diabetes mellitus have found that bone density is normal or increased in both men and women. The examiner concluded a review of the medical literature failed to demonstrate that any of the Veteran's service-connected disabilities could proximately cause or aggravate osteoporosis. The VA examiner's medical opinions in the June 2010 VA examination and the March 2012 addendum weigh heavily against the Veteran's contention that his osteoporosis and recurrent fractures are related to his in-service steroid treatment or are proximately caused by any one of his service-connected disabilities. The Board finds it significant that there is no contrary medical opinion of record. The Board has considered the Veteran's assertion that his osteoporosis and recurrent fractures are related to his in-service steroid treatment and/or are proximately caused by his service-connected disabilities, to include treatment for his asthma. The Board acknowledges that lay evidence is competent regarding features or symptoms of injury or disease when the features or symptoms are within the personal knowledge and observations of the witness. Layno v. Brown, 6 Vet. App. 465, 469-70 (1994); see also, Buchanan, 451 F.3d at 1336; Davidson, 581 F.3d. at 1315. However, lay persons are not qualified to offer an opinion that requires medical knowledge, such as a diagnosis or an opinion as to the cause of a disability that may be related to service or to a service-connected disability. See Jandreau, 492 F.3d at 1377 (holding that a layperson may provide competent evidence to establish a diagnosis where the lay person is "competent to identify the medical condition"). Here, the Veteran is capable of observing when he was required to use steroid therapy to treat his asthma, but he is not competent (i.e., professionally qualified) to offer an opinion as to a possible relationship between his osteoporosis and recurrent fractures and his use of steroid therapy in service and to treat his asthma since service, or that it was proximately caused by his service-connected disabilities. Pertinently, the VA examiner concluded that the Veteran's intermittent use of steroid therapy to treat his asthma did not likely cause his osteoporosis. Based on the foregoing, the Board finds that the evidence of record does not show that the Veteran's osteoporosis and recurrent fractures were first manifested during his period of service or within the first year after his separation from service. The first medical evidence of osteoporosis does not come until 2004 bone density scan, almost two decades after his separation from his second period of service. In addition, the weight of the evidence is against a finding that his osteoporosis and recurrent fractures are related to his in-service steroid therapy or are proximately caused by his service-connected disabilities, to include treatment for his asthma. The Board finds that the preponderance of the medical evidence is against an award of service connection on a direct or secondary basis. The benefit-of-the-doubt doctrine is not applicable. See 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). The claims must be denied. III. Increased Rating Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities, found in 38 C.F.R., Part 4. The rating schedule is primarily a guide in the evaluation of disability resulting from all types of diseases and injuries encountered as a result of or incident to military service. The ratings are intended to compensate, as far as can practicably be determined, the average impairment of earning capacity resulting from such diseases and injuries and their residual conditions in civilian occupations. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating. 38 C.F.R. § 4.7. In considering the severity of a disability, it is essential to trace the medical history of the veteran. 38 C.F.R. §§ 4.1, 4.2, 4.41. Consideration of the whole-recorded history is necessary so that a rating may accurately reflect the elements of disability present. 38 C.F.R. § 4.2; Peyton v. Derwinski, 1 Vet. App. 282 (1991). While the regulations require review of the recorded history of a disability by the adjudicator to ensure a more accurate evaluation, the regulations do not give past medical reports precedence over the current medical findings. Where an increase in the disability rating is at issue, the present level of the veteran's disability is the primary concern. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). Where a veteran appeals the initial rating assigned for a disability when a claim for service connection for that disability has been granted, evidence contemporaneous with the claim for service connection and with the rating decision granting service connection would be most probative of the degree of disability existing at the time that the initial rating was assigned and should be the evidence "used to decide whether an [initial] rating on appeal was erroneous . . . ." Fenderson v. West, 12 Vet. App. 119, 126 (1999). If later evidence obtained during the appeal period indicates that the degree of disability increased or decreased following the assignment of the initial rating, "staged" ratings may be assigned for separate periods of time based on facts found. Id.; see also Hart v. Mansfield, 21 Vet. App. 505 (2007) (VA's determination of the "present level" of a disability may result in a conclusion that the disability has undergone varying and distinct levels of severity throughout the entire time period the increased rating claim has been pending). Here, the RO awarded the Veteran a 10 percent evaluation for his disability due to Hashimoto's disease with hypothyroidism. The disability as been rated analogously to hyperthyroidism under Diagnostic Code 7903 (hyperthyroidism). See 38 C.F.R. § 4.119. Under Diagnostic Code 7903, a 10 percent rating is warranted for fatigability, or; continuous medication required for control; a 30 percent rating is warranted for fatigability, constipation, and mental sluggishness; a 60 percent rating is warranted for muscular weakness, mental disturbance, and weight gain; and a 100 percent rating is warranted for cold intolerance, muscular weakness, cardiovascular involvement, mental disturbance (dementia, slowing of thought, depression), bradycardia (less than 60 beats per minute), and sleepiness. 38 C.F.R. § 4.119, Diagnostic Code 7903. In this case, the medical evidence of record clearly shows that the Veteran's Hashimoto's disease with hypothyroidism disorder has been manifested by fatigability and is controlled by continuous medication. See the report of a July 2007 and a June 2010 VA examination reports. The record also demonstrates that the Veteran has a history of weight gain and loss. During the July 2004 VA examination, the Veteran informed the examiner that he gained 80 pounds over a period of 10 to 15 months in the past. The 2004 VA examination report showed that the Veteran had gained 10 pounds since the last VA examination in March 2001. In November 2009, the Veteran testified that he continues to experience problems maintaining his weight. He reported that he can easily gain 5 or 10 pounds in a day, and he attempts to control his weight through a healthy diet. See November 2009 Board hearing transcript page, 9. In addition, the medical evidence demonstrates that over the past nine years of current appeal period, the Veteran's weight has fluctuated greatly. He gained 35 pounds between the dates of the July 2004 VA examination and the September 2009 VA examination, and his weight then decreased by 15 pounds by the time of the June 2010 VA examination. Although the June 2010 VA examiner opined that the Veteran's Hashimoto's disease with hypothyroidism disorder was not manifested by weight gain, the clinical evidence of shows that his weight has greatly fluctuated over the entire appeal period. The Veteran also asserts that he experiences muscular weakness, mental sluggishness and mental disturbance, but the medical evidence of record shows that none of those symptoms are related to the Veteran's service-connected Hashimoto's disease with hypothyroidism disorder. Following extensive examination and testing, the March 2012 VA psychiatric examination report concluded that the Veteran did not have any mental sluggishness or disturbance due to the hypothyroid disorder. There is no other medical evidence of record that addresses whether the Veteran has mental sluggishness or disturbance which is related to the hypothyroid disorder. Rather, medical evidence of record indicates that the Veteran's history of subjective complaints of memory loss, forgetfulness, and mood instability is attributable to service-connected diabetes mellitus and history of brain anoxia. Private treatment records from Canyon Park Family Physicians dated in August 1995 show that the Veteran's concentration problems, mood swings and memory problems were felt to be caused by his diabetes mellitus. Also the report of a May 2002 Social Security Administration psychiatric evaluation found that the Veteran had cognitive disorder and depression that was secondary to his diabetes mellitus. Therefore, the Board finds that the preponderance of the evidence of record shows that symptoms of mental sluggishness or disturbance during the period pertinent to the appeal were not attributed to the hypothyroid disorder. With regard to the Veteran's complaints of muscular weakness, the medical evidence of record also does not show that any muscular weakness is related to the hypothyroid disorder. The July 2004 VA examination report shows the Veteran had normal muscle strength in his extremities and there was no sign of generalized muscular weakness or wasting. In November 2009, the Veteran testified that he experiencing muscular weakness. The June 2010 VA examination shows that physical examination revealed that the Veteran had normal muscle tone, bulk, and strength in his extremities, except of marked dorsal interossei atrophy, bilaterally. The June 2010 VA examiner found that the Veteran did not have muscular weakness as result of his service-connected Hashimoto's disease with hypothyroidism disorder. There is no other medical evidence of record that addresses whether the Veteran has muscular weakness which is related to his hypothyroid disorder. Therefore, the Board finds that the preponderance of the evidence of record shows that the Veteran's hypothyroid disorder has not resulted in muscular weakness during the period pertinent to the appeal. The record shows that the Veteran has consistently denied symptoms of constipation and cold-intolerance associated with his service-connected Hashimoto's disease with hypothyroidism disorder. See the July 2004 and June 2010 VA examination reports; as well as the Veteran's testimony from the November 2009 Board hearing. The Veteran does feel that his thyroid disorder causes him to sweat easily, but he denied any cold-intolerance. Given the above, the Board finds that the collective evidence of record shows that the Veteran's disability due to Hashimoto's disease with hypothyroidism has been manifested by fatigability and weight gain, and requires continuous medication for treatment. Collectively, the Board finds that the Veteran's symptomatology associated with his disability due to Hashimoto's disease with hypothyroidism more closely approximates the criteria associated with a 30 percent evaluation under Diagnostic Code 7903. In this regard, the Board observes that the probative lay and medical evidence of record demonstrates that the Veteran's hypothyroidism has been productive of fatigability and weight gain. Both the July 2004 and June 2010 VA examinations demonstrate the Veteran's primary symptom of hypothyroidism included fatigability. In addition, the Veteran has reported symptoms of weight gain to the July 2004 VA examiner and he has provided testimony regarding his weight gain. Moreover, the clinical findings recorded in the medical records reflect that the Veteran's weight has greatly fluctuated over the entire period under appeal. The Board acknowledges that the competent medical evidence of record does not demonstrate that the Veteran has mental sluggishness associated with his hypothyroid disability and he has consistently denied symptoms of constipation. However, when resolving all doubt in favor of the Veteran, the Board finds that his current hypothyroidism more nearly approximates the 30 percent rating criteria based on his symptomatology of fatigability and weight gains attributable to his disability under Diagnostic Code 7903. 38 C.F.R. § 4.71a. The Board also finds that the Veteran's hypothyroidism does not meet the criteria for a higher disability rating under Diagnostic Code 7903. While the Veteran does have weight gain associated with his hypothyroid disability that has been considered in the assignment of the 30 percent evaluation. Moreover, the medical records do not demonstrate any symptoms of muscular weakness or cold intolerance. The findings from both VA examination reports show that the Veteran has normal muscle tone, strength, and bulk, and the June 2010 VA examiner opined that the marked dorsal interossei atrophy was not associated with the Veteran's hypothyroid disability. The record does demonstrate that the Veteran has cardiovascular disability that is secondary to his diabetes mellitus, and he has already been award separate compensation for that symptomatology. See Esteban v. Brown, 6 Vet. App. 259 (1994). No other pertinent physical findings, complications, conditions, signs or symptoms related to the diagnosed hypothyroidism were found. Therefore, the Veteran does not meet or more nearly approximate the criteria for a disability rating higher than 30 percent under Diagnostic Code 7903. Thus, the Board finds that a higher evaluation is not warranted. The Board has considered rating the Veteran's service-connected Hashimoto's disease with hypothyroidism disability under all appropriate diagnostic codes. However, the medical evidence of record does not demonstrate that, during the period pertinent to this appeal, the Veteran has ever had hyperthyroidism, toxic or nontoxic adenoma of the thyroid gland, hyperparathyroidism, hypoparathyroidism, or Cushing's syndrome. 38 C.F.R. § 4.71a, Diagnostic Codes 7900, 7901, 7902, 7904, 7905, and 7907. Accordingly, a rating in excess of 10 percent is not warranted for the Veteran's hypothyroid disorder under any of those diagnostic codes. This issue has also been reviewed with consideration of whether staged ratings would be warranted. While there may have been occasional fluctuations of the Veteran's hypothyroid symptoms, the evidence shows no distinct periods of time during which the hypothyroid symptoms have varied to such an extent that a rating in excess of 30 percent would be warranted under any diagnostic code. 38 U.S.C.A. § 5110 (West 2002); 38 C.F.R. § 3.344 (2011); Fenderson v. West, 12 Vet. App. 119 (1999). Generally, rating a disability using either the corresponding or analogous diagnostic codes contained in the Schedule is sufficient. 38 C.F.R. §§ 4.20, 4.27. However, because the ratings are averages, it follows that an assigned rating may not completely account for each individual veteran's circumstance, but nevertheless would still be adequate to address the average impairment in earning capacity caused by disability. In exceptional cases where the rating is inadequate, it may be appropriate to assign an extraschedular rating. 38 C.F.R. § 3.321(b). 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. Thun v. Peake, 22 Vet. App. 111 (2008); Fisher v. Principi, 4 Vet. App. 57 (1993). Therefore, initially, there must be a comparison between the level of severity and symptomatology of the Veteran's service-connected disability with the established criteria found in the Schedule for that disability. Thun v. Peake, 22 Vet. App. 111 (2008). If the criteria under the Schedule reasonably describe the Veteran's disability level and symptomatology, then the Veteran's disability picture is contemplated by the Schedule, and the assigned schedular evaluation is adequate, and no referral is required. When service-connected disability affects employment in ways not contemplated by the rating schedule, § 3.321(b)(1) is applicable. VAOGCPREC 06-96 (1996), 61 Fed. Reg. 66749 (1996). The Board finds that the Veteran's disability picture is not so unusual or exceptional in nature as to render the disabilities rating for a hypothyroid disorder inadequate. The Veteran's hypothyroid disorder was rated under 38 C.F.R. § 4.119, Diagnostic Code 7903, the criteria of which are found by the Board to specifically contemplate the Veteran's level of disability and symptomatology. The Veteran's hypothyroid disorder has been manifested by fatigability and weight gain, and requires control through medication. When comparing that disability picture with the symptoms contemplated by the Schedule, the Board finds that the Veteran's symptoms are adequately contemplated by the rating for the hypothyroid disorder. A rating in excess of the currently assigned rating is provided for certain manifestations of thyroid disorders, but the medical evidence shows that those manifestations are not present in this case, or are not due to the hypothyroid disorder. The criteria for a 30 percent rating for the Veteran's hypothyroid disorder reasonably describe the Veteran's disability level and symptomatology and, therefore, the Board finds that the currently assigned schedular rating is adequate and no referral is required. VAOGCPREC 06-96 (1996), 61 Fed. Reg. 66749 (1996); 38 C.F.R. § 4.119, Diagnostic Code 7903. The Board also notes that this case does not raise a claim of entitlement to a total disability evaluation based upon individual unemployability (TDIU) due to service-connected disability Hashimoto's disease with hypothyroidism. Rice v. Shinseki, 22 Vet. App. 447 (2009) (a request for TDIU, whether expressly raised by a veteran or reasonably raised by the record, is not a separate claim for benefits, but is rather part of the adjudication of a claim for increased compensation). Rather, the evidence of record shows that the Veteran has attributed his inability to work to his service-connected diabetes mellitus and complications. See the Veteran's wife's April 2006 statement in support of the claims. As such, this matter has been referred back to the agency of original jurisdiction for appropriate actions. ORDER Entitlement to service connection for osteoporosis is denied. Entitlement to service connection for recurrent fractures is denied. Entitlement to an evaluation of 30 percent, and not higher, for Hashimoto's disease with hypothyroidism disability is granted. REMAND Unfortunately, the Board finds that there is a further VA duty to assist the Veteran in developing evidence pertinent to his claim for an increased rating for asthma. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. Initially, the Board notes that the Veteran submitted a notification letter that he was scheduled for a pulmonary function test (PFT) in April 2012 in conjunction with his increased rating claim, and the Veteran reports that he underwent that scheduled PFT. However, a copy of the report from that PFT has not yet been associated with the claims folder, and the findings from that PFT are not reflected in the most recent October 2012 supplemental statement of the case (SSOC). On remand, a copy of the PFT report from April 2012 should be associated with the claims folder and considered in re-adjudication of the claim by the agency of original jurisdiction. Although the Veteran was last afforded a VA medical examination in March 2012, the Veteran reported that he was subsequently hospitalized in August 2012 for pneumonia, and since then, he has been placed on oxygen with his C-PAP machine at night. Although the Veteran has not specifically asserted that his asthma disability has worsened, given the recent decline in his pulmonary function as suggested by the required oxygen at night, the Board finds that the Veteran should be afforded a new VA examination to evaluate the current level of severity of his asthma disability. The Court of Appeals for Veteran's Claims has held that it is within VA's duty to assist to afford the Veteran a new VA examination in order to accurately assess the current level of impairment when there is evidence that the claimed disability has worsened. Snuffer v. Gober, 10 Vet. App. 400, 402-403 (1997). Additionally, the Veteran identified that he sought treatment at a private hospital, Integris in Edmond, Oklahoma, for his pneumonia episode in August 2012. The Veteran assistance should be sought in order to obtain copies of these treatment records, as well as any other outstanding records of pertinent treatment. Accordingly, the case is REMANDED for the following action: 1. Obtain a copy of the April 2012 VA pulmonary function test conducted at the VA medical center in Oklahoma City and associate the report with the claims folder. In addition, update the claims folder with the Veteran's VA treatment records since 2010. 2. Contact the Veteran and ask him for his assistance in obtaining outstanding records of pertinent private treatment. In particular, ask the Veteran to submit a necessary release for treatment records from Integris in Edmond, Oklahoma, for his pneumonia episode in August 2012. All correspondence, as well as any treatment records obtained, should be made a part of the claims folder. If private treatment is reported and those records are not obtained, the Veteran and her representative should be provided with information concerning the negative results and afforded an opportunity to obtain the records. 38 C.F.R. § 3.159. 3. Schedule the Veteran for a VA respiratory examination to determine the severity of disability due to his service-connected asthma. The claims folder must be provided to and reviewed by the examiner in conjunction with the examination. All signs and symptoms necessary for rating the Veteran's service-connected asthma should be reported in detail (including all information for rating this disability under Diagnostic Code 6602). All necessary tests and studies are to be performed, including pulmonary function tests. It is essential that the pulmonary function study contain the full range of results necessary to rate the disability under the diagnostic criteria (FEV-1, FEV- 1/FVC). The complete rationale for all opinions expressed should be discussed, and relevant information from the claims file identified. 4. When the above actions have been accomplished, readjudicate the veteran's claim. If any benefit sought remains denied, issue a supplemental statement of the case and afford the veteran the appropriate opportunity to respond. The supplemental statement of the case should list all pertinent laws and regulations. Thereafter, the case should be returned to the Board for further appellate consideration, if otherwise in order. The appellant has the right to submit additional evidence and argument on the matter or matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). 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). ______________________________________________ L. BAKKE Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs