Citation Nr: 1315031 Decision Date: 05/07/13 Archive Date: 05/15/13 DOCKET NO. 07-22 578 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Indianapolis, Indiana THE ISSUES 1. Entitlement to service connection for gastroesophageal reflux disease (GERD). 2. Entitlement to service connection for steatohepatitis, to include as secondary to multiple service-connected disabilities. 3. Entitlement to a disability rating in excess of 30 percent for right carpal tunnel syndrome. 4. Entitlement to a total disability rating for compensation purposes based on individual unemployability (TDIU). REPRESENTATION Veteran represented by: Disabled American Veterans ATTORNEY FOR THE BOARD Shauna M. Watkins, Associate Counsel INTRODUCTION The Veteran served on active duty from July 1989 to August 2004. These matters come before the Board of Veterans' Appeals (Board) on appeal of a May 2006 rating action by the U.S. Department of Veterans Affairs (VA) Regional Office (RO) in Philadelphia, Pennsylvania, and from October 2008 and February 2010 rating actions by the RO in Indianapolis, Indiana. The RO in Indianapolis, Indiana is currently the Agency of Original Jurisdiction (AOJ). In August 2011, the Board remanded this appeal to the RO via the Appeals Management Center (AMC) in Washington, DC, for further development. The case has now been returned to the Board for appellate disposition. The Veteran's Virtual VA paperless claims file has also been reviewed in preparing this decision. FINDINGS OF FACT 1. The Veteran's current GERD is not shown to be causally or etiologically related to his active military service. 2. The Veteran's current steatohepatitis is not shown to be causally or etiologically related to his active military service, and is not shown to be caused or aggravated by a service-connected disability. 3. Throughout the appeal, the Veteran's right carpel tunnel syndrome has been manifested by moderate, incomplete paralysis of the median nerve. 4. The Veteran's service-connected disabilities are not shown to be of such severity so as to preclude substantially gainful employment. CONCLUSIONS OF LAW 1. Service connection for GERD is not established. 38 U.S.C.A. § 1110 (West 2002); 38 C.F.R. § 3.303 (2012). 2. Service connection for steatohepatitis, to include as secondary to the service-connected disabilities, is not established. 38 U.S.C.A. § 1110 (West 2002); 38 C.F.R. §§ 3.303, 3.310 (2012). 3. The criteria for a rating in excess of 30 percent for the right carpel tunnel syndrome are not met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.124a, Diagnostic Code 8515 (2012). 4. The criteria for a TDIU have not been met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 3.340, 3.341, 4.16 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Board has thoroughly reviewed all the evidence in the Veteran's claims file. Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, the evidence submitted by the Veteran or on his behalf. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (determining that the Board must review the entire record, but does not have to discuss each piece of evidence). The analysis below focuses on the most salient and relevant evidence, and on what this evidence shows, or fails to show, on the claims. The Veteran must not assume that the Board has overlooked pieces of evidence that are not explicitly discussed herein. See Timberlake v. Gober, 14 Vet. App. 122 (2000) (holding that the law requires only that the Board address its reasons for rejecting evidence favorable to the Veteran). Notice and Assistance With respect to the Veteran's claims decided herein, VA has met all statutory and regulatory notice and duty to assist provisions. See 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326 (2012). Under the Veterans Claims Assistance Act (VCAA), when VA receives a complete or substantially complete application for benefits, it is required to notify the claimant and his representative, if any, of any information and medical or lay evidence that is necessary to substantiate the claim. See 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b); Quartuccio v. Principi, 16 Vet. App. 183 (2002). In Pelegrini v. Principi, 18 Vet. App. 112, 120-21 (2004) (Pelegrini II), the United States Court of Appeals for Veterans Claims (Court) held that VA must inform the claimant of any information and evidence not of record: (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and, (3) that the claimant is expected to provide. Here, letters from the RO dated in March 2006 and April 2006 provided the Veteran with an explanation of the type of evidence necessary to substantiate his service connection claims, as well as an explanation of what evidence was to be provided by him and what evidence the VA would attempt to obtain on his behalf. Letters dated in June 2009 and November 2009 also informed the Veteran about the requirements for establishing secondary service connection. The March 2006 and April 2006 letters also provided the Veteran with information concerning the evaluations and effective dates that could be assigned should service connection be granted, pursuant to Dingess v. Nicholson, 19 Vet. App. 473 (2006). The Board notes that the June 2009 and November 2009 letters were not provided prior to the initial RO adjudication of the service connection claims in the May 2006 rating decision. However, after the Veteran was provided the June 2009 and November 2009 letters, the service connection claims were then readjudicated in the April 2010 and October 2012 Supplemental Statements of the Case (SSOCs) based on any additional evidence received in response to these additional notices. This is important to point out because if there was no VCAA notice provided prior to the initial adjudication of the claims, or for whatever reason the notice provided was inadequate or incomplete, this timing error may be effectively "cured" by providing any necessary notice and then going back and readjudicating the claims, including in a Statement of the Case (SOC) or SSOC, such that the intended purpose of the notice is not frustrated and the Veteran is given ample opportunity to participate effectively in the adjudication of his claims. In other words, this timing error in the provision of the notice is ultimately inconsequential and, therefore, at most nonprejudicial, i.e., harmless error. See Mayfield v. Nicholson, 499 F.3d 1317, 1323 (Fed. Cir. 2007) (Mayfield IV); Prickett v. Nicholson, 20 Vet. App. 370, 376 (2006). Accordingly, VA has no outstanding duty to inform the Veteran that any additional information or evidence is needed for his service connection claims. As well, letters from the RO dated in March 2008 and May 2008 provided the Veteran with an explanation of the type of evidence necessary to substantiate his TDIU claim, as well as an explanation of what evidence was to be provided by him and what evidence the VA would attempt to obtain on his behalf. The letter also provided the Veteran with information concerning the evaluation and effective date that could be assigned should his claim be granted, pursuant to Dingess v. Nicholson, 19 Vet. App. 473 (2006). This letter was provided prior to the initial RO adjudication of the TDIU claim in the October 2008 rating decision. Accordingly, VA has no outstanding duty to inform the Veteran that any additional information or evidence is needed for his TDIU claim. Regarding the increased rating claim, prior to the initial RO adjudication of this claim in the February 2010 rating decision, letters dated in August 2009 and November 2009 fully satisfied the duty to notify provisions. See 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b)(1); Quartuccio, at 187. Accordingly, VA has no outstanding duty to inform the Veteran that any additional information or evidence is needed for his increased rating claim. All the law requires is that the duty to notify is satisfied and that claimants are given the opportunity to submit information and evidence in support of their claims. Once this has been accomplished, all due process concerns have been satisfied. See Bernard v. Brown, 4 Vet. App. 384 (1993); Sutton v. Brown, 9 Vet. App. 553 (1996); see also 38 C.F.R. § 20.1102 (2012) (harmless error). In view of the foregoing, the Board finds that the Veteran was notified and aware of the evidence needed to substantiate his claims, as well as the avenues through which he might obtain such evidence, and of the allocation of responsibilities between himself and VA in obtaining such evidence. Accordingly, there is no further duty to notify. The Board also concludes that VA's duty to assist has been satisfied. The Veteran's service treatment records (STRs) and VA medical records are in the file. Private medical records identified by the Veteran have been obtained, to the extent possible. The claims file does not present evidence that the Veteran is currently receiving disability benefits from the Social Security Administration (SSA) for the disorders currently on appeal. Therefore, the Board does not need to make an attempt to obtain these records. For the foregoing reasons, the Board concludes that all reasonable efforts were made by the VA to obtain evidence necessary to substantiate the Veteran's claims. Therefore, no further assistance to the Veteran with the development of evidence is required. The duty to assist also includes, when appropriate, the duty to conduct a thorough and contemporaneous examination of the veteran. See Green v. Derwinski, 1 Vet. App. 121 (1991). In addition, where the evidence of record does not reflect the current state of the veteran's disability, a VA examination must be conducted. See Schafrath v. Derwinski, 1 Vet. App. 589 (1991); 38 C.F.R. § 3.327(a) (2012). Here, the RO provided the Veteran with appropriate and pertinent VA examinations and medical opinions in November 2004, October 2006, June 2008, October 2009, November 2009, September 2011, and September 2012. These examination reports have been included in the claims file for review. The examinations involved reviews of the claims file, thorough examinations of the Veteran, and medical opinions that were supported by sufficient rationale. Therefore, the Board finds that the examinations are adequate for rating purposes. See Barr v. Nicholson, 21 Vet. App. 303, 311 (2007) (affirming that a medical opinion is adequate if it provides sufficient detail so that the Board can perform a fully informed evaluation of the claim). Regarding the TDIU and increased rating claims, there is also no objective evidence indicating that there has been a material change in the severity of the Veteran's service-connected disabilities since he was last examined. See 38 C.F.R. § 3.327(a) (2012). The duty to assist does not require that a claim be remanded solely because of the passage of time since an otherwise adequate VA examination was conducted. See VAOPGCPREC 11-95. The recent September 2011 VA examination report is thorough and supported by the treatment records. The examination in this case is adequate upon which to base a decision. See again Barr, 21 Vet. App. at 311. Given the foregoing, the Board finds that the VA has substantially complied with the duty to obtain the requisite medical information necessary to make a decision on the Veteran's claims. The Board is also satisfied as to substantial compliance with its August 2011 remand directives. See Dyment v. West, 13 Vet. App. 141, 146-47 (1999); Stegall v. West, 11 Vet. App. 268 (1998). This included scheduling the Veteran for additional VA examinations - which he had in September 2011. An addendum VA medical opinion was also obtained in September 2012. The AMC also readjudicated his claims in the October 2012 SSOC. Thus, the Board finds that there has been substantial compliance with the Board's remand. Id. As there is no indication that any failure on the part of VA to provide additional notice or assistance reasonably affects the outcome of this case, the Board finds that any such failure is harmless. See Newhouse v. Nicholson, 497 F.3d 1298 (Fed. Cir. 2007). The Veteran has submitted argument and evidence in support of the appeal. Based on the foregoing, the Board finds that the Veteran has had a meaningful opportunity to participate in the adjudication of his claims, such that the essential fairness of the adjudication is not affected. Service Connection - General Regulations and Statutes Service connection may be established for a disease or injury incurred in or aggravated by military service. 38 U.S.C.A. § 1110; 38 C.F.R. § 3.303, 3.304. Service connection requires: (1) evidence of a current disorder; (2) evidence of in-service incurrence or aggravation of an injury or disease; and, (3) evidence of a nexus between the current disorder and the in-service disease or injury. Pond v. West, 12 Vet. App. 341 (1999); Caluza v. Brown, 7 Vet. App. 498 (1995). Service connection means that the facts, shown by evidence, establish that a particular injury or disease, resulting in a current disorder, was incurred coincident with the military service, or if pre-existing such service, was aggravated by service. This may be accomplished by affirmatively showing inception or aggravation during service. 38 C.F.R. § 3.303(a). Service connection may also be warranted for any disease diagnosed after the military discharge, when all the evidence, including that pertinent to the military service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). In order to prevail under a theory of secondary service connection, there must be: (1) evidence of a current disorder; (2) evidence of a service-connected disability; and, (3) nexus evidence establishing a connection between the service-connected disability and the current disorder. See Wallin v. West, 11 Vet. App. 509, 512 (1998). In addition, the regulations provide that service connection is warranted for a disorder that is aggravated by, proximately due to, or the result of a service-connected disease or injury. 38 C.F.R. § 3.310. Any additional impairment of earning capacity resulting from an already service-connected disability, regardless of whether or not the additional impairment is itself a separate disease or injury caused by the service-connected disability, should also be compensated. Allen v. Brown, 7 Vet. App. 439 (1995). When service connection is thus established for a secondary disorder, the secondary disorder shall be considered a part of the original disability. Id. The Board notes that 38 C.F.R. § 3.310 was amended, effective October 10, 2006. Under the revised § 3.310(b) (the existing provision at 38 C.F.R. § 3.310(b) was moved to sub-section (c)), any increase in severity of a non-service-connected disease or injury proximately due to or the result of a service-connected disease or injury, and not due to the natural progress of the disease, will be service-connected. In reaching this determination as to aggravation of a non-service-connected disorder, consideration is required as to what the competent evidence establishes as the baseline level of severity of the nonservice-connected disease or injury (prior to the onset of aggravation by service-connected disability), in comparison to the medical evidence establishing the current level of severity of the non-service-connected disease or injury. These findings as to baseline and current levels of severity are to be based upon application of the corresponding criteria under the Schedule for Rating Disabilities (38 C.F.R. part 4) for evaluating that particular non-service-connected disorder. See 71 Fed. Reg. 52,744-47 (Sept. 7, 2006). It appears as though the new regulatory amendment poses a different restriction on claimants. As such, because the Veteran's claim was pending before the regulatory change was made in 2006, the Board will consider the version of 38 C.F.R. § 3.310 in effect before the revision, as this version is more favorable to the Veteran. See generally VAOGCPREC 7-03 and VAOPGCPREC 3-00. The Board must assess the credibility and weight of all the evidence, including the medical evidence, to determine its probative value, accounting for evidence which it finds to be persuasive or unpersuasive, and providing reasons for rejecting any evidence favorable to the claimant. 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). GERD Claim The Veteran seeks service connection for GERD. In particular, the Veteran asserts that his GERD is related to his in-service complaints of chest pain and shortness of breath. As noted above, the first element of direct service connection requires medical evidence of a current disorder. Here, a current diagnosis has been established. On VA examination in October 2006, the Veteran was diagnosed with GERD. Thus, the Veteran has satisfied the first element of service connection. As stated above, the second element of direct service connection requires medical evidence, or in certain circumstances, lay testimony, of in-service incurrence or aggravation of an injury or disease. Here, the Veteran's military entrance examination did not document GERD, chest pain, or shortness of breath. The Veteran's STRs also do not document any symptoms of or treatment for GERD during his active military service. Rather, as previously stated, the Veteran asserts that his GERD is related to his in-service complaints of chest pain and shortness of breath. In this regard, the Veteran's STRs do document chest pain and shortness of breath. Specifically, the Veteran first sought treatment for indigestion and chest pain in May 2003, in which he reported chest pain for the past two weeks. The Veteran continued to seek treatment for chest pain and shortness of breath on multiple occasions, complaining of a burning in his chest that radiated to his left arm. The Veteran was eventually referred to the Medical Evaluation Board (MEB) during his active military service. The Veteran was examined by the MEB in October 2003, and was diagnosed with chest pain with a history of pericarditis. This examination included a stress test, which was found to be normal. A May 2004 MEB found that the Veteran had persistent chest pain and shortness of breath of an uncertain etiology, which began in May 2003 while the Veteran was entitled to basic military pay. The MEB found that these symptoms did not exist prior to the Veteran's military service. In June 2004, the Veteran was examined by the Physical Evaluation Board (PEB) and discharged from the military on a medical basis. The PEB diagnosed the Veteran with "chest pain (and dyspnea) on exertion, unknown etiology, but preventing vigorous physical activity. Asthma and cardiac conditions ruled out. Rated as subjective pain." The PEB found that these symptoms were incurred or aggravated while the Veteran was entitled to basic military pay. On the Veteran's military separation Report of Medical History dated in September 2003, chest pain was noted. Again, no complaints of or treatment for GERD were documented in the STRs or on the military separation examination. The Veteran did not have any work-ups for GERD, to include an esophagogastroduodenoscopy (EGD) or upper gastrointestinal (UGI) series during his active military service. As previously mentioned, the third element of service connection requires medical evidence of a nexus between the current disorder and the in-service disease or injury. Here, the only medical nexus opinions of record are either speculative or negative. Specifically, the Veteran was afforded a VA examination in November 2004. Shortness of breath of an uncertain etiology and persistent chest pain were diagnosed following a physical examination of the Veteran and a review of the claims file. The examiner found that there was insufficient clinical evidence to warrant a diagnosis of any acute or chronic disorder or residual thereof. The examiner also diagnosed the Veteran with obesity. A VA medical opinion was not provided. The Veteran had an EGD performed by the VA Medical Center (VAMC) in July 2006. The results showed "esophagogastric type mucosa with mild nonspecific chronic inflammation and minimal reactive squamoglandular ephithelial changes." The Veteran was afforded another VA examination in October 2006. The VA examiner diagnosed the Veteran with GERD. Following a physical examination of the Veteran and a review of the claims file, the VA examiner found that the Veteran's in-service symptoms of atypical chest pain with associated shortness of breath "could be" associated with his GERD, since no other cause was found after an extensive work-up and the Veteran's most recent EGD did indicate chronic inflammatory changes. However, the VA examiner also noted that the Veteran's current symptoms that he complains of are different than those symptoms that were initially described during his active military service. The examiner stated that the work-up in service was primarily targeted towards a cardiac disorder, while the Veteran's present chest pain symptoms are described by the Veteran as more of a heartburn sensation. The examiner also added that symptoms of GERD less commonly cause chronic chest pain and/or shortness of breath. There are a line of precedent cases discussing the probative value of opinions like this that are equivocal, which essentially state that it is possible the disorder at issue is attributable to the veteran's military service. See, e.g., Tirpak v. Derwinski, 2 Vet. App. 609 (1992); Perman v. Brown, 5 Vet. App. 227, 241 (1993); Alemany v. Brown, 9 Vet. App. 518, 519 (1996); Winsett v. West, 11 Vet. App. 420, 424 (1998). These cases make clear that, while an absolutely accurate determination of etiology is not a condition precedent to granting service connection, nor is definite etiology or obvious etiology, a doctor's opinion phrased in terms tantamount to "may" or "could" be related to service is an insufficient basis for an award of service connection because this is for all intents and purposes just like saying the disorder in question just as well "may or may not"" be related to the active military service. Obert v. Brown, 5 Vet. App. 30 (1993). See, too, Bloom v. West, 13 Vet. App. 185, 187 (1999) (a medical opinion based on speculation, without supporting clinical data or other rationale, does not provide the required degree of medical certainty). Accordingly, the Veteran was seen for another VA examination in May 2007 to determine if his GERD was related to his military service. The VA examiner was asked to provide an opinion on whether the Veteran's GERD is related to his documented in-service complaints of chest pain and shortness of breath. After examining the Veteran and reviewing the claims folder, the VA examiner diagnosed the Veteran with mild GERD, as there are no "erosions, ulcers, or gross inflammation of the distal esophagus." It was further stated that "if GERD is causing his chest pain, then it is due to esophageal spasms related to GERD." The examiner continued to state that he could not determine whether the Veteran's GERD was "the cause of all of his chest pain" without resorting to speculation. The Board observes that the phrasing of the May 2007 VA examiner's opinion indicates that it is based on speculation. Obert v. Brown, 5 Vet. App. 30, 33 (1993); Beausoleil v. Brown, 8 Vet. App. 459, 463 (1996); Libertine v. Brown, 9 Vet. App. 521, 523 (1996) [medical opinions which are speculative, general or inconclusive in nature cannot support a claim]. Furthermore, the VA examiner's statement that he could not determine whether the Veteran's GERD is related to his military service without resorting to speculation is troubling because the examination report is unclear as to whether the relationship cannot be determined from current medical knowledge, or that the actual cause cannot be selected from multiple potential causes. See Jones v. Shinseki, 23 Vet. App. 382, 389 (2010). Accordingly, in accordance with the Board's remand, the Veteran was afforded another VA examination in September 2011. Following a review of the claims file and a physical examination of the Veteran, the VA examiner diagnosed the Veteran with GERD. The examiner then determined that it is less likely as not (less than a 50 percent probability) that the Veteran's GERD had its clinical onset in service or is otherwise related to his active duty, to include the Veteran's in-service complaints of chest pain. The examiner reasoned that there is no medical evidence of GERD symptoms, diagnosis, or treatment for GERD while the Veteran was on active duty. Regarding the in-service chest pain and shortness of breath, the examiner stated that the Veteran's initial presentation for treatment in service was more typical of a cardiopulmonary problem than a gastrointestinal (GI) problem. The examiner stated that the Veteran's in-service complaints of chest pain radiating to the left arm associated with dyspnea on exertion are not typical for GI problems, but are very typical of a cardiac disorder. The examiner stated that at the onset of his in-service chest pain, the Veteran was found to have a pericardial friction rub, which points directly to a cardiac disorder, rather than a GI disorder. The examiner noted that the Veteran's friction rub resolved after being treated with a high-dose of aspirin for 5 1/2 weeks in service. The examiner pointed out that there were no complaints of GERD during those 5 1/2 weeks of treatment. The examiner stated that if the Veteran did have GERD, the expectation is that the 5 1/2 weeks of aspirin would have exacerbated the GERD and made it evident in service. Furthermore, the September 2011 VA examiner pointed out that the Veteran now reports two different types of chest pain - one that is similar to heartburn and one that involves his left arm. The examiner stated that these two types of chest pain are different, and the only type of chest pain described in the Veteran's STRs is the second type of chest pain. The examiner stated that there is no description of gagging or heartburn while the Veteran was reporting chest pain during his active military service. Symptoms of gagging and heartburn were not documented in the medical treatment records until after the Veteran's military discharge. Thus, the examiner found that the most likely etiology of the Veteran's GERD was lower esophageal sphincter (LES) incompetence, which the examiner found that the Veteran's weight gain probably worsens it. The examiner noted that dietary indiscretion can also worsen it. The examiner pointed out that the Veteran was not on any medications that would worsen it. A VA addendum medical opinion was also obtained in September 2012. Another VA examiner reviewed the Veteran's claims file and provided a medical opinion. The examiner found that it is less likely as not (less than 50/50 probability) that the Veteran's current GERD was related to, secondary to, or shown to be present during his active military service. The examiner reasoned that the Veteran was not shown to definitively have GERD by testing until the July 2006 VA EGD was performed. Thus, the examiner pointed out that the Veteran was not medically diagnosed with GERD until almost two years after his military discharge. The examiner noted that the Veteran had several complaints of chest pain during his active military service, but the examiner pointed out that this chest pain has not been proven to be secondary to the Veteran's current GERD. The examiner stated that chest pain can have many etiologies, which include, but are not limited to, the following: anxiety, heart disease, costochondritis, asthma, pleurisy, pericarditis, and pneumonia. Regarding the Veteran's weight, the September 2012 VA examiner stated that GERD is the result of an inappropriate transient relaxation of the LES. The examiner added that LES pressure is decreased by progesterone, chocolate, smoking, and some medications, and that GERD can also be secondary to a hypotensive LES or hiatal hernia. The examiner indicated that obesity is a risk factor for GERD. However, the examiner pointed out that just because the Veteran was obese during or after his active military service does not mean that he had GERD. In other words, the examiner fond that the Veteran was not proven to have GERD until his VA endoscope in July 2006. The September 2011 and September 2012 VA examiners clearly reviewed the STRs and the other evidence in the claims folder. They provided medical opinions supported by a rationale and that are supported by and consistent with the evidence of record. The examiners also provided an alternative etiology for the Veteran's GERD - namely, his LES incompetence. There is no positive nonspeculative medical evidence to the contrary of these opinions in the claims file. The VA and private treatment records do not provide contrary evidence. The Board finds that the 2011 and 2012 opinions are persuasive and probative on the nexus question. For all of these reasons, service connection for GERD is not warranted. Additionally, regarding the Veteran's current complaints of chest pain and shortness of breath, the treatment records only document the Veteran's complaints of chest pain and shortness of breath, but do not provide a diagnosis attributable to these complaints, following physical examinations of the Veteran. The STRs also do not provide a diagnosis for these symptoms and instead refer to the symptoms as deriving from an "unknown etiology." The only diagnosis in the claims file is GERD, but this diagnosis has not been attributed to the Veteran's complaints of chest pain and shortness of breath. Thus, the chest pain and shortness of breath symptoms do not have a supporting diagnosis. Under the applicable regulation, the term "disability" means impairment in earning capacity resulting from diseases and injuries and their residual conditions. 38 C.F.R. § 4.1 (2012); see Hunt v. Derwinski, 1 Vet. App. 292, 296 (1991); Allen v. Brown, 7 Vet. App. 439 (1995). Thus, a symptom, without a diagnosed or identifiable underlying malady or disorder, does not, in and of itself, constitute a "disability" for which service connection may be granted. See Sanchez-Benitez v. West, 13 Vet. App. 282 (1999). In the absence of proof of a present disorder, there can be no valid claim for service connection. Gilpin v. West, 155 F.3d 1353 (Fed. Cir. 1998); Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). Accordingly, service connection for chest pain and shortness of breath is not warranted because the Veteran has not satisfied the first requirement of service connection, i.e., a current chronic diagnosis. See 38 C.F.R. §§ 3.303, 3.304; see again Gilpin, 155 F.3d at 1353; Brammer, 3 Vet. App. at 225. The existence of a current GERD disability and the occurrence of an in-service event are not in dispute. Rather, the question in controversy is whether the current disability is related to the in-service event. While the Veteran is competent to describe readily observable features or symptoms of illness (see Barr v. Nicholson, 21 Vet. App. 303, 309 (2007), he is not competent to state that his GERD is in fact related to his in-service complaints of chest pain and shortness of breath. Although lay persons are competent to provide opinions on some medical issues, see Kahana v. Shinseki, 24 Vet.App. 428, 435 (2011), as to the specific issue in this case, the etiology of the Veteran's GERD, this question falls outside the realm of common knowledge of a lay person. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007) (providing that lay persons not competent to diagnose cancer). The Board notes that under the provisions of 38 U.S.C.A. § 5107(b), the benefit of the doubt is to be resolved in the claimant's favor in cases where there is an approximate balance of positive and negative evidence in regard to a material issue. The preponderance of the evidence, however, is against the Veteran's claim, and thus that doctrine is not applicable. Gilbert, 1 Vet. App. at 49. The Veteran's claim of entitlement to service connection for GERD is not warranted. Steatohepatitis Claim The Veteran seeks service connection for steatohepatitis, to include as secondary to his service-connected disabilities. The Board will begin by addressing direct service connection. As noted above, the first element of direct service connection requires medical evidence of a current disorder. Here, a current diagnosis has been established. The Veteran has been diagnosed with steatohepatitis and multiple treatment records suggest that the Veteran has nonalcoholic steatohepatitis (NASH). See VA treatment records from August 2005 and May 2009 VA. The Board observes that steatohepatitis is defined as a "fatty liver in alcoholics." See Dorland's Illustrated Medical Dictionary, 30th Edition, (2003), at page 1757. NASH is defined as "an inflammatory disease of the liver of uncertain pathogenesis and histologically resembling alcoholic hepatitis, but occurring in nonalcoholic patients." Id. Thus, the Veteran has satisfied the first element of direct service connection. As stated above, the second element of direct service connection requires medical evidence, or in certain circumstances, lay testimony, of in-service incurrence or aggravation of an injury or disease. Here, the Veteran's STRs are silent for documentation of the disorder. The records reveal no complaints or treatment related to steatohepatitis or its associated symptoms. At his military separation examination, steatohepatitis was not documented. Records, however, do show that the Veteran was noted to be obese during service. Post-service, the Veteran has been diagnosed with steatohepatitis and multiple treatment records suggest that the Veteran has nonalcoholic steatohepatitis (NASH). See VA treatment records from August 2005 and May 2009 VA. A liver biopsy was performed in March 2009 by the VAMC, in which the Veteran was officially diagnosed with NASH. As previously mentioned, the third element of direct service connection requires medical evidence of a nexus between the current disorder and the in-service disease or injury. Here, the only medical nexus opinions of record are negative. Specifically, on VA examination in September 2011, following a review of the claims file, a review of the recent medical literature, and a physical examination of the Veteran, the VA examiner diagnosed the Veteran with NASH and alcoholic steatohepatitis. The examiner then determined that it is less likely than not (less than 50/50 percent probability) that the Veteran's current NASH had its clinical onset or is otherwise related to the Veteran's active military service. The examiner reasoned that the Veteran's liver enzymes were all normal when he was released from the active duty; thus, the examiner stated that the Veteran did not have NASH at his military discharge, as abnormal liver enzymes are part of the definition of NASH. The examiner found that the etiology of the Veteran's steatohepatitis is NASH due to obesity and metabolic syndrome. The examiner added that the Veteran has dyslipidemia and metabolic syndrome (i.e., obesity, diabetes, hypertriglyceridemia, and hypertension), all of which are probably contributing to his NASH. In this regard, the examiner noted that the Veteran's claims file shows that he was overweight for some time while he was on active duty. During his active military service, the Veteran also had hyperlipidemia, elevated triglycerides, and hypertension. However, the Veteran was not found to be diabetic during his active military service; thus, the examiner found that the Veteran did not have metabolic syndrome on active duty. The examiner noted that the Veteran gained 15 pounds shortly after his military discharge (where he weighed 221 pounds). The examiner stated that this weight increase appears to have been enough to cause increased liver function tests and the later development of steatohepatitis after he left the military service. In September 2012, another VA examiner reviewed the Veteran's claims file, and provided an addendum medical opinion. Specifically, the examiner found that it is less likely as not (less than 50/50 probability) that the Veteran's current NASH is related to, secondary to, or shown to be present during his military career. The examiner reasoned that the Veteran had normal liver function tests during his active military service. The examiner found that the Veteran's current NASH was not officially diagnosed until March 2009 when the Veteran had a liver biopsy performed. The examiner stated that the medical evidence was only speculative prior to the March 2009 liver biopsy regarding the cause of the Veteran's elevated liver function tests. The examiner indicated that the treatment records also include multiple references to the fact that the Veteran's elevated liver function tests could have initially been elevated secondary to medications and/or alcohol. Therefore, in summary, the examiner found that it was not medically proven that the Veteran had NASH until 2009, which the examiner pointed out was five years after his military discharge. Regarding the Veteran's obesity, the examiner reported that NASH develops over time, and thus just because the Veteran was obese in service and soon after his military service does not mean that he had NASH at that time. The September 2011 and September 2012 VA examiners clearly reviewed the Veteran's STRs and the other evidence in the claims folder. They provided medical opinions supported by a rationale and that are supported by and consistent with the evidence of record. There is no positive medical evidence to the contrary of these opinions in the claims file. The treatment records do not provide contrary evidence. The Board finds that the 2011 and 2012 opinions are persuasive and probative on the nexus question. For all of these reasons, service connection for steatohepatitis on a direct basis is not warranted. The Board will now address secondary service connection. As noted above, the first element of secondary service connection requires medical evidence of a current disorder. Here, a current diagnosis has been established. The Veteran has been diagnosed with steatohepatitis and multiple treatment records suggest that the Veteran has NASH. See VA treatment records from August 2005 and May 2009 VA. The Board observes that steatohepatitis is defined as a "fatty liver in alcoholics." See Dorland's Illustrated Medical Dictionary, 30th Edition, (2003), at page 1757. NASH is defined as "an inflammatory disease of the liver of uncertain pathogenesis and histologically resembling alcoholic hepatitis, but occurring in nonalcoholic patients." Id. Thus, the Veteran has satisfied the first element of secondary service connection. As stated above, the second element of secondary service connection requires evidence of a service-connected disability. Here, the Veteran is currently service-connected for the following disabilities: obstructive sleep apnea; migraine headaches; right carpel tunnel syndrome; left carpel tunnel syndrome; degenerative disc disease of the cervical spine; hypertension; periodic limb movement disorder (nocturnal myoclonus); degenerative disc disease of the lumbar spine; patellofemoral syndrome of the left knee; patellofemoral syndrome of the right knee; residuals of a left ankle fracture; bilateral plantar fasciitis; and, head injury residuals. Thus, the Veteran has satisfied the second element of secondary service connection. As previously mentioned, the third element of secondary service connection requires nexus evidence establishing a connection between the service-connected disability and the current disorder. The Veteran argued that he developed NASH because he could not exercise due to his service-connected sleep "apnea and knee problems." See a March 2006 statement. Similarly, the Veteran has indicated that the medication he takes for his knee and back pain have affected his liver and that these medications, together with his inability to exercise due to his service-connected back, knee and foot disabilities, have caused him to develop a fatty liver. See a July 2009 statement. Here, the only nexus opinions of record on the issue of secondary service connection are negative. Specifically, on VA examination dated in September 2011, the VA examiner found that it was less likely than not (less than 50/50 probability) that the Veteran's current NASH was caused or aggravated (permanently worsened beyond the normal progression) by his service-connected disabilities, to include the medications taken for his service-connected disabilities and to include an inability to exercise due to the service-connected disabilities. The examiner reasoned that the Veteran is not service-connected for a disability that can cause or aggravate NASH. In so finding, the examiner was cognizant of the disease process of metabolic syndrome and recognized that service connection was in effect for hypertensive vascular disease. With these findings there can be no showing of at least fifty to fifty probability that hypertension in and of itself caused or aggravated the Veteran's NASH. Regarding the exercise argument in particular, the September 2011 VA examiner found that an inability to exercise does not cause or aggravate NASH. The examiner stated that, generally speaking, obesity and lack of exercise could lead to a worsening of NASH findings. However, the examiner pointed out that the worsening of the NASH need not be permanent, as the damage is reversible with weight loss and increased activity. The examiner also added that the Veteran's lack of exercise is not due to his service-connected disabilities, and thus the inability to exercise due to his service-connected disabilities is not aggravating the NASH. The examiner stated that the Veteran's service-connected disabilities are not significant enough to prevent exercise as part of a weight loss program, especially low-impact exercise with a gradual increase in activity coupled with diet. The examiner pointed out that there is evidence in the record that the Veteran has exercised in a pool and walked at work for exercise. The examiner added that the Veteran's orthopedic service-connected disabilities were mostly rated as 0 percent disabling, so the examiner found that these orthopedic disabilities should not be stopping the Veteran from exercising. The examiner also found that, even though the Veteran has two service-connected spine disabilities rated at 10 percent each, the Veteran would still be able to do some low-impact exercise to help himself. The examiner found that the Veteran's remaining service-connected disabilities would also not prevent the Veteran from exercising. Regarding the medications required for the Veteran's service-connected disabilities, the September 2011 VA examiner found that these medications do not and have not aggravated the Veteran's NASH. The examiner reported that there was no record of the Veteran being on any medications for his service-connected disabilities that have been found to have an association with NASH. In this regard, the examiner noted that steroids are on the list of medications that can cause steatohepatitis. The examiner reported that the Veteran was on steroids for a brief period in-service during his evaluation and treatment for dyspnea. However, since the Veteran was not on the steroids for very long, the examiner found that it was not likely that the steroids were the cause of the Veteran's elevated liver enzymes and NASH, which were diagnosed several years later. The examiner also noted that the Veteran had been on Flovent, an inhaled steroid for his breathing, in the past. However, the examiner stated that this steroid is minimally absorbed into the blood stream, and thus is also unlikely to cause liver problems. In September 2012, another VA examiner reviewed the Veteran's claims file, and provided an addendum medical opinion. However, this medical opinion only addressed direct service connection, and thus is not pertinent to the secondary service connection issue. The September 2011 VA examiner clearly reviewed the STRs and the other evidence in the claims folder. He provided a medical opinion supported by a rationale and that is supported by and consistent with the evidence of record. There is no positive medical evidence to the contrary of this opinion in the claims file. The VA and private treatment records do not provide contrary evidence. The Board finds that the 2011 opinion is persuasive and probative on the nexus question. For all of these reasons, service connection for steatohepatitis on a secondary basis is not warranted. In reaching this decision, the Board has considered the Veteran's arguments in support of his claim. The Veteran contends that his steatohepatitis is directly related to his active military service, or, in the alternative, is related to his service-connected disabilities. The existence of a current NASH disability and the occurrence of an in-service event (obesity) are not in dispute. Rather, the question in controversy is whether the current disability is related to the in-service event or service connected disability. While the Veteran is competent to describe readily observable features or symptoms of illness (see Barr v. Nicholson, 21 Vet. App. 303, 309 (2007), he is not competent to state that his NASH is in fact related to his obesity or service connected disability. Although lay persons are competent to provide opinions on some medical issues, see Kahana v. Shinseki, 24 Vet.App. 428, 435 (2011), as to the specific issue in this case, the etiology of the Veteran's NASH, this question falls outside the realm of common knowledge of a lay person. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007) (providing that lay persons not competent to diagnose cancer). The Board notes that under the provisions of 38 U.S.C.A. § 5107(b), the benefit of the doubt is to be resolved in the claimant's favor in cases where there is an approximate balance of positive and negative evidence in regard to a material issue. The preponderance of the evidence, however, is against the Veteran's claim, and thus that doctrine is not applicable. Gilbert, 1 Vet. App. at 49. The Veteran's claim of entitlement to service connection for steatohepatitis, to include as secondary to his service-connected disabilities, is not warranted. Increased Rating Claim The Veteran's service-connected right carpel tunnel syndrome is currently assigned a 30 percent evaluation under Diagnostic Code 8515. 38 C.F.R. § 4.124a. The Veteran contends that this evaluation does not adequately reflect the severity of his disability. Disability ratings are determined by the application of a schedule of ratings, which is based on average impairment of earning capacity. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4 (2012). Separate diagnostic codes identify the various disabilities. Where there is a reasonable doubt as to the degree of disability, such doubt will be resolved in favor of the claimant. 38 C.F.R. §§ 3.102, 4.3 (2012). 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 required for that rating. Otherwise, the lower rating will be assigned. 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 (2012). The degree of impairment resulting from a disability is a factual determination and generally the Board's primary focus in such cases is upon the current severity of the disability. Francisco v. Brown, 7 Vet. App. 55, 57-58 (1994); Solomon v. Brown, 6 Vet. App. 396, 402 (1994). The Court also held that "staged" ratings are appropriate for an increased rating claim when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. Hart v. Mansfield, 21 Vet. App. 505 (2007). The Veteran's service-connected right carpel tunnel syndrome is currently assigned a 30 percent evaluation under Diagnostic Code 8515. 38 C.F.R. § 4.124a. At his recent October 2009 VA examination, the Veteran told the VA examiner that he is right-handed; thus, his right arm is his dominant (major) extremity. Under Diagnostic Code 8515, moderate incomplete paralysis of the median nerve of the minor extremity warrants a 30 percent evaluation for the major extremity. Severe incomplete paralysis of the median nerve of the major extremity warrants a 50 percent evaluation. 38 C.F.R. § 4.124a. A note in the Rating Schedule pertaining to "Diseases of the Peripheral Nerves" provides that the term "incomplete paralysis" indicates a degree of lost or impaired function which is substantially less than that which results from complete paralysis of these nerve groups, whether the loss is due to the varied level of the nerve lesion or to partial nerve regeneration. When the involvement is wholly sensory, the rating should be for the mild, or at most, the moderate degree. 38 C.F.R. § 4.124a. The words "slight," "moderate," and "severe" as used in the various diagnostic codes are not defined in the VA Schedule for Rating Disabilities. 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. § 4.6 (2012). It should also be noted that use of terminology such as "severe" by VA examiners and others, although an element of evidence to be considered by the Board, is not dispositive of an issue. All evidence must be evaluated in arriving at a decision regarding an increased rating. 38 C.F.R. §§ 4.2, 4.6 (2012). As set forth at 38 C.F.R. § 4.71, Plate II (2012), the normal range of motion of the wrist is dorsiflexion from 0 to 70 degrees, palmar flexion from 0 to 80 degrees, ulnar deviation from 0 to 45 degrees, and radial deviation from 0 to 20 degrees. Forearm pronation is from 0 to 80 degrees, and forearm supination is from 0 to 85 degrees. Id. Applying the above regulations to the facts of the case, the Board finds that the Veteran is not entitled to a disability rating in excess of 30 percent for his service-connected right carpel tunnel syndrome, as the evidence does not establish that his disability is manifested by severe incomplete paralysis or neuritis of the median nerve of the major extremity - the requirements for the next higher rating of 50 percent. 38 C.F.R. § 4.124a, Diagnostic Code 8515. Specifically, since filing his increased rating claim in July 2009, the Veteran was afforded a VA examination in October 2009. At the examination, the Veteran told the VA examiner that he was right-handed. He reported that he was currently employed, but experienced problems at work with writing, in that he could only write a few sentences before he would experience numbness in his middle and ring fingers, hand, and arm. He described symptoms of numbness, stiffness, tingling, and an "electric shock like feeling" in his right fingers and hand. The Veteran stated that he wakes up at night intermittently with numbness in his ring and middle fingers and in his hand. He indicated that wrist splints do not work for him. The Veteran denied any hospitalization or surgery for his right wrist. He had not missed any days from work in the past year for his right carpel tunnel syndrome. Following a physical examination of the Veteran's right wrist and a review of his medical records, the VA examiner found that the Veteran had full muscle strength in his right hand. No motor function or nerve impairment was demonstrated at the examination. He had normal vibration, pain, light touch, and position sense in this right upper extremity. Based on this evidence, the examiner found that the Veteran's right carpel tunnel syndrome is best characterized as moderate, even though the Veteran did not have any sensory or motor abnormalities in the upper right extremity at the examination. The examiner found that the Veteran had pain and neuritis in his right wrist/hand, but not paralysis or neuralgia. In April 2010, the Veteran argued that his right carpel tunnel syndrome was "getting worse day by day," and that he now experienced numbness and sharp pain in his hand several times a day. He specified that he has been experiencing "more episodes of [his hand] going numb and painful pins and needles." Additionally, a VA treatment record from the Hand Clinic dated in October 2010 diagnosed the Veteran with moderate right sensorimotor carpel tunnel syndrome, following a physical examination of the Veteran's right arm and hand. At a March 2011 VA outpatient treatment visit, the Veteran reported that the numbness in his hand was much better. Per the Board's remand directives, the Veteran was afforded another VA examination in September 2011. At the examination, the Veteran told the VA examiner that his right carpel tunnel syndrome causes him to drop things. The Veteran reported that he was currently employed, but that he has to stop writing every 5 minutes and take a break because his right hand goes numb from the elbow down. Following a physical examination of the Veteran's right wrist, the VA examiner found that the Veteran had moderate intermittent pain, mild paresthesias and/or dysesthesias, and mild numbness in his right upper extremity. The Veteran had normal muscle strength in his right arm, and did not have muscle atrophy. His reflexes were hypoactive in his right arm, but his sensory examination of the right arm and right hand/fingers was normal. The Phalen's sign test of the right median nerve was positive. The examiner then found that the Veteran's right median nerve was manifested by moderate incomplete paralysis. The September 2011 VA examiner also reviewed and described the findings of a September 2010 VA electromyography (EMG) that was performed on the Veteran's right upper extremity. The results were abnormal, and revealed evidence of moderate right sensorimotor carpel tunnel syndrome. The carpel tunnel syndrome was shown to be demyelinating in nature without axonal involvement. In summary, the September 2011 VA examiner found that the Veteran had moderate right sensorimotor carpel tunnel syndrome. The examiner based this opinion on the Veteran's reported symptoms at the examination. The September 2010 EMG also found the Veteran's symptoms to be moderate. The examiner noted that the Veteran's physical examination was compatible with mild carpel tunnel syndrome, since his strength and sensation were normal. However, the Veteran also had a mildly positive right Phalen's test. Thus, in considering the totality of the evidence, the VA examiner found that the Veteran's right carpel tunnel syndrome was best characterized as moderate. The Veteran's remaining private and VA treatment records do not provide contrary evidence to that obtained at the VA examinations. Therefore, applying the aforementioned criteria to the facts of this case, the Board finds that the Veteran is not entitled to a higher disability rating for his service-connected right carpel tunnel syndrome. The evidence of record does not establish that the Veteran has severe incomplete paralysis or neuritis of the median nerve of the major extremity - the requirements for the next higher rating of 50 percent. Indeed, both the October 2009 and September 2011 VA examiners characterized the Veteran's right carpel tunnel syndrome as moderate, following appropriate examination and testing of the Veteran's right wrist. A moderate disability of the dominant wrist meets the requirements for the currently assigned 30 percent disability rating. 38 C.F.R. § 4.124a, Diagnostic Code 8515. Thus, the Board finds that the evidence of record does not support the assignment of a higher disability rating. The Board notes that in adjudicating a claim the competence and credibility of the Veteran must be considered. See Buchanan, 451 F.3d at 1331; Washington, 19 Vet. App. at 368-69. The Board acknowledges that the Veteran is competent to give evidence about what he observes or experiences. For example, he is competent to report that he experiences certain symptoms, such as pain, and he is credible in this regard. See, e.g., Layno, 6 Vet. App. at 465. The Veteran's competent and credible belief that his disability is worse than the assigned rating, however, is outweighed by the competent and credible medical examinations that evaluated the true extent of impairment based on objective data coupled with the lay complaints. The VA examiners have the training and expertise necessary to administer the appropriate tests for a determination on the type and degree of the impairment associated with the Veteran's complaints. For these reasons, greater evidentiary weight is placed on the physical examination findings. The Veteran's right carpel tunnel syndrome has never met the requirements for a higher disability rating since one year prior to filing his claim, so the Board cannot "stage" this rating under Hart v. Mansfield, 21 Vet. App. 505 (2007). For these reasons and bases, the preponderance of the evidence is against the Veteran's claim - in turn meaning there is no reasonable doubt to resolve in his favor and his increased rating claim must be denied. See 38 U.S.C.A. § 5107(b); 38 C.F.R. § 4.3; Alemany, 9 Vet. App. at 519. Generally, evaluating a disability using either the corresponding or analogous diagnostic codes contained in the Schedule is sufficient. See 38 C.F.R. §§ 4.20, 4.27 (2012). 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) (2012). The threshold factor for extraschedular consideration is a finding that the evidence before VA presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. Thun v. Peake, 22 Vet. App. 111, 115 (2008); see also Fisher v. Principi, 4 Vet. App. 57, 60 (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, 22 Vet. App. at 115. 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. See VAOGCPREC 06-96, 61 Fed. Reg. 66749 (1996) (determining that when service-connected disability affects employment "in ways not contemplated by the rating schedule[,]" 38 C.F.R. § 3.321(b)(1) is applicable). The Board finds that the Veteran's disability picture is not so unusual or exceptional in nature as to render his disability rating for his right carpel tunnel syndrome inadequate. The Veteran's right carpel tunnel syndrome was evaluated under 38 C.F.R. § 4.124a, Diagnostic Code 8515, the criteria of which is found by the Board to specifically contemplate the Veteran's level of disability and symptomatology. As noted above, the Veteran's right carpel tunnel syndrome is primarily manifested by numbness, tingling, and pain and examinations of the right wrist/hand/fingers have revealed normal muscle strength and sensation. The functional impact of the disability (having to take a break from writing, dropping things, etc.) described by the Veteran is not exceptional or unusual impairment. When comparing this disability picture with the symptoms contemplated by the Schedule, the Board finds that the Veteran's symptoms are more than adequately contemplated by the 30 percent disability rating for his right carpel tunnel syndrome. The evaluation assigned herein specifically contemplates a moderate disability, which is essentially analogous to the Veteran's symptoms of numbness and tingling. 38 C.F.R. § 4.20 (2012). The criteria for a 30 percent rating for the Veteran's right carpel tunnel syndrome more than reasonably describes the Veteran's disability level and symptomatology. Therefore, the currently assigned schedular evaluation is adequate and no referral is required. See VAOGCPREC 06-96, 61 Fed. Reg. 66749 (1996); see also 38 C.F.R. § 4.124a, Diagnostic Code 8515. TDIU Claim Total disability is considered to exist when there is any impairment in mind or body that is sufficient to render it impossible for the average person to follow a substantially gainful occupation. 38 C.F.R. § 3.340(a)(1). A total disability rating for compensation purposes may be assigned on the basis of individual unemployability, that is, when the disabled person is, in the judgment of the rating agency, unable to secure or follow a substantially gainful occupation as a result of service-connected disabilities. 38 C.F.R. § 4.16(a). If there is only one service-connected disability, it must be rated at 60 percent or more; if there are two or more service-connected disabilities, at least one disability must be rated at 40 percent or more, and sufficient additional disability must bring the combined rating to 70 percent or more. Id. Individual unemployability must be determined without regard to any non-service connected disabilities or the veteran's advancing age. 38 C.F.R. §§ 3.341(a), 4.19 (2012); Van Hoose v. Brown, 4 Vet. App. 361 (1993). Based on this record and evidence, it is clear that the Veteran meets the percentage requirements for consideration of a total evaluation under 38 C.F.R. § 4.16(a). The Veteran is currently service-connected for the following disabilities: obstructive sleep apnea (rated as 50 percent disabling); migraine headaches (50 percent); right carpel tunnel syndrome (30 percent); left carpel tunnel syndrome (20 percent); degenerative disc disease of the cervical spine (10 percent); hypertension (10 percent); periodic limb movement disorder (nocturnal myoclonus) (10 percent); degenerative disc disease of the lumbar spine (10 percent); patellofemoral syndrome of the left knee (0 percent); patellofemoral syndrome of the right knee (0 percent); residuals of a left ankle fracture (0 percent); bilateral plantar fasciitis (0 percent); and, head injury residuals (0 percent). By way of application of the combined ratings table, the Veteran's combined rating is 90 percent. 38 C.F.R. § 4.25 (2012). Thus, the Veteran meets the percentage requirements for consideration of a total evaluation under 38 C.F.R. § 4.16(a). The Board must now consider whether the competent evidence otherwise demonstrates that the Veteran is unable to secure or follow a substantially gainful occupation due to his service-connected disabilities. The Board finds that the Veteran's service-connected disabilities do not render him unable to obtain or maintain substantially gainful employment. Initially, the Board notes that the Veteran is currently employed. At no time during the appeal period has the Veteran been unemployed. Instead, the Veteran argues that he should be entitled to a TDIU due to the impairments in his daily employment that are caused by his service-connected disabilities. In this regard, the Veteran was afforded a General Medical Examination in June 2008. Following a physical examination of the Veteran, the VA examiner provided employability opinions for each of the Veteran's service-connected disabilities. Regarding the service-connected obstructive sleep apnea (OSA), the June 2008 VA examiner found that so long as this disability was treated with the Veteran's continuous positive airway pressure (CPAP) machine, then the disability would not interfere with his ability to work. The examiner noted that the Veteran did not have any evidence of right-sided heart failure by an echocardiogram (ECHO), which would indicate poorly treated OSA. Regarding his service-connected periodic limb movement disorder (PLMD), the examiner noted that this disorder primarily occurs at night. The Veteran did not demonstrate any evidence of extra leg movement during the examination. Thus, the examiner found that the PLMD was mild and would not interfere with the Veteran's ability to work. Regarding his bilateral carpel tunnel syndrome, the Veteran told the examiner that he has problems with computer work and his finger goes numb when he writes because of this disability. The examiner found that the Veteran's carpel tunnel syndrome would be aggravated by any job that required repetitive wrist movement. However, the examiner noted that the Veteran is still able to work at activities that do not include repetitive wrist movement. Regarding his service-connected migraine headaches, the Veteran told the examiner that when he has a migraine, he is unable to go to work that day. The examiner found that the service-connected migraine headaches would interfere with the Veteran's ability to work, but the Veteran only experiences migraines two times per month. Regarding the Veteran's hypertension, the examiner noted that the Veteran reported at the examination that his hypertension does not have a significant effect on his employment or his activities of daily living. The examiner stated that the Veteran has not had any medicine changes for his hypertension in the last five years. Regarding his degenerative joint disease of the cervical spine, the June 2008 VA examiner found that the Veteran's work style might have to be modified because of this disability. However, the examiner noted that the cervical spine disability was mild. Regarding the Veteran's bilateral knee disability, the examiner pointed out that the Veteran had not been seen by orthopedics for some time for the evaluation of his knees. The Veteran reported that he only takes Motrin for the treatment of his knees. The examiner found that the Veteran might be more suited to sedentary employment because of this disability. Regarding his left ankle fracture residuals, the Veteran told the examiner that this disability gets worse if he sits for long periods of time. The examiner noted that the Veteran reported at the examination that this disability had little impact on his activities of daily living. Regarding his bilateral plantar fasciitis, the Veteran reported daily pain in his feet. The examiner found that the Veteran had bilateral heel spurs on X-ray. The examiner found that modifications in the Veteran's footwear might be beneficial to him, but this disability does not preclude the Veteran from employment. Again, the examiner indicated that the Veteran might need to consider sedentary employment. Regarding his head injury residuals, the examiner noted that the Veteran at the examination reported that this disability does not interfere with his activities of daily living. The Veteran was afforded a VA spine examination in September 2008. At the examination, the Veteran reported daily moderate pain in his lumbar spine. He was currently employed full-time as a health technician, and denied any time lost from work in the past year due to his lumbar spine disability. Following a physical examination of the Veteran and a review of his claims file, the VA examiner found that the Veteran's lumbar spine disability had significant effects on his occupation. Specifically, the examiner noted that the Veteran is not able to demonstrate exercises as part of his job duties, and he has to change positions because his back pain prevents him from sitting for more than one hour and standing for more than 30 minutes at a time. The Veteran was afforded a VA examination in October 2009 to assess the current severity of his bilateral carpel tunnel syndrome. At the examination, the Veteran was currently employed, but experienced problems at work with writing because of his bilateral carpel tunnel syndrome. The Veteran reported that he could only write a few sentences before he would experience numbness in his middle and ring fingers, hand, and arm. In the past year, the Veteran denied any time lost from work due to his bilateral carpel tunnel syndrome. Following a physical examination of the Veteran and a review of his medical records, the VA examiner found that the Veteran's bilateral carpel tunnel syndrome had significant effects on his occupation. Specifically, the examiner noted that the Veteran had to stop and let his hands rest from writing, which slowed him down at work. The Veteran was also afforded a VA examination in October 2009 to assess the current severity of his migraine headaches. At the examination, the Veteran was currently employed, but reported that he had to call a family member to pick him up from work if he experienced a migraine. The Veteran described increased absenteeism because of his migraines. Thus, based on this increased absenteeism, and following a physical examination of the Veteran and a review of his medical records, the VA examiner found that the Veteran's migraine headaches had significant effects on his occupation. The Veteran was afforded a VA examination in November 2009 to assess the current severity of his service-connected degenerative disc disease of the cervical spine. At the examination, the Veteran was currently employed, and denied any time lost from work in the past year for this disability. Following a physical examination of the Veteran and a review of his medical records, the VA examiner found that the Veteran's degenerative disc disease of the cervical spine had no significant effects on his occupation. The Veteran was afforded a VA examination in September 2011 to assess the current severity of his right carpel tunnel syndrome. At the examination, the Veteran told the VA examiner that his right carpel tunnel syndrome causes him to drop things. The Veteran reported that he was currently employed, but that he has to stop writing every 5 minutes and take a break because his right hand goes numb from the elbow down. Following a physical examination of the Veteran and a review of his claims file, the VA examiner found that the Veteran's bilateral carpel tunnel syndrome does impact his ability to work. The examiner referred to the Veteran's statements at the examination. These VA examiners, following a complete interview with the Veteran, determined that the Veteran's service-connected disabilities interfere with his ability to work, but do not render him unemployable. The Veteran is currently able to maintain employment with his service-connected disabilities and has been for many years. At no time during his appeal period has the Veteran been unemployed. There are no medical opinions to the contrary in the claims file, and the treatment records do not provide contrary evidence. To date, no physicians (VA or private) have determined that the Veteran is unemployable due to his service-connected disabilities. The Board declines to get an opinion on whether the Veteran's disabilities together render him unemployable. Any opinion asserting that the Veteran is unemployable due to all service-connected disabilities would be deemed not credible and inconsistent with the evidence of record that shows sustained employment. In short, the Veteran's service-connected disabilities do not preclude him from securing and maintaining substantially gainful employment consistent with his educational and vocational experiences. His non-service-connected disorders and advancing age may not be considered in determining his eligibility for a TDIU. 38 C.F.R. §§ 3.341(a), 4.19; Van Hoose, 4 Vet. App. at 361. In reaching the above determination, the Board has considered the Veteran's and his mother's lay statements as to the nature and severity of the Veteran's service-connected symptomatology. The Veteran and his mother are certainly competent to describe the Veteran's current symptoms ( see Layno, 6 Vet. App. at 470) but the contention that the Veteran is unemployable is not credible given the fact of the Veteran's employed status. Layno, 6 Vet. App. at 470. To the extent that the Veteran and his mother argue or suggest that the clinical data supports a TDIU evaluation, they are not competent to make such an assertion. Although laypersons are competent to provide opinions on some medical issues, see Kahana, 24 Vet. App. at 435, as to the specific issue in this case, whether the severity of the service-connected disabilities prevent the Veteran's employability, this issue falls outside the realm of common knowledge of a layperson. See Jandreau, 492 F.3d at 1377 n.4 (laypersons not competent to diagnose cancer). Moreover, a finding of unemployability is not credible. Accordingly, the Board finds that the evidence is not in equipoise on the matter of whether the Veteran is unemployable due to his service-connected disabilities. The Board finds that the allegations of unemployability provided by the Veteran are neither persuasive nor supportable when viewed in light of the evidence of record. See 38 C.F.R. § 3.159(a). The benefit of the doubt rule is not for application. 38 U.S.C.A. § 5107(b). The TDIU claim is denied. ORDER The claim for service connection for GERD is denied. The claim for service connection for steatohepatitis, to include as secondary to the service-connected disabilities, is denied. An evaluation in excess of 30 percent for the right carpel tunnel syndrome is denied. Entitlement to a TDIU rating is denied. ____________________________________________ TANYA A. SMITH Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs