Citation Nr: 1318467 Decision Date: 06/06/13 Archive Date: 06/11/13 DOCKET NO. 08-11 649 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUES 1. Entitlement to service connection for a disability manifested by chest palpitations and pain, to include a panic and a cardiovascular disorder. 2. Entitlement to a disability evaluation in excess of 10 percent for a cervical spine disability prior to December 6, 2010 and a disability evaluation in excess of 20 percent for the period from December 6, 2010 to September 25, 2011 and from March 1, 2012 onward. 3. Entitlement to a disability evaluation in excess of 10 percent for a back disability prior to December 6, 2010 and to a disability evaluation in excess of 20 percent thereafter. 4. Entitlement to a compensable disability evaluation for a left knee disability prior to December 6, 2010 and to a disability evaluation in excess of 10 percent thereafter. 5. Entitlement to a disability evaluation in excess of 10 percent for a left ankle disability. 6. Entitlement to a compensable disability evaluation for hemorrhoids. 7. Entitlement to a compensable disability evaluation for right ear hearing loss. 8. Entitlement to a total rating based upon individual unemployability (TDIU) due to service-connected disabilities. REPRESENTATION Veteran represented by: The American Legion WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD D. M. Ames, Counsel INTRODUCTION The Veteran had active service from December 1983 to February 1984 and from September 1989 to April 1998. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a December 2006 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in St. Petersburg, Florida. During the pendency of the appeal, a May 2012 rating decision increased the Veteran's disability evaluation for his cervical spine disability from 10 percent to 20 percent, effective December 6, 2010. He underwent surgery for this disability and as a result was assigned a temporary 100 percent evaluation for the period from September 26, 2011 to February 28, 2012. A 20 percent evaluation was assigned effective March 1, 2012. The rating decision also increased the Veteran's disability evaluation for his back disability from 10 percent to 20 percent, effective December 6, 2010, and his disability evaluation for his left knee disability from noncompensable to 10 percent, also effective December 6, 2010. Applicable law mandates that when a veteran seeks an increased evaluation, it will generally be presumed that the maximum benefit allowed by law and regulation is sought, and it follows that such a claim remains in controversy where less than the maximum benefit available is awarded. See AB v. Brown, 6 Vet. App. 35 (1993). The Veteran testified at a hearing in October 2009 before the undersigned. A copy of the transcript has been associated with the claims file. A review of the Virtual VA paperless claims processing system reveals additional VA treatment records through May 2012 that are pertinent to the present appeal. In the May 2012 Supplemental Statement of the Case, the RO specifically stated that the Veteran's VA treatment records through May 2012 were reviewed prior to the adjudication of the claims. Therefore there is no prejudice to the Veteran in the Board's adjudication of his claims In November 2010 the Board denied the Veteran's claim for service connection for a disability manifested by chest palpitations and pain and remanded the remaining issues for further development. The Veteran appealed the Board's denial of his heart palpitations claim to the U. S. Court of Appeals for Veterans Claims (Court), and in a July 2011 Order, the Court granted the parties' Joint Motion for Remand (Joint Motion), vacated the Board's November 2010 denial, and remanded the matter to the Board for development consistent with the Joint Motion. In February 2012 the Board remanded this case to the RO via the Appeals Management Center (AMC) for further development and it has now been returned to the Board. In July 2012, the Veteran indicated that he disagreed with the recoupment of disability severance pay. This matter has not been developed and is referred to the RO for appropriate action. FINDINGS OF FACT 1. The preponderance of the evidence reflects that the Veteran does not have a disability manifested by chest palpitations and pain, to include a panic and a cardiovascular disorder due to any incident of his active duty service. 2. Prior to December 6, 2010, the Veteran's cervical spine disability manifested as painful, limited motion. 3. For the period from December 6, 2010 to September 25, 2011 and from March 1, 2012 onward, the Veteran's cervical spine disability manifested as flexion from 0 to 30 degrees with pain from 20 to 30 degrees. 4. Prior to December 6, 2010, the Veteran's back disability manifested as normal range of motion of the thoracolumbar spine without pain. 5. As of December 6, 2010, the Veteran's back disability manifested as painful, limited motion. 6. Prior to December 6, 2010, the Veteran's left knee disability manifested as normal extension and flexion without pain. 7. As of December 6, 2010, the Veteran's left knee disability manifested as painful, limited motion with crepitus and tenderness. 8. The Veteran's left knee is mildly unstable. 9. The Veteran's left ankle disability manifested as marked limitation of motion beginning on December 6, 2010. 10. The Veteran's internal hemorrhoids are non-thrombosed, reducible, and do not produce excessive or redundant tissue. 11. At worst, the Veteran has Level II hearing loss in his right ear. 12. The preponderance of the evidence shows that the Veteran's service-connected disabilities do not preclude him from securing and maintaining all forms of substantially gainful employment. Sedentary forms of employment are not precluded. CONCLUSIONS OF LAW 1. The Veteran's disability manifested by chest palpitations and pain, to include a panic and a cardiovascular disorder was not incurred or aggravated in service. 38 U.S.C.A. §§ 1101, 1110, 1131, 5107 (West 2002 and Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.303 (2012). 2. The criteria for a disability evaluation in excess of 10 percent for a cervical spine disability prior to December 6, 2010 have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 and Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1-4.14, 4.40, 4.45, 4.71a, Diagnostic Codes 5237, 5243 (2012). 3. The criteria for a disability evaluation in excess of 20 percent for a cervical spine disability for the period from December 6, 2010 to September 25, 2011 and from March 1, 2012 onward have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 and Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1-4.14, 4.40, 4.45, 4.71a, Diagnostic Codes 5237, 5243 (2012). 4. The criteria for a disability evaluation in excess of 10 percent for a back disability prior to December 6, 2010 have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 and Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1-4.14, 4.40, 4.45, 4.71a, Diagnostic Codes 5010, 5242 (2012). 5. The criteria for a disability evaluation in excess of 20 percent for a back disability as of December 6, 2010 have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 and Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1-4.14, 4.40, 4.45, 4.71a, Diagnostic Codes 5010, 5242 (2012). 6. The criteria for a compensable disability evaluation for a left knee disability prior to December 6, 2010 have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 and Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1-4.14, 4.40, 4.45, 4.71a, Diagnostic Codes 5010, 5261 (2012). 7. The criteria for a disability evaluation in excess of 10 percent for a left knee disability as of December 6, 2010 have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 and Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1-4.14, 4.40, 4.45, 4.71a, Diagnostic Codes 5010, 5261 (2012). 8. The criteria for 10 percent disability evaluation for instability of the left knee have been approximated. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 and Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1-4.14, 4.40, 4.45, 4.71a, Diagnostic Code 5257 (2012); VAOPGCPREC 9-98 (August 14, 1998). 9. Effective December 6, 2010, the criteria for a 20 percent evaluation for marked limitation of motion of the left ankle have been approximated. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 and Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1-4.14, 4.71a, Diagnostic Code 5271 (2012). 10. The criteria for a compensable disability evaluation for hemorrhoids have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 and Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1-4.14, 4.114, Diagnostic Code 7336 (2012). 11. The criteria for a compensable disability evaluation for right ear hearing loss have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 and Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.321, 3.353, 3.385, 4.1-4.14, 4.85, 4.86, Diagnostic Code 6100 (2012). 12. The criteria for a TDIU have not been met. 38 U.S.C.A. §§ 1154(a), 1155, 5107 (West 2002); 38 C.F.R. §§ 3.102 , 3.340, 3.341, 4.1, 4.16, 4.19 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Duty to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA) describes VA's duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002 and Supp. 2012); 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a) (2012). Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the Veteran and his representative, if any, of any information and medical or lay evidence that is necessary to substantiate the claim, and to indicate which information and evidence VA will obtain and which information and evidence the claimant is expected to provide. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b); Quartuccio v. Principi, 16 Vet. App. 183 (2002). VCAA notice requirements apply to all five elements of a service connection claim: (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. Dingess/Hartman v. Nicholson, 19 Vet. App. 473, 486 (2006). The notice must be provided to the Veteran prior to the initial adjudication of his claim. Pelegrini v. Principi, 18 Vet. App. 112 (2004). However, if VCAA notice was not provided prior to the initial adjudication of the claim or if provided, was inadequate or incomplete, such an error can be "cured" by providing any necessary notice and then readjudicating the claim, 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 the claim. See Mayfield v. Nicholson, 499 F.3d 1317, 1323 (Fed. Cir. 2007) (Mayfield IV); Prickett v. Nicholson, 20 Vet. App. 370, 376 (2006). Defective timing or content of VCAA notice is not prejudicial to a claimant if the error does not affect the essential fairness of the adjudication. Sanders v. Nicholson, 487 F.3d 881, 889 (Fed. Cir. 2007), rev'd on other grounds, Shinseki v. Sanders/Simmons, 556 U.S. __ (2009). VA has satisfied its duty to notify by issuing pre-adjudication notice letters in June 2006 and September 2006. The June 2006 letter advised the Veteran of what evidence was required to substantiate his increased evaluation and TDIU claims and the September 2006 letter informed him of what evidence was required to substantiate his service connection claim. Both letters advised him of his and VA's respective duties for obtaining evidence. Both letters provided notice regarding the disability evaluation and effective date elements of a service connection claim. Dingess, 19 Vet. App. at 473. In a claim for an increased evaluation, the VCAA requirement is generic notice: the type of evidence needed to substantiate the claim, which consists of evidence demonstrating a worsening or increase in severity of the disability and the effect that worsening has on employment, as well as general notice regarding how disability ratings and effective dates are assigned. Vazquez-Flores v. Shinseki, 580 F.3d 1270 (Fed. Cir. 2009). The June 2006 letter provided this information. The duty to assist provisions of the VCAA have been met. The claims file contains service treatment records (STRs), reports of post-service medical treatment, and reports of VA examinations in October 2006, November 2006, December 2010, and April 2012. The examinations were adequate because they were based on a thorough examination, a description of the Veteran's pertinent medical history, a complete review of the claims folder, and appropriate diagnostic tests. The April 2012 examiner also provided a rationale for the opinion with regard to service connection for a disability manifested by heart palpitations and chest pain. See Barr v. Nicholson, 21 Vet. App. 303, 312 (2007); Stefl v. Nicholson, 21 Vet. App. 120, 124-25 (2007) (holding an examination is considered adequate when it is based on consideration of the appellant's prior medical history and examinations and also describes the disability in sufficient detail so that the Board's evaluation of the disability will be a fully informed one). The Veteran testified at a hearing in October 2009. The Court held that at a hearing on appeal, a Veterans Law Judge has a duty to explain fully the issues and a duty to suggest the submission of evidence that may have been overlooked. Bryant v. Shinseki, 23 Vet. App. 488, 492 (2010). In this case, Bryant compliance has been met. The issues were clearly set forth. The undersigned asked the Veteran about outstanding evidence to include whether he received disability benefits from the Social Security Administration (SSA) and he responded in the negative. This case was remanded in November 2010 so that so that the Veteran could undergo VA examinations for his neck, back, knee, ankle, hearing loss, and TDIU claims. It was remanded again in February 2012 to comply with the June 2011 Joint Motion's request for a heart and psychiatric evaluation. Additional VA treatment records were also requested. The Veteran underwent adequate VA examinations in December 2010 and April 2012. His outstanding VA treatment records were obtained. Thus, the Board is satisfied that there was substantial compliance with its remand directives. See Stegall v. West, 11 Vet. App. 268 (1998); Dyment v. West, 13 Vet. App. 141, 146-47 (1999). The Veteran has not made the RO or the Board aware of any additional evidence that must be obtained in order to fairly decide the appeal. He has been given ample opportunity to present evidence and argument in support of his claims. Pursuant to 38 C.F.R. § 3.655, all relevant evidence necessary for an equitable disposition of the Veteran's appeal of this issue has been obtained and the case is ready for appellate review. General due process considerations have been complied with by VA. See 38 C.F.R. § 3.103 (2012). II. Service Connection Claim Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active military service. 38 U.S.C.A. § 1110; 38 C.F.R. § 3.303. That an injury or disease occurred in service is not enough; there must be chronic disability resulting from that injury or disease. If there is no showing of a resulting chronic condition during service, then a showing of continuity of symptomatology after service is required to support a finding of chronicity for certain diseases. 38 C.F.R. §§ 3.303(a),(b), 3.309(a); see also Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Service connection may also be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). In order to establish service connection for the claimed disorder, 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, or in certain circumstances, lay evidence of a nexus between the claimed in-service disease or injury and the current disability. See 38 C.F.R. § 3.303; see also Hickson v. West, 12 Vet. App. 247, 253 (1999); Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009). The determination as to whether these requirements are met is based on an analysis of all the evidence of record and the evaluation of its credibility and probative value. See Baldwin v. West, 13 Vet. App. 1, 8 (1999). Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, all of the evidence submitted by the Veteran or on his behalf. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (finding that the Board must review the entire record, but does not have to discuss each piece of evidence). The analysis herein focuses on the most salient and relevant evidence and on what this evidence shows, or fails to show, on the claim. 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). The Board must determine the value of all evidence submitted, including lay and medical evidence. Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006). The evaluation of evidence generally involves a 3-step inquiry. First, the Board must determine whether the evidence comes from a "competent" source. The Board must then determine if the evidence is credible, or worthy of belief. Barr v. Nicholson, 21 Vet. App. 303, 308 (2007) (observing that once evidence is determined to be competent, the Board must determine whether such evidence is also credible). The third step of this inquiry requires the Board to weigh the probative value of the proffered evidence in light of the entirety of the record. The standard of proof to be applied in decisions on claims for veterans' benefits is set forth in 38 U.S.C.A. § 5107 (West 2002). A claimant is entitled to the benefit of the doubt when there is an approximate balance of positive and negative evidence. See 38 C.F.R. § 3.102. When a claimant seeks benefits and the evidence is in relative equipoise, the claimant prevails. See Gilbert v. Derwinski, 1 Vet. App. 49 (1990). The preponderance of the evidence must be against the claim for benefits to be denied. See Alemany v. Brown, 9 Vet. App. 518 (1996). In its November 2010 decision, the Board found that the Veteran did not have a heart condition. In the June 2011 Joint Motion, the parties expressly stipulated that after lengthy development and examination, the Veteran does not have a heart condition. As a result, the Joint Motion implicitly agreed with the Board's factual finding underlying its denial that the Veteran's recurrent complaints of chest palpitations and discomfort were not indicative of a diagnosable heart condition. Therefore, it is not necessary to repeat the Board's November 2010 analysis of the Veteran's heart condition claim. Since the November 2010 remand, the medical evidence of record has not shown a diagnosis of a heart condition. In April 2012, the Veteran underwent a VA heart examination, pursuant to the June 2011 Joint Motion. The April 2012 examiner conducted a thorough review of the Veteran's claims file including his STRs. The examiner noted instances where the Veteran was seen in service for heart palpitations and chest pain. The examiner also reviewed the Veteran's VA treatment records which indicated normal diagnostic testing. At the examination, the Veteran reported taking atenolol for arrhythmia but the examiner found that he was taking this medication for control of hypertension. He also reported having three undiagnosed heart attacks that the examiner did not find confirmed by the record. The Veteran reported intermittent atrial fibrillation, with more than four episodes in the past 12 months. The examiner noted that this was documented per the Veteran's report as opposed to as the result of diagnostic testing. The examiner concluded that the Veteran did not have ischemic heart disease, has not had a myocardial infarction, does not have congestive heart failure, and does not have arrhythmia or any other heart or heart valve condition. Upon examination, the Veteran's heart rhythm was regular with normal sounds. His pulses were normal. He did not have edema of the lower extremities. The examiner stated that there were no other pertinent physical findings. The examiner opined that the Veteran did not have any form of a diagnosable heart condition. The examiner reasoned that the Veteran underwent cardiac catheterizations and echocardiograms that were all normal. These two tests are the main definitive tests for structural heart disease. While the Veteran had some EKG and Holter findings, they were not indicative of a structural heart condition. The examiner noted that stress, anxiety, and pain are among the factors that can cause the heart to beat more quickly or have extra beat such as premature ventricular contractions (PVCs) or supraventricular extra beats that manifest on an EKG. These rapid or extra beats can be felt by the patient as "palpitations," and the STRs note that the Veteran complained of them. The examiner explained that palpitations are symptoms and not a diagnosis. They can exist when someone is having a heart attack, but also when he is frightened and the adrenaline in his system makes his heart beat faster. When felt by a patient, palpitations do not mean that a heart condition exists, and in the Veteran's case, testing to evaluate the palpitations was normal. The examiner stated that it is "not unusual" for a person's EKG to look different on different days, depending on blood pressure, heart rate, and state of calmness or anxiety. The Veteran was concerned because he was diagnosed with "angina" and "unstable angina" in service. The examiner defined this as severe constricting pain or sensation of pressure in the chest., "resulting from ischemia of the heart muscle." The examiner concluded that the Veteran did not have ischemia because his coronary arteries were normal during diagnostic testing. The examiner noted that the "working diagnosis" of angina in the STRs became "atypical chest pain," a term used for chest pain that "is not of cardiac origin but whose etiology is unknown." The Veteran also reported that he was diagnosed with syncope in service. The examiner defined syncope as "loss of consciousness and postural tone caused by diminished cerebral blood flow." The examiner elaborated that cardiac syncope means "fainting with unconsciousness of any cardiac cause." The Veteran's STRs noted a normal cardiac evaluation following his episode of syncope, so the examiner concluded that it was not cardiac syncope. For these reasons, the examiner opined that the Veteran does not have a heart condition. The April 2012 examiner's opinion and well-reasoned rationale provide significant probative weight. As required by the June 2011 Joint Motion, the Veteran underwent a VA psychiatric evaluation in April 2012, specifically to determine whether he had a panic disorder or other psychiatric condition. The examiner found that the only Axis I diagnosis applicable to the Veteran was alcohol abuse in full, sustained remission. After a review of the claims file and a diagnostic examination, the examiner concluded that the Veteran's symptoms do not meet the criteria for panic disorder as set forth in The American Psychiatric Association: Diagnostic And Statistical Manual of Mental Disorders, (4th ed. 1994) (DSM- IV). The examiner noted that absent or minimal psychiatric symptoms were reported at the examination, and that there was no objective evidence of functional impairment socially, occupationally, academically, or in the Veteran's activities of daily living due, to psychiatric symptoms. The opinion of the VA examiner provides probative weight against the Veteran's claim. The Veteran continues to assert that because he was treated for heart palpitations and chest pain in service, that he has a heart condition. 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, whether the he has a heart condition, 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) (lay persons not competent to diagnose cancer). Further, his assertion has been investigated by competent medical examination and found not supportable. Id. The evidence of record does not show that the Veteran has a heart condition or disability that is manifested by heart palpitations or chest pain. The first element of a service connection claim is not satisfied. Hickson, 12 Vet. App. at 253. The Veteran's STRs show treatment for chest pain and heart palpitations. However, as explained by the April 2012 examiner, his STRs do not show that the Veteran had a heart condition or disability in service. The second element of a service connection claim is not met. Hickson, 12 Vet. App. at 253. Lastly, the nexus element of a service connection claim is not satisfied. Id. The Veteran has asserted that his claimed heart problem manifested in service and that he has experienced symptoms continuously since that time. However, his claimed disability is not a chronic condition as set forth in 38 C.F.R. § 3.303(a). Therefore, the theory of continuity of symptomatology is not applicable in this case. 38 C.F.R. § 3.303(a),(b); see also Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Further, as noted above, the VA examiner found that the Veteran does not have a heart condition or a psychiatric condition. Therefore the evidence of record does not support a nexus between the claimed disability and the Veteran's period of active service. The Veteran has opined that he currently has a heart condition that is related to service. However, even though laypeople are competent to provide opinions on some medical issues, the Veteran is not competent to provide an opinion on this specific matter. Further, it was investigated by competent medical examination and found not supportable. Kahana, 24 Vet. App. at 435; Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). In determining whether service connection is warranted, VA is responsible for considering both the positive and negative evidence. If the evidence, as a whole, is supportive or is in relative equipoise (i.e., about evenly balanced), then the Veteran prevails. Conversely, if the preponderance of the evidence is negative, then service connection must be denied. See 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). See also Dela Cruz v. Principi, 15 Vet. App. 143, 148-49 (2001). Since the preponderance of the evidence is against the claim, the provisions of 38 U. S. C. A. 5107(b) regarding reasonable doubt are not applicable, and his claim must be denied. See 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102; Alemany v. Brown, 9 Vet. App. 518, 519 (1996). III. Increased Evaluation Claims Disability ratings are determined by applying the criteria established in VA's Schedule for Rating Disabilities, which is based upon the average impairment of earning capacity. Individual disabilities are assigned separate Diagnostic Codes. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 4.1, 4.20 (2011). When a question arises as to which of two ratings applies under a particular Diagnostic Code, the higher evaluation is assigned if the disability more nearly approximates the criteria for the higher rating; otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. Consideration must given to increased evaluations under other potentially applicable Diagnostic Codes. Schafrath v. Derwinski, 1 Vet. App. 589, 595 (1991). After careful consideration of the evidence, any reasonable doubt remaining is resolved in favor of the Veteran. 38 C.F.R. § 4.3. The Veteran's entire history is to be considered when making disability evaluations. 38 C.F.R. § 4.1. Where an increase in an existing disability rating based upon established entitlement to compensation is at issue, the present level of disability is the primary concern. Francisco v. Brown, 7 Vet. App. 55 (1994). Where the evidence contains factual findings that demonstrate distinct time periods in which the service connected disability exhibited diverse symptoms meeting the criteria for different ratings during the course of the appeal, the assignment of staged ratings would be necessary. See Hart v. Mansfield, 21 Vet. App. 505 (2007). The Veteran submitted his claims for increased evaluations in May 2006. "The relevant temporal focus for adjudicating an increased rating claim is on the evidence concerning the state of the disability from the time period one year before the claim was filed until VA makes a final decision on the claim." Hart v. Mansfield, 21 Vet. App. 505, 509 (2007). A. Cervical Spine Disability Under VA regulations for spine disabilities, intervertebral disc syndrome (IVDS) can be evaluated under the General Rating Formula for Diseases and Injuries of the Spine, or under the Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes, whichever method results in the higher evaluation when all disabilities are combined under 38 C.F.R. § 4.25. These criteria apply with or without symptoms such as pain (whether or not it radiates), stiffness, or aching in the area of the spine affected by residuals of injury or disease. The Veteran has been diagnosed with IVDS in his cervical spine, and his disability is evaluated under Diagnostic Code 5243, IVDS. 38 C.F.R. § 4.71a (2012). IVDS warrants a 10 percent evaluation when the Veteran has incapacitating episodes having a total duration of at least one week but less than two weeks during the past 12 months. A 20 percent evaluation is warranted when the Veteran has incapacitating episodes having a total duration of a least 2 weeks but less than 4 weeks during the past 12 months. Id. For purposes of assigning evaluations under Code 5243, an "incapacitating episode" is a period of acute signs and symptoms due to intervertebral disc syndrome that requires bed rest prescribed by a physician and treatment by a physician. 38 C.F.R. § 4.71a, Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes, Note 1 (2012). There is no evidence of record indicating the Veteran has ever had an incapacitating episode due to his neck disability. Therefore, the Formula for Rating Intervertebral Disc Syndrome does not apply and the General Rating Formula for Diseases and Injuries of the Spine is more favorable to him. Under the General Rating Formula for Diseases and Injuries of the Spine, a 10 percent evaluation is warranted when forward flexion of the cervical spine is greater than 30 degrees but not greater than 40 degrees; or, the combined range of motion of the cervical spine is greater than 170 degrees but not greater than 335 degrees; or, there is muscle spasm, guarding, or localized tenderness not resulting in abnormal gait or abnormal spinal contour; or, there is vertebral body fracture with loss of 50 percent or more of the height. A 20 percent evaluation is warranted when forward flexion of the cervical spine is greater than 15 degrees but not greater than 30 degrees; or, the combined range of motion of the cervical spine is not greater than 170 degrees; or, there is muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. A 30 percent evaluation is warranted when the forward flexion of the cervical spine is 15 degrees or less; or, there is favorable ankylosis of the entire cervical spine. 38 C.F.R. § 4.71a. Normal range of motion for the cervical spine is 0 to 45 degrees of forward flexion, 0 to 45 degrees of extension, 0 to 45 degrees of lateral flexion bilaterally, and 0 to 80 degrees of lateral rotation bilaterally. The normal combined range of motion of the cervical spine is 340 degrees. 38 C.F.R. § 4.71a, Plate V (2012). When an evaluation of a disability is based upon limitation of motion, the Board must also consider, in conjunction with the otherwise applicable Diagnostic Code, any additional functional loss the Veteran may have sustained by virtue of other factors as described in 38 C.F.R. §§ 4.40 and 4.45. DeLuca v. Brown, 8 Vet. App. 202, 206 (1995). Such factors include more or less movement than normal, weakened movement, excess fatigability, incoordination, pain on movement, swelling, and deformity or atrophy from disuse. A finding of functional loss due to pain must be supported by adequate pathology and evidenced by the visible behavior of the Veteran. 38 C.F.R. § 4.40; Johnston v. Brown, 10 Vet. App. 80, 85 (1997). 1. Period Prior to December 6, 2010 In October 2006, the Veteran underwent a VA joints examination. He complained of constant neck pain with stiffness. He reported occasional paresthesias in his fingers on both hands. Upon examination, the examiner found that the Veteran did not have ankylosis of the cervical spine. He had normal posture with an antalgic gait. There was no point tenderness, weakness, or muscle spasm. His forward flexion was normal from 0 to 45 degrees without pain. His extension was from 0 to 10 degrees with pain at 10 degrees. His lateral flexion was normal from 0 to 45 degrees without pain, bilaterally. His lateral rotation was 0 to 60 degrees with pain at 60 degrees, bilaterally. The combined range of motion of his cervical spine was 265 degrees. The results of the October 2006 VA examination do not show that the Veteran's disability picture is more closely approximated by a 20 percent evaluation. Even when considering painful motion, his forward flexion was normal without pain and his combined range of motion was significantly greater than 120 degrees. At a February 2008 VA physical therapy session for his neck, the Veteran complained of decreased strength, flexibility, and range of motion. He also complained of soft tissue restriction, limitations on his activities of daily living, postural deviations, impaired joint mobility, and gait deviations. His ranges of motion were not measured. At his October 2009 hearing, the Veteran testified that sometimes his neck pain prevented him from getting out of bed for several hours. He stated that this occasionally occurred two to three times per week. The Veteran is competent to discuss observable symptoms such as pain. Layno v. Brown, 6 Vet. App. 465 (1994). His statements are also credible. Barr v. Nicholson, 21 Vet. App. 303, 308 (2007). However, they are not sufficient to show that his neck disability meets the criteria for a 20 percent evaluation. The remaining medical evidence of record shows treatment for neck pain but does not provide measurements for ranges of motion in degrees. The Veteran has asserted that the disability evaluation for his neck disability is not sufficient but has not advanced specific arguments to that extent other than a general increase in his pain level. The evidence of record prior to December 6, 2010 does not support an increased evaluation of his cervical spine disability. Even when considering functional limitations due to pain and other factors identified in 38 C.F.R. §§ 4.40, 4.45, the Board finds that the Veteran's functional loss from his cervical spine disability does not equate to more than the disability picture contemplated by the 10 percent rating already assigned prior to December 6, 2010. 38 C.F.R. § 4.71a. With regard to the Veteran's subjective complaints of pain, "pain itself does not rise to the level of functional loss as contemplated by VA regulations applicable to the musculoskeletal system." Mitchell v. Shinseki, 25 Vet. App. 32 (2011). Rather, pain, may result in functional loss, but only if it limits the ability "to perform the normal working movements of the body with normal excursion, strength, speed, coordination [, or] endurance." Id., quoting 38 C.F.R. § 4.40. As the Veteran has not been diagnosed with radiculopathy, a separate evaluation for this condition is not warranted. 38 C.F.R. § 4.71a. In conclusion, the Board finds that the overall disability picture for the Veteran's cervical spine disability does not more closely approximate a 20 percent rating. 38 C.F.R. § 4.7. The preponderance of the evidence is against the claim so the benefit of the doubt rule is not applicable. See 38 U.S.C.A. § 5107(b); Gilbert, 1 Vet. App. at 54-56. There is no evidentiary basis upon which to assign a rating in excess of 10 percent and since there is no basis for assigning an increased rating, there is no basis for assigning a staged rating. Hart, 21 Vet. App. at 505. 2. Period from December 6, 2010 to September 25, 2011 and from March 1, 2012 Onward On December 6, 2010 the Veteran underwent a VA examination. The examiner found that the Veteran had spasm on both sides of his cervical spine. He also had painful motion and tenderness. He did not have atrophy, guarding, or weakness. His flexion was from 0 to 30 degrees with pain from 20 to 30 degrees. His extension was 0 to 20 degrees with pain from 5 to 20 degrees. His lateral rotation was from 0 to 40 degrees with pain from 30 to 40 degrees, bilaterally. His lateral flexion was from 0 to 30 degrees with pain from 20 to 30 degrees, bilaterally. There was no additional limitation of motion after repetitive movement. The examiner diagnosed degenerative joint disease of the cervical spine from C2-7 and degenerative disc disease from C4-5. The December 2010 examination was the basis for the grant of a 20 percent disability evaluation for the Veteran's cervical spine. However, it does not show that the disability meets the criteria for a 30 percent evaluation because the Veteran's forward flexion was 30 degrees. Although he had pain from 20 to 30 degrees, no additional limitation of motion was found after repetitive motion testing. Further, the Veteran did not have favorable ankylosis of the entre cervical spine. Because he retains mobility in his cervical spine, he does not manifest ankylosis of any form. See Dinsay v. Brown, 9 Vet. App. 79, 81 (1996); Lewis v. Derwinski, 3 Vet. App. 259 (1992) (indicating that ankylosis is complete immobility of the joint in a fixed position, either favorable or unfavorable). A July 2011 VA treatment record shows that his forward flexion was 50 degrees. His extension was 10 degrees. His left lateral rotation was 20 degrees. His right lateral rotation was 50 degrees. His lateral flexion was not measured. He had tenderness to palpation over the lower posterior cervical vertebra. This record does not show that his forward flexion was 15 degrees or less or that he had ankylosis of the cervical spine. In September 2011, he underwent an anterior cervical diskectomy and fusion from C5 to C6. As a result, he received a temporary 100 percent evaluation for convalescence from September 26, 2011 to February 28, 2012. An April 2012 VA treatment record noted that his neck pain had resolved following his surgery. The remaining medical evidence for the period from December 6, 2010 to September 25, 2011 and from March 1, 2012 onward, does not provide range of motion measurements of the Veteran's cervical spine. The Veteran has asserted that the disability evaluation for his neck disability is not sufficient but has not advanced specific arguments to that extent other than a general increase in his pain level. Even when considering functional limitations due to pain and other factors identified in 38 C.F.R. §§ 4.40, 4.45, the Board finds that the Veteran's functional loss from his cervical spine disability does not equate to more than the disability picture contemplated by the 20 percent rating already assigned for the period from December 6, 2010 to September 25, 2011 and from March 1, 2012 onward. 38 C.F.R. § 4.71a. With regard to the Veteran's subjective complaints of pain, "pain itself does not rise to the level of functional loss as contemplated by VA regulations applicable to the musculoskeletal system." Mitchell v. Shinseki, 25 Vet. App. 32 (2011). Rather, pain, may result in functional loss, but only if it limits the ability "to perform the normal working movements of the body with normal excursion, strength, speed, coordination [, or] endurance." Id., quoting 38 C.F.R. § 4.40. As the Veteran has not been diagnosed with radiculopathy, a separate evaluation for this condition is not warranted. 4.71a. In conclusion, the Board finds that the overall disability picture for the Veteran's cervical spine disability does not more closely approximate a 30 percent rating. 38 C.F.R. § 4.7. The preponderance of the evidence is against the claim so the benefit of the doubt rule is not applicable. See 38 U.S.C.A. § 5107(b); Gilbert, 1 Vet. App. at 54-56. There is no evidentiary basis upon which to assign a rating in excess of 20 percent and since there is no basis for assigning an increased rating, there is no basis for assigning a staged rating. Hart, 21 Vet. App. at 505. For the appeal period, the Board has considered whether referral for an extraschedular rating is appropriate under the provisions of 38 C.F.R. § 3.321(b)(1). The threshold factor for extraschedular consideration is a finding that the evidence presents such an exceptional disability picture that the available schedular evaluations for the service-connected disability at issue are inadequate. Therefore, initially, there must be a comparison between the level of severity and the symptomatology of the claimant's disability with the established criteria provided in the rating schedule for the disability. If the criteria reasonably describe the claimant's disability level and symptomatology, then the disability picture is contemplated by the rating schedule, the assigned evaluation is therefore adequate, and no referral for extraschedular consideration is required. Thun v. Peake, 22 Vet. App. 111 (2008), aff'd, Thun v. Shinseki, 572 F.3d 1366 (Fed. Cir. 2009). As described above, the manifestations of the Veteran's neck disability are contemplated by the schedular criteria compensating for painful limitation of motion; no examiner has reported an exceptional disability picture with symptoms not represented in the rating schedule. In sum, there is no indication that the average industrial impairment from the disability would be in excess of that contemplated by the assigned rating. Accordingly, the Board has determined that referral of this case for extraschedular consideration is not in order. B. Back Disability The Veteran's back disability is evaluated under Diagnostic Code 5010-5242, traumatic arthritis and degenerative arthritis of the spine. 38 C.F.R. § 4.71a. Under DC 5010, the rater is instructed to rate traumatic arthritis as degenerative arthritis, DC 5003. Under DC 5003, the disability is evaluated based upon limitation of motion of the affected part. When limitation of motion is noncompensable, a 10 percent rating is warranted when there is x-ray evidence of involvement of 2 or more major joints or 2 or more minor joint groups. A 20 percent rating is warranted where there is x-ray evidence of the involvement of 2 or more major joints or 2 or more minor joint groups with occasional incapacitating exacerbations. 38 C.F.R. § 4.71a. The following are considered minor joint groups: cervical vertebrae, dorsal vertebrae, and lumbar vertebrae. 38 C.F.R. § 4.45(f). The Veteran has been diagnosed with IVDS in his thoracolumbar spine. As noted above, IVDS warrants a 10 percent evaluation when the Veteran has incapacitating episodes having a total duration of at least one week but less than two weeks during the past 12 months. A 20 percent evaluation is warranted when the veteran has incapacitating episodes having a total duration of a least 2 weeks but less than 4 weeks during the past 12 months. Id. There is no evidence of record indicating the Veteran has ever had an incapacitating episode due to his back disability. 38 C.F.R. § 4.71a, Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes, Note 1 (2012). Therefore, the Formula for Rating Intervertebral Disc Syndrome does not apply and the General Rating Formula for Diseases and Injuries of the Spine is more favorable to the Veteran. Under the General Rating Formula for Diseases and Injuries of the Spine a 10 percent evaluation is warranted when forward flexion of the thoracolumbar spine is greater than 60 degrees but not greater than 85 degrees; or, the combined range of motion of the thoracolumbar spine is greater than 120 degrees but not greater than 235 degrees; or, there is muscle spasm, guarding, or localized tenderness not resulting in abnormal gait or abnormal spinal contour; or, there is vertebral body fracture with loss of 50 percent or more of the height. 38 C.F.R. § 4.71a. A 20 percent evaluation is warranted when the forward flexion of the thoracolumbar spine is greater than 30 degrees but not greater than 60 degrees; or, the combined range of motion of the thoracolumbar spine is not greater than 120 degrees; or, there is muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. Id. The criteria for a 30 percent evaluation pertain only to the cervical spine and are therefore not applicable. A 40 percent evaluation is warranted when the forward flexion of the thoracolumbar spine is 30 degrees or less; or, there is favorable ankylosis of the entire thoracolumbar spine. 38 C.F.R. § 4.71a (2012). Normal range of the thoracolumbar spine is 0 to 90 degrees of forward flexion, 0 to 30 degrees of extension, 0 to 30 degrees of lateral flexion bilaterally, and 0 to 30 degrees of lateral rotation bilaterally. The combined range of motion of the thoracolumbar spine is 240 degrees. 38 C.F.R. § 4.71a, Plate V (2012). As noted above, when an evaluation of a disability is based upon limitation of motion, the Board must also consider, in conjunction with the otherwise applicable Diagnostic Code, any additional functional loss the Veteran may have sustained by virtue of other factors as described in 38 C.F.R. §§ 4.40 and 4.45. DeLuca v. Brown, 8 Vet. App. 202, 206 (1995). 1. Period Prior to December 6, 2010 In October 2006, the Veteran underwent a VA examination. He complained of low back pain with occasional radiation down his thighs. He also complained of stiffness in his back. He denied flare ups and bowel and bladder problems. He stated that he fell occasionally. His posture was normal with an antalgic gait. He had no point tenderness or muscle spasm. His forward flexion was normal from 0 to 90 degrees without pain. His extension was normal from 0 to 30 degrees without pain. His lateral flexion was 0 to 90 degrees without pain, bilaterally. His lateral rotation was from 0 to 30 degrees without pain. After repetitive motion testing, the Veteran did not have pain and there was no additional limitation of motion. His strength was normal and his sensory examination revealed intact sensation to all modalities of testing. The examiner found that he did not have ankylosis of the thoracolumbar spine. The results of his VA examination show normal range of motion of the thoracolumbar spine without pain. The examination does not show that the criteria for a 20 percent evaluation are met. Although the Veteran had an abnormal gait, it was not caused by muscle spasm or guarding. At a July 2008 VA physical therapy session, the Veteran reported decreased strength, flexibility, and range of motion. He also complained of soft tissue restriction, limitations in activities of daily living, postural deviations, impaired joint mobility, and gait deviations. His ranges of motion were not measured. At his October 2009 hearing, the Veteran testified that his back "locks up" once a week. He stated that he had constant low back pain and that sometimes he could not get out of bed due to its severity. He stated that he had muscle spasm. The Veteran is competent to discuss these observable symptoms. Layno v. Brown, 6 Vet. App. 465 (1994). Further, the Board finds his testimony credible. Barr v. Nicholson, 21 Vet. App. 303, 308 (2007). However, it does not show that his reported spasm resulted in abnormal posture or spinal curvature. The remaining medical evidence of record shows treatment for his back disability but does not provide measurements for ranges of motion in degrees. The Veteran has asserted that the disability evaluation for his back disability is not sufficient but has not advanced specific arguments to that extent other than a general increase in his pain level. The evidence of record prior to December 6, 2010 does not support an increased evaluation of his back disability under the General Rating Formula for Diseases and Injuries of the Spine. Even if the Veteran's limitation of motion was not compensable, his disability does not meet the criteria for a 20 percent evaluation under Diagnostic Code 5010. Although the lumbar vertebrae are considered minor joint groups, there is no evidence of record to show that he has occasional incapacitating exacerbations. 38 C.F.R. § 4.71a. Therefore, a 20 percent evaluation under Diagnostic Code 5010 is not warranted. When considering functional limitations due to pain and other factors identified in 38 C.F.R. §§ 4.40, 4.45, the Board finds that the Veteran's functional loss from his lumbar spine disability does not equate to more than the disability picture contemplated by the 10 percent rating already assigned prior to December 6, 2010. 38 C.F.R. § 4.71a. With regard to the Veteran's subjective complaints of pain, "pain itself does not rise to the level of functional loss as contemplated by VA regulations applicable to the musculoskeletal system." Mitchell v. Shinseki, 25 Vet. App. 32 (2011). Rather, pain, may result in functional loss, but only if it limits the ability "to perform the normal working movements of the body with normal excursion, strength, speed, coordination [, or] endurance." Id., quoting 38 C.F.R. § 4.40. As the Veteran has not been diagnosed with radiculopathy, a separate evaluation for this condition is not warranted. As noted above, his sensory examination was intact to all modalities of testing. 4.71a. In conclusion, the Board finds that the overall disability picture for the Veteran's back disability does not more closely approximate a 20 percent rating. 38 C.F.R. § 4.7. The preponderance of the evidence is against the claim so the benefit of the doubt rule is not applicable. See 38 U.S.C.A. § 5107(b); Gilbert, 1 Vet. App. at 54-56. There is no evidentiary basis upon which to assign a rating in excess of 10 percent and since there is no basis for assigning an increased rating, there is no basis for assigning a staged rating. Hart, 21 Vet. App. at 505. 2. Period As of December 6, 2010 The Veteran underwent a VA examination on December 6, 2010. He reported daytime urinary frequency and nocturia. The examiner stated that the Veteran was followed by his primary care provider for his genitourinary problems and that they were unrelated to his back disability. The Veteran also reported numbness, paresthesias, and leg and foot weakens. He complained of fatigue, decreased motion, stiffness, weakness, muscle spasm, severe daily pain, and radiating pain to both thighs. He described the radiating pain as tingling and a pins and needles sensation. He did not use assistive devices. Upon examination, he limped with his left leg. He had no abnormal kyphosis, reverse lordosis, list, scoliosis, or ankylosis. He had lumbar flattening, muscle spasm, and localized tenderness that was severe enough to cause an abnormal gait or spinal contour. His forward flexion was from 0 to 85 degrees with pain from 70 to 85 degrees. His extension was from 0 to 20 degrees with pain from 5 to 20 degrees. His lateral flexion was 0 to 30 degrees with pain from 20 to 30 degrees, bilaterally. His lateral rotation was 0 to 30 degrees with pain from 25 to 30 degrees bilaterally. Following repetitive motion there was no additional limitation of motion. Sensory examination showed intact sensation to vibration, position sense, pain/pinprick, and light touch. There were no dysesthesias. His muscle tone was normal with no atrophy. The examiner diagnosed degenerative disc disease from L4-S1. The December 2010 examination was the basis for the grant of a 20 percent evaluation. However, it does not show that the Veteran's forward flexion is limited to 30 degrees or less. At its most severe, his forward flexion is painful from 70 to 85 degrees. This does not approach a limitation to 30 degrees or less. Further, the examiner found that the Veteran did not have ankylosis. Therefore the results of the December 2010 examination do not support a 40 percent evaluation. 38 C.F.R. § 4.71a. A July 2011 VA treatment record notes that the Veteran reported back pain but denied that it radiated to his legs. An April 2012 VA treatment record shows that the Veteran reported an increase in back pain. He specifically stated that the pain did not radiate to his legs. He denied changes in bowel and bladder function. Upon examination, the physician found that he had full range of motion. He also had tenderness to palpation in the lower paraspinous muscles and vertebrae. Sensory examination was normal. The Veteran was able to walk on his heels and toes. Additional medical evidence of record shows complaints of back pain but does not include measurements of his ranges of motion or discussions of functional loss. The Veteran has asserted that the disability evaluation for his back disability is not sufficient but has not advanced specific arguments to that extent other than a general increase in his pain level. Even when considering functional limitations due to pain and other factors identified in 38 C.F.R. §§ 4.40, 4.45, the Board finds that the Veteran's functional loss from his lumbar spine disability does not equate to more than the disability picture contemplated by the 20 percent rating already assigned following to December 6, 2010. 38 C.F.R. § 4.71a. With regard to the Veteran's subjective complaints of pain, "pain itself does not rise to the level of functional loss as contemplated by VA regulations applicable to the musculoskeletal system." Mitchell v. Shinseki, 25 Vet. App. 32 (2011). Rather, pain, may result in functional loss, but only if it limits the ability "to perform the normal working movements of the body with normal excursion, strength, speed, coordination [, or] endurance." Id., quoting 38 C.F.R. § 4.40. As the Veteran has not been diagnosed with radiculopathy, a separate evaluation for this condition is not warranted. As noted above, his sensory examination was intact to all modalities of testing. 4.71a. In conclusion, the Board finds that the overall disability picture for the Veteran's back disability does not more closely approximate a 40 percent rating after December 6, 2010. 38 C.F.R. § 4.7. The preponderance of the evidence is against the claim so the benefit of the doubt rule is not applicable. See 38 U.S.C.A. § 5107(b); Gilbert, 1 Vet. App. at 54-56. There is no evidentiary basis upon which to assign a rating in excess of 20 percent and since there is no basis for assigning an increased rating, there is no basis for assigning a staged rating. Hart, 21 Vet. App. at 505. Throughout the appeal period, as described above, the manifestations of the Veteran's back disability are contemplated by the schedular criteria compensating for painful limitation of motion; no examiner has reported an exceptional disability picture with symptoms not represented in the rating schedule. In sum, there is no indication that the average industrial impairment from the disability would be in excess of that contemplated by the assigned rating. Accordingly, the Board has determined that referral of this case for extraschedular consideration is not in order. Thun v. Peake, 22 Vet. App. 111 (2008), aff'd, Thun v. Shinseki, 572 F.3d 1366 (Fed. Cir. 2009). C. Left Knee Disability The Veteran's left knee disability is evaluated under Diagnostic Code 5010-5261, traumatic arthritis and limitation of extension of the leg. 38 C.F.R. § 4.71a (2012). Under DC 5010, the rater is instructed to rate traumatic arthritis as degenerative arthritis, DC 5003. Under DC 5003, the disability is evaluated based upon limitation of motion of the affected part. When limitation of motion is noncompensable, a 10 percent rating is warranted when there is x-ray evidence of involvement of 2 or more major joints or 2 or more minor joint groups. A 20 percent rating is warranted where there is x-ray evidence of the involvement of 2 or more major joints or 2 or more minor joint groups with occasional incapacitating exacerbations. 38 C.F.R. § 4.71a. There are two Diagnostic Codes for limitation of motion of the knee, they provide criteria for limitation of flexion and extension of the leg. As noted above, when an evaluation of a disability is based upon limitation of motion, the Board must also consider, in conjunction with the otherwise applicable Diagnostic Code, any additional functional loss the Veteran may have sustained by virtue of other factors as described in 38 C.F.R. §§ 4.40 and 4.45. DeLuca v. Brown, 8 Vet. App. 202, 206 (1995). Under Diagnostic Code 5260, limitation of flexion of the leg, a noncompensable evaluation is warranted when flexion is limited to 60 degrees. A 10 percent evaluation is warranted when flexion of the leg is limited to 45 degrees. A 20 percent evaluation is warranted when flexion is limited to 30 degrees. 38 C.F.R. § 4.71a. Normal flexion is 140 degrees. 38 C.F.R. § 4.71a, Plate II. Under Diagnostic Code 5261, limitation of extension of the leg, a noncompensable evaluation is warranted when extension is limited to 5 degrees. A 10 percent evaluation is warranted when extension of the leg is limited to 10 degrees. A 20 percent evaluation is warranted when extension is limited to 15 degrees. 38 C.F.R. § 4.71a. Normal extension is 0 degrees. 38 C.F.R. § 4.71a, Plate II. The Board is bound in its decisions by the regulations of the Department, instructions of the Secretary, and precedent opinions of the General Counsel of the VA. 38 U.S.C.A. § 7104(c) (West 2002); 38 C.F.R. § 20.101(a) (2012). Separate ratings are available for limitation of flexion and limitation of extension under Diagnostic Codes 5260 and 5261. VAOPGCPREC 9-2004 (2004). At worst, for the entirety of the appeal period, the Veteran's flexion was 100 degrees with pain at 90 degrees at his December 2010 examination. Therefore, even when considering functional loss due to pain, his loss of flexion does not more closely approximate a limitation to 60 degrees, which is required for a noncompensable evaluation under Diagnostic Code 5260. 38 C.F.R. § 4.71a. Because his limitation of flexion does not meet the criteria for a noncompensable evaluation, a separate evaluation for limitation of flexion under Diagnostic Codes 5260 is not warranted during the appeal period. VAOPGCPREC 9-98 (1998); VAOPGCPREC 9-2004 (2004). VA's General Counsel has held that a claimant who has arthritis as shown by x-ray and instability of the knee may be rated separately under Diagnostic Codes 5003 and 5257. VAOPGCPREC 23-97; 62 Fed. Reg. 63,604 (1997). However, the General Counsel subsequently clarified that for a knee disability rated under DC 5257 or DC 5259 to warrant a separate rating for arthritis based on x-ray findings and limitation of motion, the limitation of motion under DC 5260 or DC 5261 need not be compensable but must at least meet the criteria for a noncompensable rating. VAOPGCPREC 9-98 (1998). But, read together, DC 5003 and 38 C.F.R. § 4.59 provide that painful motion due to degenerative arthritis, which is established by x-ray, is deemed to be limitation of motion and warrants the minimum rating for a joint, even if there is no actual limitation of motion. Id., citing Lichtenfels v. Derwinski, 1 Vet. App. 484, 488 (1991). Under DC 5257, a 10 percent evaluation is warranted when there is slight recurrent subluxation or lateral instability. A 20 percent evaluation is warranted when there is moderate recurrent subluxation or lateral instability. A 30 percent evaluation is warranted for severe recurrent subluxation or lateral instability. 38 C.F.R. § 4.71a. DC 5257 is based upon instability and subluxation, not limitation of motion, as a result, the criteria set forth in DeLuca do not apply. DeLuca v. Brown, 8 Vet. App. 202, 206 (1995). 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. 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 In a May 2012 rating decision, the RO increased the Veteran's disability evaluation for a left knee disability from noncompensable to 10 percent, based upon painful motion of the knee as evidenced during his December 6, 2010 VA examination. 1. Period Prior to December 6, 2010 In October 2006, the Veteran underwent a VA examination. He complained of left knee pain on the medial and lateral aspects. He also reported stiffness, instability, and weakness. He denied swelling, heat, redness, subluxation, and dislocation. He stated that he had flare-ups every two months. Upon examination, he had a slightly antalgic gait. There was no edema or point tenderness. His extension and flexion were both normal at 0 and 140 degrees without pain. After repetitive motion, his ranges of motion did not change and pain was not reported. The examiner specifically found no evidence of instability of the joint and stated that the Veteran's McMurray test for medial and lateral meniscus entrapment was also negative. At his October 2009 hearing, the Veteran stated that he felt like his "inner...and lower legs are not aligned anymore," and complained of instability and pain. He stated that he fell three to four times per week. The Veteran is competent to discuss observable symptoms such as feelings of instability in his knee joint. Layno v. Brown, 6 Vet. App. 465 (1994). Further, his testimony regarding his falling is credible. Barr v. Nicholson, 21 Vet. App. 303, 308 (2007). His testimony constitutes probative evidence that he has subjective complaints of instability of his left knee. Because he has slight instability of the knee joint, a separate 10 percent evaluation will be granted for the left knee under Diagnostic Code 5257. 38 C.F.R. § 4.71a, VAOPGCPREC 9-98 (August 14, 1998). However, as his reports of instability are subjective only and there is no medical evidence showing instability of the joint, the severity does not reach the level of moderate, which is needed for a 20 percent evaluation under Diagnostic Code 5257. There is no other medical or lay evidence of record showing range of motion measurements. Based upon the findings of the October 2006 VA examiner, a compensable evaluation for limitation of extension is not warranted. His extension was normal at 0 degrees with no painful motion or functional loss. 38 C.F.R. §§ 4.40, 4.45. Therefore, there is no evidence that his extension was limited to 10 degrees, which is the required criterion for a 10 percent evaluation under Diagnostic Code 5261. The Board acknowledges the Veteran's subjective reports of pain. The Court has held, however, that "pain itself does not rise to the level of functional loss as contemplated by VA regulations applicable to the musculoskeletal system." Mitchell v. Shinseki, 25 Vet. App. 32 (2011). Rather, pain, may result in functional loss, but only if it limits the ability "to perform the normal working movements of the body with normal excursion, strength, speed, coordination [, or] endurance." Id., quoting 38 C.F.R. § 4.40. The Veteran has arthritis in both his left knee and left ankle, constituting two major joint groups. 38 C.F.R. § 4.45(f). However, service connection for his left ankle disability has been granted and evaluated under Diagnostic Code 5010-5271. Therefore, to assign a 10 percent evaluation under Diagnostic Code 5010 for his knee and ankle arthritis a second time would constitute impermissible pyramiding and is therefore not warranted. 38 C.F.R. § 4.14. In summary, for the period prior to December 6, 2010, the preponderance of the evidence is against the claim for a compensable disability evaluation under Diagnostic Code 5010-5261 so the benefit of the doubt rule is not applicable. See 38 U.S.C.A. § 5107(b); Gilbert, 1 Vet. App. at 54-56. There is no evidentiary basis upon which to assign a compensable rating and since there is no basis for assigning an increased rating, there is no basis for assigning a staged rating. Hart, 21 Vet. App. at 505. However, a separate 10 percent evaluation is granted under Diagnostic Code 5257 for slight instability of the knee. 38 C.F.R. § 4.71a. 2. Period As of December 6, 2010 In December 2010, the Veteran underwent a second VA examination. He reported pain, giving way, stiffness, weakness, decreased speed of motion, repeated effusion, swelling, tenderness, and flare-ups every 2-3 weeks that last 1-2 days. He denied episodes of locking, incoordination, and subluxation. He did not use an assistive device but limped on his left leg. Upon examination, the examiner found crepitus and tenderness. He specifically found that the knee joint was stable and that the Veteran did not have ankylosis. His ligaments were intact. His flexion was 100 degrees with pain beginning at 90 degrees. His extension was normal at 0 degrees. After repetitive motion, he had no additional limitation of motion and no reported additional pain, fatigue, weakness, or incoordination. The examiner found that the Veteran's knee disability caused decreased mobility. It also caused difficulty with lifting and carrying. It had a severe impact on his ability to do chores, exercise, play sports, and engage in recreation. It had moderate impact on his ability to shop, travel, and drive. It had no impact on his ability to feed himself, bathe, dress, use the toilet, or groom. He could not run and was advised to avoid squatting, kneeling, and climbing ladders. The December 2010 VA examination was the basis for the increase of the Veteran's disability evaluation to 10 percent. The remaining medical and lay evidence of record does not contain additional measurements of limitation of motion. Even when considering functional limitations due to pain and other factors identified in 38 C.F.R. §§ 4.40, 4.45, and assuming that the Veteran's flexion ended at 90 degrees, his limitation of flexion is not limited to 30 degrees, which is necessary for a 20 percent evaluation under Diagnostic Code 5260, and his limitation of extension is not limited to 15 degrees, which is necessary for a 20 percent evaluation under Diagnostic Code 5261. A 20 percent evaluation based upon limitation of motion is not warranted. The Board acknowledges the Veteran's subjective reports of pain. The Court has held, however, that "pain itself does not rise to the level of functional loss as contemplated by VA regulations applicable to the musculoskeletal system." Mitchell v. Shinseki, 25 Vet. App. 32 (2011). Rather, pain, may result in functional loss, but only if it limits the ability "to perform the normal working movements of the body with normal excursion, strength, speed, coordination [, or] endurance." Id., quoting 38 C.F.R. § 4.40. Further, there is no evidence that he has incapacitating exacerbations from his left knee disability. Therefore, a 20 percent evaluation under Diagnostic Code 5003 is not warranted. 38 C.F.R. § 4.71a. Lastly, as discussed above, a separate 10 percent evaluation was granted for mild instability of the left knee under Diagnostic Code 5257. 38 C.F.R. § 4.71a, VAOPGCPREC 9-98 (August 14, 1998). His reports of instability at his December 2010 examination were subjective only and there is no medical evidence showing instability of the joint. The severity does not reach the level of moderate, which is needed for a 20 percent evaluation under Diagnostic Code 5257. With regard to other potentially applicable Diagnostic Codes for the Veteran's knee disability, for the duration of the appeal period, the Veteran's knee has never been ankylosed, there was no malunion or nonunion of the tibia and fibula, and there were no symptoms from the removal or dislocation of semilunar cartilage. See 38 C.F.R. § 4.71a, Diagnostic Codes 5256, 5258, 5259, 5262 (2012); see also VAOPGCPREC 23-97, 62 Fed. Reg. 63604 (1997); VAOPGCPREC 9-98, 63 Fed. Reg. 56704 (1998). Accordingly, application of these Diagnostic Codes is unwarranted. See Butts v. Brown, 5 Vet. App. 532 (1993) (choice of Diagnostic Code should be upheld if supported by explanation and evidence). In conclusion, the preponderance of the evidence is against the claim so the benefit of the doubt rule is not applicable. See 38 U.S.C.A. § 5107(b); Gilbert, 1 Vet. App. at 54-56. There is no evidentiary basis upon which to assign a rating in excess of 10 percent under any potentially applicable Diagnostic Code, and since there is no basis for assigning an increased rating, there is no basis for assigning a staged rating. Hart, 21 Vet. App. at 505. Throughout the appeal period, as described above, the manifestations of the Veteran's left knee are contemplated by the schedular criteria that compensate for painful limitation of motion and instability; no examiner has reported an exceptional disability picture with symptoms not represented in the rating schedule. In sum, there is no indication that the average industrial impairment from the disability would be in excess of that contemplated by the assigned rating. Accordingly, the Board has determined that referral of this case for extraschedular consideration is not in order. Thun v. Peake, 22 Vet. App. 111 (2008), aff'd, Thun v. Shinseki, 572 F.3d 1366 (Fed. Cir. 2009). D. Left Ankle The Veteran's left ankle disability is evaluated under Diagnostic Code 5010-5271, traumatic arthritis and limitation of motion of the ankle. Under Diagnostic Code 5271, a 10 percent evaluation is warranted for moderate limitation of motion of the ankle. A 20 percent evaluation is assigned for marked limitation of motion of the ankle. 38 C.F.R. § 4.71a. Normal dorsiflexion is 20 degrees. Normal plantar flexion is 45 degrees. 38 C.F.R. § 4.71a, Plate II. Because the evaluation of his disability is based upon limitation of motion, additional functional loss must be considered. 38 C.F.R. §§ 4.40 and 4.45; DeLuca v. Brown, 8 Vet. App. 202, 206 (1995). In October 2006, the Veteran underwent a VA examination. He complained of continuous pain over the medial aspect of his ankle. He reported weakness, stiffness, and instability. He denied redness, heat, subluxation, and dislocation. He stated that he had swelling fairly continuously. He stated that he could walk approximately 100 feet. Upon examination, he had mild edema and minimal tenderness. His dorsiflexion was normal at 20 degrees. His plantar flexion was normal at 45 degrees. His ranges of motion were performed without pain and were unchanged after repetitive motion. The examiner found that there was no varus or valgus angulation of the os calcis in relation to the long axis of the tibia or fibula. He underwent a second VA examination in December 2010. He reported pain, stiffness, weakness, incoordination, decreased speed of motion, swelling, tenderness, and flare ups every two to three weeks. He did not use assistive devices. Upon examination, there was crepitus and tenderness. The examiner found that there was no instability or ankylosis. The Veteran's dorsiflexion was 10 degrees with pain at 5 degrees. His plantar flexion was 30 degrees with pain at 25 degrees. After repetitive motion testing, his ranges of motion were unchanged and there was no reported additional pain, fatigue, weakness, or incoordination. The examiner concluded that the Veteran's left ankle disability caused decreased mobility and problems lifting and carrying. It had a severe impact on his ability to do chores, exercise, play sports, and engage in recreation. It had moderate impact on his ability to shop, travel, and drive. It had no impact on his ability to feed himself, bathe, dress, use the toilet, or groom. He could not run and was advised to avoid squatting, kneeling, and climbing ladders. The Board finds that 10 degrees of dorsiflexion of the left ankle is reflective of marked limitation of motion. Further, his plantar flexion is also limited, with a loss of 15 degrees of motion. See 38 C.F.R. § 4.71a, DC 5271. The appeal is granted, effective December 6, 2010, the date of his VA examination. A 20 percent rating is the highest rating available for limitation of motion of the ankle under DC 5271. Id. Therefore it is not necessary to consider whether 38 C.F.R. §§ 4.40 and 4.45 are applicable. Johnston v. Brown, 10 Vet. App. 80, 85 (1997). There are other potentially applicable Diagnostic Codes for the Veteran's left ankle disability. Under Diagnostic Code 5272, a 10 percent evaluation is warranted when there is ankylosis of the subastragalar or tarsal joint in a good weight bearing position. A 20 percent evaluation is warranted when there is ankylosis of the subastragalar or tarsal joint in a poor weight bearing position. Under Diagnostic Code 5273, a 10 percent evaluation is warranted when there is malunion of the os calcis or astragalus with moderate deformity. A 20 percent evaluation is warranted when there is malunion of the os calcis or astragalus with marked deformity. Under Diagnostic Code 5274, a 20 percent evaluation is warranted for an astragalectomy. 38 C.F.R. § 4.71a. None of these Diagnostic Codes provide criteria for an evaluation higher than 20 percent. Therefore, they are not applicable in this case. 38 C.F.R. § 4.71a. The only other Diagnostic Code that pertains to ankle disabilities is Diagnostic Code 5270, under which a 20 percent evaluation is warranted for ankylosis of the ankle in less than 30 degrees of plantar flexion. A 30 percent evaluation is warranted for ankylosis of the ankle in plantar flexion between 30 degrees and 40 degrees, or in dorsiflexion, between 0 degrees and 10 degrees. Id. As noted above, the Veteran retains mobility in his ankle joint; he does not manifest ankylosis of any form. See Dinsay v. Brown, 9 Vet. App. 79, 81 (1996); Lewis v. Derwinski, 3 Vet. App. 259 (1992). Therefore, a higher evaluation under Diagnostic Code 5270 is not warranted. In conclusion, a 20 percent evaluation for marked limitation of motion of the left ankle is granted effective December 6, 2010, the date that it was shown that he had lost 50 percent of his dorsiflexion. 38 C.F.R. § 4.71a; see also Alemany v. Brown, 9 Vet. App. 518, 519 (1996); Brown v. Brown , 5 Vet. App. 413, 421 (1993). As described above, the manifestations of the Veteran's left ankle are contemplated by the schedular criteria that compensate for painful limitation of motion; no examiner has reported an exceptional disability picture with symptoms not represented in the rating schedule. In sum, there is no indication that the average industrial impairment from the disability would be in excess of that contemplated by the assigned rating. Accordingly, the Board has determined that referral of this case for extraschedular consideration is not in order. Thun v. Peake, 22 Vet. App. 111 (2008), aff'd, Thun v. Shinseki, 572 F.3d 1366 (Fed. Cir. 2009). E. Hemorrhoids The Veteran's hemorrhoids are currently evaluated as noncompensable under Diagnostic Code 7336, external or internal hemorrhoids. 38 C.F.R. § 4.114. Under Diagnostic Code 7336, a noncompensable evaluation is warranted when there are mild or moderate hemorrhoids. A 10 percent evaluation is warranted when the hemorrhoids are large or thrombotic, irreducible, with excessive redundant tissue, evidencing frequent recurrences. Id. In October 2006, the Veteran underwent a VA examination. He reported a history of hemorrhoids but denied bleeding. He reported good sphincter control but stated that he was always constipated. He denied having diarrhea. He was on a high fiber diet and used stool softeners and laxatives. Upon examination, he had internal hemorrhoids at 4 and 8 o'clock. The examiner stated that there was no bleeding. The examiner noted that a January 2006 colonoscopy showed non-thrombosed internal and external hemorrhoids. The Veteran was diagnosed with stable hemorrhoids without bleeding. At his October 2009 hearing, the Veteran testified that could not have a bowel movement on a daily basis. He stated that sometimes, he had a moderate amount of blood in his stool. He stated that he had both internal and external hemorrhoids, and that he was on a high fiber diet. The Veteran is competent to report observable symptoms such as blood in stool and constipation. Layno v. Brown, 6 Vet. App. 465 (1994). His testimony is credible. Barr v. Nicholson, 21 Vet. App. 303, 308 (2007). It provides evidence in support of his claim. In December 2010, he underwent a second VA examination. He stated that his high fiber diet produced fair results. He complained of anal itching and burning. He had problems passing stool, pain, tenesmus, and swelling. He denied having diarrhea. He stated that he had occasional bleeding and had four or more recurrences per year, without thrombosis. The examiner stated that the Veteran did not have a history of thrombosis, fecal incontinence, or perianal discharge. Upon examination, he had both internal and external hemorrhoids. His internal hemorrhoid was 2 by .5 centimeters. He had external hemorrhoids measuring 1.5 by .5 centimeters at 4 and 8 o'clock. They were reducible. There was no evidence of prolapse or thrombosis. There was evidence of bleeding. There was no excessive or redundant tissue. The Veteran did not have a fistula or stricture, and his sphincter was not impaired. The examiner concluded that the Veteran's hemorrhoids had a significant impact because they caused pain and problems at work. The remaining medical and lay evidence of record does not address the Veteran's level of disability from hemorrhoids. The evidence of record does not support a compensable evaluation for hemorrhoids. VA examiner found that the Veteran's hemorrhoids were not thrombotic, were reducible, and that the Veteran did not have excessive redundant tissue. There is no evidence to the contrary. The criteria for a 10 percent evaluation under Diagnostic Code 7336 are not met. 38 C.F.R. § 4.114. The preponderance of the evidence is against the claim so the benefit of the doubt rule is not applicable. See 38 U.S.C.A. § 5107(b); Gilbert, 1 Vet. App. at 54-56. There is no evidentiary basis upon which to assign a compensable rating, and since there is no basis for assigning an increased rating, there is no basis for assigning a staged rating. Hart, 21 Vet. App. at 505. The appeal is denied. As described above, the manifestations of the Veteran's mild to moderate hemorrhoids are contemplated by the schedular criteria that compensate for them; no examiner has reported an exceptional disability picture with symptoms not represented in the rating schedule. In sum, there is no indication that the average industrial impairment from the disability would be in excess of that contemplated by the assigned rating. Accordingly, the Board has determined that referral of this case for extraschedular consideration is not in order. Thun v. Peake, 22 Vet. App. 111 (2008), aff'd, Thun v. Shinseki, 572 F.3d 1366 (Fed. Cir. 2009). F. Hearing Loss, Right Ear Impaired hearing will be considered a disability only after threshold requirements are met. See 38 C.F.R. § 3.385. Once a disability is established, levels of hearing loss are determined by considering the pure tone threshold average and speech discrimination percentage scores, resulting in a Roman numeral designation for hearing loss. 38 C.F.R. § 4.85(b), Table VI. Disability ratings are assigned by combining the level of hearing loss in each ear. 38 C.F.R. § 4.85(e), Table VII. See Lendenmann v. Principi, 3 Vet. App. 345 (1992) (assignment of disability ratings for hearing impairment are derived by a mechanical application of the rating schedule to the numeric designations assigned after audiometric evaluations are rendered). If, as in this case, impaired hearing is only service-connected in one ear, the non-service-connected ear will be assigned a Roman numeral value of I. 38 C.F.R. § 4.85(f). Table VI, "Numeric Designation of Hearing Impairment Based on Pure tone Threshold Average and Speech Discrimination" is used to determine a Roman numeral designation (I through XI) for hearing impairment in each ear based on consideration of speech discrimination as well as pure tone threshold averages, unless the examiner certifies that use of the speech discrimination test is not appropriate. In that case, table VIa, "Numeric Designation of Hearing Impairment Based Only on Pure tone Threshold Average" is used. Table VII, "Percentage Evaluation for Hearing Impairment" is then used to determine the percentage evaluation by combining the Roman numeral of each ear. 38 C.F.R. §§ 3.383, 3.385, 4.85(b). If the Veteran has either of two exceptional pattern of hearing impairment, the Roman numeral value is determined using both Table VI and VIa. 38 C.F.R. § 4.86. This method is used if the Veteran's pure tone threshold at each of the four specified frequencies is 55 decibels or more, or if the Veteran's pure tone threshold is 30 decibels or less at 1000 Hertz and 70 decibels or more at 2000 Hertz. Whichever table results in a higher Roman numeral value is used to calculate a disability evaluation using Table VII. Id. In this case, the Veteran's pattern of hearing loss does not meet the criteria for an exceptional pattern of hearing impairment. The Veteran underwent a VA examination in November 2006. His pure tone thresholds, in decibels, were as follows: HERTZ 500 1000 2000 3000 4000 RIGHT -- 15 25 30 45 LEFT -- 5 10 5 30 The average puretone threshold was 29 in the right ear and 13 in the left ear. Speech audiometry revealed speech recognition ability of 84 percent in the right ear and 96 percent in the left ear. During the November 2006 VA audiological examination, the Veteran reported that he lost his hearing completely approximately three times per day. That was a description of the effect of his disability on his daily activities. 38 C.F.R. § 4.10. See Martinak v. Nicholson, 21 Vet. App. 447, 455-56 (2007). The Veteran's non-service-connected left ear hearing loss is assigned the Roman numeral value of I. 38 C.F.R. § 4.85(f). Applying the results of his examination to Table VI, his right ear is also assigned a Roman numeral value of II. Applying this value to Table VII, the Board must find that the Veteran's hearing impairment in his right ear warrants a noncompensable evaluation, and not more. At his October 2009 hearing, the Veteran stated that he had to turn the television volume to its loudest in order to hear it. The Veteran underwent a second VA examination in December 2010. His pure tone thresholds, in decibels, were as follows: HERTZ 500 1000 2000 3000 4000 RIGHT -- 15 30 40 55 LEFT -- 10 20 20 45 The average puretone threshold was 35 in the right ear and 24 in the left ear. Speech audiometry revealed speech recognition ability of 98 percent in the right ear and 96 percent in the left ear. During the December 2010 VA audiological examination, the Veteran reported that he had problems hearing background noise, and that his ears "plug[ged] up" and he could not hear for five minutes to one hour, several times a day. That was a description of the effect of his disability on his daily activities. 38 C.F.R. § 4.10. See Martinak, 21 Vet. App. at 455-56. The Veteran's non-service-connected left ear hearing loss is assigned the Roman numeral value of I. 38 C.F.R. § 4.85(f). Applying the results of his examination to Table VI, his right ear is also assigned a Roman numeral value of I. Applying this value to Table VII, the Board must find that the Veteran's hearing impairment in his right ear warrants a noncompensable evaluation, and not more. 38 C.F.R. § 4.85. The preponderance of the evidence is against the claim so the benefit of the doubt rule is not applicable. See 38 U.S.C.A. § 5107(b); Gilbert, 1 Vet. App. at 54-56. There is no evidentiary basis upon which to assign a compensable rating for bilateral hearing loss, and since there is no basis for assigning an increased rating, there is no basis for assigning a staged rating. Hart, 21 Vet. App. at 505. As described above, the manifestations of the Veteran's hearing loss in the right ear are contemplated by the schedular criteria that compensates for them; no examiner has reported an exceptional disability picture with symptoms not it under Diagnostic Code 6100. At worst, his right ear hearing loss is assigned a Roman numeral value of II, which when combined with a value of Level I for his non-service-connected ear, results in a noncompensable evaluation. 38 C.F.R. §§ 4.85, 4.86. In sum, there is no indication that the average industrial impairment from the disability would be in excess of that contemplated by the assigned rating. Accordingly, the Board has determined that referral of this case for extraschedular consideration is not in order. Thun v. Peake, 22 Vet. App. 111 (2008), aff'd, Thun v. Shinseki, 572 F.3d 1366 (Fed. Cir. 2009). III. Total Rating Based Upon Individual Unemployability (TDIU) To establish entitlement to a TDIU, there must be an impairment so severe that it is impossible to follow a substantially gainful occupation. See 38 U.S.C.A. § 1155; 38 C.F.R. §§ 3.340, 3.341, 4.16. In reaching such a determination, the central inquiry is "whether the Veteran's service connected disabilities alone are of sufficient severity to produce unemployability." Hatlestad v. Brown, 5 Vet. App. 524, 529 (1993). Neither non-service-connected disabilities nor advancing age may be considered in the determination. 38 C.F.R. §§ 3.341, 4.19; Van Hoose v. Brown, 4 Vet. App. 361, 363 (1993). For VA purposes, the term "unemployability" is synonymous with an inability to secure and follow a substantially gainful occupation. VAOPGCPREC 75-91; 57 Fed. Reg. 2317 (1992). Substantially gainful employment is that which is ordinarily followed by the nondisabled to earn a livelihood, with earnings common to the particular occupation in the community where the Veteran resides. Moore (Robert) v. Derwinski, 1 Vet. App. 356 (1991). This suggests a living wage. Ferraro v. Derwinski, 1 Vet. App. 326, 332 (1991). Marginal employment shall not be considered substantially gainful employment. 38 C.F.R. § 4.16(a). The ability to work sporadically or obtain marginal employment is not substantially gainful employment. Moore, 1 Vet. App. at 358. The question is whether the Veteran is capable of performing the physical and mental acts required by employment and not whether the Veteran is, in fact, employed. See Van Hoose v. Brown, 4 Vet. App. 361 (1993). A TDIU requires that the record reflect some factor that "takes the claimant's case outside the norm" of any other Veteran rated at the same level. Id., (citing 38 C.F.R. §§ 4.1 , 4.15). Consideration may be given to the Veteran's level of education, special training, and previous work experience in arriving at a conclusion, but not to his age or to the impairment caused by non-service-connected disabilities. See 38 C.F.R. §§ 3.341, 4.16, 4.19. VA regulations establish objective and subjective standards for an award of total rating based on unemployability. When the Veteran's schedular rating is less than total (for a single or combination of disabilities), a total rating may nonetheless be assigned provided that if there is only one service-connected disability, this disability shall be rated at 60 percent or more. When there are two or more disabilities, at least one disability must be ratable at 40 percent or more, and any additional disabilities must result in a combined rating of 70 percent or more, and the disabled person must be unable to secure or follow a substantially gainful occupation. See 38 C.F.R. § 4.16(a). A total disability rating may also be assigned on an extra-schedular basis, pursuant to the procedures set forth in 38 C.F.R. § 4.16(b), for veterans who are unemployable by reason of service-connected disabilities, but who fail to meet the percentage standards set forth in section 4.16(a). The Veteran has ten service connected disabilities. Hypertension, migraine headaches, hemorrhoids, and right ear hearing loss are all assigned noncompensable evaluations. Left knee arthritis, left varicocele, and tinnitus are assigned 10 percent ratings. A neck disability and a back disability are each evaluated as 20 percent disabling. In this Board decision, a separate 10 percent evaluation was granted for instability in the left knee for the duration of the appeal period. This Board decision also increased the Veteran's disability evaluation for left ankle arthritis from 10 to 20 percent effective December 6, 2010. Prior to December 6, 2010, the Veteran's combined disability evaluation was 50 percent, when taking into account the separate 10 percent evaluation granted for instability of the knee. 38 C.F.R. § 4.25. The threshold criteria set forth in 38 C.F.R. § 4.16(a) are not met. All cases of Veterans who are unemployable by reason of service-connected disabilities, but who fail to meet the percentage standards of 38 C.F.R. § 4.16(a), are to be referred to the Under Secretary for Benefits or the Director, Compensation and Pension Service for consideration of an extraschedular evaluation. § 4.16(b). The Board must therefore determine whether the Veteran is unemployable due to his service-connected disabilities. The Board does not have the authority to assign an extraschedular TDIU rating in the first instance. Bowling v. Principi, 15 Vet. App. 1 (2001). An extraschedular rating is requested by the RO and approved by the Under Secretary Benefits or by the Director of Compensation and Pension Services. In its May 2012 SSOC, the RO considered an extraschedular rating and determined that referral for such extraschedular rating is not appropriate The Board may accordingly consider the issue without prejudice to the Veteran. An extraschedular rating is warranted upon a finding that the Veteran is unable to secure or follow substantially gainful employment. 38 C.F.R. § 4.16(b). In October 2006, a VA examiner found that the Veteran's orthopedic disabilities did not prevent him from securing gainful employment. In November 2006, a VA examiner concluded that the Veteran's hearing loss might cause some difficulty hearing some of the soft, high frequency consonant sounds of conversational speech in his right ear. However, word recognition in the right ear was good. The examiner concluded that the difficulties would have a minimal effect on the Veteran's overall ability to communicate and that he could communicate well enough to maintain substantially gainful employment consistent with his educational and occupational experiences. At his October 2009 hearing, the Veteran testified that that he could not stand or walk for long periods of time. He also stated that he had non-service-connected disabilities such as glaucoma that contributed to his unemployability. He testified that he applied for jobs but no one would hire him because he was a disabled veteran. There is no evidence of record suggesting that prior to December 6, 2010, the Veteran's service connected disabilities alone prevented him from securing gainful employment. While the Veteran's statements regarding an inability to work for many years due to physical disability are credible, the Board finds that greater probative weight should be accorded the objective clinical findings in this case as outlined above that do not show a level of disability associated with the Veteran's service-connected disabilities that would prevent obtaining and maintaining all forms of gainful employment. Further, the Veteran specifically testified that some of his non-service-connected disabilities contributed to his inability to work. As the preponderance of the evidence is against a finding that the Veteran is unemployable solely as the result of his service-connected disabilities, the Board finds that entitlement to a total disability rating based on individual unemployability, on an extraschedular basis, is not warranted. In making these determinations, the Board has considered the provisions of 38 U.S.C.A. § 5107(b), but there is not such a state of approximate balance of the positive evidence with the negative evidence to otherwise warrant a favorable decision. Effective December 6, 2010, the assignment of a 20 percent evaluation for the Veteran's left ankle disability increased his combined disability evaluation to 70 percent. 38 C.F.R. § 4.25. Therefore, the threshold set forth in 38 C.F.R. § 4.16(a) is met. At his December 2010 spine and joints examinations, the examiner concluded that the Veteran's back and neck disabilities did not preclude sedentary employment not requiring lifting, bending, carrying, climbing stairs and ladders, operation of machinery, driving, walking more than 100 feet, standing more than a few minutes, kneeling, and squatting. It was noted that in a sedentary employment situation, the Veteran should be allowed immediate access to restrooms and allowed to frequently change his body position. At his December 2010 VA examination for hemorrhoids, the examiner concluded that the Veteran's hemorrhoids do not preclude employment not requiring exertion or standing for more than a few minutes and that required immediate access to a restroom. The medical and lay evidence of record does not show that the Veteran's service-connected disabilities render him unemployable. To the contrary, VA examiners have found him capable of sedentary employment. As the preponderance of the evidence is against a finding that the Veteran is unemployable solely as the result of his service-connected disability, the Board finds that entitlement to a total disability rating based on individual unemployability is not warranted. Because a preponderance of the evidence is against assigning a TDIU in this case, the benefit of the doubt doctrine is not applicable. 38 U.S.C.A. § 5107(b). Therefore, the claim of entitlement to a TDIU must be denied. ORDER Service connection for a disability manifested by chest palpitations and pain, to include a panic and a cardiovascular disorder is denied. A disability evaluation in excess of 10 percent for a cervical spine disability prior to December 6, 2010 is denied. A disability evaluation in excess of 20 percent for a cervical spine disability for the period from December 6, 2010 to September 25, 2011 and from March 1, 2012 onward is denied. A disability evaluation in excess of 10 percent for a back disability prior to December 6, 2010 is denied. A disability evaluation in excess of 20 percent for a back disability as of December 6, 2010 is denied. A compensable disability evaluation for a left knee disability prior to December 6, 2010 is denied. A disability evaluation in excess of 10 percent for a left knee disability as of December 6, 2010 is denied. A separate 10 percent evaluation for instability of the left knee is granted for the appeal period. A 20 percent disability evaluation for a left ankle disability is granted, effective December 6, 2010. A compensable disability evaluation for hemorrhoids is denied. A compensable disability evaluation for right ear hearing loss is denied. Entitlement to a TDIU is denied. ____________________________________________ K. PARAKKAL Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs