Citation Nr: 1322749 Decision Date: 07/17/13 Archive Date: 07/24/13 DOCKET NO. 10-22 747 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Winston-Salem, North Carolina THE ISSUES 1. Entitlement to service connection for a back disorder. 2. Entitlement to an initial compensable rating for hypertension. 3. Entitlement to an initial compensable rating for rhinitis. REPRESENTATION Appellant represented by: North Carolina Division of Veterans Affairs ATTORNEY FOR THE BOARD D.J. Drucker, Counsel INTRODUCTION The Veteran had active military service from June 1970 to January 1978. This matter comes to the Board of Veterans' Appeals (Board) on appeal from July 2009 and August 2010 rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in Winston-Salem, North Carolina. The June 2009 rating decision denied service connection for lumbar degenerative joint disease, and the August 2010 rating decision granted service connection for hypertension and rhinitis, that were assigned initial noncompensable disability evaluations effective from February 18, 2010. In February 2013, the Board requested a medical opinion, pursuant to 38 U.S.C.A. § 7109 and as set forth in a designated Veterans Health Administration (VHA) Directive, in response to the appellant's claim of entitlement to service connection for a back disorder. See 38 U.S.C.A. § 7109(a) (West 2002) and 38 C.F.R. § 20.901 (2012). See generally Wray v. Brown, 7 Vet. App. 488, 493 (1995). A VHA medical opinion was rendered in April 2013. In May 2013, the appellant was given an opportunity to present additional argument and, in a signed statement dated later that month, indicated that he had no further evidence or argument to submit. FINDINGS OF FACT 1. The evidence of record preponderates against a finding that a back disorder, currently diagnosed as multi-level degenerative disc disease, acquired spinal stenosis, and lumbar area and residual spine changes post-laminectomy surgery, had its onset in service, is otherwise related to the Veteran's military service, or was manifest to a compensable degree within one year of his discharge from active service. 2. Resolving all doubt in the Veteran's favor, hypertension requires medication and is manifested by systolic blood pressure readings at or near 160 or more; it has not been manifested by predominant diastolic blood pressure of 110 or more or a predominant systolic blood pressure of 200 or more. 3. The Veteran's service-connected rhinitis is not manifested polyps, or evidence that he suffers from a greater than 50 percent obstruction of the nasal passage on both sides, or complete obstruction on one side. CONCLUSIONS OF LAW 1. The criteria for service connection for a back disorder have not been met. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 1131, 1137, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309, 3.310 (2012). 2. Resolving all doubt in the Veteran's favor, the schedular criteria for an initial 10 percent rating, but no higher, for hypertension are met since February 18, 2010. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 4.7, 4.104, Diagnostic Code 7101 (2012). 3. The schedular criteria for an initial compensable rating for rhinitis have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 4.7, 4.97, Diagnostic Code 6522 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Duty to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA) and implementing regulations impose obligations on VA to provide claimants with notice and assistance. 38 U.S.C.A. §§ 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2012); Pub.L. 112-154, §§ 504(a)(1)-(2), 505(a)-(b) (Aug. 6, 2012) (to be codified at 38 U.S.C.A. §§ 5103(a)-(b), 5103A(b)-(c)); 38 C.F.R §§ 3.102, 3.156(a), 3.159, 3.326(a) (2012). Proper VCAA notice must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; (3) that the claimant is expected to provide; and (4) must ask the claimant to provide any evidence in her or his possession that pertains to the claim. Pub.L. 112-154, §§ 504(a)(1)-(2) (to be codified at 38 U.S.C.A. § 5103(a)); 38 C.F.R. § 3.159(b)(1) (20). VCAA notice should be provided to a claimant before the initial unfavorable agency of original jurisdiction (AOJ) decision on a claim. Pelegrini v. Principi, 18 Vet. App. 112 (2004). The United States Court of Appeals for Veterans Claims (court or veteran's court) had held that, at a minimum, adequate VCAA notice in an increased rating claim required that VA notify the claimant that, to substantiate such a claim: (1) the claimant must provide, or ask VA to obtain, medical or lay evidence demonstrating a worsening or increase in severity of the disability and the effect that worsening has on the claimant's employment and daily life; (2) if the diagnostic code under which the claimant is rated contains criteria necessary for entitlement to a higher disability rating that would not be satisfied by the claimant demonstrating a noticeable worsening or increase in severity of the disability and the effect of that worsening has on the claimant's employment and daily life (such as a specific measurement or test result), the Secretary must provide at least general notice of that requirement to the claimant; (3) the claimant must be notified that, should an increase in disability be found, a disability rating will be determined by applying relevant diagnostic codes; and (4) the notice must also provide examples of the types of medical and lay evidence that the claimant may submit (or ask VA to obtain) that are relevant to establishing entitlement to increased compensation. Vazquez-Flores v. Peake, 22 Vet. App. 37 (2008). The Federal Circuit vacated the court's decision, overturning the requirement that VA provide notice that the claim could be substantiated by evidence of a disability's impact on daily life and that VA provide notice with regard to potential diagnostic code criteria (element 2). Vazquez-Flores v. Shinseki, 580 F.3d 1270 (Fed. Cir. 2009). The generic first, third, and fourth elements (contained in the veteran's court's decision) were not disturbed by the Federal Circuit's decision. In February and April 2009 and March and May 2010 letters, the Veteran was provided with notice of the information and evidence that VA would seek to provide and the information and evidence that he was expected to provide. In the February 2009 and March 2010 letters, the Veteran was informed of how VA determines disability ratings and effective dates, as required by Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006); and was given the notice required by the surviving portions of Vazquez-Flores. VA has done everything reasonably possible to assist the Veteran with respect to his claims for benefits in accordance with 38 U.S.C.A. § 5103A and 38 C.F.R. § 3.159(c). His service treatment and personnel records and VA and private records have been associated with the claims file, to the extent available. All reasonably identified and available medical records have been secured. Records obtained from the Social Security Administration (SSA) show that the Veteran was found to be totally disabled since February 2005 due to residuals of a cerebrovascular accident (CVA) and essential hypertension. A review of the Veteran's Virtual VA electronic file does not reveal any additional evidence relevant to the claims for service connection for a back disorder and higher initial ratings for hypertension and rhinitis currently on appeal. In June 2009 and June 2010, the Veteran underwent VA examinations and the examination reports are of record. 38 C.F.R. § 3.326 (2012). Upon review of the record and the June 2009 VA spine examination report, the Board obtained a VHA opinion regarding the Veteran's claim for service connection for a back disorder. A copy of the VHA report was provided to the Veteran and his representative in May 2013 and, later that month, the Veteran indicated that he had no further evidence or argument to submit. The Board finds that the April 2013 VHA report is adequate for rating purposes as the claims file was reviewed, the examiner reviewed the pertinent history, provided clinical findings and diagnoses, and offered an etiological opinion with rationale from which the Board can reach a fair determination. The records satisfy 38 C.F.R. § 3.326. The April 2013 VHA report makes up for the deficiencies in the June 2009 VA spine examination report as to this matter. The Board finds the duties to notify and assist have been met. II. Factual Background and Legal Analysis The Board notes that it has thoroughly reviewed the record in conjunction with this case, including the Veteran's service treatment records, VA and non-VA medical records and examination reports, dated from 1991 to 2013, and the Veteran's written statements in support of his claims. Although there is an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, the extensive evidence submitted by the appellant or on his behalf. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (the Board must review the entire record, but does not have to discuss each piece of evidence). Rather, the analysis below will focus specifically on what the evidence shows, or fails to show, on the claims. See Timberlake v. Gober, 14 Vet. App. 122, 129 (2000) (noting that the Board must analyze the credibility and probative value of the evidence, account for the evidence which it finds to be persuasive or unpersuasive, and provide the reasons for its rejection of any material evidence favorable to the claimant). A. Service Connection Under 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303, a veteran is entitled to disability compensation for disability resulting from personal injury or disease incurred in or aggravated by active military service. Evidence of continuity of symptomatology from the time of service until the present is required where the chronicity of a condition manifested during service either has not been established or might reasonably be questioned. 38 C.F.R. § 3.303(b); but see Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013) (the theory of continuity of symptomatology can be applied only in cases involving those conditions explicitly recognized as chronic under 38 C.F.R. § 3.309(a)). Case law has established that lay evidence can be competent and sufficient to establish a diagnosis of a condition when (1) a layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). When considering whether lay evidence is competent the Board must determine, on a case by case basis, whether the appellant's particular disability is the type of disability for which lay evidence may be competent. Kahana v. Shinseki, 24 Vet. App. 428 (2011). To establish a right to compensation for a present disability, a veteran must show: "(1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service" - the so-called "nexus requirement." Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2009) (quoting Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). This is a direct service connection theory of entitlement. Certain chronic diseases, such as arthritis, may be presumed to have been incurred in or aggravated by service if manifest to a compensable degree within one year of discharge from active service. See 38 U.S.C.A. §§ 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.307, 3.309. This is also a direct service connection theory of entitlement. Where the determinative issue involves medical causation or a medical diagnosis, there must be competent evidence to the effect that the claim is plausible. However, although the Veteran is competent in certain situations to provide a diagnosis of a simple condition such as a headache, varicose veins, or tinnitus, the Veteran is not competent to provide evidence as to more complex medical questions, such as the etiology of orthopedic pathology, as is the case here. See Woehlaert v. Nicholson, 21 Vet. App. 456 (2007). In determining whether service connection is warranted for a disability, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the Veteran prevailing in either event, or whether a preponderance of the evidence is against the claim, in which case the claim is denied. 38 U.S.C.A. § 5107; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). In this regard, the Board must assess the credibility and probative value of evidence, and, provided that it offers an adequate statement of reasons or bases, the Board may favor one medical opinion over another. See Owens v. Brown, 7 Vet. App. 429, 433 (1995); Wood v. Derwinski, 1 Vet. App. 190 (1991). While the Board is not free to ignore the opinion of a treating physician, it is free to discount the credibility of that physician's statement. See Guerrieri v. Brown, 4 Vet. App. 467, 471-73 (1993); Sanden v. Derwinski, 2 Vet. App. 97, 101 (1992). In written statements in support of his claim, the Veteran asserts that he has a back disorder that is due to his military service. He contends that he injured his back in service and that he experienced back pain since discharge. Thus, he maintains that service connection is warranted for a back disorder. Upon review of the evidence of record, and after considering the laws and regulations applicable to the Veteran's claim, the Board finds that service connection is not warranted. Service treatment records show that, in June 1975, the Veteran was seen for complaints of low back pain, diagnosed as lumbar strain. Records indicate that he was placed on limited duty in June 1975 due to his lumbar strain. On an April 1976 Report of Medical History, completed at the time of a periodic service examination, the Veteran checked no to having recurrent back pain. When examined at that time, clinical evaluation of his spine was generally normal. A separation examination report is not of record. Post service, VA and non-VA medical records and examination reports, dated from 1991 to 2010, document the Veteran's reports of back pain beginning in 2005. While the Veteran frequently received treatment for unrelated conditions prior to this time, he did not indicate that he had chronic back pain. A February 21, 2005 private treatment record shows that the Veteran complained of pain in his lower right back that went down his right leg and hip for two weeks. The impression was right-sided sciatica. According to a March 1, 2005 private record, the Veteran had symtoms of radiating low back pain for three weeks. He denied any recent trauma. The Veteran said that he fell off a truck as a teenager when he was 18 years old (that would have been prior to his entering military service). He made no other reports of having suffered any additional back injuries. Results of a private magnetic resonance image (MRI) performed on March 11, 2005 include lumbar degenerative disc disease, most pronounced at L3-4 with circumferential bulge and superimposed right paracentral and lateral protrusion. An April 4, 2005 private medical record indicates that the Veteran had a two-month history of orthopedic pain, mostly in the right low back and right thigh as far as his knee. An August 4, 2005 record reflects that he had a one-year history of back pain and treatment. Results of a private computed tomography (CT) examination, performed on August 15, 2005, include advanced degenerative disc disease at L4-L4 with associated minimal bulging, and milder L5-S1 degenerative disc disease. A private discogram record, also dated on August 15, 2005, indicates that the Veteran had lumbar spondylosis with stenosis, leg pain, and degenerative painful discs. In a September 2005 orthopedic note, T.A.D., M.D., opined that the Veteran complained about stenosis-type symptomatology rather than mechanical lumbar spine pain and advised a decompression procedure. A lumbar diskectomy at L3-4 and a right L3-4 hemilaminectomy was performed by Dr. T.A.D. in October 2005. A July 24, 2006 private MRI report reflects changes associated with the Veteran's surgery on the right side of L3-4. At L4-5, there was mild flattening of the thecal sac with superimposed posterior central protrusion that was unchanged and significant lateral recess changes. An August 11, 2006 private orthopedic note includes a clinical impression of lumbar degenerative disc disease with lumbar stenosis. The record also indicates that Dr. T.A.D. released the Veteran to full time work that he could not do, and the Veteran was then fired. According to November 2 and December 14, 2007 VA primary care notes, a January 30, 2008 VA pulmonary note, and a July 30, 2008 VA neurology consult record, the Veteran received disability benefits since 2005 due back pain/back disease. In June 2009, the Veteran underwent VA examination of his spine. According to the examination report, the examiner reviewed the Veteran's medical records and performed a clinical evaluation. The diagnosis was lumbar degenerative joint disease. The examiner noted that the Veteran had a lumbar strain in 1975, for which he was placed on light duty for three days, with no subsequent notes showing follow-up treatment. In the VA examiner's opinion, given the single in-service episode of lumbar strain, it was less likely than not that the Veteran's current spine pain was a continuation of the spine pain noted in service, as there was no chronicity established of the condition while in the military. Then, in an August 2010 signed statement, L.F.C., M.D., noted that she treated the Veteran and he had chronic back pain since an in-service injury in the 1970s. She said that he continued to experience exacerbation of his back and neck pain with the slightest exertion. According to Dr. C., the Veteran developed progressive lumbar degenerative joint disease over the years that was most likely a continuation of the injuries he sustained during military service. In a September 2011 signed statement, the Veteran reported that Dr. C. reviewed his service medical records before providing her opinion. In February 2013, the Board requested a VHA opinion as to nature of the Veteran's current back disabilities. The Board also asked, as to each back disorder identified, whether there was a 50 percent probability or more that it had its clinical onset in service or was otherwise related to active duty. As to the Veteran's diagnosis of degenerative joint disease of the spine, the Board also asked if it was clinically manifested within the first post service year (if not present in service). The VHA examiner was particularly requested to address the opinions rendered by the June 2009 VA examiner and Dr. C. in August 2010. In the April 2013 VHA report, a VA neurosurgeon opined that none of the Veteran's current back conditions (multi-level degenerative disc disease, acquired spinal stenosis, and lumbar area and residual spine changes post laminectomy-surgery) were caused by, or were a continuation of, his service injury of June 1975. In the VA medical specialist's opinion, the Veteran's back conditions were "more likely than not related to [the Veteran's] tobacco use, and the natural aging process of the spine." The VHA examiner further opined that there was no indication or medical probability that the clinical onset of symtoms or findings of degenerative joint disease of the spine began during the Veteran's active service period or within one year of separation from military service. As to Dr. C.'s August 2010 opinion, the VHA neurosurgery specialist explained that there was no medical evidence in her own records or any others to place the onset of the Veteran's symtoms and findings of degenerative joint disease of the spine any earlier than 2003. The VA neurosurgeon stated that Dr. C.'s report of medical continuity of these symtoms with the Veteran's period of service was not based on the facts of the Veteran's treatment records. The VHA examiner further noted that he concurred with the findings of the June 2009 VA examiner. Where a medical expert has fairly considered all the evidence, his opinion may be accepted as an adequate statement of the reasons and bases for a decision when the Board adopts such an opinion. Wray v. Brown, 7 Vet. App. at 493. The Board does, in fact, adopt the VHA specialist's opinion on which it bases its determination that service connection for a back disorder is not warranted. Since the VHA physician's opinion was based on a review of the pertinent medical history, and was supported by sound rationale, it provides compelling evidence against the appellant's claim. The Board emphasizes that the VHA medical expert provided a valid medical analysis to the significant facts of this case in reaching his conclusion. In other words, the VHA physician did not only provide data and conclusions, but also provided a clear and reasoned analysis that the court has held is where most of the probative value of a medical opinion comes is derived. See Nieves-Rodriguez v. Peake, 22 Vet App 295 (2008); see also Wray v. Brown, 7 Vet. App. at 493. The court has held that the value of a physician's statement is dependent, in part, upon the extent to which it reflects "clinical data or other rationale to support his opinion." Bloom v. West, 12 Vet. App. 185, 187 (1999) (a medical opinion based on speculation, without supporting clinical data or other rationale, does not provide the required degree of medical certainty). Thus, a medical opinion is inadequate when it is unsupported by clinical evidence. Black v. Brown, 5 Vet. App. 177, 180 (1995). The Board therefore places greater weight on the VHA opinion, that finds that the Veteran did not have a back disorder that was incurred in or aggravated by active military service, than on the August 2010 opinion rendered by Dr. C., to the effect that the Veteran had chronic back pain since an in-service injury and developed progressive lumbar degenerative joint disease over the years that was most likely a continuation of the injuries he sustained during military service. See Owens v. Brown, 7 Vet. App. at 433 (holding that VA may favor the opinion of one competent medical expert over that of another when decision makers give an adequate statement of reasons and bases); Guerrieri v. Brown, 4 Vet. App. at 473 ("the probative value of medical opinion evidence is based on the medical expert's personal examination of the patient, the physician's knowledge and skill in analyzing the data, and the medical conclusion the physician reaches"). But a medical opinion may not be discounted solely because the examiner did not review the claims file. Nieves-Rodriguez v. Peake, 22 Vet. App. at 304. It is the responsibility of the Board to weigh the evidence, including the medical evidence, and determine where to give credit and where to withhold the same and, in so doing, the Board may accept one medical opinion and reject others. Evans v. West, 12 Vet. App. 22, 30 (1998), citing Owens v. Brown, 7 Vet. App. at 433. But, we are mindful that we cannot make our own independent medical determinations, and that we must have plausible reasons, based upon medical evidence in the record, for favoring one medical opinion over another. Evans v. West, supra; see also Rucker v. Brown, 10 Vet. App. 67, 74 (1997), citing Colvin v. Derwinski, 1 Vet. App. 171 (1991). Thus, the weight to be accorded the various items of evidence in this case must be determined by the quality of the evidence, and not necessarily by its quantity or source. In evaluating the ultimate merit of this claim, the Board ascribes the greatest probative value to the medical opinion provided by the VHA examiner who provided the written opinion in April 2013. This medical specialist, with expertise in neurosurgery, had the opportunity to review all the Veteran's medical records regarding the diagnoses of multi-level degenerative disc disease, acquired spinal stenosis, and lumbar area and residual spine changes post-laminectomy surgery. The VHA examiner opined that the Veteran's back conditions were less likely than not caused by or a continuation of his service injury in June 1975 and that they were more likely than not related to his tobacco use and the natural aging process of the spine. Additionally, the VHA medical specialist found no indication or medical probability that the clinical onset of the Veteran's symtoms or findings of degenerative joint disease of the spine began during the Veteran's active service period or within year of separation of military service. The VHA examiner explained that there was no medical evidence in Dr. C.'s own records or any others to place the onset of the Veteran's symtoms and findings of degenerative joint disease any earlier than 2003. See Prejean v. West, 13 Vet. App. 444, 448-9 (2000) (factors for assessing the probative value of a medical opinion include the thoroughness and detail of the opinion). The Board finds that, given the scope and depth of the VHA examiner's expertise and rationale, this opinion carries more weight than that of Dr. C. See Bloom v. West, Black v. Brown, supra. In sum, the overall evidence demonstrates that the Veteran's back disorders, diagnosed as multi-level degenerative disc disease, acquired spinal stenosis, and lumbar area and multi-level spine changes post-laminectomy surgery, are not related to his period of active military service and degenerative disc disease of the spine was not manifested to a compensable degree within one year of his discharge from active service. In denying service connection as to the claim on appeal, the Board has considered the Veteran's contention that a relationship exists between his current back conditions and military service. In adjudicating this claim, the Board must assess the Veteran's competence and credibility. See Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006); Washington v. Nicholson, 19 Vet. App. 362, 368-69 (2005). In Barr v. Nicholson, 21 Vet. App. 303 (2007), the court emphasized that lay testimony is competent if it is limited to matters that the witness has actually observed and is within the realm of the witnesses personal knowledge. See also 38 C.F.R. § 3.159(a)(2) (Competent lay evidence means any evidence not requiring that the proponent have specialized education, training or experience. Lay evidence is competent if it is provided by a person who has knowledge of the facts or circumstances and conveys matters that can be observed and described by a lay person). The Veteran is competent to describe his observable symptoms, such as increased back pain. However, he is not competent to make a statement of causation that is a medical determination. Barr v. Nicholson, 21 Vet. App. at 303; Buchanan v. Nicholson, 451 F.3d at 1331. To the extent he is claiming that back problems have persisted since service, this is inconsistent with the overall record, which reflects that his back symptomatology manifested after service. The Board has considered the Veteran's statements as to his incurrence during service, in light of his service treatment records, post-service medical evidence, and the June 2009 VA examiner's opinion, the August 2010 statement from Dr. C., and the April 2013 VHA medical opinion. However, the record reflects that the Veteran was treated on just one occasion for complaints of back pain in June 1975. The post service records show that degenerative disc disease of the spine was found in approximately 2003 or 2005, nearly 25 years after his discharge from service. In this regard, the gap in time between military service and the first post-service medical evidence of a back disorder is, in itself, significant, and weighs against the appellant's claim. See Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000) (to the effect that a lengthy period of absence of medical complaints for condition can be considered as a factor in resolving claim); see also Mense v. Derwinski, 1 Vet. App. 354, 356 (1991) (affirming the Board's denial of service connection where veteran failed to account for lengthy time period between service and initial symptoms of disability). The Board recognizes that the absence of documented post-service treatment cannot, by itself, invalidate the Veteran's claims of continuous symptomatology. Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006). However, to the extent that the Veteran is claiming continuity of back symptoms since service, he is not a reliable historian. He made no mention of back pain during his April 1976 periodic service examination, and examination of his spine at that time was normal. He has not explained why he failed to mention pertinent difficulty when examined pursuant to service requirements. Further, the March 1, 2005 private record shows that the Veteran gave a three week history of radiating low back pain and reported that he fell from a truck when he was 18 years old, that would have been prior to entering service. The April 2005 private record shows that the Veteran had a two month history of back pain, and the August 2005 record describes a one year history of back pain and treatment. None of these records relate the Veteran's back pain to an in-service injury or event. The Board does not find that there is credible evidence of continuity of symptomatology present in this case. Moreover, while the Veteran is competent to state that he experienced back problems in service, he is not competent to state that he has degenerative disc disease, acquired spinal stenosis, and lumbar area and residual spine changes post-laminectomy surgery or another spinal disease due to his military service. The clinical pathology of spine disorders is not readily recognizable by a layman, such as varicose veins or acne. See Jandreau v. Nicholson. Even medical professionals rely on laboratory test results, x-rays, and other diagnostic tools to diagnose degenerative disc disease and other spine disorders. The Veteran's contentions are outweighed by the medical evidence of record. The April 2013 VHA examiner, who reviewed the in-service treatment records and the post service medical records, concluded that the Veteran had multi-level degenerative disc disease, acquired spinal stenosis, and lumbar area and residual spine changes post-laminectomy surgery, that was not due to military service. This opinion is entirely consistent with that of the June 2009 VA examiner. The Veteran's contentions as to etiology are not deemed competent and thus are not probative. Here, the Board is left with just one documented complaint of back pain in service, no documented complaints or findings of a diagnosed a back disorder after service until approximately 2003 or 2005, and a VHA medical opinion to the effect that the Veteran's diagnosed degenerative disc disease, acquired spinal stenosis, and lumbar area and residual spine changes post-laminectomy surgery, was not caused or aggravated by military service. The pertinent questions in this case regarding causation are medical in nature. As discussed above, the medical opinion of the April 2013 VHA examiner (based on a review of the claims file and with knowledge of the Veteran's in-service duties and in-service complaints), deemed the most reliable evidence of record, was negative. In sum, a clear preponderance of the objective and probative medical evidence of record is against the Veteran's claim for service connection for a back disorder and his claim must be denied. The benefit-of-doubt rule does not apply when the Board finds that a preponderance of the evidence is against the claim. Ortiz v. Principi, 274 F. 3d 1361, 1365 (Fed. Cir. 2001). B. Increased Ratings Disability evaluations are determined by the application of a schedule of ratings which is based, as far as can practically be determined, on the average impairment of earning capacity. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1 (2012). Each service-connected disability is rated on the basis of specific criteria identified by Diagnostic Codes. 38 C.F.R. § 4.27 (2012). In order to evaluate the level of disability and any changes in condition, it is necessary to consider the complete medical history of the Veteran's condition. Schafrath v. Derwinski, 1 Vet. App. 589, 594 (1991). However, where an increase in the level of a service-connected disability is at issue, the primary concern is the present level of disability. Francisco v. Brown, 7 Vet. App. 55 (1994). In Fenderson v. West, 12 Vet. App. 119, 126 (1999), the court noted that where the question for consideration is propriety of the initial evaluation assigned, as in this case, evaluation of the medical evidence since the grant of service connection and consideration of the appropriateness of a "staged rating" is required. Id. In the case of an increased rating, a claimant may experience multiple distinct degrees of disability that might result in different levels of compensation from the time the increased rating claim was filed until a final decision is made. Hart v. Mansfield, 21 Vet. App. 505 (2007). The analysis in the following decision is therefore undertaken with consideration of the possibility that different ratings may be warranted for different time periods. When all the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the appellant prevailing in either event, or whether a preponderance of the evidence is against a claim, in which case, the claim is denied. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Where there is a question as to which of two evaluations is to be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. In view of the number of atypical instances it is not expected, especially with the more fully described grades of disabilities, that all cases will show all the findings specified. Findings sufficiently characteristic to identify the disease and the disability therefrom, and above all, coordination of rating with impairment of function will, however, be expected in all instances. 38 C.F.R. § 4.21 (2012). Competent medical evidence means evidence provided by a person who is qualified through education, training, or experience to offer medical diagnoses, statements, or opinions. Competent medical evidence may also mean statements conveying sound medical principles found in medical treatises. It also includes statements contained in authoritative writings, such as medical and scientific articles and research reports or analyses. 38 C.F.R. § 3.159(a)(1). Competent lay evidence means any evidence not requiring that the proponent have specialized education, training, or experience. Lay evidence is competent if it is provided by a person who has knowledge of the facts or circumstances and conveys matters that can be observed and described by a lay person. 38 C.F.R. § 3.159(a)(2). The Veteran's statements describing the symptoms of his service-connected hypertension and rhinitis disabilities are deemed competent. These statements must be considered with the clinical evidence of record and in conjunction with the pertinent rating criteria. 1. Hypertension The Veteran asserts that the current manifestations of his service-connected hypertension disability are more severe than is represented by the initially assigned non-compensable rating. In written statements, including his September 2011 substantive appeal, the Veteran said that he took prescribed medication to control his hypertension. The August 2010 RO rating decision granted service connection for hypertension that was assigned an initial non-compensable disability rating under Diagnostic Code 7101, effective from February 18, 2010. 38 C.F.R. § 4.104, Diagnostic Code 7101. Under Diagnostic Code 7101, the rating schedule provides for a 10 percent evaluation for diastolic pressure predominantly 100 or more, or; systolic pressure of 160 or more, or; minimum evaluation for an individual with a history of diastolic pressure predominantly 100 or more who requires continuous medication for control. Id. A 20 percent rating is warranted when diastolic pressure is predominantly 110 or more, or; systolic pressure is predominantly 200 or more. Id. A 40 percent evaluation requires diastolic pressure of predominantly 120 or more. Id. As mentioned above, the Veteran was found totally disabled by SSA since February 2005, primarily due to residuals of a CVA and, secondarily, to essential hypertension, according to a January 2008 SSA record. VA and non-VA outpatient records, dated from 2005 to 2010, reflect that the Veteran regularly took prescribed medication to treat his hypertension. A November 30, 2006 private record shows that he took Hydrochlorothiazide daily. More recently, the VA and non-VA medical records, including a June 2008 VA record, show that the Veteran also regularly took two additional medications for his hypertension: Lisinopril, and Metoprolol. He was evidently compliant with taking his prescribed medications as reflected in blood pressure readings during this time. According to the June 2010 VA examination report, the Veteran reported having headaches when his blood pressure was high. He described his headaches as localized in the front, moderate in severity, and not prostrating. The Veteran's blood pressure readings were 154/97, 158/97, and 160/100. At that time, the examiner reported that the Veteran took medication for his high blood pressure that was helpful. Given the above, the Board finds that an initial 10 percent rating is warranted for the Veteran's service-connected hypertension. The Veteran has continuously used medication to control hypertension throughout the entire pendency of his claim. While blood pressure readings since the June 2010 VA examination reflect lower readings, the Board finds that the criteria for a compensable evaluation are met or nearly approximated. At the time of the June 2010 VA examination, the systolic readings were at or near 160. The Board has resolved all doubt in favor of the Veteran and finds that an initial 10 percent evaluation is warranted for hypertension. See 38 U.S.C.A. § 5107(b). The Board does note, however, the absence of any findings of diastolic pressure of 110 or more, or systolic pressure of 200 or more, let alone predominantly; the criteria for an even higher initial evaluation are therefore not met. As such, an initial 10 percent rating, but no more, is warranted for the Veteran's service-connected hypertension since February 18, 2010. However, a higher rating is not warranted, as there is no objective evidence of predominant diastolic blood pressure of 110 or more or a predominant systolic blood pressure of 200 or more. The benefit of the doubt has been resolved in the Veteran's favor to this limited extent. 38 U.S.C.A. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. at 49. 2. Rhinitis The Veteran also seeks an initial compensable rating for his service-connected rhinitis. In his September 2011 substantive appeal, he asserted that he experienced sinus tenderness and severe flare-ups that lasted several days at a time. The August 2010 rating decision granted service connection for rhinitis and assigned an initial noncompensable rating under Diagnostic Code 6522 that evaluates both allergic and vasomotor rhinitis. 38 C.F.R. § 4.97, Diagnostic Code 6522. Under Diagnostic Code 6522, a 10 percent evaluation is assigned when there are no polyps, but with greater than 50 percent obstruction of the nasal passage on both sides or complete obstruction on one side. Id. A 30 percent evaluation is assigned when there are polyps as well. Id. A January 28, 2008 VA otolaryngology consult record indicates that the Veteran had rhinitis and a deviated septum. He complained of chronic nasal drainage, used Flunisolide recently with some improvement, and denied nasal obstruction until his nose was dry. This record indicates that radiology records showed no air-fluid levels to suggest acute sinusitis. There was moderately thickened mucosa about both osteomeatal complexes. There was also mild to moderate thickening of the left maxillary antral mucosa with prominent inferior turbinates and prominent rightward septal deviation. There was no definite bony erosion or hyperostosis. On examination, there was a symmetric round 2.5 centimeter (cm) cyst-like mass on the Veteran's left nasal bone. No muscosal lesions, ulcerations, or masses were noted in the oral cavity and orophyarynx. A flexible nasopharyngoscopy revealed that the nasopharynx, orophyarynx, base of the tongue, epiglottis, vallecula, and pyriform sinuses were without muscosal lesions, ulcerations, or masses, and there was no mucopus. There was hyperpigmented mucosa throughout. The impression was rhinitis and septal deviation with no significant sinusitis on CT or clinically. It was noted that a septoplasty may improve nasal obstruction but would not address the Veteran's rhinitis. Excision of the external nasal cyst that did not impede breathing could also be considered. June 2008 VA and non-VA medical records reveal that the Veteran's prescribed medications include Flunisolide nasal spray and Montelukast (for allergies). An August 2008 VA primary care note shows that the Veteran complained of increased sinus pain/drainage and felt like he had an infection. He thought the Singulair was helpful and continued to take Flunisolide. On examination, there was increased sinus pain in the maxillary sinuses, bilaterally, swollen engorged turbinates, and mild erythema, but no exudates. October 2008 VA otolaryngology outpatient notes reflect that the Veteran was seen for complaints of a left nasal swelling and pain. He noted a mass or swelling in the left nasofacial groove for approximately one year that was never painful or problematic. Earlier in the week, he noticed that it increased in size, and was very tight and painful. The physical examination revealed a 3 cm by 3 cm area of fullness in his left nasofacial groove that was erythematous and indurated with palpable fluctuance. It was extremely tender to palpation. Examination of the Veteran's nose also showed that the septum was midline, there were boggy turbinates, and no evidence of mucopus on anterior rhinoscopy. Debris and pus were expressed from the nasal mass. The assessment was infected epidermal cyst. When seen for follow up, at the end of October, the Veteran was doing well, with no pain, drainage, or swelling. He wanted the cyst removed when the area was completely healed. A January 14, 2009 VA treatment record reflects that the Veteran had an occasional cough and post-nasal drip when his allergic rhinitis was active. There was no report of nasal airway obstruction on either side or polyps. A June 11, 2009 private treatment record from the Granville Health System includes a diagnosis of allergic rhinitis but does not discuss nasal obstruction on either side or polyps. In June 2010, the Veteran underwent VA examination. According to the examination report, the examiner reviewed the Veteran's medical records and performed a clinical evaluation. The Veteran used a nasal spray and oral medication for his rhinitis. He reported that his flare-ups interfered with his breathing through his nose and denied having a purulent discharge, speech impairment, chronic sinusitis, or other symtoms. His flare ups could be severe, lasted several days, and he had problems year round. The physical examination revealed no allergic or vasomotor rhinitis, bacterial rhinitis, obstruction, septal deviation, tissue loss, or sinus tenderness. The Veteran's soft palate, larynx, and pharynx, were normal. The diagnosis was allergic rhinitis. There were no problems with activities of daily living. The Veteran was not working and last worked in 2005 as a custodian. He was not out of work because of rhinitis and the VA examiner later noted that the Veteran was retired. Upon review of the objective and credible medical evidence of record, the Board concludes that the evidence does not support a finding that the Veteran is entitled to an initial compensable disability rating for his service-connected rhinitis. This is so because there is no clinical evidence of polyps and the Veteran did not suffer from nasal airway obstruction of greater than 50 percent on both sides, or complete obstruction on one side, as noted in his VA treatment records, and the results of the June 2010 VA examination. Therefore, there is simply no basis on which to base a compensable rating for the service-connected rhinitis under Diagnostic Code 6522. There is no evidence that a rating higher than 10 percent is warranted under any other potentially applicable Diagnostic Codes as there is no evidence of sinusitis, nasal disfigurement (including loss of part of the nose or scars), deviated septum, bacterial rhinitis or granulomatous rhinitis. Thus consideration of other relevant Diagnostic Codes (Diagnostic Codes 6502, 6504, 6510-6514, 6523 or 6524) is not warranted. As such, the preponderance of the probative and credible evidence is against the Veteran's claim for an initial compensable rating for his service-connected rhinitis. Moreover, as the preponderance of the evidence of record is against the claim for an increased initial rating for rhinitis, the benefit-of-the-doubt rule does not apply, and the claim must be denied. 38 U.S.C.A. § 5107(b). Both Disabilities The Board has also considered whether the Veteran's hypertension and rhinitis disabilities present an exceptional or unusual disability picture as to render impractical the application of the regular schedular standards such that referral to the appropriate officials for consideration of an extra-schedular rating is warranted. See 38 C.F.R. § 3.321(b)(1) (2012); Bagwell v. Brown, 9 Vet. App. 337, 338-39 (1996). Pursuant to § 3.321(b)(1), the Under Secretary for Benefits or the Director, Compensation and Pension Service, is authorized to approve an extraschedular evaluation if the case "presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization as to render impractical the application of the regular schedular standards." 38 C.F.R. § 3.321(b)(1) (2012). The question of an extraschedular rating is a component of a claim for an increased rating. See Bagwell v. Brown, 9 Vet. App. 337, 339 (1996). Although the Board may not assign an extraschedular rating in the first instance, it must specifically adjudicate whether to refer a case for extraschedular evaluation when the issue either is raised by the claimant or is reasonably raised by the evidence of record. Barringer v. Peake, 22 Vet. App. 242 (2008). When it is not possible to separate the effects of a non-service-connected condition from those of a service-connected disorder, reasonable doubt should be resolved in the claimant's favor with regard to the question of whether certain signs and symptoms can be attributed to the service- connected disability. See Mittleider v. West, 11 Vet. App. 181, 182 (1998). Here the Board has considered Mittleider and attributed all potentially service-connected symtoms to his service-connected hypertension and rhinitis disabilities before considering if the Veteran is entitled to an extra-schedular rating. If the evidence raises the question of entitlement to an extraschedular rating, the threshold factor for extraschedular consideration is a finding that the evidence before VA presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. Therefore, initially, there must be a comparison between the level of severity and symptomatology of the claimant's service-connected disability with the established criteria found in the rating schedule for that disability. Thun v. Peake, 22 Vet. App. 111 (2008). Under the approach prescribed by VA, if the criteria reasonably describe the claimant's disability level and symptomatology, then the claimant's disability picture is contemplated by the rating schedule, the assigned schedular evaluation is, therefore, adequate, and no referral is required. In the second step of the inquiry, however, if the schedular evaluation does not contemplate the claimant's level of disability and symptomatology and is found inadequate, the RO or Board must determine whether the claimant's exceptional disability picture exhibits other related factors such as those provided by the regulation as "governing norms." 38 C.F.R. 3.321(b)(1) (related factors include "marked interference with employment" and "frequent periods of hospitalization"). The evidence does not show marked interference with employment or frequent hospitalization as a result of the Veteran's hypertension and rhinitis disabilities that would warrant consideration of referral for an extraschedular rating. Notably, the June 2010 VA examiner reported that the Veteran was not working but it was not due to rhinitis. The manifestations of the Veteran's disabilities are nasal tenderness and congestion, breathing difficulty, and high blood pressure. The rating schedule contemplates these symptoms. Diagnostic Codes 6522, 7101. The rating schedule is meant to compensate for average impairment in earning capacity and for considerable time lost from work commensurate with the percentage evaluations. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. Thus, the Board finds that the threshold test is not met for referral for extraschedular consideration. Id.; see also Thun v. Peake, 22 Vet. App. at 111. In sum, an initial 10 percent rating, but no higher, is warranted for the Veteran's hypertension from February 18, 2010, and the benefit of the doubt has been resolved in the Veteran's favor to this limited extent. 38 U.S.C.A. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. at 49. As the preponderance of the evidence of record is against an initial compensable rating for rhinitis, the benefit-of-the-doubt rule does not apply, and this claim must be denied. 38 U.S.C.A. § 5107(b). In addition, the Board notes that if the claimant or the record reasonably raises the question of whether the Veteran is unemployable due to the disability for which an increased rating is sought, then part and parcel to that claim for a higher rating is whether a total rating based on individual unemployability (TDIU) as a result of that disability is warranted. See Rice v. Shinseki, 22 Vet. App. 447 (2009). Here, the record reveals that the Veteran told the June 2010 VA examiner that he was not working and was retired. It has not been suggested that his hypertension and rhinitis disabilities preclude his employment. Thus, any further consideration of the Veteran's claim under Rice is not warranted at this time. The Board recognizes that the Veteran was awarded SSA disability benefits based, in part, upon his hypertension disorder, effective from February 2005. The Board observes that the SSA employs different criteria than VA in determining total disability and, thus, the Board is not required to reach the same conclusion (regarding the award of an increased rating), as the statutes and regulations governing the VA adjudications are substantially different from those governing SSA adjudications. See Masors v. Derwinski, 2 Vet. App. 181, 188 (1992). The Board does not find that symptoms of hypertension by themselves are totally disabling. Finally, in view of the holding in Fenderson, and, based upon the record, the Board finds that at no time since the Veteran filed his initial claim for service connection have the disabilities on appeal been more disabling than as currently rated under the present decision of the Board. ORDER Service connection for a back disorder is denied. An initial 10 percent rating, but no higher, is granted for hypertension from February 18, 2010, subject to the laws and regulations governing the award of monetary benefits. An initial compensable rating for rhinitis is denied. ____________________________________________ DELYVONNE M. WHITEHEAD Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs