Citation Nr: 1327137 Decision Date: 08/26/13 Archive Date: 08/29/13 DOCKET NO. 08-30 161A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Cheyenne, Wyoming THE ISSUES 1. Entitlement to an increased evaluation greater than 20 percent for spondylosis and scoliosis of the lumbar spine (formerly rated as herniated nucleus pulposus (HNP) of L5-S1) prior to September 8, 2009. 2. Entitlement to an increased evaluation greater than 40 percent for spondylosis and scoliosis of the lumbar spine from September 8, 2009. 3. Entitlement to an increased evaluation greater than 20 percent for right lower extremity radiculopathy. 4. Entitlement to an increased evaluation greater than 20 percent for left lower extremity radiculopathy. 5. Entitlement to a compensable evaluation for postoperative nasal fracture with perforated septum. 6. Entitlement to service connection for a hepatitis C infection. 7. Entitlement to service connection for a chronic heart condition, claimed as transient ischemic attacks (TIAs). 8. Entitlement to a total rating for individual unemployability due to service-connected disabilities (TDIU). REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD Bernard T. DoMinh, Counsel INTRODUCTION The Veteran served on active duty from December 1974 to December 1994. This matter comes to the Board of Veterans' Appeals (Board) on appeal from an April 2008 rating decision by the Cheyenne, Wyoming, Regional Office (RO) of the Department of Veterans Affairs (VA) which, inter alia, granted the Veteran an increased evaluation, from zero percent to 20 percent, for spondylosis and scoliosis of the lumbar spine (formerly rated as HNP of L5-S1), with an effective date of September 13, 2007, based on the date of receipt of his application to reopen his claim for a rating increase. 38 C.F.R. § 3.400(o)(2). Also on appeal are the denials of a compensable evaluation for post-operative nasal fracture with perforated septum, service connection for hepatitis C and a heart condition (claimed as TIAs), and a TDIU. The TDIU claim was implicitly raised in the claim for a rating increase received on September 13, 2007, and is deemed to be part and parcel to the increased rating claims now on appeal. See Rice v. Shinseki, 22 Vet. App. 447 (2009). It is inextricably intertwined with the increased rating claims. Therefore, notwithstanding the RO's adjudication and denial of the TDIU claim as a stand-alone issue in rating decisions dated in February 2010 and May 2012, there is no finality with respect only to these denials of individual unemployability because the TDIU claim remains pending until final appellate disposition of the intertwined increased rating claims on appeal. Accordingly, the TDIU claim as an issue on appeal is properly before the Board. (Procedurally, the Veteran is not required to specifically appeal the February 2010 and May 2012 rating decisions with respect only to the TDIU issue, as his perfection of the appeal of the underlying claims for rating increases for his service-connected disabilities serves to perfect an appeal of the intertwined TDIU claim.) During the course of the appeal, a February 2010 rating decision increased the 20 percent rating assigned for spondylosis and scoliosis of the lumbar spine of the lumbar spine to 40 percent, effective from September 8, 2009. A February 2012 rating decision granted the Veteran separate ratings for radiculopathy of the lower extremities, bilaterally, as secondary to his service-connected spondylosis and scoliosis of the lumbar spine. The rating decision assigned an award of a 20 percent evaluation for radiculopathy of the right lower extremity (effective June 10, 2011), and a 20 percent evaluation for radiculopathy of the left lower extremity (effective February 10, 2012). As these issues stem from the pending increased rating claim for a low back disability that is presently on appeal, they are also presently subject to appellate consideration by the Board. In a May 2013 hearing before the undersigned traveling Veterans Law Judge sitting at the RO, the Veteran, accompanied by his representative, presented evidence and oral testimony and arguments in support of his appeal. A transcript of this hearing has been obtained and associated with the Veteran's claims file for the Board's review and consideration. FINDINGS OF FACT 1. At a May 2013 hearing before the Board, prior to the promulgation of a decision in the appeal, the appellant expressly requested to withdraw his appeal with regard to the denial of his claims for service connection for a hepatitis C infection and a compensable evaluation for postoperative nasal fracture with perforated septum, which are currently in appellate status. 2. A chronic heart condition, to include a heart condition manifested by TIAs, did not have its onset during active military service. 3. Despite his complaints of constant subjective back pain with pain on motion and pain on use, the Veteran's spondylosis and scoliosis of the lumbar spine (formerly rated as HNP of L5-S1) did not result in limitation of forward flexion of the thoracolumbar spine to 30 degrees or less or ankylosis of the lumbar spine prior to September 8, 2009. 4. Despite his complaints of constant subjective back pain with pain on motion and pain on use, the Veteran's spondylosis and scoliosis of the lumbar spine (formerly rated as HNP of L5-S1) did not result in ankylosis of the lumbar spine for the period from September 8, 2009. 5. The service-connected spondylosis and scoliosis of the lumbar spine (formerly rated as HNP of L5-S1) is not manifested by any incapacitating episodes of intervertebral disc syndrome at any time during the pendency of the present claim (i.e., from September 13, 2006 to the present). 6. The radiculopathy of the Veteran's right lower extremity is manifested by subjective complaints of constant neurological pain down the length of the entire limb, which produces impairment that equates to not more than moderate incomplete paralysis of the right sciatic nerve. 7. The radiculopathy of the Veteran's left lower extremity is manifested by subjective complaints of constant neurological pain down the length of the entire limb, which produces impairment that equates to not more than moderate incomplete paralysis of the left sciatic nerve. 8. The Veteran is precluded from securing and following a substantially gainful occupation, including in a sedentary capacity, by reason of his service-connected low back disability. CONCLUSIONS OF LAW 1. The criteria for withdrawal of the appeal for service connection for a hepatitis C infection and a compensable evaluation for postoperative nasal fracture with perforated septum have been met. 38 U.S.C.A. § 7105(b)(2), (d)(5) (West 2002); 38 C.F.R. § 20.204 (2012). 2. A chronic heart condition, to include a heart condition manifested by TIAs, was not incurred, nor is one presumed to have been incurred in active duty. 38 U.S.C.A. §§ 1110, 1111, 1112, 1113, 1131, 1137 (West 2002); 38 C.F.R. §§ 3.303, 3.307, 3.309 (2012). 3. The criteria for an evaluation greater than 20 percent for spondylosis and scoliosis of the lumbar spine (formerly rated as HNP of L5-S1) prior to September 8, 2009 have not been met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. § 4.71a, Diagnostic Code 5243 (2012). 4. The criteria for an evaluation greater than 40 percent for spondylosis and scoliosis of the lumbar spine from September 8, 2009 have not been met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. § 4.71a, Diagnostic Code 5243 (2012). 5. The criteria for an evaluation above 20 percent for radiculopathy of the right lower extremity as of June 10, 2011, have not been met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. § 4.124a, Diagnostic Code 8520 (2012). 6. The criteria for an evaluation above 20 percent for radiculopathy of the left lower extremity as of February 10, 2012, have not been met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. § 4.124a, Diagnostic Code 8520 (2012). 7. The criteria for a TDIU have been met. 38 U.S.C.A. §§ 1155, 5107(b) (West 2002); 38 C.F.R. §§ 3.340, 3.341, 4.3, 4.16(a), 4.25 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS (a.) Entitlement to service connection for a hepatitis C infection and a compensable evaluation for postoperative nasal fracture with perforated septum. The Board may dismiss any appeal which fails to allege specific error of fact or law in the determination being appealed. 38 U.S.C.A. § 7105 (West 2002). An appeal may be withdrawn as to any or all issues involved in the appeal at any time before the Board promulgates a decision. 38 C.F.R. § 20.204 (2012). Withdrawal may be made by the appellant or by his or her authorized representative. 38 C.F.R. § 20.204. In the present case, the claims of entitlement to service connection for a hepatitis C infection and a compensable evaluation for postoperative nasal fracture with perforated septum were certified to the Board in February 2013. Thereafter, at a May 2013 Board hearing, which was held at the RO before the undersigned traveling Veterans Law Judge, the Veteran expressly requested a withdrawal of his appeal of the April 2008 rating decision denying service connection for a hepatitis C infection and a compensable evaluation for postoperative nasal fracture with perforated septum. This withdrawal request was orally presented to the Board and subsequently reduced to writing in the form of a hearing transcript and was submitted prior to promulgation of an appellate decision with respect to these issues; hence, there remain no allegations of errors of fact or law for appellate consideration with respect to these specifics matters. Accordingly, the Board does not have jurisdiction to review the appeal of these issues and they are therefore dismissed. (b.) The Veterans Claims Assistance Act of 2000 (VCAA) and VA's duty to assist. With respect to the claims decided herein, the Board notes at the outset that, in accordance with the VCAA, VA has an obligation to notify claimants what information or evidence is needed in order to substantiate a claim, as well as a duty to assist claimants by making reasonable efforts to get the evidence needed. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A and 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2012); see also Quartuccio v. Principi, 16 Vet. App. 183, 187 (2002). Generally, the notice requirements of a claim have five elements: veteran status, existence of a disability, a connection between the veteran's service and the disability, degree of disability, and effective date of the disability. Dingess v. Nicholson, 19 Vet. App. 473 (2006). VCAA notice must also: (1) inform the claimant about the information and evidence necessary to substantiate the claim; (2) inform the claimant about the information and evidence that VA will seek to provide; (3) inform the claimant about the information and evidence the claimant is expected to provide; and (4) request that the claimant provide any evidence in his possession that pertains to the claim. See 38 U.S.C. § 5103(a); 38 C.F.R. § 3.159(b); Beverly v. Nicholson, 19 Vet. App. 394, 403 (2005) (outlining VCAA notice requirements). 38 C.F.R. § 3.159(b) has since been revised and the requirement that VA request that the claimant provide any evidence in his possession that pertains to the claim was removed from the regulation. The current claims that will be adjudicated on the merits were filed on September 13, 2007. A VCAA notice letter was dispatched to the Veteran in November 2007, prior to the April 2008 rating decision now on appeal. This letter addressed the issues on appeal and satisfied the above-described mandates, as well as the requirements that the Veteran be informed of how VA calculates degree of disability and assigns an effective date for the disability, as prescribed in Dingess v. Nicholson, 19 Vet. App. 473 (2006). As fully compliant notice preceded the initial adjudication of the Veteran's claims adjudicated herein, there is no timing of notice defect. VA also has a duty to assist the Veteran in obtaining evidence necessary to substantiate a claim. 38 U.S.C.A. § 5103A(a) ("The Secretary shall make reasonable efforts to assist a claimant in obtaining evidence necessary to substantiate the . . . claim"). This duty includes assisting the Veteran in obtaining records and providing medical examinations or obtaining medical opinions when such are necessary to make a decision on the claim. 38 U.S.C.A. § 5103A(b), (c), (d) (setting forth Secretary's various duties to claimant). VA informed the Veteran of its duty to assist in obtaining records and supportive evidence with regard to the service connection claim and increased rating claims adjudicated herein. As pertinent to the claim for VA compensation for a heart condition (claimed as TIAs), the Veteran's service treatment records and all relevant post-service records from VA and the Social Security Administration (SSA) have been obtained and associated with the evidence. Additionally, the Veteran has been afforded the opportunity to submit oral testimony in support of his claim. The Board has also reviewed the Veteran's claims file as it appears on the Virtual VA electronic information database for any additional pertinent medical records. The Board notes that the Veteran was not provided with a VA examination addressing the claim for service connection for heart condition (claimed as TIAs). However, this deficit does not render the existing record unusable for purposes of adjudicating the claim on the merits. The Board is mindful of the test prescribed by the United States Court of Appeals for Veterans Claims (Court) in McLendon v. Nicholson, 20 Vet. App. 79, 81 (2006), regarding whether a medical examination is necessary to adjudicate a claim, and finds that the absence of an examination addressing the heart condition (TIA) issue is not prejudicial to the Veteran's claim as he has not met the criteria under McLendon to warrant such an examination and, furthermore, the service and post-service VA and private medical records presently associated with the claims file provide sufficient evidence to decide the claim. A VA examination is therefore not necessary to adjudicate this particular matter. Specifically, the Board finds that the Veteran has not met all four elements set forth in McLendon, which emphasize that a VA examination must be provided when there is: (1) competent evidence of current disability or recurrent symptoms; (2) establishment of an in-service event, injury, or disease; (3) an indication that the current disability may be associated with the in-service event; and (4) insufficient competent medical evidence to decide the claim. As will be further discussed below, the Board has determined that the competent and credible evidence does not objectively establish a current diagnosis of, or in-service diagnostic history of a heart disability or TIAs, or an in-service event, injury, or disease relating his claimed history of a heart condition and TIAs to his period of active service. The first, second and third elements of the McLendon test have not been met. Therefore, the absence of a clinical examination addressing the heart condition and TIA claim does not constitute a breach of VA's duty to assist. With regard to the increased rating and TDIU claims on appeal, as these stem from September 13, 2007, when the Veteran filed his claim for increased ratings for the service-connected disabilities at issue, the relevant time period and evidence that must be addressed in the adjudication of the claim encompasses the period from September 13, 2006 to the present, in order to allow the Board to consider the applicability of a staged rating. See 38 C.F.R. § 3.400(o)(2) (2012); Hart v. Mansfield, 21 Vet. App. 505 (2007). In this regard, the Board observes that private, Social Security Administration (SSA), and VA clinical records for the period spanning 2006 to 2012, including reports of VA medical examinations of the disabilities at issue, dated in March 2008, September 2009 (with an October 2009 addendum opinion) and February 2012, have been obtained and associated with the claims file, or are otherwise viewable on the Virtual VA electronic information database. The Board has reviewed the aforementioned examination reports and notes that the Veteran's claims file was reviewed by the VA clinicians who performed them, and that these examiners provided adequate discussion of their clinical observations and rationales to support their individual findings and conclusions within the context of the Veteran's pertinent clinical history as contained within his claims file. The examinations are therefore deemed adequate for rating purposes. See Barr v. Nicholson, 21 Vet. App. 303, 311-12 (2007); Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007). The Veteran was provided with the opportunity to present oral testimony in support of his claims before the undersigned Veterans Law Judge in a May 2013 hearing. At the time of the hearing, he was accompanied by his representative and had the benefit of his advice and counsel. In Bryant v. Shinseki, 23 Vet. App. 488 (2010), the Court held that 38 C.F.R. § 3.103(c)(2) (2012) requires that the Decision Review Officer or Veterans Law Judge who chairs a hearing fulfill two duties to comply with the above regulation. These duties consist of (1) explaining fully the issues and (2) discussing the submission of evidence that may have been overlooked. Bryant v. Shinseki, 23 Vet. App. 488 (2010). At the May 2013 Board hearing, the presiding Veterans Law Judge's questions and the oral testimony of the Veteran focused on the elements necessary to substantiate, inter alia, the Veteran's claims of entitlement to service connection for a heart condition (claimed as TIAs) and increased ratings for his low back disability and bilateral radiculopathy of his lower extremities (and, by implication in view of his statements regarding his inability to work due to back pain, a TDIU). See transcript of May 7, 2013 Board hearing. Thus, the Board finds that the Veterans Law Judge presiding over the May 2013 hearing has substantially fulfilled his obligations as required under 38 C.F.R. § 3.103(c)(2). Bryant, supra. Based on the foregoing, the Board finds that the VA fulfilled its VCAA duties to notify and to assist the Veteran in the evidentiary development of the claims decided herein, and thus no additional assistance or notification is required. The Veteran has suffered no prejudice that would warrant a remand, and his procedural rights have not been abridged. See Bernard v. Brown, 4 Vet. App. 384 (1993). The Board will therefore proceed with the adjudication of this appeal. The Board has thoroughly reviewed all the evidence in the Veteran's claims file. Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, the evidence submitted by the 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). The analysis below focuses on the most salient and relevant evidence and on what this evidence shows, or fails to show, on the claims. The appellant must not assume that the Board has overlooked pieces of evidence that are not explicitly discussed herein. See Timberlake v. Gober, 14 Vet. App. 122 (2000) (the law requires only that the Board address its reasons for rejecting evidence favorable to the claimant). The Board must assess the credibility and weight of all evidence, including the medical evidence, to determine its probative value, accounting for evidence which it finds to be persuasive or unpersuasive, and providing reasons for rejecting any evidence favorable to the claimant. Equal weight is not accorded to each piece of evidence contained in the record; every item of evidence does not have the same probative value. 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. See Gilbert v. Derwinski, 1 Vet. App. 49 (1990). (c.) Entitlement to service connection for a chronic heart condition, claimed as TIAs. In order to establish service connection for a disability, there must be (1) medical evidence of a current disability; (2) medical or, in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and (3) medical evidence of a nexus between the claimed in-service disease or injury and the current disability. See Hickson v. West, 12 Vet. App. 247, 253 (1999). Service connection involves many factors, but basically means that the facts, shown by the evidence, establish that a particular injury or disease resulting in disability was incurred coincident with service, or if pre-existing such service, was aggravated therein. This may be accomplished by affirmatively showing inception or aggravation during service or through the application of statutory presumptions. 38 C.F.R. § 3.303(a) (2012). With chronic disability or disease shown as such in service (or within the presumptive period under 38 C.F.R. § 3.307 (2012)) so as to permit a finding of service connection, subsequent manifestations of the same chronic disease at any later date, however remote, are service connected, unless clearly attributable to intercurrent causes. This rule does not mean that any notation of treatment for cardiac complaints or symptoms while in military service will permit service connection for a heart condition or TIAs, first shown as a clear-cut clinical entity, at some later date. For the showing of chronic disease in service there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time, as distinguished from merely isolated findings or a diagnosis including the word "chronic." When the disease identity is established, there is no requirement of evidentiary showing of continuity. Service connection may be granted for any disease diagnosed after discharge from active duty when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). For veterans who have served 90 days or more of active service during a war period or after December 31, 1946, certain chronic disabilities, such as cardiovascular disease, are presumed to have been incurred in service if manifest to a compensable degree within one year of discharge from service. 38 U.S.C.A. §§ 1101, 1112 (West 2002); 38 C.F.R. §§ 3.307, 3.309 (2012). If there is no evidence of a chronic condition during service or an applicable presumptive period, then a showing of continuity of symptomatology after service may serve as an alternative method of establishing the second and/or third element of a service connection claim. See 38 C.F.R. § 3.303(b); Savage v. Gober, 10 Vet. App. 488 (1997). Continuity of symptomatology may be established if a claimant can demonstrate (1) that a condition was "noted" during service; (2) evidence of post-service continuity of the same symptomatology; and (3) medical or, in certain circumstances, lay evidence of a nexus between the present disability and the post-service symptomatology. Evidence of a chronic condition must be medical, unless it relates to a condition to which lay observation is competent. If service connection is established by continuity of symptomatology, there must be medical evidence that relates a current condition to that symptomatology. See Savage, 10 Vet. App. at 495-98; see also Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013), in which the United States Court of Appeals for the Federal Circuit (Federal Circuit) held that the theory of continuity of symptomatology can be used only in cases involving those diseases and conditions explicitly recognized as chronic in 38 C.F.R. § 3.309(a). The Board notes that ischemic heart disease (including, but not limited to, acute, subacute, and old myocardial infarction; atherosclerotic cardiovascular disease including coronary artery disease (including coronary spasm) and coronary bypass surgery; and stable, unstable and Prinzmetal's angina) are recognized in 38 C.F.R. § 3.309(e) as a disease presumptively associated with exposure to herbicide agents used during the Vietnam War Era. Although the Veteran's service personnel records show that he served in the United States Air Force during the last years of the Vietnam War Era, these records do not demonstrate that he was ever deployed to the Republic of Vietnam during his period of active duty. The Veteran does not contend otherwise. Thusly, the Veteran is not presumed to have been exposed to chemical herbicides (including Agent Orange) that were used by American forces in defoliant operations in Vietnam. See 38 C.F.R. § 3.307(a)(6)(iii) (2012). The Board notes that at his May 2013 hearing, the Veteran testified that in the 1980s he was admitted into a hospital emergency room in service for a "mild heart attack" and had displayed symptoms of dizziness, blurred vision, loss of balance and consciousness, and memory loss during this time and several other times during service. The Veteran contends that these were symptoms of TIAs in service and he stated that his current treating physicians at VA had informed him that they believed he had current symptoms that are similar to those noted in service that represented manifestations of TIAs. Other than hypertension, whose onset in service is documented in the Veteran's service treatment records and is a vascular disease for which he is service-connected at the 10 percent rate, the service treatment records show normal clinical findings pertinent to his heart and cardiac system throughout his entire period of active duty, with no indication of treatment for heart disease, strokes or cerebrovascular accidents, or other relevant chronic cardiac disease. No mention of TIAs is presented in the service treatment records. The service treatment records show that the Veteran's heart and neurological system were normal on enlistment examination in July 1974. In June 1979, he sustained a mild concussion playing softball with no loss of consciousness. He was examined and found to be neurologically intact with no sequalae. In March 1985, he was treated for severe occipital headaches. CT scan of his head was negative and laboratory studies were normal. In January 1986, his complaints were determined to be tension headaches that were successfully relieved with prescribed medication. In November 1989, the Veteran received emergency room treatment after he collapsed at work and complained of severe headaches, dizziness and weakness. Tests were conducted to rule out cardiac causes for his symptoms. No cardiac abnormalities were detected and his cardiac status was cleared. Neurological examination, which included an electroencephalogram (EEG) and a CT scan, revealed intact cranial nerves and no neurological abnormalities or sensory motor deficits. Psychiatric examination determined that the Veteran's complaints were psychosomatic and secondary to psychiatric distress. A June 1990 service treatment note shows that the Veteran presented with complaints of dizziness that were clinically determined to be a symptom of his hypertension (for which he is presently service connected and receiving VA compensation). A June 1992 periodic medical examination shows no mention of TIAs. Short-term memory loss reported by the Veteran was attributed to depression and a side-effect of prescribed medications. The Veteran was discharged from active duty in December 1994. Post-service VA examination in February 1995 shows normal electrocardiogram (ECG), no TIAs, strokes, or cerebrovascular accidents, or vascular abnormalities manifested by dizziness or loss of consciousness. The Veteran's reported history of acute memory impairment was objectively attributed to his reaction to medications prescribed in service. Thereafter, the post-service VA medical records show notations of TIAs by history, per the Veteran's self-reported accounts, but no actual clinical diagnosis of past or current TIAs, strokes, or cerebrovascular accidents. A VA physician's note dated in December 2007 states that the Veteran's reported symptoms of gastric upset, a ringing sensation in his ears, occasional slurred speech and dizziness, and weakness in his knees and arms during periods of emotional stress were more consistent with an anxiety reaction and not a TIA. VA examination of September 2008 notes hypertension, but found no hypertensive heart disease or cardiac abnormalities of any kind. The post-service medical records as a whole do not show any diagnosed heart condition that is objectively linked to the Veteran's period of active service. The Board has considered the relevant evidence discussed above and finds that there is no basis to award the Veteran service connection for a heart condition, claimed as TIAs. His service treatment records show no onset of a chronic cardiac disorder or TIAs during active duty, nor is there evidence of a chronic and disabling cardiac condition within one year following his separation of active duty in December 1994, or a current cardiac condition objectively attributed to his military service or otherwise to a service-connected disability. His symptoms of dizziness, imbalance, mental confusion, and loss of consciousness shown in service are acute conditions related to his service-connected hypertension or non-service-connected psychiatric diagnoses, or to prescribed medications, which are not shown in the clinical records from service to have produced any chronic complications or sequalae. The Board has considered the Veteran's general contention that he has a current disability manifested by recurring spells of dizziness, blurred vision, loss of balance, and loss of consciousness, which he believes are due to TIAs in service. Although his claims file indicates that the Veteran had attended four years of college (see VA psychiatric examination dated in April 2011), his vocational background is not in medicine and the evidence does not indicate that he has had any formal medical training. Although lay persons such as the Veteran are competent to provide opinions on some medical issues, the specific matter here (existence of a chronic heart condition and/or TIAs during and after service) falls outside the realm of common knowledge of a lay person. Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011); Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). The claimed condition at issue is not the type of disability that is readily amenable to mere lay diagnosis or probative comment regarding its etiology, as the evidence shows it is verifiable only through clinical examination by a trained physician or specialist to assess and diagnose it properly. Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009); Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007); & Woehlaert v. Nicholson, 21 Vet. App. 456, 462 (2007). The Veteran is not shown to possess the requisite medical training, expertise, or credentials needed to render a diagnosis or a competent opinion as to medical causation. Nothing in the record demonstrates that he received any special training or acquired any medical expertise in evaluating a heart condition or TIAs. King v. Shinseki, 700 F.3d 1339, 1345 (Fed.Cir.2012). His lay assertion does not constitute competent medical evidence and lacks probative value. In view of the foregoing discussion, the Board concludes that the weight of the objective medical evidence is against the Veteran's claim of entitlement to service connection for a heart condition, claimed as TIAs. As previously stated, there is no probative clinical evidence establishing onset of this claimed disease during the Veteran's period of active duty, no clinical evidence of a heart condition, claimed as TIAs, manifest within one year following his discharge from service in December 1994, and no clinical evidence that conclusively presents a diagnosis of a heart condition, including TIAs, objectively linked to his period of military service. His claim in this regard must therefore be denied. Because the evidence in this case is not approximately balanced with respect to the merits of the claim, the benefit-of-the-doubt doctrine does not apply. 38 U.S.C.A. § 5107(b) (West 2002); 38 C.F.R. § 3.102 (2012); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Increased ratings - generally. Disability ratings are determined by applying the criteria set forth in the VA's Schedule for Rating Disabilities, which is based on the average impairment of earning capacity. Individual disabilities are assigned separate diagnostic codes. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1 (2012). The basis of disability evaluations is the ability of the body as a whole, or of the psyche, or of a system or organ of the body to function under the ordinary conditions of daily life including employment. 38 C.F.R. § 4.10 (2012). In determining the severity of a disability, the Board is required to consider the potential application of various other provisions of the regulations governing VA benefits, whether or not they were raised by the Veteran, as well as the entire history of the Veteran's disability. 38 C.F.R. §§ 4.1, 4.2 (2012); Schafrath v. Derwinski, 1 Vet. App. 589, 595 (1991). If the disability more closely approximates the criteria for the higher of two ratings, the higher rating will be assigned; otherwise, the lower rating is assigned. 38 C.F.R. § 4.7 (2012). It is not expected that all cases will show all the findings specified; however, findings sufficiently characteristic to identify the disease and the disability therefrom and coordination of rating with impairment of function will be expected in all instances. 38 C.F.R. § 4.21 (2012). In deciding this appeal, the Board has considered whether separate ratings for different periods of time, based on the facts found, are warranted, a practice of assigning ratings referred to as "staging the ratings." See Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2008). Based on the September 13, 2007 date of VA's receipt of the Veteran's application to reopen his claims for a rating increase, the relevant temporal focus for the TDIU and the increased rating claims for a chronic low back disability and bilateral lower extremity neuropathy is from September 13, 2006. See 38 C.F.R. § 3.400 (2012). (d.) Entitlement to an increased evaluation greater than 20 percent for spondylosis and scoliosis of the lumbar spine (formerly rated as HNP of L5-S1) prior to September 8, 2009, and an increased evaluation greater than 40 percent for spondylosis and scoliosis of the lumbar spine from September 8, 2009. The Veteran is service-connected for spondylosis and scoliosis of the lumbar spine (formerly rated as HNP of L5-S1), which his service treatment records indicate is the result of a traumatic straining injury incurred during active duty when a heavy missile came loose and fell on him. The criteria for rating all spine disabilities are set forth in a General Rating Formula for Diseases and Injuries of the Spine provide that these disabilities are to be evaluated either 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 rating when all disabilities are combined under 38 C.F.R. § 4.25. Disability of the musculoskeletal system is primarily the inability, due to damage or infection in the parts of the system, to perform the normal working movements of the body with normal excursion, strength, speed, coordination, and endurance. It is essential that the examination on which ratings are based adequately portray the anatomical damage and the functional loss with respect to all of these elements. In evaluating disabilities of the musculoskeletal system, it is necessary to consider, along with the schedular criteria, functional loss due to flare-ups of pain, fatigability, incoordination, pain on movement, and weakness. DeLuca v. Brown, 8 Vet. App. 202 (1995). The functional loss may be due to absence of part, or all, of the necessary bones, joints and muscles, or associated innervations, or other pathology and evidenced by visible behavior of the claimant undertaking the motion. Weakness is as important as limitation of motion, and a part that becomes painful on use must be regarded as seriously disabled. 38 C.F.R. § 4.40 . Pain on movement, swelling, deformity or atrophy of disuse as well as instability of station, disturbance of locomotion, interference with sitting, standing and weight bearing are relevant considerations for determination of joint disabilities. 38 C.F.R. § 4.45 . Painful, unstable, or misaligned joints due to a healed injury are entitled to at least the minimal compensable rating for the joint. 38 C.F.R. § 4.59 . The pertinent part of the General Formula for rating disability of the lumbar spine is as follows: 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 Unfavorable ankylosis of the entire spine, assign a 100 percent rating. Unfavorable ankylosis of the entire thoracolumbar spine, assign a 50 percent rating. Forward flexion of the thoracolumbar spine 30 degrees or less; or, favorable ankylosis of the entire thoracolumbar spine, assign a 40 percent rating. Forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees; or, the combined range of motion of the thoracolumbar spine not greater than 120 degrees; or, muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spine contour such as scoliosis, reversed lordosis, or abnormal kyphosis, assign a 20 percent rating. Note (1): Evaluate any associated objective neurologic abnormalities. . . separately, under an appropriate diagnostic code. Note (2): (See also Plate V.) For VA compensation purposes, normal forward flexion of the thoracolumbar spine is zero to 90 degrees, extension is zero to 30 degrees, left and right lateral flexion are zero to 30 degrees, and left and right lateral rotation are zero to 30 degrees. The combined range of motion refers to the sum of the range of forward flexion, extension, left and right lateral flexion, and left and right rotation. The normal combined range of motion of the thoracolumbar spine is 240 degrees. The normal ranges of motion for spinal motion provided in this note are the maximum that can be used for calculation of the combined range of motion. Note (3): In exceptional cases, an examiner may state that because of age, body habitus, neurologic disease, or other factors not the result of disease or injury of the spine, the range of motion of the spine in a particular individual should be considered normal for that individual, even though it does not conform to the normal range of motion stated in Note (2). Provided that the examiner supplies an explanation, the examiner's assessment that the range of motion is normal for that individual will be accepted. Note (4): Round each range of motion measurement to the nearest five degrees. Note (5): For VA compensation purposes, unfavorable ankylosis is a condition in which the entire thoracolumbar spine, or the entire spine. . . is fixed in flexion or extension, and the ankylosis results in one or more of the following: difficulty walking because of a limited line of vision; restricted opening of the mouth and chewing; breathing limited to diaphragmatic respiration; gastrointestinal symptoms due to pressure of the costal margin on the abdomen; dyspnea or dysphagia; atlantoaxial or cervical subluxation or dislocation; or neurologic symptoms due to nerve root stretching. Fixation of a spinal segment in neutral position (zero degrees) always represents favorable ankylosis. Note (6): Separately evaluate disability of the thoracolumbar and cervical spine segments, except when there is unfavorable ankylosis of both segments, which will be rated as a single disability. Formula for Rating Intervertebral Disc Syndrome (IVDS) Based on Incapacitating Episodes provides as follows: With incapacitating episodes having a total duration of at least 6 weeks during the past 12 months, assignment of a 60 percent evaluation is warranted. With incapacitating episodes having a total duration of at least 4 weeks but less than 6 weeks during the past 12 months, assignment of a 40 percent evaluation is warranted. With incapacitating episodes having a total duration of at least 2 weeks but less than 4 weeks during the past 12 months, assignment of a 20 percent evaluation is warranted. With incapacitating episodes having a total duration of at least one week but less than 2 weeks during the past 12 months, assignment of a 10 percent evaluation is warranted. Note (1): For purposes of evaluations under diagnostic code 5243 [intervertebral disc syndrome], 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. Note (2): If intervertebral disc syndrome is present in more than one spinal segment, provided that the effects in each spinal segment are clearly distinct, evaluate each segment on the basis of incapacitating episodes or under the General Rating Formula for Diseases and Injuries of the Spine, whichever method results in a higher evaluation for that segment. 38 C.F.R. § 4.71a, Diagnostic Code 5243 (2012). Inasmuch as the Veteran is in receipt of a 40 percent schedular rating for the period since September 8, 2009, the only basis for a higher rating under the General Rating Formula for Diseases and Injuries of the Spine is if there is evidence of ankylosis. See Johnston v. Brown, 10 Vet. App. 80 (1997) (if a claimant is already receiving the maximum disability rating available based on symptomatology that includes limitation of motion, it is not necessary to consider whether 38 C.F.R. §§ 4.40 and 4.45 are applicable). The record fails to show that the Veteran's disability has been manifested by unfavorable ankylosis of the entire thoracolumbar spine. The Board has reviewed the entirety of the pertinent medical record for the period from September 8, 2009 to the present, and the clinical evidence does not show that the Veteran's service-connected spondylosis and scoliosis of the lumbar spine is manifested by ankylosis (i.e., in which the entire thoracolumbar spine, or the entire spine is fixed in flexion or extension). As this specific clinical finding has not been objectively demonstrated, there is no basis to allow an evaluation above 40 percent on application of the rating schedule for the Veteran's service-connected spondylosis and scoliosis of the lumbar spine. There was also objective demonstration of incapacitating episodes of radiculopathic symptoms associated with intervertebral disc syndrome (IVDS). He made no report of incapacitating episodes at his September 2009 VA examination. The February 2012 examiner specifically noted that the Veteran had had no incapacitating episodes in the past year. VA treatment records are similarly negative. The claim for an increased evaluation greater than 40 percent for spondylosis and scoliosis of the lumbar spine from September 8, 2009 must therefore be denied. With respect to that part of the claim in which the appellant seeks an increased rating above 20 percent for spondylosis and scoliosis of the lumbar spine (formerly rated as HNP of L5-S1) prior to September 8, 2009, the entirety of the clinical evidence objectively demonstrates that for the period from September 13, 2006 to September 7, 2009, the service-connected low back disability is manifested by constant pain, pain on use, and pain on motion, which necessitates treatment with prescribed narcotic medication (Oxycontin) to partially relieve the symptoms. Medical imaging pertinent to the period prior to September 8, 2009 reveals degenerative joint and disc pathology at the site of his lumbosacral spine. Range of motion testing of his thoracolumbar spine in March 2008 revealed forward flexion to 45 degrees with pain. There was no evidence ankylosis. Such does not warrant the assignment of a higher (40 percent) rating. There is also no credible evidence of limitation of motion or of pain on use or flare-ups that result in limitation of motion to the extent that the lumbar spine disability would warrant a higher rating. 38 C.F.R. §§ 4.40 , 4.45, 4.59; DeLuca v. Brown, 8 Vet. App. 202 (1995). It is not disputed that the Veteran has limited motion of the thoracolumbar spine and that there is pain on motion and loss of function. Yet, the Board finds that the 20 percent disability rating adequately compensates him for his painful motion and functional loss. The limitation of forward flexion to 45 degrees factored in the complaint of pain. The 2008 VA examiner also described the Veteran as experiencing pain on motion as well as increased pain after three repetitions. However, that examiner noted that there was no additional loss of motion or weakness following those repetitions. The provisions of 38 C.F.R. §§ 4.40 and 4.45 have been considered, but they do not provide a basis for the assignment of a higher rating under these circumstances. Indeed, the Court clarified that there is a difference between pain that may exist in joint motion as opposed to pain that actually places additional limitation of the particular range of motion. Mitchell v. Shinseki, 25 Vet. App. 32 (2011). The Court specifically discounted the notion that the highest disability ratings are warranted where pain is merely evident as it would lead to potentially "absurd results." Id. at 43 (limiting the scope and application of its prior holding in Lichtenfels v. Derwinski, 1 Vet. App. 484 (1991)). It was stated that 38 C.F.R. § 4.40 provides that joint pain alone, and even pain throughout the entire range of motion, but without evidence of decreased functional ability, does not warrant the minimum compensable rating. In this case, a higher rating based on guarding for anticipated pain without any quantifiable loss due to actual pain does not serve as basis for an increased rating. The Veteran was already being adequately compensated for pain. The record also fails to show that the Veteran's disability has been manifested by incapacitating episodes having a total duration of at least 6 weeks during the past 12 months. VA treatment records and the VA examination are both negative for any findings of incapacitation due to IVDS. The assignment of a 40 percent rating is not warranted. Next, consideration has been given as to whether the evidence supports the assignment of a separate compensable rating for neurological impairment. Here, the Veteran has already been evaluated for such and is currently in receipt of a 20 percent ratings for right and left lumbar radiculopathy. The ratings for those disabilities are considered below. However, aside the Veteran's radiculopathy, the Board finds that there is no competent medical evidence of any associated objective neurologic abnormalities as a result of the lumbar strain to be separately evaluated under an appropriate diagnostic code. The 2012 VA examiner specifically noted that there were no neurologic abnormalities such bowel or bladder pathologic reflexes. (e.) Entitlement to an increased evaluation greater than 20 percent for right lower extremity radiculopathy and left lower extremity radiculopathy. The Veteran is in receipt of separate compensable ratings for bilateral radiculopathy of his lower extremities. Each lower extremity is rated for impairment due to paralysis of the sciatic nerve under the criteria contained in 38 C.F.R. § 4.124a, Diagnostic Code 8520 (2012), which provides for the following evaluations: Complete paralysis of the sciatic nerve; the foot dangles and drops, no active movement is possible of muscles below the knee, flexion of the knee is weakened or (very rarely) lost, rate as 80 percent disabling. Severe incomplete paralysis of the sciatic nerve with marked muscular atrophy, rate as 60 percent disabling. Moderately severe incomplete paralysis of the sciatic nerve, rate as 40 percent disabling. Moderate incomplete paralysis of the sciatic nerve, rate as 20 percent disabling. Mild incomplete paralysis of the sciatic nerve, rate as 10 percent disabling. 38 C.F.R. § 4.124a, Diagnostic Code 8520 (2012). With regard to the Veteran's right lower extremity, the clinical evidence shows that June 10, 2011 is the date on which it was first objectively established that radiculopathy of this limb was present and linked to the disc disease component of his service-connected low back disability. Medical records pertinent to the period from June 10, 2011 to the present includes VA outpatient treatment records and the report of a February 2012 VA examination, which demonstrates that the Veteran's radiculopathy of his right lower extremity is manifested by subjective complaints of constant pain and perceived numbness in the leg and loss of sensation in his right foot, although objective testing did not confirm the presence of actual numbness. With regard to the Veteran's left lower extremity, the clinical evidence shows that a VA examination conducted on February 10, 2012, established for the first time that radiculopathy of the left lower extremity was present, manifested by subjective complaints of constant neurologic pain, which was linked to the disc disease component of his service-connected low back disability. VA examination of February 2012 shows that testing of the proximal and distal muscles of both the right and left lower extremity revealed 5/5 muscle strength and no objective motor function impairment. No muscle atrophy was indicated. Sensory testing revealed abnormal hypoactivity of his right and left knee and ankle deep tendon reflexes, which were each 1+, with otherwise normal sensation to light touch throughout the entire length of both lower extremities. No impairment of right or left lower extremity joint function due to peripheral neuropathy or abnormality of gait and balance was indicated. No paresthesias or dyesthesias was indicated. The neuritis and neuralgia affecting the lower extremities were objectively demonstrated, characterized as constant neuropathic pain that was "moderate" in intensity and severity. As it relates to the Veteran's peripheral neuropathy of each lower extremity, the above evidence presents an overall disability picture of impairment due to neuritis and neuralgia that is analogous to moderate incomplete paralysis of the sciatic nerve, although no actual paralysis is demonstrated. The primary manifestation of the disability is constant pain in each limb. However, no impairment of reflexes, gait, and balance, and no muscle atrophy or muscle tissue abnormality were shown. The Board cannot concede that the overall disability picture more closely approximates the criteria for a 20 percent evaluation on the basis of moderate incomplete paralysis of the right or left sciatic nerve. Therefore, in view of the foregoing discussion, the claim for an evaluation greater than 20 percent for peripheral neuropathy of the right lower extremity from June 10, 2011, and the claim for an evaluation greater than 20 percent for peripheral neuropathy of the left lower extremity from February 10, 2012 must be denied. Because the evidence in this case is not approximately balanced with respect to the merits of this specific claim, the benefit-of-the-doubt doctrine does not apply. 38 U.S.C.A. § 5107(b) (West 2002); 38 C.F.R. § 3.102 (2012); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). (f.) Extraschedular consideration. A rating in excess of the assigned schedular evaluations for the Veteran's service-connected disabilities addressed herein on the merits may be granted when it is demonstrated that the particular disability 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. See 38 C.F.R. § 3.321(b)(1) (2012). To accord justice in an exceptional case where the schedular standards are found to be inadequate, the field station is authorized to refer the case to the Under Secretary for Benefits or the Director, Compensation and Pension Service, for assignment of an extraschedular evaluation commensurate with the average earning capacity impairment. 38 C.F.R. § 3.321(b)(1) (2012). The Court has held that the Board is precluded by regulation from assigning an extraschedular rating under 38 C.F.R. § 3.321(b)(1) (2012) in the first instance; however, the Board is not precluded from raising this question, and in fact is obligated to liberally read all documents and oral testimony of record and identify all potential theories of entitlement to a benefit under the law and regulations. See Floyd v. Brown, 9 Vet. App. 88 (1996). The Court further held that the Board must address referral under 38 C.F.R. § 3.321(b)(1) only where circumstances are presented which the Director of VA's Compensation and Pension Service might consider exceptional or unusual. See Shipwash v. Brown, 8 Vet. App. 218, 277 (1995). Extraschedular consideration involves a three step analysis. Thun v. Peake, 22 Vet. App. 111 (2008). First, the Board or the RO must determine whether the schedular rating criteria reasonably describe the Veteran's disability level and symptomatology. Id. at 115. If the schedular rating criteria do reasonably describe the Veteran's disability level and symptomatology, the assigned schedular evaluation is adequate, referral for extraschedular consideration is not required, and the analysis stops. Id. If the RO or the Board finds that the schedular evaluation does not contemplate the Veteran's level of disability and symptomatology, then either the RO or the Board must determine whether the Veteran's exceptional disability picture includes other related factors such as marked interference with employment and frequent periods of hospitalization. Id. at 116. If this is the case, then the RO or the Board must refer the matter to the Under Secretary for Benefits or the Director of the Compensation and Pension Service for the third step of the analysis, determining whether justice requires assignment of an extraschedular rating. Id. The Board finds that there is no evidence that the Veteran's service-connected disabilities currently at issue (i.e., spondylosis and scoliosis of the lumbar spine and bilateral radiculopathy of his lower extremities) have presented such an unusual or exceptional disability picture at any time between September 13, 2006 to the present, so as to require consideration of an extraschedular evaluation pursuant to the provisions of 38 C.F.R. § 3.321(b) (2012). Specifically, the evidence of record does not indicate the Veteran is frequently hospitalized for any of these aforementioned service-connected disabilities. The Veteran has testified at his May 2013 hearing before the Board that his back disability prevents him from standing or sitting for prolonged periods of time, which thusly prevented him from engaging in travel, which was reportedly one of the requirements of his former employer (the Department of Homeland Security) at which he once held a sedentary desk position. However, the clinical and testimonial evidence does not indicate marked interference with his ability to travel and work at a desk, as the Veteran stated that he was able to operate a motor vehicle and had, in fact, been able to drive himself a considerable distance to the RO for his Board hearing, taking breaks for rest as required. The VA examinations of September 2009 and February 2012, and the Veteran's hearing before the Board in May 2013, indicate that he is able to walk a distance of several city blocks without resting, which he does daily to partially relieve his low back symptoms as he is unable to sit or stand without moving for prolonged periods. The criteria of the applicable rating schedules are therefore deemed to adequately contemplate the Veteran's present level of impairment due to the disabilities at issue, as individually considered. As such, the Board cannot concede that the Veteran's spondylosis and scoliosis of the lumbar spine and bilateral radiculopathy of his lower extremities, each standing by itself, causes marked interference with his employment capacity. Higher ratings are available for each of the Veteran's disabilities, but for the reasons described in the above decision, higher ratings were denied in each case. For each disability the clinical evidence and medical opinions fail to show that the disability picture created by these disabilities, in isolation, is of an exceptional or unusual nature. Having reviewed the record with these mandates in mind, the Board finds that the schedular ratings presently assigned to these disabilities adequately reflects the state of their impairment for the period to which they are applied, and that there is no evidentiary basis for referral of the case for extraschedular consideration with regard to any of these issues. (g.) Entitlement to a TDIU. The issue of entitlement to a TDIU is properly before the Board as a component of the Veteran's increased rating claims on appeal. See Rice v. Shinseki, 22 Vet. App. 447 (2009). VA will grant a total rating for compensation purposes based on individual unemployability when the evidence shows that a veteran is precluded, by reason of service-connected disability, from obtaining and maintaining any form of gainful employment consistent with his or her education and occupational experience. See 38 C.F.R. §§ 3.340, 3.341, 4.16 (2012). Under the applicable regulations, benefits based on individual unemployability are granted only when it is established that the service-connected disability or disabilities are so severe, standing alone, as to prevent the retaining of gainful employment. While the regulations do not provide a definition of "substantially gainful employment," VA Adjudication Procedure Manual, M21-1 MR, Part IV, Subpart ii, Chapter 2 (Dec. 13, 2005) (previously cited at M21-1, Part IV, paragraph 7.09), defines the term as that "at which non-disabled individuals earn their livelihood with earnings comparable to the particular occupation in the community where the Veteran resides." In Hatlestad v. Derwinski, 5 Vet. App. 524, 529 (1993), the Court held that the central inquiry in determining whether a Veteran is entitled to TDIU is whether his service-connected disabilities alone are of sufficient severity to produce unemployability. Under 38 C.F.R. § 4.16, if there is only one such disability, it must be rated at least 60 percent disabling to qualify for benefits based on individual unemployability. If there are two or more such disabilities, there shall be at least one disability ratable at 40 percent or more, and sufficient additional disability to bring the combined rating to 70 percent or more. See 38 C.F.R. § 4.16(a) (2012). In determining whether unemployability exists, consideration may be given to the veteran's level of education, special training, and previous work experience, but it may not be given to his or her age or to any impairment caused by non-service-connected disabilities. See 38 C.F.R. §§ 3.341, 4.16, 4.19 (2012); see also Van Hoose v. Brown, 4 Vet. App. 361 (1993). When reasonable doubt arises as to the degree of disability, such doubt will be resolved in a Veteran's favor. 38 C.F.R. § 4.3 (2012). The determination as to whether a total disability is appropriate should not be based solely upon demonstrated difficulty in obtaining employment in one particular field, which could also potentially be due to external bases such as economic factors, but rather to all reasonably available sources of employment under the circumstances. See Ferraro v. Derwinski, 1 Vet. App. 326, 331-332 (1991). The Veteran is presently service-connected for spondylosis and scoliosis of the lumbar spine (rated 40 percent), radiculopathy of the right lower extremity (rated 20 percent), radiculopathy of the left lower extremity (rated 20 percent), hypertension (rated 10 percent), gastroesophageal reflux disease (rated 10 percent), right ankle sprain (rated noncompensable), left ankle sprain (rated noncompensable), and post-operative nasal fracture with perforated septum (rated noncompensable), which produces a combined disability rating of 70 percent under 38 C.F.R. § 4.25 (2012). Therefore, the Veteran has met the rating requirement for eligibility for a TDIU under 38 C.F.R. § 4.16(a). As relevant, the Board notes that the Veteran is presently 56 years old at the time of this writing. His medical records indicate that he has a four-year college degree and his hearing testimony and medical records indicate that he was employed in a sedentary desk position with the Department of Homeland Security up until 2005, when he reportedly quit his position due to symptoms associated with his service-connected chronic low back disability, which prevented him from working in a sedentary position or engaging in travel by automobile, which was reportedly a requirement for his job. SSA records associated with the Veteran's claims file show that the SSA has determined that the Veteran is disabled for purposes of SSA benefits due to disorders of his muscle, ligament, and fascia atrophy (which incorporates his service-connected back disorder and associated impairment) and an affective/mood disorder as of August 2009. While this evidence is probative, SSA administrative decisions and regulations are nevertheless not binding on VA or the Board, although findings made by the SSA regarding the existence of a total and permanent disability and resulting unemployability are relevant to determining whether TDIU is applicable under VA laws and regulations and thus must be considered. Collier v. Derwinski, 1 Vet. App. 413, 417 (1991). The medical records associated with the claims file shows that he is regularly using prescribed opiate medications (Oxycontin) to control his constant back pain, and the file indicates that his constant need to use narcotic painkillers also adversely impacts his capacity for maintaining employment. With regard to the specific question of the impact of the Veteran's service-connected disabilities, particularly his back disability, on his occupational capacity, his treating VA physician expressed an opinion in February 2008 that: [With] all the pain [including from his back] that [the Veteran] is having, he [has] a difficult time finding any type of work and he is also on [regularly prescribed] narcotics because of the pain. . ., which has. . . complicated his [ability to find] work. He has been looking for work. . . and cannot find anyone willing to hire him or[,] if they are willing to hire him, it is [for] a job he really cannot do because of the chronic pain that he is having. In an October 2009 VA addendum opinion, a medical doctor and a physician's assistant reviewed the Veteran's claims file and determined, in pertinent part, that "Regarding [the Veteran's service-connected] back condition, it is as likely as not that sedentary employment would be feasible." The Board finds it noteworthy that the Veteran is already deemed to be 70 percent disabled by the combined rating of all his service-connected disabilities and that furthermore the SSA has found him to be disabled from working due, at least in large part, to his service-connected low back disability, notwithstanding his college degree and vocational background in sedentary executive positions. The February 2008 opinion of his treating physician is very probative, given her familiarity with the particulars of his individual medical case, and the opinion indicates that he is precluded from even working in the capacity of his vocation and training as a white-collar desk-bound professional due to his back pain and the need for regular use of prescribed opioids to control it. Parsing the language of the October 2009 opinion of the VA medical doctor and physician's assistant, their statement that it is as likely as not that sedentary employment would be feasible given the Veteran's back disability may be interpreted as meaning that sedentary employment would also as likely as not be infeasible. The evidence is therefore in relative equipoise regarding the question of whether or not the Veteran is individually unemployable as a result of the effects of his service-connected low back disability and its associated bilateral radiculopathy of his lower extremities, which could reasonably be construed as a single disabling entity. See 38 C.F.R. § 4.16(a)(2) (2012). Resolving any doubt in this regard in favor of the Veteran, the Board concludes that he is unable to obtain and retain gainful employment due to his service-connected back disability (to include neurological impairment of his lower extremities). His claim for a TDIU under the regulatory provisions of 38 C.F.R. § 4.16(a) is thusly granted. 38 U.S.C.A. § 5107(b) (West 2002); 38 C.F.R. § 4.3 (2012); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). ORDER The appeal of the April 2008 rating decision, with respect to the issue of entitlement to service connection for a hepatitis C infection, is dismissed. The appeal of the April 2008 rating decision, with respect to the issue of entitlement to a compensable evaluation for postoperative nasal fracture with perforated septum, is dismissed. Service connection for a heart condition, claimed as TIAs, is denied. An increased evaluation greater than 20 percent for spondylosis and scoliosis of the lumbar spine (formerly rated as HNP of L5-S1) prior to September 8, 2009 is denied. An increased evaluation greater than 40 percent for spondylosis and scoliosis of the lumbar spine from September 8, 2009 is denied. An increased evaluation greater than 20 percent for radiculopathy of the right lower extremity is denied. An increased evaluation greater than 20 percent for radiculopathy of the left lower extremity is denied. A TDIU is granted. ____________________________________________ MICHAEL A. HERMAN Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs