Citation Nr: 1333906 Decision Date: 10/25/13 Archive Date: 11/06/13 DOCKET NO. 12-30 780 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUES 1. Entitlement to an initial compensable rating for prostate cancer before August 16, 2013, and to a rating higher than 40 percent since. 2. Entitlement to an initial compensable rating for peripheral neuropathy of the right lower extremity. 3. Entitlement to an initial compensable rating for peripheral neuropathy of the left lower extremity. REPRESENTATION Veteran represented by: Disabled American Veterans ATTORNEY FOR THE BOARD C. Kedem, Counsel INTRODUCTION The Veteran served on active duty in the U.S. Navy, including as a dental officer, from August 1960 to June 1992. This appeal to the Board of Veterans' Appeals (Board) is from a September 2011 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in St. Petersburg, Florida, which granted service connection for prostate cancer, Type II Diabetes Mellitus, and for peripheral neuropathy of the right and left lower extremities. The Veteran appealed for higher initial ratings for these service-connected disabilities. See Fenderson v. West, 12 Vet. App. 119, 125-26 (1999) (when a Veteran appeals the initial rating for a disability, VA must consider whether to "stage" the rating, meaning assign different ratings at different times since the effective date of the award if there have been occasions when the disability has been more severe than at others; this will compensate him for this variance). However, in his October 2012 Substantive Appeal to the Board (on VA Form 9), he clarified that he was only appealing the initial ratings assigned for his prostate cancer and bilateral lower extremity peripheral neuropathy. In May 2013, the Board remanded these claims to the RO via the Appeals Management Center (AMC) for further development and consideration. And in a September 2013 decision, on remand, the AMC increased the rating for the prostate cancer from 0 to 40 percent as of August 16, 2013. The Veteran since has continued to appeal for an even higher rating for this service-connected disability. AB v. Brown, 6 Vet. App. 35, 38-39 (1993) (It is presumed he is seeking the highest possible rating absent express indication otherwise). So this claim now concerns whether he was entitled to an initial compensable rating for his prostate cancer prior to August 16, 2013, and whether he has been entitled to a rating higher than 40 percent for this disability since. The AMC continued to deny compensable ratings for his bilateral (right and left) lower extremity peripheral neuropathy, so those claims also are again before the Board. This appeal was processed using VA's electronic ("Virtual VA") paperless claims processing system. Accordingly, any future consideration of this Veteran's case should take into consideration the existence of this electronic record. FINDINGS OF FACT 1. Before August 16, 2013, the Veteran's prostate cancer residuals were manifested by no more than daytime voiding at intervals of between one and two hours. 2. Since August 16, 2013, his prostate cancer residuals have been manifested additionally by the need for absorbent materials that have to be changed two to four times a day and by radiation proctitis. 3. As for his right and left lower extremity peripheral neuropathy, he has what amounts to moderate associated impairment and symptoms - including persistent pain and burning sensations. CONCLUSIONS OF LAW 1. For the initial period at issue before August 16, 2013, the criteria are met for a higher 20 percent initial rating, though no greater rating, for the residuals of the prostate cancer. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 4.3, 4.7, 4.115a, 4.115b, Diagnostic Code 7528 (2013). 2. The criteria have never been met, however, even since August 16, 2013, for a rating higher than 40 percent for the residuals of the prostate cancer. Id. 3. But the criteria are met for a 10 percent rating, though no greater rating, for the radiation proctitis. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 4.3, 4.7, 4.20, 4.114, 4.115b, Diagnostic Code 7528-7336 (2013). 4. The criteria also are met for higher 20 percent ratings, though no greater ratings, for the right and left lower extremity peripheral neuropathy. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 4.3, 4.7, 4.124a, Diagnostic Code 8521 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veterans Claims Assistance Act of 2000 (VCAA) The VCAA and its implementing regulations impose obligations on VA to provide those claiming entitlement to VA benefits with notice and assistance upon receipt of a complete or substantially complete application. 38 U.S.C.A. §§ 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2013); 38 C.F.R. §§ 3.102, 3.156(a), 3.326(a) (2013). The notice requirements of VCAA require VA to notify the claimant of what information or evidence is necessary to substantiate the claim; what subset of the necessary information or evidence, if any, the claimant is to provide; and what subset of the necessary information or evidence, if any, VA will attempt to obtain on the claimant's behalf. The so-called "fourth element" of this notice requesting the claimant to provide any evidence in his personal possession pertaining to the claim was removed from the language of 38 C.F.R. § 3.159(b)(1). See 73 Fed. Reg. 23,353-356 (April 30, 2008). The Court issued a decision in the appeal of Dingess v. Nicholson, 19 Vet. App. 473 (2006), which held that the notice requirements of 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) apply to all five elements of a service-connection claim: (1) Veteran status; (2) existence of a disability; (3) a connection between a Veteran's service and the disability; but also the "downstream" (4) degree of disability, i.e., disability rating; and (5) effective date of the disability in the eventuality service connection is granted. This appeal, however, concerns the ratings initially assigned following the granting of service connection for these disabilities. In initial-rating cases, as here, where service connection has been granted and an initial disability rating and effective date assigned, VCAA notice under 38 U.S.C.A. § 5103(a) is no longer required because the purpose that the notice is intended to serve has been fulfilled by the granting of the underlying claim of entitlement to service connection. Dingess/Hartman, 19 Vet. App. at 490; Dunlap v. Nicholson, 21 Vet. App. 112 (2007). VA does not then have to provide additional notice concerning the "downstream" disability rating and effective date elements of the claim. VAOPGCPREC 8-2003, 69 Fed. Reg. 25180 (May 5, 2004). According to the holding in Goodwin v. Peake, 22 Vet. App. 128 (2008), and its progeny, instead of issuing an additional VCAA notice letter in this situation concerning the "downstream" disability rating and effective date elements of the claim, the provisions of 38 U.S.C.A. § 7105(d) require VA to issue a statement of the case (SOC) if the disagreement is not resolved, and this occurred in this particular instance. The RO provided the Veteran this required SOC, also since has provided him supplemental SOCs (SSOCs), citing the applicable statutes and regulations governing the assignment of disability ratings and contain discussion of the reasons or bases for not assigning higher initial ratings in this instance. He therefore has received all required notice concerning these claims. The Board also is satisfied VA has made the required efforts to assist him with these claims, including by obtaining all potentially relevant records and evidence. The file contains, in pertinent part, his personal statements, private medical records, and VA medical examination reports. When VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure the examination or opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). The Board finds that the August 2013 VA medical examinations and opinions are adequate since they are based on a review of the records, physical examinations, and history he provided. Furthermore, all opinions and conclusions are fully substantiated. Accordingly, the Board finds that VA's duty to assist with respect to obtaining a VA examination or opinion concerning these downstream initial-rating claims has been met. 38 C.F.R. § 3.159(c)(4). Standard of Review After the evidence has been assembled, it is the Board's responsibility to evaluate the entire record. 38 U.S.C.A. § 7104(a) (West 2002). When there is an approximate balance of evidence regarding the merits of an issue material to the determination of a matter, the benefit of the doubt in resolving each such issue shall be given to the claimant. 38 U.S.C.A. § 5107; 38 C.F.R. §§ 3.102, 4.3 (2013) (reasonable doubt to be resolved in Veteran's favor). In Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990), the Court stated that "a Veteran need only demonstrate that there is an 'approximate balance of positive and negative evidence' in order to prevail." To deny a claim on its merits, the preponderance of the evidence must be against the claim. See Alemany v. Brown, 9 Vet. App. 518, 519 (1996), citing Gilbert, 1 Vet. App. at 54. Increased Ratings Disability evaluations are determined by the application of the Schedule for Rating Disabilities, which assigns ratings based on the average impairment of earning capacity resulting from a service-connected disability. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4. Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. In 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). Where, as here, the appeal arises from the original assignment of a disability evaluation following an award of service connection, the severity of the disability at issue is to be considered during the entire period from the initial assignment of the disability rating to the present time. And if there have been times when the disability has been more severe than at others, the rating must be "staged". Fenderson, 12 Vet. App. at 125-26. Hyphenated diagnostic codes are used when a rating under one diagnostic code requires use of an additional diagnostic code to identify the basis for the evaluation assigned. The additional code is shown after a hyphen. Regulations provide that, when a disability not specifically provided for in the rating schedule is encountered, it will be rated under a closely related disease or injury in which not only the functions affected, but the anatomical localization and symptomatology are closely analogous. 38 C.F.R. § 4.20. Residuals of Prostate Cancer This disability was rated a zero-percent disabling, so noncompensable, before August 16, 2013, and has been rated as 40-percent disabling since under the provisions of Diagnostic Code 7528. 38 C.F.R. § 4.115b. Diagnostic Code 7528 pertains to malignant neoplasms of the genitourinary system. Id. Diagnostic Code 7528 indicates a 100 percent evaluation is warranted for malignant neoplasms of the genitourinary system. Under the express provisions of Diagnostic Code 7528, following cessation of surgical, x-ray, antineoplastic chemotherapy or another therapeutic procedure, the rating of 100 percent shall continue with a mandatory VA examination at the expiration of six months. If there is no evidence of record that shows any local recurrence or metastasis, the Veteran is to be rated on the residuals such as voiding dysfunction or renal dysfunction, whichever is predominant. 38 C.F.R. § 4.115b, Diagnostic Code 7528. According to the provisions of 38 C.F.R. § 4.115a, diseases of the genitourinary system generally result in disabilities related to renal or voiding dysfunctions, infections, or a combination of these. The following sections provide descriptions of various levels of disability in each of these symptom areas. Where diagnostic codes refer the decisionmaker to these specific areas of dysfunction, only the predominant area of dysfunction shall be considered for rating purposes. Because the areas of dysfunction described below do not cover all symptoms resulting from genitourinary diseases, specific diagnoses may include a description of symptoms assigned to that diagnosis. In May 2011, BTM, M.D., noted complaints of rectal bleeding. A physical examination revealed external hemorrhoids, but these were not the source of the Veteran's bleeding according to Dr. BTM. Rather, the Veteran had radiation proctitis. In a May 2011 record, RH, M.D. indicated that the Veteran was one year post proton therapy for prostate cancer. The main problem was blood in the stool on a daily basis. There was urinary urgency almost all of the time. There was increased urinary frequency about half of the time. There was a weak stream approximately 20 percent of the time. There was also nocturia twice a night on average. On August 2011 VA examination, the examiner indicated that there were no urinary symptoms, no urinary leakage, no general symptoms due to urinary disease, no history of recurrent urinary tract infections, no history of obstructed voiding, no urinary tract stones, no renal dysfunction/failure, no history of acute nephritis, no history of hydronephrosis, and no cardiovascular symptoms. There was erectile dysfunction. However, the bladder examination was normal. The anus and rectum examination was normal, and examination of the urethra was normal. The diagnosis was of prostate cancer in remission. The examiner indicated that the foregoing diagnosis had no occupational impact and no impact upon the usual daily activities. In his October 2011 notice of disagreement (NOD), the Veteran wrote that he awoke to urinate twice a night and that he had daytime urinary frequency that was from 30 minutes to two hours and that, if he did not urinate immediately, there was leakage. He also noted that he suffered from radiation proctitis. A November 2011 notation from Dr. BTM indicated the Veteran still had radiation proctitis and rectal bleeding due to the foregoing as well as to hemorrhoids. A November 2011 record from Dr. RH indicated there was no blood in the urine. However, there was high urinary frequency and urinary urgency almost all of the time. There was a weak stream about half of the time. There was straining less than half of the time. There was incomplete voiding less than 20 percent of the time. There was nocturia approximately twice a night. There was occasional blood in the stool and rectal urgency. In a November 2011 written statement, the Veteran indicated he was experiencing rectal bleeding and that he often had to change his underwear during the day. He recounted that there were times when blood soaked through his pants and that he had been diagnosed with radiation proctitis. Additionally, he reported urinary urgency and urinary frequency of 20 to 25 times a day. According to him, there was urinary leakage if he did not urinate immediately after feeling the urge to void. He further complained of nocturia. In August 2013, he had another VA compensation examination. The examiner indicated there was a voiding dysfunction that caused urine leakage. Absorbent materials had to be changed two to four times a day. No appliance was necessary. Voiding dysfunction caused increased urinary frequency. Urinary frequency was every one to two hours during the day, and the Veteran awoke to void twice a night. There were symptoms of obstructed voiding; the stream was markedly slow and weak. There were no urinary tract or kidney infections. There was erectile dysfunction (ED) but no retrograde ejaculation. There were no other residuals of prostate cancer. The disability had no impact on employment. Under 38 C.F.R. § 4.115a, genitourinary symptoms are rated according to the predominant area of dysfunction. The options are renal dysfunction, voiding dysfunction, urinary frequency, obstructed voiding, and urinary tract infections. The Veteran does not suffer from renal dysfunction or from urinary tract infections, so these areas of dysfunction need not be considered further. Voiding dysfunction is rated under the particular condition such as urine leakage, frequency, or obstructed voiding. Continual urine leakage, post-surgical urinary diversion, urinary incontinence, of stress incontinence requiring the use of an appliance or the wearing of absorbent materials which must be changed more than four times a day warrants a 60 percent evaluation. 38 C.F.R. § 4.115a. That which requires the wearing of absorbent materials that must be changed two to four times a day warrants a 40 percent evaluation. Id. That which requires the wearing of absorbent materials which must be changed less than two times a day warranted a 20 percent evaluation. Id. As to urinary frequency, daytime voiding at intervals of less than one hour or awakening to void five or more times a night warrants a 40 percent evaluation. Id. Daytime voiding at intervals of between one and two hours or awakening to void three to four times a night warrants a 20 percent evaluation. Id. Daytime voiding at intervals of between two and two three or awakening to void two times a night warrants a 10 percent evaluation. Id. Under obstructed voiding, urinary retention requiring intermittent or continuous catheterization warrants a 30 percent evaluation. Id. Marked obstructive symptomatology (hesitancy, slow or weak stream, decreased force of stream) with any combination of the following (1) post-void residuals greater than 150 cc; (2) uroflowmetry markedly diminished peak flow rate (less than 10 cc/sec); (3) recurrent urinary tract infections secondary to obstruction; (4) stricture disease requiring periodic dilation every two to three months warrants a 10 percent evaluation. Id. Obstructive symptomatology with or without stricture disease requiring dilation one to two times percent year warrants a zero percent evaluation. Id. As apparent from the foregoing provisions, at no time during the appeal period is an evaluation exceeding 40 percent warranted. Regarding the potentially relevant areas of dysfunction, an evaluation exceeding 40 percent is only available for voiding dysfunction manifested by requiring the use of an appliance or absorbent materials that must be changed more than four times a day. Such symptoms would warrant a 60 percent evaluation. They are not, however, present in the Veteran's case. Because an evaluation exceeding 40 percent is not warranted at any time during the appeal period, the Board must now determine whether a compensable evaluation is warranted before August 16, 2013, meaning a rating higher than the 0 percent initially assigned. The August 2011 VA examination was performed in a year during which private examination reports indicated material symptoms both before and after August. The August 2011 examination, therefore, holds little sway. The Board finds that routine private treatment records before and after August 2011 reflecting symptoms worse than those shown on examination in August 2011 render the August 2011 VA examination report less probative that the other competent and credible evidence. See Madden v. Gober, 125 F.3d 1477, 1481 (Fed. Cir. 1997), cert. denied, 523 U.S. 1046 (1998) (in adjudicating a claim, the Board is charged with the duty to assess the credibility and weight given to evidence); see also Jefferson v. Principi, 271 F.3d 1072, 1076 (Fed. Cir. 2001) (recognizing the Board's inherent fact-finding ability). The private medical records, as well as the Veteran's competent lay statements regarding his readily observable symptomatology dated before August 16, 2013, reveal a disability picture that more nearly approximates the criteria for a higher 20 percent evaluation under urinary frequency, which necessitates a daytime voiding interval of between one and two hours. 38 C.F.R. §§ 4.7, 4.115a, Urinary Frequency. The evidence does not show a daytime voiding interval of less than once an hour or five or more times during the night. Thus, an evaluation of 40 percent is not warranted under the criteria for urinary frequency. Id. The Board recognizes that the Veteran reported a higher frequency of urination in his October 2011 NOD. But the Board finds that personal estimate inconsistent with other reports he made to physicians, which reflected a lesser frequency. The Board finds the statements to health care providers more credible than those made in connection with an appeal regarding a claim for pecuniary benefits. See Rucker v. Brown, 10 Vet. App. 67, 73 (1997) (lay statements found in medical records when medical treatment was being rendered may be afforded greater probative value; statements made to physicians for purposes of diagnosis and treatment are exceptionally trustworthy because the declarant has a strong motive to tell the truth in order to receive proper care). In weighing credibility, VA may consider interest, bias, inconsistent statements, bad character, internal inconsistency, facial plausibility, self interest, consistency with other evidence of record, malingering, desire for monetary gain, and demeanor of the witness. Caluza v. Brown, 7 Vet. App. 498 (1995). Thus, the Board does not credit the estimation of frequency in the October 2011 NOD. The Board observes that an evaluation exceeding 20 percent under the criteria for obstructed voiding is not warranted because a 30 percent evaluation under the applicable provisions would require catheterization, and the Veteran does not have urinary retention requiring either intermittent or continuous catheterization. 38 C.F.R. § 4.115a, Obstructed voiding. Finally, an evaluation exceeding 20 percent also is not warranted under the criteria applicable to voiding dysfunction. 38 C.F.R. § 4.115a, Voiding Dysfunction. An evaluation exceeding 20 percent would require wearing absorbent materials that must be changed two to four times a day. Id. None of the evidence of record before August 16, 2013 mentions the need for or use of absorbent materials. Thus, again, an evaluation exceeding 20 percent is not warranted under the criteria for voiding dysfunction. Id. The Board is of the opinion, however, that a separate evaluation is warranted for the radiation proctitis causing rectal bleeding, as this is a residual of the prostate cancer treatment. As already alluded to, the evaluation of the same disability under several DCs, known as pyramiding, must be avoided. 38 C.F.R. § 4.14. But separate ratings may be assigned for distinct disabilities resulting from the same injury where the symptomatology for one condition is not duplicative of or overlapping with the symptomatology of the other condition. See Esteban v. Brown, 6 Vet. App. 259, 262 (1994); see also Amberman v. Shinseki, 570 F.3d 1377, 1381 (2009). With this in mind, the Board will evaluate this manifestation under DC 7528-7336. 38 C.F.R. §§ 4.20, 4.114, 4.115b. The rating schedule provides for a noncompensable (zero percent) rating for mild or moderate internal or external hemorrhoids. 38 C.F.R. § 4.114, Diagnostic Code 7336. Large or thrombotic hemorrhoids, irreducible, with excessive redundant tissue, evidencing frequent recurrences, are rated 10-percent disabling. Id. Hemorrhoids with persistent bleeding and with secondary anemia, or with fissures, are rated 20-percent disabling. Id. The Board concludes that a 10 percent evaluation is warranted for the radiation proctitis due to frequently recurring symptoms. Id. A 20 percent evaluation is not warranted because the evidence does not reflect persistent bleeding with such symptoms as secondary anemia. Id. The 10 percent evaluation is warranted for the entire appeal period, as there is no indication the rectal bleeding resolved. Fenderson, supra. Peripheral Neuropathy of the Right and Left Lower Extremities This disability has been rated as zero-percent disabling for each lower extremity under the provisions of Diagnostic Code 8521. 38 C.F.R. § 4.124a. Diagnostic Code 8521 pertains to the external popliteal nerve. Under this code, complete paralysis of the external popliteal nerve; foot drop and slight droop of first phalanges of all toes, cannot dorsiflex the foot, extension (dorsal flexion) of proximal phalanges of toes lost; abduction of foot lost, adduction weakened; anesthesia covers entire dorsum of foot and toes warrants a 40 percent rating. Incomplete paralysis is assigned ratings of 10 to 30 percent depending on the severity of the claimant's symptoms. A 30 percent rating is assigned for severe incomplete paralysis of the external popliteal nerve. A 20 percent rating is assigned for moderate incomplete paralysis of the external popliteal nerve. A 10 percent rating is assigned for mild incomplete paralysis of the external popliteal nerve. Words such as "mild", "moderate," and "severe" are not defined in the VA Schedule for Rating Disabilities, at least as concerning this specific disability. Rather than applying a mechanical formula, the Board must evaluate all of the evidence to the end that its decision is "equitable and just." See 38 C.F.R. § 4.6 (2013). The Board nonetheless observes in passing that "mild" is defined as "not very severe." See Webster's New World Dictionary, Second College Edition (1999), 694. "Moderate" is defined as "of average or medium quantity, quality, or extent." Id. at 704. And "Severe" is generally defined as "extremely intense." Id. at 1012. During his August 2011 VA medical examination, the Veteran reported a burning sensation and pain in his feet. The objective sensory examination was normal. The examiner diagnosed bilateral peripheral neuropathy of the lower extremities that had no impact on employability or on the usual daily activities. March 2012 private medical records reveal complaints of numbness and burning pain in the feet as well as absent sensation on Semmes-Weinstein testing. During his more recent VA examination in August 2013, the Veteran reported constant pain in his lower extremities. The pain was usually dull and mild. There were moderate paresthesias in the lower extremities as well as bilateral moderate numbness and decreased sensation to light touch. His gait was normal, and he required no assistive devices for ambulation. The examiner diagnosed bilateral lower extremity peripheral neuropathy that had no functional impact on the Veteran's ability to work. The Veteran does not suffer from complete paralysis of the external popliteal nerve with foot drop and other related symptoms. Thus, the Board must determine whether he instead has what amounts to mild, moderate, or severe incomplete paralysis of this affected nerve in each lower extremity. Upon review of the record, it appears that the symptoms of lower extremity peripheral neuropathy reported by him have been fairly consistent during the appeal period. He is competent to provide evidence regarding peripheral neuropathy symptoms because they are readily apparent through the senses. See Layno, supra. Moreover, the Board has no reason to question his credibility in reporting his lower extremity peripheral neuropathy symptoms. Thus, his assertions regarding lower extremity symptomatology constitute competent and credible evidence. Id.; see also Washington v. Nicholson, 19 Vet. App. 362, 367-68 (2005) (stating that it is the Board's duty, as fact finder, to determine the credibility and weight to be given to the evidence). Whatever rating is deemed appropriate, therefore, will apply to the entire appeal period, and a staged rating need not be considered. See generally Fenderson, supra. Although his right and left lower extremity symptoms have been described as both mild and moderate, the Board finds that the disability picture for each lower extremity more nearly approximates that necessary for a 20 percent evaluation as a moderate disability. 38 C.F.R. §§ 4.3, 4.7, 4.124a, Diagnostic Code 8521. First, because his symptoms have been described as moderate at least on occasion. Additionally, the Board finds that the persistence of the symptoms coupled with apparently constant pain and discomfort militates in favor of a finding of a moderate disability picture on the whole. See Madden, supra. An even higher 30 percent evaluation is not warranted under Diagnostic Code 8521, however, because the competent and credible evidence does not indicate a severe disability picture. Indeed, the Veteran's gait is normal, he requires no assistive devices for ambulating, and there is no apparent occupational impact or impact upon the ability to perform routine daily activities. The Board has reviewed the Rating Schedule for other potentially applicable DCs. However, there is no provision more appropriate for rating his right lower extremity peripheral neuropathy and left lower extremity peripheral neuropathy than Diagnostic Code 8521. See Schafrath, supra. See also Butts v. Brown, 5 Vet. App. 532, 539 (1993) (holding that the Board's choice of Diagnostic Code should be upheld if supported by explanation and evidence); Pernorio v. Derwinski, 2 Vet. App. 625, 629 (1992) (indicating that any change in Diagnostic Code must be specifically explained). The Derivative Issue of Employability The Court has held 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 an increased rating is whether a total disability rating due to individual unemployability (TDIU) as a result of that disability is warranted. Rice v. Shinseki, 22 Vet. App. 447, 453 (2009). In this case, however, a claim for a TDIU is not raised by the record. Specifically, the evidence of record fails to show or even suggest the Veteran is unemployable due to his prostate cancer residuals or his right and left lower extremity peripheral neuropathy. To the contrary, the VA examiners commented that these service-connected disabilities have no effect on the Veteran's employability. Therefore, the Board finds that no further consideration of a TDIU is warranted. Extraschedular Consideration The potential application of the various other provisions of Title 38 of the Code of Federal Regulations also have been considered, including 38 C.F.R. § 3.321(b)(1) (2013), which provides procedures for referral or assignment of an extraschedular evaluation. Schafrath, 1 Vet. App. at 593. The question of an extraschedular rating is a component of a claim for an increased rating. Bagwell v. Brown, 9 Vet. App. 337, 339 (1996). And 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). The VA 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). 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. 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. Thun v. Peake, 22 Vet. App. 111 (2008). Here, the Board finds that the schedular rating criteria contemplate the Veteran's service-connected prostate cancer residuals. The criteria specifically provide for ratings based on the presence of voiding dysfunction to include incontinence, urinary frequency, and obstructed voiding. Because the schedular rating criteria are adequate to rate the disability to include all of his disability manifestations, there is no exceptional or unusual disability picture to render impractical the application of the regular schedular standards. The scheduler criteria also contemplate his service-connected peripheral neuropathy of the right and left lower extremities. The ratings assigned to each lower extremity under Diagnostic Code 8521 are based on the average impairment of earning capacity resulting from disability associated with nerve disorders. The rating criteria specifically contemplate the severity of incomplete paralysis of the external popliteal nerve. The record contains no indication these disabilities cause greater difficulty than that contemplated by the 20 percent ratings that have been assigned to each lower extremity in this decision. Because the schedular rating criteria are adequate to rate the peripheral neuropathy disabilities, including all of his disability manifestations, there is no exceptional or unusual disability picture to render impractical the application of the regular schedular standards For these reasons and bases, the Board finds that the criteria for referral for extraschedular rating have not been met. 38 C.F.R. § 3.321(b)(1). ORDER A higher 20 percent initial rating is granted for the residuals of the prostate cancer for the initial period at issue before August 16, 2013, subject to the statutes and regulations governing the payment of VA compensation. But a rating higher than 40 percent for these prostate cancer residuals, including since August 16, 2013, is denied. However, a 10 percent rating is granted for radiation proctitis, subject to the statutes and regulations governing the payment of VA compensation. Higher 20 percent initial ratings also are granted for the right and left lower extremity peripheral neuropathy, subject to the statutes and regulations governing the payment of VA compensation. ______________________________________________ KEITH W. ALLEN Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs