Citation Nr: 1335369 Decision Date: 11/04/13 Archive Date: 11/13/13 DOCKET NO. 10-15 120 ) DATE ) ) On appeal from the Department of Veterans Affairs (VA) Regional Office (RO) in Muskogee, Oklahoma THE ISSUES 1. Entitlement to service connection for post traumatic stress disorder (PTSD). 2. Entitlement to an evaluation in excess of 20 percent for degenerative disc disease of the lumbosacral spine with arthritis. 3. Entitlement to an increased (compensable) evaluation for seborrheic dermatitis. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD Christopher Maynard, Counsel INTRODUCTION The Veteran had active service from July 1966 to April 1970 and from March 1972 to July 1990. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a July 2009 decision by the RO which granted an increased rating to 20 percent for the Veteran's low back disability, and denied service connection for PTSD and an increased rating for seborrheic dermatitis. By rating action in September 2009, the RO, in part, denied service connection for depression. The Veteran and his representative were notified of this decision and did not appeal. In that rating action, the RO also granted service connection for defective hearing; rated noncompensably disabling. The Veteran disagreed with the noncompensable rating assigned, and a statement of the case was promulgated in August 2010. However, the Veteran did not perfect an appeal for that issue. Accordingly, these matters are not in appellate status and will not be addressed in this decision. The United States Court of Appeals for Veterans Claims has held that VA should consider alternative psychiatric disorders within the scope of an initial claim for service connection for a specific psychiatric disorder. See Clemons v. Shinseki, 23 Vet. App. 1 (2009). In this case, however, the Veteran has specifically limited his claim to the issue of service connection for PTSD. The Veteran did not appeal the denial of his claim of service connection for depression, and that matter is final Therefore, because the Veteran clearly limited his current claim to only service connection for PTSD, the Board's jurisdiction is limited. See 38 U.S.C.A. § 7105 (West 2002). FINDINGS OF FACT 1. The Veteran has not reported any stressor incident or fearful experience in service or provided any competent medical evidence of a diagnosis of PTSD, and was not shown to have PTSD on VA psychiatric examination during this appeal. 2. The Veteran's low back disability is manifested by pain and limitation of motion to no less than 60 degrees with a combined range of motion greater than 120 degrees, without guarding, abnormal gait or spinal contour and no incapacitating episodes; additional functional loss of use due to pain, weakness, fatigability, or incoordination to a degree commensurate with the criteria for a higher evaluation is not demonstrated. 3. The Veteran's seborrheic dermatitis is manifested by a recurring rash, primarily on his neck/upper back area that affects less than 5 percent of the exposed area and total body surface, and requires systemic corticosteroid therapy. CONCLUSIONS OF LAW 1. The Veteran does not have PTSD due to disease or injury which was incurred in or aggravated by service. 38 U.S.C.A. §§ 1110, 1131, 1154(a), 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304, 3.307, 3.309 (2012). 2. The criteria for an evaluation in excess of 20 percent for degenerative disc disease of the lumbosacral spine with arthritis are not met. 38 U.S.C.A. §§ 1155, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.159, 4.3, 4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5242 (2012). 3. The criteria for an increased evaluation to 10 percent, and no higher, for seborrheic dermatitis are met. 38 U.S.C.A. §§ 1155, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.159, 4.3, 4.7, 4.118, Part 4, including Diagnostic Code 7806 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS VCAA Before addressing the merits of the Veteran's claim, the Board is required to ensure that the VA's "duty to notify" and "duty to assist" obligations have been satisfied. See 38 U.S.C.A. §§ 5103, 5103A (West 2002); 38 C.F.R. § 3.159 (2012). Under the Veterans Claims Assistance Act (VCAA), when VA receives a complete or substantially complete application for benefits, it must notify the claimant of the information and evidence not of record that is necessary to substantiate a claim, which information and evidence VA will obtain, and which information and evidence the claimant is expected to provide. 38 C.F.R. § 3.159. Such notice must indicate that a disability rating and an effective date for the award of benefits will be assigned if there is a favorable disposition of the claim. Id; 38 U.S.C.A. §§ 5100, 5102, 5106, 5107, 5126; 38 C.F.R. §§ 3.326; see also Pelegrini v. Principi, 18 Vet. App. 112, 120-21 (2004) (Pelegrini II); Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). The notification obligation in this case was accomplished by way of a letter from the RO to the Veteran dated in April 2009. See Quartuccio v. Principi, 16 Vet. App. 183 (2002); Pelegrini v. Principi, 18 Vet. App. 112 (2004); Mayfield v. Nicholson, 19 Vet. App. 103 (2005), rev'd on other grounds, 444 F. 3d 1328 (Fed. Cir. 2006). With respect to the duty to assist in this case, the Veteran's service treatment records (STRs) and all VA and private medical records identified by him have been obtained and associated with the claims file. The Veteran's Virtual VA records have also been reviewed. The Veteran was examined by VA during the pendency of this appeal, and was scheduled for a Travel Board hearing in July 2011, but failed to report, and did not request to be rescheduled. As such, his hearing request is deemed withdrawn. 38 C.F.R. § 20.704(d). The Board finds that the VA and QTC examinations were comprehensive in scope and adequate upon which to base a decision on the merits of the issues on appeal. The reports included a detailed description of the Veteran's medical history, a discussion and analysis of the clinical findings, and provided rational explanations for the conclusions reached. Concerning the claim for PTSD, in the April 2009 RO letter the Veteran, was provided with a questionnaire and requested to provide VA with specific details of his alleged stressors that resulted in his claimed PTSD and a list of any healthcare providers who have treated him since his discharge from service. However, the Veteran did not return the enclosed stressor questionnaire or provide VA with any information concerning his alleged stressors. In July 2009, the RO made a formal finding that there was insufficient information to attempt to verify any stressful events through appropriate channels, and notified the Veteran in the statement of the case (SOC) promulgated in March 2010. In light of the Veteran's failure to provide VA with the requested information concerning any alleged stressor in service, including on VA QTC psychiatric examination in November 2010, and the psychologist's assessment that the Veteran does not meet the criteria for a diagnosis of PTSD, the Board finds that any additional record search would be futile. Further, neither the Veteran nor his representative have made the RO or the Board aware of any additional evidence that needs to be obtained in order to fairly decide the issues on appeal, and have not argued that any error or deficiency in the accomplishment of the duty to notify and duty to assist has prejudiced him in the adjudication of his appeal. See Shinseki v. Sanders, 129 S.Ct.1696 (2009). Based on a review of the claims file, the Board finds that there is no indication in the record that any additional evidence relevant to the issues to be decided herein is available and not part of the claims file. See Mayfield v. Nicholson, 499 F.3d 1317 (Fed. Cir. 2007). Therefore, the Board finds that duty to notify and duty to assist have been satisfied and will proceed to the merits of the Veteran's appeal. Service Connection - In General Service connection will be granted if the evidence demonstrates that a current disability resulted from an injury or disease incurred in or aggravated by active military service. 38 U.S.C.A. § 1110; 38 C.F.R. § 3.303(a). Establishing service connection generally requires (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) competent evidence of a nexus between the claimed in-service disease or injury and the present disability. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004); see Caluza v. Brown, 7 Vet. App. 498, 506 (1995), aff'd per curiam, 78 F.3d 604 (Fed.Cir.1996) (table); see also Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004); Hickson v. West, 12 Vet. App. 247, 253 (1999); 38 C.F.R. § 3.303. In relevant part, 38 U.S.C. § 1154(a) requires that the VA give "due consideration" to "all pertinent medical and lay evidence" in evaluating a claim to disability or death benefits. Lay evidence can be competent and sufficient to establish a diagnosis of a condition when (1) a layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed.Cir.2007). In fact, competent medical evidence is not necessarily required when the determinative issue involves either medical etiology or a medical diagnosis. Id. at 1376-77; see also Buchanan v. Nicholson, 451 F .3d 1331, 1337 (Fed.Cir.2006); Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. Sept 14, 2009). Service connection for PTSD requires: (1) medical evidence diagnosing the condition, (2) credible supporting evidence that the claimed in-service stressor actually occurred, and (3) a link, established by medical evidence, between current symptomatology and the claimed, in-service stressor. 38 C.F.R. § 3.304(f). The evidence necessary to establish the occurrence of a stressor during service to support a diagnosis of PTSD will vary depending upon whether the Veteran engaged in "combat with the enemy" as established by official records, including recognized military combat citations, or other supportive evidence. If VA finds that the Veteran engaged in combat with the enemy and the alleged stressor is combat-related, then the Veteran's lay testimony or statement is accepted as conclusive evidence of the stressor's occurrence and no further development or corroborative evidence is required, provided that such testimony is found to be "satisfactory," i.e., credible, and "consistent with the circumstances, conditions or hardships of service." See 38 U.S.C.A. § 1154(b); 38 C.F.R. § 3.304(f); Dizoglio v. Brown, 9 Vet. App. 163, 164 (1996); West v. Brown, 7 Vet. App. 70, 76 (1994); Zarycki v. Brown, 6 Vet. App. 91, 98 (1993). If, however, VA determines that the Veteran did not engage in combat with the enemy or that the Veteran engaged in combat with the enemy but the alleged stressor is not combat-related, the Veteran's lay testimony, by itself, is insufficient to establish the occurrence of the alleged stressor. Instead, the record must contain credible supporting evidence that corroborates the Veteran's statements or testimony. Cohen v. Brown, 10 Vet. App. 128, 142 (1993). The regulations pertaining to PTSD were recently amended and 38 C.F.R. § 3.304(f)(3) no longer requires the verification of an in-service stressor if involving "fear of hostile military or terrorist activity." Rather, lay testimony alone can be used to establish the occurrence of an in-service stressor in these situations. The new regulatory provision requires that: (1) A VA psychiatrist or psychologist, or contract equivalent, must confirm that the claimed stressor is adequate to support a diagnosis of PTSD; (2) the claimed stressor is consistent with the places, types, and circumstances of the Veteran's service; and (3) the Veteran's symptoms are related to the claimed stressor. Id. The liberalizing criteria contained in the new § 3.304(f)(3) will be applied to PTSD service connection claims that are pending as of the effective date of the regulation (July 13, 2010) and to claims filed on or after this effective date. In cases where a Veteran asserts service connection for injuries or disease incurred or aggravated in combat, 38 U.S.C.A. § 1154(b) and its implementing regulation, 38 C.F.R. § 3.304(d), are applicable. This statute and regulation ease the evidentiary burden of a combat Veteran by permitting the use, under certain circumstances, of lay evidence. If the Veteran was engaged in combat with the enemy, VA shall accept as sufficient proof of service connection satisfactory lay or other evidence of service incurrence, if the lay or other evidence is consistent with the circumstances, conditions, or hardships of such service. 38 U.S.C.A. § 1154(b); 38 C.F.R. § 3.304(d). To establish service connection, however, there must be medical evidence of a nexus between the current disability and the combat injury if it involves a complex medical issue. See Davidson v. Shinseki, 581 F.3d 1313, 1315-16 (Fed. Cir. 2009); Dalton v. Nicholson, 21 Vet. App. 23, 36-37 (2007). The Board is charged with the duty to assess the credibility and weight given to evidence. Madden v. Gober, 125 F.3d 1477, 1481 (Fed. Cir. 1997), cert. denied, 523 U.S. 1046 (1998); Wensch v. Principi, 15 Vet. App. 362, 367 (2001). Indeed, in Jefferson v. Principi, 271 F.3d 1072 (Fed. Cir. 2001), the United States Court of Appeals for the Federal Circuit (Federal Circuit), citing its decision in Madden, recognized that that Board had inherent fact-finding ability. Id. at 1076; see also 38 U.S.C.A. § 7104(a) (West 2002). Moreover, the United States Court of Appeals for Veterans Claims (Court) has declared that in adjudicating a claim, the Board has the responsibility to weigh and assess the evidence. Bryan v. West, 13 Vet. App. 482, 488-89 (2000); Wilson v. Derwinski, 2 Vet. App. 614, 618 (1992). PTSD As noted above, while the Veteran seeks to establish service connection for PTSD related to service, he has not provided VA with any stressor information that he believes is the cause of his current psychiatric problems. Nonetheless, the Veteran was afforded a VA QTC examination in November 2010 to determine whether he has PTSD that is related to service. At that time, the Veteran reported that he served 25 years in the Navy and was a mechanic on an aircraft carrier. He said that he participated in combat activities during the Vietnam war, but did not describe any specific traumatic incidents or fearful experiences. He said that a good friend of his was killed on the USS Forrestal in Vietnam, but that he could not recall his friend's name and was not present at his death. The Veteran reported that he was "paranoid" around people, gets irritated with "stupid drivers" and did not want to be around other people, except retired military. He said that his symptoms began about five to seven years ago, but that he had not sought any treatment. The examiner included a discussion of the Veteran's reported symptoms with respect to the DSM IV criteria and concluded that he did not meet the criteria for a diagnosis of PTSD. The diagnosis was depression, not otherwise specified (NOS). The evidentiary record also includes numerous VA outpatient notes showing treatment for various maladies from 2009 to 2011. When first seen by VA mental health services in February 2009, the Veteran reported that he gets upset by "stupid people - negative people - like they don't care, no respect for anybody" and said that his symptoms began about five years earlier, but could not recall any specific precipitating cause. He said that he just doesn't like to be around a lot of people and gets "real aggravated" with them. The diagnosis was depressive disorder, NOS. When seen in September 2009, the Veteran reported that drinks beer almost daily and was encouraged by friends to seek help with his drinking. He said that he wanted to cut back on his drinking and believes that it contributed to his depression. The assessment was alcohol dependency. When seen in December 2009, the Veteran reported that he was feeling much better since he quit drinking hard liquor, and that he had good neighbors and friends and helps out on their farm. He said that he drinks six to eight beers a day, more or less, but would not state specifically how much he drank and did not want to speak with a substance abuse counselor. The assessment was alcohol dependence. The examiner indicated psychotherapy would be terminated secondary to his improvement and lack of issues and motivation to address anything else. As noted above, service connection for PTSD requires: (1) medical evidence diagnosing the condition, (2) credible supporting evidence that the claimed in-service stressor actually occurred, and (3) a link, established by medical evidence, between current symptomatology and the claimed, in-service stressor. 38 C.F.R. § 3.304(f). In this case, while the Veteran believes that he has PTSD related to service, he has not reported any specific traumatic incident or fearful experience in service or provided VA with any stressor information, and has not submitted any competent medical evidence of a diagnosis of PTSD. The Veteran does not allege, nor do the STRs show any complaints, treatment, abnormalities or diagnosis for any psychiatric problems in service or until some 14 years after his discharge from service. When first seen by VA in February 2009, the Veteran described his frustration and disappointment with inconsiderate and disrespectful people in general, and reported that his symptoms began about five years earlier. Moreover, the Veteran was not shown to meet the criteria for a diagnosis of PTSD when examined by VA in November 2010. The psychologist interviewed the Veteran, elicited a detailed history of his military service and psychiatric complaints, and offered a rational and plausible explanation for concluding that the Veteran does not have PTSD. See Wray v. Brown, 7 Vet. App. 488, 493 (1995); see also Preteen v. West, 13 Vet. App. 444, 448-9 (2000) (factors for assessing the probative value of a medical opinion include the thoroughness and detail of the opinion.). Based on the evidence of record, the Board finds that the totality of the competent, probative evidence is against the claim of service connection for PTSD. As noted above, in order to prevail on a claim of service connection for PTSD, a threshold matter is whether the Veteran manifests PTSD. Here, there is no objective evidence or competent medical opinion that the Veteran has PTSD under DSM-IV criteria. Unlike McClain v. Nicolson, 21 Vet. App. 319 (2007), this is not a case where a diagnosis is conceded as established at one time and become asymptomatic. Rather, the Board finds that the Veteran has never manifested PTSD. Accordingly, the claim is denied. The benefit of the doubt has been considered, but there is not an approximate balance of positive and negative evidence regarding the merits of the issue on appeal. Therefore, that doctrine is not for application in this case because the preponderance of the evidence is against the Veteran's claim. See Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). Increased Ratings - In General In general, when an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). However, staged ratings are appropriate in any increased-rating claim in which distinct time periods with different ratable symptoms can be identified. Hart v. Mansfield, 21 Vet. App. 505 (2007). Disability evaluations are determined by the application of a schedule of ratings, which is based on average impairment of earning capacity. Separate diagnostic codes identify the various disabilities. 38 U.S.C.A. § 1155; 38 C.F.R., Part 4. The percentage ratings in VA's Schedule for Rating Disabilities (Schedule) represent as far as can practicably be determined the average impairment in earning capacity resulting from such disabilities and their residual conditions in civil occupations. 38 C.F.R. § 4.1. 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 these elements. The functional loss may be due to absence of part, or all, of the necessary bones, joints and muscles, or associated structures, or to deformity, adhesions, defective enervation, or other pathology, or it may be due to pain, supported by adequate pathology and evidenced by visible behavior of the claimant undertaking the motion. Weakness is as important as limitation of motion, and a part which becomes painful on use must be regarded as seriously disabled. 38 C.F.R. §§ 4.10, 4.40, 4.45. Low Back Disability The Veteran contends that he has chronic low back pain and believes that the 20 percent evaluation currently assigned does not adequately reflect the severity of his disability. While the Veteran is competent to offer evidence as to the visible symptoms or manifestations of a disease or disability, his belief as to its current severity under pertinent rating criteria or the nature of the service-connected pathology is not probative evidence. Only someone qualified by knowledge, training, expertise, skill, or education, which the Veteran is not shown by the record to possess, may provide evidence requiring medical knowledge. See Barr v. Nicholson, 21 Vet. App. 303, 309 (2007); Layno v. Brown, 6 Vet. App. 465, 470 (1994). The Veteran's low back disability is rated 20 percent disabling under Diagnostic Codes (DC) 5242 for degenerative arthritis of the spine. The regulations provide for evaluation of the spine under the General Rating Formula for Diseases and Injuries of the Spine or under the Formula for Rating Intervertebral Disc Syndrome (IDS) Based on Incapacitating Episodes, whichever method results in the higher evaluation when all disabilities are combined under § 4.25. 38 C.F.R. § 4.71a, The Spine, Note (6) (2012). Under the General Rating Formula, the regulations provide, in pertinent part, for a 20 percent rating when forward flexion of the thoracolumbar spine is greater than 30 degrees, but not greater than 60 degrees; or the combined range of motion of the thoracolumbar spine is not greater than 120 degrees; or there is muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. A 40 percent rating is assigned when forward flexion of the thoracolumbar spine is to 30 degrees or less; or with favorable ankylosis of the entire thoracolumbar spine. A 50 percent rating is warranted if there is unfavorable ankylosis of the entire thoracolumbar spine. A 100 percent rating is warranted if there is unfavorable ankylosis of the entire spine. These ratings are warranted if the above-mentioned manifestations are present, 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. 38 C.F.R. § 4.71a, DCs 5235 to 5243 (2012). The rating criteria under the General Formula for Diseases and Injuries of the Spine also provide, in pertinent part, the following Notes: Note (1): Evaluate any associated objective neurologic abnormalities, including, but not limited to, bowel or bladder impairment, 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 combined normal range of motion of the thoracolumbar spine is 240 degrees. The normal ranges of motion for each component of the spinal motion provided in this note are the maximum that can be used for calculation of the combined range of motion. Id. Under the Formula Based on Incapacitating Episodes, a 10 percent evaluation is assigned with incapacitating episodes having a total duration of at least one week but less than two weeks during the past 12 months; a 20 percent evaluation is assigned with incapacitating episodes of having a total duration of at least two weeks but less than four weeks during the past 12 months; a 40 percent evaluation is assigned with incapacitating episodes of having a total duration of at least four weeks but less than six weeks during the past 12 months; and a 60 percent evaluation is assigned with incapacitating episodes of having a total duration of at least six weeks during the past 12 months. Id. Note (1): For purposes of evaluations under 5243, an incapacitating episode is a period of acute signs and symptoms due to intervertebral disc syndrome that requires bed rest prescribed by a physician and treatment by a physician. Under DC 8520, mild incomplete paralysis of the sciatic nerve is assigned a 10 percent rating, moderate incomplete paralysis is assigned a 20 percent rating, and a 40 percent evaluation is assigned for moderately severe incomplete paralysis. Complete paralysis is where the foot dangles and drops, no active movement possible of muscles below the knee, and flexion of the knee weakened or lost. DC 8520. Incomplete paralysis indicates a degree of lost or impaired function substantially less than the type picture for complete paralysis given, whether due to varied level of the nerve lesion or to partial regeneration. When the involvement is wholly sensory, the rating should be for the mild, or at most, the moderate degree. 38 C.F.R. § 4.124a. On VA QTC examination in May 2009, the Veteran complained of constant low back pain with stiffness, numbness, loss of bowel and bladder control. The Veteran described his pain as crushing, burning, aching, sticking and cramping, and said that it was an 8 on a scale of 1 to 10. The pain could be elicited by stress and was relieved with Tylenol. The Veteran denied any incapacitating episodes, but said that he doesn't like to leave the house due to his inability to control his bladder. On examination, there was some tenderness but no evidence of muscle spasm or radiating pain on movement and straight leg raising was negative. Forward flexion was to 60 degrees with extension, right and left lateral flexion and right and left rotation to 30 degrees. There was no pain on motion or additional range of motion loss due to pain, fatigue, weakness, lack of endurance or on repetitive movement. There was no signs of intervertebral disc syndrome or permanent nerve root involvement. On neurological evaluation, motor function, sensory and reflexes were within normal limits. Rectal examination was entirely normal with no evidence of hemorrhoids, fissures or masses. The Veteran's prostate and genital examination was within normal limits. X-ray studies revealed degenerative arthritis and degenerative disc disease of the lumbar spine. In an addendum report, dated in May 2009, the QTC examiner noted that the Veteran had a scar on the right flank secondary to kidney surgery (history of tumor removed from kidney), but that there was no evidence of incontinence, stains or use of absorbent pads, and no loss of rectal tone. The diagnoses included degenerative arthritis and degenerative disc disease of the lumbar spine. When examined by VA in February 2011, the Veteran reported severe low back pain with flare-ups every two to three weeks, lasting three to seven days precipitated by standing or walking more than 30 minutes, excessive bending and stooping and lifting more than 40 pounds, alleviated by rest, hot shower and medication. The Veteran denied any history of incontinence, but reported urgency and frequency two to three times a day and three times a night with occasional fecal and incontinence. He also reported spasms and paresthesias, but denied any numbness. The Veteran said that he was not sure of the cause of his symptoms and had never been told that they were related to his low back disability. He described constant, moderate pain up to six days a week, lasting one to two days at a time. He could walk a quarter to less than a mile and did not require any assistive devices. On examination, the Veteran's posture and gait were normal and there was no evidence of kyphosis, lumbar lordosis, listing, scoliosis, or curvature of the spine. There was some tenderness and pain on motion, but no evidence of spasm, muscle atrophy, guarding or weakness. Forward flexion was to 70 degrees and extension, rotation and right and left lateral flexion was to 20 degrees with pain on motion in all modalities. On repetitive motion, forward flexion was to 60 degrees with extension, rotation and right and left lateral flexion to 15 degrees with pain. Reflexes, motor function and sensation was within normal limits. X-ray studies showed some loss of normal lordosis suggestive of spasm, and moderate degenerative disc disease of the lumbar spine. The VA outpatient reports of record from 2009 to 2011 showed no complaints, treatment or findings pertaining to the Veteran's lumbosacral spine. A list of the Veteran's VA prescriptions included Triamcinolone cream. In the instant case, the evidence showed that the Veteran has good range of motion of the lumbar spine, but no evidence of muscle atrophy or any neurological abnormalities. The most severe limitation of forward flexion of the thoracolumbar spine was to 60 degrees (May 2009 QTC examination), with the most severe combined range of motion to 170 degrees (February 2011 VA examination). While there was some evidence of possible muscle spasm, there was no guarding or any evidence of an abnormal gait or abnormal spinal contour, such as, scoliosis, reverse lordosis or abnormal kyphosis. Accordingly, there is no basis for the assignment of a higher evaluation based on the general rating formula criteria. Additionally, the Veteran has not had any incapacitating episodes (periods of acute signs and symptoms that requires bed rest prescribed by a physician and treatment by a physician), having a total duration of at least two weeks but less than four weeks in any 12 month period during the pendency of this appeal. Likewise, the evidence does not show any significant neurological impairment associated with the Veteran's lumbar spine. While the Veteran has reported a history of bowel and bladder problems of unknown etiology, the VA examiner in May 2009 found no evidence of incontinence, stains or loss of rectal tone, and noted that the Veteran did not wear any pads. Moreover, the VA examiner in February 2011 opined that the Veteran's bowel and bladder complaints were not related to his low back disability. Thus, a rating in excess of 20 percent based on incapacitating episodes is not warranted. The Board has also considered whether an increased evaluation is in order in this case when separately evaluating and combining the orthopedic and neurologic manifestations of the Veteran's low back disability under the orthopedic rating criteria and applicable neurologic rating criteria. In this regard, the Board notes that while the Veteran reported a history of numbness and paresthesias when examined by VA during the pendency of this appeal, there was no objective evidence of any associated weakness, sensory loss, or extremity muscle atrophy. Sensation was intact in the lower extremities, straight leg raising was negative, and there was no evidence of any bowel or bladder impairment associated with the low back disability. Based on the clinical and diagnostic evidence of record, the Board finds no evidence of clinically significant symptoms compatible with sciatic neuropathy associated with the Veteran's low back disability. Therefore, a compensable evaluation is not warranted under DC 8520 for mild incomplete paralysis of the sciatic nerve. Thus, consideration of separately evaluating and combining the neurologic and orthopedic manifestations of the Veteran's lumbar spine disability would not result in a higher rating. Consideration must also be given to any functional impairment of the Veteran's ability to engage in ordinary activities and the effect of pain on the functional abilities. 38 C.F.R. §§ 4.10, 4.40, 4.45, 4.59 (2012). In this regard, the Board observes that under the Rating Schedule, the general rating formula notes that the rating criteria are to be applied with or without symptoms such as pain, stiffness, or aching in the area of the spine affected by residuals of injury or disease. Other than the Veteran's report of chronic pain and stiffness, there was no evidence of visible behavior or adequate pathology to suggest that any additional functional impairment was commensurate with the criteria necessary for an evaluation in excess of 20 percent for either spinal segment. The Court has held that, "a finding of functional loss due to pain must be supported by adequate pathology and evidenced by the visible behavior of the claimant. 38 C.F.R. § 4.40." Johnston v. Brown, 10 Vet. App. 80, 85 (1997). As noted above, the VA examinations during the pendency of this appeal showed no muscle weakness, atrophy or neurological impairments, and the range of motion demonstrated is specifically contemplated by the rating schedule. While the Veteran was shown to have some additional limitation of motion (to 60 degrees) on repetitive movement when examined by VA in February 2011, the degree of limitation was entirely consistent with the criteria for a 20 percent rating, and no higher. Accordingly, the Board finds that there was no evidence of visible behavior or adequate pathology to suggest that any additional functional impairment was commensurate with the criteria necessary for a higher evaluation. Mitchell v. Shinseki, 25 Vet. App. 32 (2011) (holding that pain must affect some aspect of "the normal working movements of the body" such as "excursion, strength, speed, coordination, and endurance," in order to constitute functional loss.) Applying the appropriate diagnostic codes to the facts of this case, the objective assessment of the Veteran's present impairment from his low back disability does not suggest that he has sufficient symptoms so as to a warrant an evaluation in excess of 20 percent. Accordingly, the Board finds that the 20 percent evaluation assigned accurately depicts the severity of the Veteran's low back disability for the entirety of the rating period on appeal, and there is no basis for a higher staged rating. See Hart v. Mansfield, 21 Vet. App. 505 (2007); see also, Fenderson v. West, 12 Vet. App. 119 (1999). Seborrheic Dermatitis The Veteran contends that he has a recurring skin rash on his neck, upper back, hands and face off and on, which he treats with a prescription cream, and believes that his skin disorder should be assigned a compensable evaluation. The Veteran's skin disorder is rated noncompensably disabling under DC 7806 for dermatitis/eczema, which provides for a zero percent rating where the skin disability covers less than 5 percent of the entire body or less than 5 percent of the exposed areas affected, and no more than topical therapy was required over the past 12-month period. A 10 percent rating is assigned where the skin disability covers at least 5 percent, but less than 20 percent of the entire body, or at least 5 percent, but less than 20 percent of the exposed areas affected, or, intermittent systemic therapy such as corticosteroids or other immunosuppressive drugs were required for a total duration of less than six weeks during the past 12-month period. A 30 percent rating is assigned when the disorder covers 20 to 40 percent of his entire body or 20 to 40 percent of exposed areas affected, or by systemic therapy being required for a total duration of six weeks or more, but not constantly, during the past 12-month period. The objective findings on VA examination in May 2009 showed only some mild exfoliation on the Veteran's back area. There was no ulcerations, crusting, disfigurement, tissue loss, indurations, inflexibility, hypo- or hyperpigmentation, abnormal texture or limitation of motion of the affected area. The examiner indicated that the exfoliation represented zero percent of skin in the exposed area and covered 0.1 percent the whole body. The exfoliation was not associated with systemic disease or a nervous condition. The Veteran reported that he had to use a prescription steroid cream for 30 days in the past 12 months for his skin disorder, and did not experience any side effects from the medication. When examined by VA in January 2011, the Veteran reported that he had a rash on the back of his neck about three weeks earlier that he treated with a steroid cream with good results. On examination, there was no evidence of an active skin rash or any skin condition on the Veteran's hands, face or neck. There was a small elevated popular lesion measuring 0.5 cm by 0.3 cm on the right thigh, without oozing or discharge and was not tender or painful on palpation. There was also a healed linear scar on the left maxillary area from a previous basal cell carcinoma (BCC) excision. However, the examiner opined that the BCC was not likely related to the Veteran's seborrheic dermatitis. The diagnoses included history of dermatitis with no current skin rash. In this case, the evidence does not show that the Veteran's dermatitis covers at least 5 percent of the entire body or 5 percent of the exposed areas affected. However, the evidence showed he has required intermittent systemic therapy with a corticosteroid (Triamcinolone cream) for a total duration of less than six weeks in a 12-month period during the pendency of this appeal. Accordingly, the Board finds the preponderance of the evidence favors the assignment of a 10 percent evaluation for the Veteran's seborrheic dermatitis. The medical reports do not show that the Veteran's dermatitis covered at least 20 percent of his entire body or 20 percent of exposed areas affected, or that systemic therapy was required for a total duration of six weeks or more for any 12-month period during the pendency of this appeal. Accordingly, an evaluation in excess of 10 percent is not warranted. Collateral Matters Consideration has also been given regarding whether the schedular evaluations are inadequate, thus requiring that the RO refer a claim to the Under Secretary for Benefits or to the Director, Compensation and Pension Service, for consideration of "an extra-schedular evaluation commensurate with the average earning capacity impairment due exclusively to the service-connected disability or disabilities." 38 C.F.R. § 3.321(b)(1); Barringer v. Peake, 22 Vet. App. 242, 243-44 (2008) (noting that the issue of an extraschedular rating is a component of a claim for an increased rating and referral for consideration must be addressed either when raised by the veteran or reasonably raised by the record). In determining whether an extra-schedular evaluation is for consideration, the Board must first consider whether there is an exceptional or unusual disability picture, which occurs where the diagnostic criteria do not reasonably describe or contemplate the severity and symptomatology of a veteran's service-connected disability. See Thun v. Peake, 22 Vet. App. 111, 115 (2008). If there is an exceptional or unusual disability picture, the Board must next consider whether the disability picture exhibits other factors such as marked interference with employment and frequent periods of hospitalization. Thun, 22 Vet. App. at 115-16. When those two elements are met, the appeal must be referred for consideration of the assignment of an extra-schedular rating. Otherwise, the schedular evaluation is adequate, and referral is not required. 38 C.F.R. § 3.321(b)(1)(2012); Thun, 22 Vet. App. at 116. The rating criteria in this case are not inadequate. An evaluation in excess of the assigned ratings is provided for certain manifestations of the service-connected disabilities, but the evidence reflects that those manifestations are not present in this case. The Veteran primarily complains of low pain and itching, irritated skin during active skin rashes. These are not exceptional or unusual features of the disabilities and are symptoms contemplated in the rating criteria and related regulations. As the Board finds that the Veteran's disability picture is contemplated by the rating schedule, the inquiry ends and the Board need not consider whether the disability picture for his low back disability and seborrheic dermatitis exhibits other related factors such as marked interference with employment and frequent periods of hospitalization. Accordingly, referral for consideration of an extra-schedular rating is not warranted. Finally, the Board notes that, in Rice v. Shinseki, 22 Vet. App. 447 (2009), the Court held that a claim for a total rating based on individual unemployability (TDIU) is part of an increased rating claim when such claim is expressly raised by the Veteran or reasonably raised by the record. The Court further held that when evidence of unemployability is submitted at the same time that the Veteran is appealing the initial rating assigned for a disability, the claim for TDIU will be considered part and parcel of the claim for benefits for the underlying disability. Id. In this case, the Board finds that a claim for a TDIU was not expressly raised by the Veteran or reasonably raised by the record. While the Veteran has alleged that his low back disability and skin disease cause some functional limitations during flare-ups or when his skin rash is active, the objective findings of record do not show or otherwise suggest that his low back disability or dermatitis would preclude substantially gainful employment. His skin disorder is well controlled with medication and his low back disability, even after repetitive motion, does not cause more than moderate impairment. The Veteran served over 22 years in the Navy, then worked some 17 years in various jobs after service, including as a bar tender, short order cook and maintenance man and retired when he was eligible for Social Security. (See November 2010 QTC and February 2011 VA examination reports). Based on the evidence of record, the Board finds that further consideration of a TDIU is not warranted. ORDER Service connection for PTSD is denied. An increased evaluation for degenerative disc and degenerative joint disease of the lumbosacral spine is denied. An increased rating to 10 percent for seborrheic dermatitis is granted, subject to VA regulations concerning the payment of monetary benefits. ____________________________________________ WAYNE M. BRAEUER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs