Citation Nr: 1335600 Decision Date: 11/04/13 Archive Date: 11/13/13 DOCKET NO. 08-26 442A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in New York, New York THE ISSUES 1. Entitlement to service connection for a cervical spine disorder. 2. Entitlement to service connection for Addison's disease. 3. Entitlement to a disability rating in excess of 20 percent for a low back disability. 4. Entitlement to a disability rating in excess of 10 percent for right lower radiculopathy. 5. Entitlement to a disability rating in excess of 10 percent for left lower radiculopathy. 6. Entitlement to a total disability rating based on individual unemployability due to service-connected disabilities. WITNESSES AT HEARING ON APPEAL The Veteran and his wife ATTORNEY FOR THE BOARD M. Moore, Associate Counsel INTRODUCTION The Veteran served on active duty from February 1972 to April 1981. These matters come before the Board of Veterans' Appeals (Board) on appeal from a June 2007 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Cleveland, Ohio, that continued a 20 percent evaluation for status post excision of herniated nucleus pulposus with degenerative arthritis of the lumbosacral spine, denied service connection for Addison's disease, and declined to reopen a previously denied claim for service connection for a history of spondylosis of the cervical spine. His case is currently under the jurisdiction of the VA RO in New York, New York. In February 2012, the Veteran and his wife presented sworn testimony during a video conference hearing in Albany, New York, which was chaired by the undersigned Veterans Law Judge. A transcript of the hearing has been associated with the Veteran's claims file. In September 2012, the Board reopened the Veteran's previously denied claim of entitlement to service connection for a cervical spine disability and remanded his claims for service connection for a cervical spine disability and Addison's disease, an increased rating for a low back disability, and a total disability rating based on individual unemployability due to service-connected disabilities (TDIU) to the Appeals Management Center (AMC) for further evidentiary development. By a rating action dated in May 2013, the AMC granted separate 10 percent evaluations effective April 22, 2013 for the Veteran's right lower radiculopathy and left lower radiculopathy associated with his low back disability. As these neurological impairments are to be considered in the evaluation of the Veteran's low back disability, the Board will also consider whether the Veteran is entitled to increased ratings for his radiculopathies. The issues on appeal have been recharacterized to reflect this change. FINDINGS OF FACT 1. A chronic neck disorder was not shown in service, degenerative disc disease of the cervical spine was not diagnosed within one year of service discharge, and the preponderance of the evidence is against a finding that a cervical spine disability is the result of a disease or injury in active duty service. 2. The evidence does not establish that the Veteran was exposed to herbicide agents in service or that he served in the Republic of Vietnam. 3. An endocrine was not shown in service or within one year of service discharge; and, the preponderance of the evidence is against a finding that the Veteran's diagnosed Addison's disease is related to his active service. 4. The Veteran's service-connected low back disability is manifested by forward flexion of no less than 50 degrees with pain, extension of no less than 20 degrees with pain, right lateral flexion of no less than 20 degrees with pain, left lateral flexion of no less than 20 degrees with pain, right lateral rotation of no less than 20 degrees with pain, and left lateral rotation of no less than 20 degrees with pain, with no evidence of ankylosis or incapacitating episodes. 5. For the entire period on appeal, the Veteran's service-connected right lower radiculopathy has been manifested by no more than mild incomplete paralysis of the sciatic nerve, with numbness and intermittent radiating pain and no evidence of muscle atrophy or complete paralysis of the sciatic nerve. 6. For the entire period on appeal, the Veteran's service-connected left lower radiculopathy has been manifested by no more than mild incomplete paralysis of the sciatic nerve, with numbness and intermittent radiating pain and no evidence of muscle atrophy or complete paralysis of the sciatic nerve. 7. The Veteran does not have a signal service connected disability rated at 60 percent disabling or a total combined disability rating of 70 percent. 8. The evidence of record demonstrates that the Veteran is unemployable based solely on his service-connected disabilities. CONCLUSIONS OF LAW 1. A cervical spine disability was not incurred in or aggravated by the Veteran's active duty service and arthritis of the cervical spine may not be presumed to have been. 38 U.S.C.A. §§ 1110, 1131, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.159, 3.303, 3.304, 3.307, 3.309 (2013). 2. Addison's disease was not incurred in or aggravated by the Veteran's active duty service. 38 U.S.C.A. §§ 1110, 1131, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.159, 3.303, 3.304 (2013). 3. The criteria for a disability rating in excess of 20 percent for status post excision of a herniated nucleus pulposus with degenerative arthritis of the lumbosacral spine have not been met. 38 U.S.C.A. §§ 1155, 5102, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.159, 3.321, 4.40, 4.45, 4.71a, Diagnostic Code 5243 (2013). 4. The criteria for a 10 percent disability rating, but not greater, have been met for right lower radiculopathy for the entire period on appeal. 38 U.S.C.A. § 1155, 5102, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.159, 3.321, 4.124a, Diagnostic Code 8520 (2013). 5. The criteria for a 10 percent disability rating, but not greater, have been met for left lower radiculopathy for the entire period on appeal. 38 U.S.C.A. § 1155, 5102, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.159, 3.321, 4.124a, Diagnostic Code 8520 (2013). 6. The criteria for TDIU have been met on an extraschedular basis. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 3.340, 3.341, 4.16(b), 4.19, 4.25 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Board has thoroughly reviewed all the evidence in the Veteran's claims file. While 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 Veteran 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 claim. The Veteran 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 Veteran). 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 Veteran. 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, the Board is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the Veteran prevailing in either event, or whether a preponderance of the evidence is against a claim, in which case, the claim is denied. See Gilbert v. Derwinski, 1 Vet. App. 49 (1990). I. Duties to Notify and Assist VA has a duty to notify and a duty to assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5103, 5103A; 38 C.F.R. §§ 3.159, 3.326(a). Proper notice from VA must inform the claimant and his representative, if any, prior to the initial unfavorable decision on a claim by the AOJ of any information and any medical or lay evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b); Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004); Quartuccio v. Principi, 16 Vet. App. 183 (2002). These notice requirements apply to all five elements of a service-connection claim (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). Information that a disability rating and an effective date for the award of benefits will be assigned if service connection is awarded must be included. Id. A September 2006 letter provided all required notice elements, including information regarding disability ratings and effective dates. While the Veteran was not provided notice specific to TDIU, he was provided notice regarding the higher rating claim from which the claim for TDIU arose. Additionally, a May 2013 letter from the Director of Compensation Service notifies the Veteran of the regulations and requirements for the assignment of a TDIU, including on an extraschedular basis. Further, his statements to VA and the VA examiners pertaining to his past employment and the effect his low back disability has had upon employment reflect actual knowledge of the evidence necessary to support a claim for TDIU. Thus, the Board finds that VA has fulfilled its duty to notify. The Veteran submitted private MRI reports for the cervical, thoracic, and lumbar spines without a waiver of review by the agency of original jurisdiction. Although these MRI reports address the Veteran's cervical and lumbar spine disabilities on appeal, they are not pertinent as they merely duplicate diagnoses already of record and fail to provide any medical nexus (for the cervical spine) or findings of limited motion (for the lumbar spine). A remand is not necessary to allow to AOJ to consider this evidence in the first instance. 38 C.F.R.§ 20.1304(c) (2013). VA's duty to assist has also been satisfied. The Veteran's service treatment records, personnel records, Social Security Administration (SSA) records, VA examination reports, VA treatment records, and all obtainable private treatment records are in the file. The Veteran claims that his service treatment records and personnel records have been "sanitized" due to his participation in classified operations. However, as discussed in greater detail below, there is simply to support such an allegation. The service treatment records and personnel records cover the Veteran's entire period of service and there is no indication from the National Personnel Record Center that the Veteran's records are in any way incomplete or have been altered or destroyed. The Veteran does not claim that any missing treatment records would show inservice treatment for Addison's disease or additional treatment for neck complaints. Moreover, these claims are not being denied solely on a lack of inservice injury. Any missing service records would not help to substantiate his claims. The record indicates that the Veteran underwent VA examinations to address his neck disability, Addison's disease, and employability in October 2006 and April 2013. The reports from those examinations have been included in the claims file for review. The examinations each involved a review of the claims file, a thorough examination and interview of the Veteran, and a conclusion that was supported by sufficient rationale. The examinations are thereby adequate for to decide the Veteran's service connection and TDIU claims. See Barr v. Nicholson, 21 Vet. App. 303, 311 (2007) (affirming that a medical opinion is adequate if it provides sufficient detail so that the Board can perform a fully informed evaluation of the claim). The RO also provided the Veteran with VA examinations for his low back disability in October 2006 and April 2013. The examiner obtained a thorough history and provided detailed a physical examination, including the appropriate range of motion testing. Thus, the Board finds that the October 2006 and April 2013 examinations are adequate for determining the disability rating for the Veteran's service-connected low back disability. See Barr, supra. There is no evidence indicating that there has been a material change in the severity of the Veteran's service-connected low back disability since he was last examined. See 38 C.F.R. § 3.327(a). The duty to assist does not require that a claim be remanded solely because of the passage of time since an otherwise adequate examination was conducted. VAOPGCPREC 11-95. Thus, the Board finds that a new VA examination is not necessary at this time. Some discussion of the Veteran's February 2012 personal hearing is necessary as well. The individual presiding over a hearing must comply with the duties set forth in 38 C.F.R. § 3.103(c)(2). See Bryant v. Shinseki, 23 Vet. App. 488 (2010). These duties consist of (1) fully explaining the issues and (2) suggesting the submission of evidence that may have been overlooked. They were met here. The issues on appeal were identified. Information was also elicited from the Veteran concerning his contentions regarding the etiology of his neck disability and Addison's disease, his alleged service in Vietnam, and the effects of his service-connected low back disability, including on his employability. Notably, the Veteran's testimony triggered the Board's decision to remand the matter to obtain the above referenced VA examinations and to attempt to verify any service in Vietnam. Finally, as noted above, these matter were remanded for additional evidentiary development including obtaining outstanding VA and private treatment records, attempting to verify if the Veteran had service in Vietnam, including by obtaining his personnel records, and affording the Veteran new VA examinations and opinions, including obtaining an opinion on his employability. The Board is obligated by law to ensure that the AMC complies with its directives; where the remand orders of the Board are not complied with, the Board errs as a matter of law when it fails to ensure compliance. See Stegall v. West, 11 Vet. App. 268 (1998). A review of the record reflects that the AMC sent the Veteran a letter asking him to identify and provide a release of information for any outstanding private treatment records. The Veteran did not respond. The AMC also obtained the Veteran's personnel records and updated VA treatment records and afforded him a VA endocrine and spine examination in April 2013. Finally, the AMC referred the question of whether the Veteran's disabilities warranted the assignment of a TDIU on an extraschedular basis to the Director of Compensation Service in May 2013. Accordingly, all remand instructions issued by the Board have been complied with and this matter is once again before the Board. As there is no indication that any failure on the part of VA to provide additional notice or assistance reasonably affects the outcome of these claims, the Board finds that any such failure is harmless. See Mayfield v. Nicholson, 19 Vet. App. 103 (2005), rev'd on other grounds, Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). II. Merits of the Claims A. Service Connection Service connection may be established for a disability resulting from personal injury suffered or disease contracted in the line of duty in the active military, naval, or air service. 38 U.S.C.A. §§ 1110, 1131 (West 2002). However, that an injury or disease occurred in service is not enough; there must also be a chronic disability resulting from that injury or disease. If there is no showing of the chronic disability during service, then a showing of continuous symptoms after service is required to support a finding of chronicity. 38 C.F.R. § 3.303(b). For this purpose, a chronic disease is one listed at 38 C.F.R. § 3.309(a). See Walker v. Shinseki, 708 F.3d 1331, 1338-39 (Fed. Cir. Feb. 21, 2013) (holding that the term "chronic disease in 38 C.F.R. § 3.309(b) is limited to a chronic disease listed at 38 C.F.R. § 3.309(a)). A grant of service connection under 38 C.F.R. § 3.303(b) does not require proof of the nexus element; it is presumed. Id. Where a veteran served continuously for 90 days or more during a period of war, or during peacetime service after December 31, 1946, and certain diseases, such as arthritis and endocrine disorders (such as Addison's disease), become manifest to a degree of 10 percent or more within 1 year from date of termination of such service, such disease shall be presumed to have been incurred in service, even though there is no evidence of such disease during the period of service. 38 U.S.C.A. §§ 1101, 1112, 1113 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.307, 3.309. Service connection may also be granted for any injury or disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease or injury was incurred in service. 38 C.F.R. § 3.303(d) (2012). 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). Cervical Spine Disability The Veteran claims that he currently has a cervical spine disability that is the result of his active duty service. He says he first experienced neck pain in service as a result of a compression injury of the spine from parachuting and that this resulted in his current cervical spine disability. Post-service VA and private treatment records show complaints of neck pain and diagnoses of degenerative cervical spondylosis and degenerative disc disease at C3-4, C4-5, C5-6, and C6-7. The first element of Hickson is met. A review of the service treatment records shows no reference to an injury to the neck or cervical spine. However, the Veteran was seen and treated once in service for neck pain. See service treatment record, October 1980. As such, the second element of Hickson is met. As for the question of a medical nexus between the current diagnosis of degenerative disc disease of the cervical spine and the in-service complaint of neck pain, the Veteran was examined in April 2013. He gave a history of one week of neck pain in service with intermittent neck pain since a few years after his discharge which eventually became constant. The examiner diagnosed the Veteran with degenerative disc disease of the cervical spine and concluded that it was not related to service because the Veteran only had a single isolated experience of neck pain in service with no follow up treatment or subsequent inservice complaints. Rather, he concluded that the Veteran's neck disability was related to the age-related degenerative process. The medical evidence also includes VA and private treatment records noting the Veteran's complaints of neck pain and associated diagnoses. These records are generally consistent with the VA examinations and fail to provide any opinion on the etiology of his neck complaints. Although the treatment records do not provide any opinion linking the Veteran's neck disability to his military service, his wife, a registered nurse (RN) in New York state, suggested such a link at the February 2012 Board hearing. The Veteran's wife stated that she believed that her husband suffered from a compression injury of the low spine in service and that the effects of the trauma gradually moved up the spine. The initial low back injury progressed to damage the entire spine. Therefore, she believed that his cervical spine disability was related to his military service. The Board finds the Veteran's wife's opinion to be less probative than the VA examiner's. The Veteran's wife based her opinion on the premise that the Veteran suffered a compression injury in service - a premise that is not supported by the service treatment records. The only service treatment record to address the Veteran's neck complaints makes no such diagnosis and notes the Veteran's denial of trauma prior to the onset of neck pain. Additionally, the April 2013 VA examiner review the entire claims file prior to forming his opinion. Presumably, he reviewed the hearing transcript and the Veteran's wife's medical opinion and considered this in deciding that the Veteran's neck disability was not related to service. The April 2013 VA examiner is also a medical doctor (MD), a profession requiring more education and training than that of an RN and a profession permitted by law to make medical diagnoses. Indeed, the Board has some concerns about the competency of the Veteran's wife to provide such an opinion on the etiology of the Veteran's cervical spine disability. New York state law limits an RN's practice to "diagnosing and treating human responses to actual or potential health problems through such services as casefinding, health teaching, health counseling, and provision of care supportive to or restorative of life and well-being, and executing medical regimens prescribed by a licensed physician, dentist or other licensed health care provider." N.Y. Educ. § 6902(1) (2012). Diagnosing as an RN is distinguished from medical diagnosis and is limited to the "identification of and discrimination between physical and psychosocial signs and symptoms essential to effective execution and management of the nursing regimen." N.Y. Educ. § 6901 (2012). It does not appear from the applicable New York state regulations that RNs have the authority to diagnose or subsequently opine on the etiology of a particular diagnosis. Moreover, even if the Board were to accept the Veteran's wife as competent to provide a nexus opinion, the Board notes that it is free to favor one medical opinion over another as long as it provides an adequate basis for doing so. See Evans v. West, 12 Vet. App. 22, 30 (1998); Owens v. Brown, 7 Vet. App. 429, 433 (1995). Whether a physician (or in this case RN) provides a basis for his or her medical opinion goes to the weight or credibility of the evidence in the adjudication of the merits. See Hernandez-Toyens v. West, 11 Vet. App. 379, 382 (1998). Other factors for assessing the probative value of a medical opinion are the physician's access to the claims folder and the thoroughness and detail of the opinion. See Prejean v. West, 13 Vet. App. 444, 448-49 (2000). Thus, the Board finds the April 2013 VA examiner's opinion, as an MD, more probative as to the etiology of the Veteran's cervical spine disability than the Veteran's wife's opinion, as an RN with experiences mostly in oncology and medical surgery. The Veteran's wife's hearing testimony is less probative as a nexus opinion than the VA negative opinion and is insufficient to grant service connection for the Veteran's cervical spine disability. The only other evidence which purports to link the Veteran's current cervical spine disability to his military service consists of the Veteran's own statements. Although lay persons are competent to provide opinions on some medical issues, see Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011), as to the specific issue in this case, a cervical spine disability falls outside the realm of common knowledge of a lay person. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007) (lay persons not competent to diagnose cancer). Although the Board readily acknowledges that Veteran is competent to report symptoms of neck pain, there is no indication that the Veteran is competent to etiologically associate this neck pain and diagnosis to his military service. The Veteran has not been 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 the Veteran received any special training or acquired any medical expertise in evaluating orthopedic or spinal disorders. See King v. Shinseki, 700 F.3d 1339, 1345 (Fed.Cir.2012). This lay evidence does not constitute competent medical evidence and lacks probative value. The Board is also aware of the provisions of 38 C.F.R. § 3.303(b), referenced above, relating to chronicity and continuity of symptomatology. The Veteran complains of intermittent neck pain since service. The VA examiner considered these complaints in forming his opinion. He acknowledged the Veteran's complaints and reported history. However, he still found that his current diagnosis was not related to his active service. As such, the Board finds that the medical nexus element of Hickson cannot be met via continuity of symptomatology. As explained above, the competent medical evidence of record does not demonstrate that there is a relationship between the Veteran's active duty service and his current cervical spine disability. Although the Board notes the Veteran's current disability and in-service complaints, without sufficiently probative evidence of a medical nexus, service connection cannot be granted. There is also no indication that the Veteran was treated for or diagnosed with arthritis of the cervical spine within a year of service so as to support a grant of service connection on a presumptive basis. 38 U.S.C.A. §§ 1101, 1112, 1113 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.307, 3.309. The presumption of service connection for arthritis of the cervical spine is not applicable. Accordingly, the Board finds that the claim of entitlement to service connection for a cervical spine disability must be denied. In reaching this conclusion, the Board has considered the applicability of the benefit-of-the-doubt doctrine. However, as the preponderance of the evidence is against the Veteran's claim of entitlement to service connection, that doctrine is not applicable. 38 U.S.C.A. § 5107(b) (West 2002); 38 C.F.R. § 3.102 (2012); see also Ortiz v. Principi, 274 F.3d 1361, 1365 (Fed. Cir. 2001). Addison's Disease The Veteran claims that he currently has Addison's disease that is the result of his active duty service. Specifically, he claims that he served in a highly classified unit in the Republic of Vietnam in 1972 and that his Addison's disease may be related to exposure to herbicides during that time. He further argues that he has no family history of Addison's disease or other explanation for his diagnosis. Post-service VA and private treatment records and exam reports show that the Veteran has been diagnosed with Addison's disease, secondary Addison's disease, dysfunction of the pituitary gland, and adrenal insufficiency. As such, the first element of Hickson is met. A review of the service treatment records is negative for any diagnosis of Addison's disease or other complaints related to the endocrine system. The Veteran does not claim that his Addison's disease began in service or that he experienced any symptoms until 2000. Rather, he claims that he served in the Republic of Vietnam in 1972 and was, therefore, presumed to have been exposed to herbicide agents. 38 U.S.C.A. § 1116(f) (West 2002); 38 C.F.R. § 3.307(a)(6)(iii) (2012) (a "veteran who, during active military, naval, or air service, served in the Republic of Vietnam during the period beginning on January 9, 1962, and ending on May 7, 1975, shall be presumed to have been exposed during such service to an herbicide agent . . . unless there is affirmative evidence to establish that the veteran was not exposed to any such agent during that service."). He claims that his service records do not reflect his service in Vietnam because he served in classified operations with Special Forces/the Green Berets and his records have been "sanitized." The Board has carefully reviewed the Veteran's service records and concludes that the evidence does not support his allegation of service in Vietnam. Notably, the Veteran's personnel records reflect that his only foreign service was in Germany from 1978 to 1981. It appears that all of his service prior to that time was within the United States. Further, the Veteran's military occupational specialties (MOS) of administrative specialist and personnel administrative specialist. There is no indication that he served in the Special Forces or with a Special Forces unit, which would necessitated service in classified operations in Vietnam, Laos, and Cambodia. He is likewise not shown have received any awards or decorations consistent with service in the Republic of Vietnam or the Special Forces. Interestingly, the Veteran was not granted a secret-level security clearance until 1977. Surely if he served in classified operations in 1972, he would have received a secret-level or top secret-level security clearance at that time. With regard to the Veteran's claim that his personnel records do not accurately reflect his service, the Board notes that he requested a correction to his DD-214 in 1982, shortly after discharge, asking that his date of promotion to E6 be changed. Clearly the Veteran had thoroughly reviewed his DD-214 for accuracy at that time and was aware of the process to seek correction of any perceived errors. The fact that he made no mention of "sanitized" service records and did not seek to have his DD-214 amended to reflect service in Vietnam contradicts his current contentions of altered service records. In short, the evidence simply does not support a finding that the Veteran had service in Vietnam during the relevant period. The presumption of exposure to herbicide agents cannot be applied in this case. Moreover, even if the Board were to accept that the Veteran was exposed to herbicides in service, his claim would still fail as there is no evidence to support a medical nexus between herbicide exposure and his current Addison's disease. The Veteran was recently examined in April 2013. At that time, the VA examiner noted that the Veteran was diagnosed about 10 years earlier with adrenal insufficiency and that he has been on hydrocortisone replacement since that time. He also acknowledged letters from the Veteran's private endocrinologist and oncologist, one of which described the Veteran's Addison's disease as idiopathic and the other of which failed to make any conclusive statement regarding the etiology of his Addison's disease. The examiner concluded that he was unable to find any link between herbicide and exposure, but did note the Veteran's history of metastatic liver cancer that was treated with surgery and chemotherapy. He was unable to provide a positive nexus opinion linking the Veteran's Addison's disease and his military service. The medical evidence also includes VA and private treatment records that reference the Veteran's Addison's disease diagnosis. None of these treatment records link the Veteran's Addison's disease to his military. To the contrary, multiple VA treatment records speculate that the Veteran's Addison's disease may be secondary to his nonservice-connected liver cancer or associated surgery. See VA treatment records, February 2006, February 2009. The Veteran has also submitted letters from two of his private physicians that he claims link his Addison's disease to his military service. To the extent that these represent positive nexus opinions, the Board finds them less probative than the April 2013 VA examiner's opinion. See Evans, supra; Owens, supra. A February 2012 letter from his endocrinologist, Dr. J. W., indicated that the Veteran's pituitary gland dysfunction is idiopathic and that he was unaware of any data linking Agent Orange and Addison's disease, but that he also was not aware of any data ruling out such an association. A March 2012 letter from the Veteran's oncologist states that he was unaware of any family history of Addison's disease and that the Veteran's health had been influenced adversely by his exposure to toxins in Vietnam. The February and March 2012 opinion letters are speculative in nature. Neither physician provides any rationale for there being a positive correlation between herbicides and Addison's disease. Further, as discussed above, the Board finds that the Veteran was not exposed to herbicides in service and that his reports of service in Vietnam are not credible. Thus, any opinion based on the Veteran's reports of such exposure lacks any probative value whatsoever. See Coburn v. Nicholson, 19 Vet. App. 427 (2006). The Veteran's wife also attempted to provide a positive nexus opinion at the February 2012 Board hearing for the Veteran's Addison's disease. She stated that she believed the Veteran's Addison's disease was related to inservice herbicide exposure because he did not have any family history of Addison's disease and there was no other explanation for the development of this disease. As noted above, the Board has concerns about her competency to offer such an opinion. Notwithstanding these concerns, the Board finds her opinion lacks probative value as it is based on the incorrect premise that the Veteran was exposed to herbicides. Further, her statement that no other possible cause for Addison's disease has been identified is incorrect. As noted above, VA treatment records have suggested a link between the Veteran's Addison's disease and his nonservice-connected liver cancer. His wife's hearing testimony does not constitute sufficiently probative evidence of a medical link between the Veteran's Addison's disease and his military service. The only other evidence which purports to link the Veteran's current Addison's disease to his military service consists of his own statements. Although laypersons, such as the Veteran, are sometimes competent to provide opinions on certain medical questions, the specific issue in this case falls outside the realm of common knowledge of a lay person as it involves making definitive clinical diagnoses based on knowledge of endocrinology. See Kahana, supra; Jandreau, supra. While the Veteran can describe what he experiences (in this case, symptoms of Addison's disease), he is not able to provide competent evidence as to the etiology of this diagnosis. Providing such an opinion requires medical expertise in the causes of adrenal insufficiency, particularly in the context of a history of metastatic liver cancer with surgical and chemotherapy treatment. The Veteran has no such expertise. See Jandreau, supra; see also 38 C.F.R. § 3.159 (a)(1) (2012). The Board is also aware of the provisions of 38 C.F.R. § 3.303(b), referenced above, relating to chronicity and continuity of symptomatology. However, the Veteran has not complained of symptoms of Addison's disease since service. Rather, he has testified that he first experienced endocrine symptoms in 2000, nearly 20 years after his separation from service. Further, the Board notes that the provisions of 38 C.F.R. § 3.303(b) only apply to chronic diseases as listed in 38 C.F.R. § 3.309(a). See Walker, supra. Addison's disease is not on the list of chronic diseases. As such, the Board finds that the medical nexus element of Hickson cannot be met via continuity of symptomatology. As explained above, the evidence does not demonstrate that the Veteran had service in the Republic of Vietnam or was exposed to herbicides or that there is a relationship between his active duty service and his current Addison's disease. Although the Board notes the Veteran's current disability and discredited reports of service in Vietnam, without sufficiently probative evidence of service in Vietnam and a medical nexus, service connection cannot be granted. Accordingly, the Board finds that the claim of entitlement to service connection for Addison's disease must be denied. In reaching this conclusion, the Board has considered the applicability of the benefit-of-the-doubt doctrine. However, as the preponderance of the evidence is against the Veteran's claim of entitlement to service connection, that doctrine is not applicable. 38 U.S.C.A. § 5107(b) (West 2002); 38 C.F.R. § 3.102; see also Ortiz, supra. B. Increased Ratings The Veteran has been assigned a 20 percent evaluation under Diagnostic Code 5243 for his service-connected low back disability. He has also been assigned 10 percent evaluations under Diagnostic Code 8520 effective April 22, 2013 for his right and left lower radiculopathies associated with his low back disability. He seeks higher ratings for his low back disability and associated radiculopathies for the entire appeals period. Disability evaluations are determined by evaluating the extent to which a veteran's service-connected disability adversely affects his or her ability to function under the ordinary conditions of daily life, including employment, by comparing his or her symptomatology with the criteria set forth in the Schedule for Rating Disabilities. The percentage ratings represent as far as can practicably be determined the average impairment in earning capacity resulting from such diseases and injuries and the residual conditions in civilian occupations. Generally, the degree of disabilities specified are considered adequate to compensate for considerable loss of working time from exacerbation or illness proportionate to the severity of the several grades of disability. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. § 4.1. Separate diagnostic codes identify the various disabilities and the criteria for specific ratings. If two disability evaluations are potentially applicable, the higher evaluation will be assigned to the disability picture that more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7 (2012). Any reasonable doubt regarding the degree of disability will be resolved in favor of the veteran. 38 C.F.R. § 4.3. The veteran's entire history is reviewed when making a disability determination. 38 C.F.R. § 4.1. But where service connection has already been established, and increase in the disability rating is at issue, it is the present level of the disability that is of primary concern. See Francisco v. Brown, 7 Vet. App. 55 (1994). However, in such cases, when the factual findings show distinct time periods during which a claimant exhibits symptoms of the disability at issue and such symptoms warrant different evaluations, staged evaluations may also be assigned. See Hart v. Mansfield, 21 Vet. App. 505 (2007). The evaluation of the same disability under various diagnoses, known as pyramiding, is generally to be avoided. 38 C.F.R. § 4.14. The critical element in permitting the assignment of several ratings under various diagnostic codes is that none of the symptomatology for any one of the disabilities is duplicative or overlapping with the symptomatology of the other disability. See Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994). Intervertebral disc syndrome (preoperatively or postoperatively) is evaluated under either the General Rating Formula for Diseases and Injuries of the Spine or under the Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes, whichever method results in the higher evaluation when all disabilities are combined under 38 C.F.R. § 4.25. 38 C.F.R. § 4.71a, Diagnostic Code 5243 (2012). Under the current General Rating Formula for Diseases and Injuries of the Spine, a 20 percent rating is assigned for forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees; or 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 spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. A 40 percent evaluation is assigned for forward flexion of the thoracolumbar spine of 30 degrees or less; or, favorable ankylosis of the entire thoracolumbar spine. A 50 percent evaluation is assigned for unfavorable ankylosis of the entire thoracolumbar spine. A 100 percent evaluation is assigned for unfavorable ankylosis of the entire spine. 38 C.F.R. § 4.71a, Diagnostic Codes 5235 to 5243 (2012). For VA compensation purposes, normal forward flexion of the lumbar spine is 0 to 90 degrees, extension is 0 to 30 degrees, left and right lateral flexion are 0 to 30 degrees, and left and right lateral rotation are 0 to 30 degrees. 38 C.F.R. § 4.71a, Diagnostic Codes 5235 to 5243, Note (2) (2012). 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. Id. The normal combined range of motion of the thoracolumbar spine is 240 degrees. Id. The normal ranges of motion for each component of 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 for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes, a 10 percent evaluation is assigned for intervertebral disc syndrome with incapacitating episodes having a total duration of at least 1 week but less than 2 weeks during the past 12 months; a 20 percent evaluation is assigned for incapacitating episodes having a total duration of at least 2 weeks but less than 4 weeks during the past 12 months; a 40 percent evaluation is assigned for incapacitating episodes having a total duration of at least 4 weeks but less than 6 weeks during the past 12 months; and a 60 percent evaluation is assigned for incapacitating episodes having a total duration of at least 6 weeks during the past 12 months. 38 C.F.R. § 4.71a, Diagnostic Code 5243 (2012). For purposes of evaluations under the Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes, 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. Id. at Note (1). When evaluating disabilities of the musculoskeletal system, 38 C.F.R. § 4.40 allows for consideration of functional loss due to pain and weakness causing additional disability beyond that reflected on range of motion measurements. See DeLuca v. Brown, 8 Vet. App. 202 (1995). Further, 38 C.F.R. § 4.45 provides that consideration also be given to weakened movement, excess fatigability and incoordination. The Veteran first underwent a VA spine examination to evaluate his low back disability in conjunction with his instant claim in October 2006. He complained of moderate to severe and severe low back pain which radiated to both legs. He reported taking pain medication with no side effects. He denied flare ups, incapacitating episodes, and any constitutional symptoms of arthritis. He reported weakness and numbness in both legs and only being able to walk with a walker. Even with the walker, the examiner noted that he was limited to walking for 30 to 50 feet or 10 minutes at a time. The Veteran denied any bowel or bladder impairment and the examiner noted that he had erectile dysfunction. The examiner also noted that the Veteran was able to do activities of daily living including eating, grooming, bathing, toileting, and dressing, but that he usually did not drive and did not engage in recreational activities. He determined that the Veteran could not bend, push, pull, stoop, use a ladder, take stairs, or walk on uneven surfaces, and observed a limping gait, postural abnormalities, lumbar lordosis, painful motion and spasm, and tenderness. He recorded range of motion measurements of 55 degrees of forward flexion with pain, 40 degrees of backward extension with pain, 20 degrees of right lateral flexion with no distress, 25 degrees of left lateral flexion with pain, 20 degrees of right lateral rotation with pain, and 20 degrees of left lateral rotation with pain. Although he noted the Veteran's pain on motion, he stated that there was no additional limitation due to pain, fatigue, weakness, or lack endurance following repetitive use. The examiner also observed diminished pinprick, temperature, and touch on both feet and legs. He concluded that the Veteran's low back disability prevented him from engaging in recreational activities, driving more than occasionally, and performing his occupation. The Veteran was next examined in April 2013. He complained of low back pain with flare ups of increased pain that lasted days to a few weeks with no incapacitating episodes. He also reported a history of multiple disc surgeries and having to use a cane and taking morphine for his pain. The examiner recorded range of motion measurements of 50 degrees of forward flexion with pain at 50 degrees, 20 degrees of extension with pain at 20 degrees, 20 degrees of right lateral flexion with pain at 20 degrees, 20 degrees of left lateral flexion with pain at 20 degrees, 30 degrees of right lateral rotation with pain at 30 degrees, and 30 degrees of left lateral rotation with pain at 30 degrees. The Veteran was able to perform three repetitions of all ranges of motion with no additional limitation. The examiner also observed tenderness or pain on palpation with no guarding or spasms of the lumbosacral spine and mild symptoms of radiculopathy of the bilateral lower extremities, including intermittent pain and numbness. He determined that the Veteran did not have any other neurologic abnormalities or findings related to his low back disability. Although he noted the Veteran's lumbar spine scar, he determined it was not painful or unstable. He concluded that the Veteran's degenerative disc disease and degenerative joint disease of the lumbosacral spine limited him to sitting, standing, or walking for no more than 20 to 30 minutes, very light lifting, and no repetitive bending. He further opined that the Veteran could not engage in either sedentary or physical employment. In addition to the VA examination reports, the medical evidence of record includes VA and private treatment records for the low back which are consistent with the VA examination findings. An April 2006 private treatment record notes the Veteran's limited range of motion of the lumbar spine, but does not provide specific measurements. Additionally, an October 2008 treatment record also noted that the Veteran had evidence of lumbar radiculopathy on electrodiagnostic testing and ambulated with bilateral canes in no acute distress. A February 2010 private treatment record notes that the Veteran is functioning at a relatively high level and that he was being "somewhat melodramatic" with regards to his spinal complaints. Finally, a March 2011 letter from the Veteran's private physician, Dr. D. R. D., notes that the Veteran has severe degenerative disease of the entire spine, resulting in severe impairment as it relates to his activities of daily living. Although Dr. D. R. D. cites the Veteran's pain and use of medications and ambulatory devices, he does not provide any more specific information regarding the Veteran's limitations. In addition to the medical evidence, the Veteran has submitted lay statements and hearing testimony from his friend and his wife, as well as personal statements and hearing testimony. This lay evidence corroborates the functional limitations noted by the VA examiners, including use of a walker/cane, limits in movement and activities, and postural abnormalities. Based on the medical and lay evidence of record, the Board finds that the Veteran does not meet the criteria for a disability rating in excess of 20 percent for his low back disability. His forward flexion of the thoracolumbar spine is not limited to 30 degrees or less, nor is there any evidence of favorable or unfavorable ankylosis of any part of the spine. As such, a disability rating in excess of 20 percent based on limitation of motion or ankylosis under the General Rating Formula for Diseases and Injuries of the Spine cannot be assigned for the Veteran's low back disability. With respect to the possibility of assigning a higher disability rating according to 38 C.F.R. § 4.40 and 4.45 for the Veteran's low back disability, the Board has considered the Veteran's complaints of pain and limitation of motion, particularly during a flare up. However, there is no objective evidence to support a finding of forward flexion limited to less than 30 degrees or ankylosis during a flare up. Both VA examiners noted the Veteran's complaints of pain, but specifically stated that his painful motion did not result in any additional limitation. Further, the Board considered the point at which the Veteran first experienced pain in affirming his current 20 percent evaluation. As such, the Board finds that additional compensation need not be assigned for the Veteran's low back disability under 38 C.F.R. §§ 4.40 or 4.45. See also DeLuca, supra. With regard to applying the Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes, there is no indication in the medical evidence of record that the Veteran has experienced any incapacitating episodes as defined in VA regulations. He specifically denied any incapacitating episodes to both the October 2006 and April 2013 examiner. The VA and private treatment records are also negative for any notations of physician-prescribed bed rest to qualify as an incapacitating episode for rating purposes. 38 C.F.R. § 4.71a, Diagnostic Code 5243, Note (1). Thus, an increased rating cannot be assigned under these criteria. The Board notes that, according to Note (1), any associated objective neurologic abnormalities, including, but not limited to, bowel or bladder impairment, must be evaluated separately under the appropriate diagnostic code. There is no evidence of any bowel or bladder impairment or other neurologic abnormalities to warrant separate evaluations, other than the radiculopathies for which the Veteran has received separate evaluations. With regard to the Veteran's separately compensated right and left lower radiculopathies, separate 10 percent ratings have been assigned for each extremity effective April 22, 2013. Under Diagnostic Code 8520, a 10 percent evaluation is assigned for mild incomplete paralysis of the sciatic nerve. A 20 percent evaluation is assigned for moderate incomplete paralysis of the sciatic nerve. A 40 percent evaluation is assigned for moderately severe incomplete paralysis of the sciatic nerve. A 60 percent evaluation is assigned for severe incomplete paralysis of the sciatic nerve with marked muscular atrophy. Finally, an 80 percent evaluation is assigned for complete paralysis of the sciatic nerve with the foot dangling and dropping, no active movement of muscles below the knee possible, and flexion of the knee weakened or (very rarely) lost. 38 C.F.R. § 4.124a, Diagnostic Code 8520 (2012). The medical and lay evidence supports 10 percent evaluations for right and left lower radiculopathies for the entire period on appeal. At the time of his first VA examination in October 2006, the Veteran complained of numbness and radiating pain to both legs. The examiner also observed diminished pinprick, temperature, and touch for the bilateral lower extremities. VA and private treatment records reiterate these complaints and findings. Notably, an October 2008 private treatment record references electrodiagnostic testing from 2006 which showed evidence of lumbar radiculopathy. There is no indication that his radicular symptoms have changed throughout the appeals period or in April 2013. Separate 10 percent evaluations are appropriate for the entire period on appeal. With regard to evaluations in excess of 10 percent at any point during the appeals period, the Board finds that the evidence does not support such an increase. The April 2013 examiner specifically noted that the Veteran's sciatic nerve radiculopathy symptoms were intermittent and mild. There is no evidence of more serious symptoms to warrant a finding of moderate, moderately severe, or severe incomplete paralysis or complete paralysis of the sciatic nerve, such as foot drop or muscle atrophy, at any point during the appeals period. Increased ratings for his right and left lower radiculopathies cannot be assigned at any point during the appeals period. Furthermore, there is no indication in the record that the Veteran experiences any other neurologic abnormalities due to his low back disability. The Board notes that the Veteran has complained of bladder impairment that he attributed to his service-connected low back disability. However, this is not supported by the medical evidence. Specifically, both the October 2006 and April 2013 VA examiners found that the Veteran did not have bowel or bladder impairment attributable to his low back disability. The Board notes that the October 2006 VA examiner noted that the Veteran experienced erectile dysfunction. However, this mere notation does not include any opinion on the etiology of his erectile dysfunction or link to his low back disability. Thus, an increased evaluation cannot be assigned for neurologic abnormalities. Additionally, the Board notes that there is no indication in the medical evidence of record that the Veteran's symptomatology warranted other than the currently assigned 20 percent disability rating throughout the appeal period. An assignment of staged ratings is not warranted. See Hart, supra. In reaching the above-stated conclusions, the Board has considered the applicability of the benefit-of-the-doubt doctrine. However, as the preponderance of the evidence is against the Veteran's claims of entitlement to evaluations in excess of these for his low back disability with associated radiculopathies, that doctrine is not applicable. See 38 U.S.C.A. § 5107(b) (West 2002); 38 C.F.R. § 3.102 (2012); see also Ortiz, supra. The Board has also considered the potential application of other various provisions, including 38 C.F.R. § 3.321(b)(1), for exceptional cases where schedular evaluations are found to be inadequate. See Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Ordinarily, the VA Schedule will apply unless there are exceptional or unusual factors which would render application of the schedule impractical. See Fisher v. Principi, 4 Vet. App. 57, 60 (1993). According to the regulation, an extraschedular disability rating is warranted upon a finding that the case presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization that would render impractical the application of the regular schedular standards. 38 C.F.R. § 3.321(b)(1) (201); Fanning v. Brown, 4 Vet. App. 225, 229 (1993). In Thun v. Peake, 22 Vet. App. 111, 115-16 (2008), the Court set forth a three-step inquiry for determining whether a veteran is entitled to an extraschedular rating. First, as a threshold issue, the Board must determine whether the veteran's disability picture is contemplated by the rating schedule. If so, the rating schedule is adequate and an extraschedular referral is not necessary. If, however, the veteran's disability level and symptomatology are not contemplated by the rating schedule, the Board must turn to the second step of the inquiry, that is whether the veteran's exceptional disability picture exhibits other related factors such as those provided by the regulation as "governing norms." These include marked interference with employment and frequent periods of hospitalization. Third, if the first and second steps are met, then the case must be referred to the VA Under Secretary for Benefits or the Director of the Compensation and Pension Service to determine whether, to accord justice, a veteran's disability picture requires the assignment of an extraschedular rating. With regard to the Veteran's service-connected low back disability and associated radiculopathies, the evidence of record does not reflect that the Veteran's disability picture is so exceptional as to not be contemplated by the rating schedule. There is no unusual clinical picture presented, nor is there any other factor which takes the disability outside the usual rating criteria. The rating criteria for the Veteran's currently assigned 20 percent and 10 percent disability ratings under Diagnostic Codes 5243 and 8520 contemplate his level of symptomatology. Specifically, the criteria account for all limitation of motion and any symptoms related to his low back disability and any complaints relating to sciatic nerve paralysis. The Veteran's complaints of pain, limited range of motion due to pain, and functional limitation are also adequately contemplated by the rating schedule. Notably, 38 C.F.R. §§ 4.40 and 4.45 adequately contemplate any functional loss due to pain, weakness, fatigability, incoordination, or pain on movement of the joint. As the Veteran's disability picture is contemplated by the rating schedule, the threshold issue under Thun is not met and any further consideration of governing norms or referral to the appropriate VA officials for extraschedular consideration is not necessary. In short, the evidence does not support the proposition that the Veteran's service-connected disability presents such an exceptional or unusual disability picture as to render impractical the application of the regular schedular standards and to warrant the assignment of an extraschedular rating under 38 C.F.R. § 3.321(b)(1) (2012). Thus, referral of these issues to the appropriate VA officials for consideration of an extraschedular evaluation is not warranted. C. TDIU The Veteran has complained that his neck, low back (with associated radiculopathies), and Addison's symptoms prevent him from gaining and maintaining employment. As discussed in great detail above, the Veteran has been denied service connection for his neck disability and Addison's disease. Further, he has not claimed that his remaining service-connected disabilities (prostatitis, asthma, hemorrhoids, and left forearm and left thigh lipoma/cyst excisions) have any effect on his employability. See Veteran's Application for Compensation and/or Pension, April 2006; Board hearing transcript, February 2012. Therefore, the Board will consider whether his low back disability, with associated radiculopathies, is outside the norm and renders him unemployable. VA will grant a total rating for compensation purposes based on 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. 38 C.F.R. §§ 3.340, 3.341, 4.16. 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. 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. 38 C.F.R. § 4.16(a). Where these percentage requirements are not met, entitlement to benefits on an extraschedular basis may be considered when a veteran is unable to secure and follow a substantially gainful occupation by reason of service-connected disability, and consideration is given to the veteran's background including his or her employment and educational history. 38 C.F.R. § 4.16(b). The Board does not have the authority to assign an extraschedular total disability rating for compensation purposes based on individual unemployability in the first instance. See Bowling v. Principi, 15 Vet. App. 1 (2001). 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 nonservice-connected disabilities. 38 C.F.R. §§ 3.341, 4.16, 4.19. The Veteran filed his claim for TDIU on April 1, 2006. In a May 2013 rating decision, he was granted service connection for right lower radiculopathy and left lower radiculopathy, each assigned a 10 percent evaluation effective April 22, 2013. This decision has assigned the 10 percent ratings for the radiculopathies to the date of claim. He is also in receipt of several non-compensable disability ratings. As such, the Veteran has a combined rating to 40 percent throughout the course of the appeal. Put another way, the Veteran has not had a single service-connected disability ratable at 60 percent or more, and his total disability rating has been less than 70 percent. His service-connected disabilities do not meet the percentage rating standards for schedular TDIU. 38 C.F.R. § 4.16(a). Nonetheless, the Board must consider whether the evidence warrants the assignment of TDIU on an extraschedular basis under the provisions of 38 C.F.R. § 4.16(b). As noted above, the Board may not grant an extraschedular TDIU in the first instance and must first instead refer the case to appropriate VA officials for a initial determination as to the appropriateness of extraschedular TDIU. See Bowling, 15 Vet. App. at 6. Although the Board is precluded from initially assigning an extraschedular rating, there is no restriction on the Board's ability to review the adjudication of an extraschedular rating once the Director of Compensation and Pension (C&P) determines that an extraschedular rating is not warranted. Anderson v. Shinseki, 22 Vet. App. 423, 427-28 (2009); see also Floyd v. Brown, 9 Vet. App. 88, 96 (1996) (stating that once Board properly refers an extraschedular rating issue to Director of C&P for review, the appellant may "continue[ ] to appeal the extraschedular rating aspect of this claim"); see also 38 U.S.C.A. §§ 511(a), 7104(a) (West 2002) ("All questions in a matter ... subject to decision by the Secretary shall be subject to one review on appeal to the ... Board."). Here, the AMC referred the Veteran's case to the Director of C&P for consideration of extraschedular TDIU. A May 2013 decision from the Director determined that extraschedular TDIU was not warranted. While the Director's office conducted a detailed review of the April 2013 VA examination, shown by the extensive summary of such, there is limited analysis of why that evidence supports the stated conclusion that "the evidence does not demonstrate that the Veteran is unable to secure and follow any substantially gainful occupation." The decision references the Veteran's outstanding (now denied) claim for service connection for a cervical spine disability and the April 2013 VA examiner's opinion that the Veteran is unable to perform physical or sedentary employment. Although there is some reference to the Veteran's ability to sit, stand, or walk for up to 20 to 30 minutes at a time, the denial does not provide a thorough rationale or reasoning for its conclusion. As discussed in greater detail in the increased rating section above, the Veteran was examined for his low back disability in October 2006 and April 2013. The October 2006 examiner noted several functional limitations relating to the Veteran's low back and concluded that he would not work with machinery. He also noted that the Veteran reported leaving his job in 2001 due to his low back disability and that he would be unable to perform that job. Although the examiner did not give an opinion on the Veteran's employability overall, just in the context of his most recent job, he did provide relevant details regarding the Veteran's functional limitations. Specifically, he noted that the Veteran could not bend, push, pull, stoop, or use a ladder or take stairs, and that he was limited to walking for 10 minutes at a time with a walker. The April 2013 examiner specifically addressed the Veteran's employability in light of his service-connected low back disability. He noted that the Veteran could not sit, stand, or walk for longer than 20 to 30 minutes at a time or engage in repetitive bending or any lifting other than very light. He concluded that the Veteran could not perform either sedentary or physical employment and was therefore precluded from gainful employment due to his service-connected low back disability. The Director of Compensation Service's note that the Veteran had an outstanding cervical spine service connection claim seems to insinuate that the April 2013 examiner's opinion was based on all of the Veteran's spinal disabilities. However, the Board's review of the examination report finds that the examiner separated his discussion of each disability and that these findings are specific to his service-connected lumbosacral spine disability. The remaining medical evidence, including VA and private treatment records, reiterates the Veteran's severe functional limitations from his low back disability. Notably, there is no evidence to contradict the April 2013 VA examiner's conclusion that the Veteran is unemployable. Rather, the only additional medical evidence to address his employability, a December 2006 letter from his private physician, Dr. K. H., states that he is completely and permanently disabled due to his spinal conditions with associated neurological diagnoses. Although Dr. K. H. does not specifically state that the Veteran is unemployable, he is clearly implying such from his use of the term "completely disabled." As the medical evidence has established that the Veteran's capacity to perform both physical and sedentary occupational tasks is severely impaired, the Board finds that he is unable to obtain or retain substantially gainful employment by reason of his service-connected low back disability. Accordingly, the criteria for TDIU, on an extraschedular basis, have been met. (CONTINUED NEXT PAGE) ORDER Entitlement to service connection for a cervical spine disability is denied. Entitlement to service connection for Addison's disease is denied. Entitlement to a disability rating in excess of 20 percent for a low back disability is denied. Entitlement to a disability rating of 10 percent for right lower radiculopathy is granted for the entire period on appeal, subject to the laws and regulations governing the award of monetary benefits. Entitlement to a disability rating of 10 percent for left lower radiculopathy is granted for the entire period on appeal, subject to the laws and regulations governing the award of monetary benefits. Entitlement to a total disability rating based on individual unemployability due to service-connected disability is granted, on an extraschedular basis, subject to the laws and regulations governing the award of monetary benefits. ____________________________________________ MICHAEL A. HERMAN Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs