Citation Nr: 1621672 Decision Date: 05/31/16 Archive Date: 06/08/16 DOCKET NO. 14-00 923 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Pittsburgh, Pennsylvania THE ISSUES 1. Entitlement to a disability rating higher than 40 percent for spondylosis and degenerative disc disease of the lumbar spine. 2. Entitlement to a disability rating higher than 10 percent for epidermophytosis of the feet. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD C. Fleming, Counsel INTRODUCTION The Veteran had active military service from June 1944 to November 1944. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a January 2008 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Pittsburgh, Pennsylvania, in which the RO denied the benefits sought on appeal. The Veteran timely appealed the decision, and in pertinent part, the Board remanded the issues listed above in October 2015 for further evidentiary development and adjudication. In that remand, the Board instructed the agency of original jurisdiction (AOJ) to obtain additional VA examination and then re-adjudicate the claims. The AOJ obtained VA examinations in November 2015 and provided the Veteran a supplemental statement of the case (SSOC) in February 2016 in which it again denied his claims for increase. Thus, there has been compliance with the Board's remand instructions. See Stegall v. West, 11 Vet. App. 268, 271 (1998) (noting that 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). The Veteran testified before the undersigned at a hearing at the RO in August 2015. A transcript of the hearing has been associated with the Veteran's claims file. This appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2015). 38 U.S.C.A. § 7107(a)(2) (West 2014). FINDINGS OF FACT 1. The Veteran's spondylosis and degenerative disc disease of the lumbar spine has been manifested by flexion of the lumbar spine no worse than 5 degrees when pain on motion is taken into consideration, as well as muscle spasm, guarding, and tenderness to palpation; his disability is not manifested by unfavorable ankylosis of the entire thoracolumbar spine or by prescribed bed rest that amounts to 6 weeks in a 12-month period. 2. The Veteran's epidermophytosis of the feet has not been shown to cover more than 5 percent of total body area; it requires the use of a topical antifungal lotion but no systemic therapy, corticosteroid treatment, or immunosuppressive drugs. CONCLUSIONS OF LAW 1. The criteria for a disability rating higher than 40 percent for spondylosis and degenerative disc disease of the lumbar spine have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.3, 4.7, 4.40, 4.45, 4.59, 4.71, 4.71a, Diagnostic Code 5242 (2015). 2. The criteria for a disability rating higher than 10 percent for epidermophytosis of the feet have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.3, 4.7, 4.118, Diagnostic Codes 7806, 7813 (2015). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Duties to Notify and Assist At the outset, the Board notes the Veterans Claims Assistance Act of 2000 (VCAA), Pub. L. No. 106-475, 114 Stat. 2096 (2000), enacted in November 2000. See 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, and 5107 (West 2014). To implement the provisions of the law, VA promulgated regulations codified at 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2015). The VCAA and its implementing regulations include, upon the submission of a substantially complete application for benefits, an enhanced duty on the part of VA to notify a claimant of the information and evidence needed to substantiate a claim, as well as the duty to notify the claimant of what evidence will be obtained by whom. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b). In addition, they define the obligation of VA with respect to its duty to assist a claimant in obtaining evidence. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159(c). Here, the Board finds that all notification and development action needed to arrive at a decision on the claims on appeal has been accomplished. In this respect, through a September 2011 notice letter, the Veteran received notice of the information and evidence needed to substantiate his claims. Thereafter, he was afforded the opportunity to respond. Hence, the Board finds that the Veteran has been afforded ample opportunity to submit information and/or evidence needed to substantiate his claims. The Board also finds that the September 2011 notice letter satisfies the statutory and regulatory requirement that VA notify a claimant what evidence, if any, will be obtained by the claimant and which evidence, if any, will be retrieved by VA. See Quartuccio v. Principi, 16 Vet. App. 183, 187 (2002) (addressing the duties imposed by 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b)). In the letter, the RO notified the Veteran that VA was required to make reasonable efforts to obtain medical records, employment records, or records from other Federal agencies. The RO also requested that the Veteran identify any medical providers from whom he wanted the RO to obtain and consider evidence. Proper VCAA notice must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. See Pelegrini v. Principi, 18 Vet. App. 112, 121 (2004). These requirements were met by the aforementioned September 2011 notice letter. The Board thus finds that "the appellant [was] provided the content-complying notice to which he [was] entitled." Pelegrini, 18 Vet. App. at 122. In this regard, the more detailed notice requirements set forth in 38 U.S.C.A. §§ 7105(d) and 5103A have been met. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006), aff'd, Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007). In addition, the Veteran was given the opportunity to respond following the September 2011 notice letter. The Board also points out that there is no indication that any additional action is needed to comply with the duty to assist in connection with the claims on appeal. Records of the Veteran's post-service treatment from VA treatment providers are of record. In addition, the Veteran was afforded VA examinations in May 2011, September 2011, September 2014, and November 2015; reports of those examinations are of record. In that connection, the Board notes that when VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). As noted below, the Board finds that the VA examinations obtained in this case are adequate, as they are predicated on consideration of all of the pertinent evidence of record, to include the Veteran's statements, and document that the examiners conducted full physical examination of the Veteran. Accordingly, the Board finds that VA's duty to assist with respect to obtaining a VA examination or opinion regarding the claims on appeal has been met. 38 C.F.R. § 3.159(c)(4). The Veteran has further been given the opportunity to submit evidence, and he has provided written argument in support of his claims and has testified before the undersigned Veterans Law Judge. The Veteran has not identified, and the record does not indicate, existing records pertinent to the claims that need to be obtained. Under these circumstances, the Board finds that VA has complied with all duties to notify and assist required under 38 U.S.C.A. § 5103A and 38 C.F.R. § 3.159. II. Analysis The Veteran contends that his service-connected spondylosis and degenerative disc disease of the lumbar spine is more disabling than reflected by the 40 percent rating currently assigned. He also contends that his service-connected epidermophytosis of the feet is more disabling than reflected by the 10 percent rating currently assigned. Relevant medical evidence consists of VA examinations conducted in May 2011, September 2011, September 2014, and November 2015, as well as records of treatment the Veteran has received from VA treatment providers. Report of the May 2011 VA skin examination reflects that the Veteran was diagnosed with dermatophytosis of the feet that was treated with daily topical cream. He complained at the time of itchy, dry, flaky skin on his feet and reported flare-ups every month that caused the skin between his toes to break out, as well as cracking, bleeding, and itching and mild limitation of motion of the feet. Physical examination revealed dry, scaling skin on the feet affecting less than 5 percent of total body area, with no exposed areas affected. Report of VA orthopedic examination conducted in September 2011 reflects that the Veteran reported progressively worsening pain in his low back that flared up with activity. He reported muscle spasm in the back "very rarely" and denied bowel or bladder complaints. The Veteran denied any total incapacitation over the previous 12 months. He was noted to walk with a walker and to stand with a stooped posture. Range-of-motion testing revealed flexion to 55 degrees, with pain beginning at 40 degrees. The examiner noted exquisite tenderness to palpation, muscle spasm, and increased pain in the back on repetitive-motion testing. The examiner noted that the Veteran had weakened movement, fatigability, and pain on motion of the lumbar spine. The examiner diagnosed the Veteran with spondylosis and degenerative disc disease of the lumbar spine and found the Veteran to have intervertebral disc syndrome without any incapacitating episodes over the previous 12 months. At the September 2011 VA skin examination, the Veteran again complained of itchy, dry, flaky skin on his feet as well as problems with his toenails. He reported flare-ups with breakouts between the toes and occasional cracking and bleeding. He again reported treating the disorder with topical cream. He stated that his feet often itched and that the itching occasionally "comes up his legs." The examiner found a total of less than 5 percent of total body area affected, with no exposed areas affected. The diagnosis was dermatophytosis treated with constant or near-constant topical medication. At the September 2014 VA orthopedic examination, the Veteran reported that he had constant back pain that worsened with bending and lifting. He also complained of pain in his legs and stated that he used a cane or a walker for ambulation. The examiner noted that the Veteran experienced weakness, fatigability, incoordination, instability, and disturbance of locomotion due to his back disorder. Physical examination found him to have flexion to 40 degrees, with pain beginning at 35 degrees, although the examiner noted that the Veteran stood at 30 degrees of forward flexion as baseline. The examiner also noted tenderness to palpation but found no ankylosis to be present. Report of the September 2014 VA skin examination reflects that the examiner again diagnosed dermatophytosis of the feet. The Veteran complained of dry, flaky skin on his feet, as well as an occasional rash between his toes. He reported using a topical cream daily to treat the symptoms and stated that he experienced flare-ups every week to every month. The examiner found the total body area affected to be less than 5 percent, with no exposed areas affected. Report of the November VA orthopedic examination reflects that the Veteran continued to complain of back pain that radiated into his lower extremities, as well as occasional muscle spasms in his back. He reported that he could sit for at least 2 hours but stand for only 5 to 10 minutes and walk for 20 yards with a walker before needing a rest. He was noted to use a walker or wheelchair regularly. He denied any bowel or bladder symptoms but complained that activity caused worsening back pain. Range-of-motion testing showed flexion to 55 degrees with pain and guarding, although the examiner noted that the Veteran's lumbar spine was flexed to at least 90 degrees as he sat in his wheelchair. The Veteran was unable to complete repetitive motion testing due to concerns about balance and strength, but the examiner estimated that repetition would cause an additional loss of 5 to 10 degrees of forward flexion. Physical examination showed guarding, spasm, and tenderness to palpation of the paraspinal muscles. The examiner found no ankylosis or intervertebral disc syndrome. The Veteran was noted to have radiculopathy of the lower extremities, but no other neurological disorders were diagnosed. The Veteran also underwent an additional VA skin examination in November 2015. At that time, he was again diagnosed with dermatophytoses of the feet. He reported using topical medication daily, and the examiner found his symptoms to be "well controlled," with no pain or itching unless he discontinued use of the medication. Flare-ups were noted to cause itching, irritation, and cracking of the skin on his feet. The examiner acknowledged the Veteran's report of experiencing similar symptoms on the legs, back, arms, and hands but found that the symptoms occurring on the "other areas of the body (other than feet) are more likely just episodes of dry skin and NOT related to his foot issues." The total body area affected was again found to be less than 5 percent, , with no exposed areas affected, and little dryness and no significant lesions, sores, or other skin abnormalities observed. In addition, the Veteran has received ongoing treatment from VA treatment providers for his complaints of pain in the lumbar spine and skin symptoms on his feet. He has also testified before the undersigned Veterans Law Judge, at which time he complained that his skin symptoms were affecting his arms, hands, back, and legs. He also stated at the hearing that his back pain had worsened and that he was using his wheelchair more frequently for ambulation. The Veteran's entire history is reviewed when making disability evaluations. See generally 38 C.F.R. § 4.1; Schafrath v. Derwinski, 1 Vet. App. 589 (1995). Where entitlement to compensation already has been established and 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). Where entitlement to compensation has already been established, VA must address the evidence concerning the state of the disability from the time period one year before the claim for an increase was filed until VA makes a final decision on the claim. The Court has held that consideration of the appropriateness of a staged rating is required. See Hart v. Mansfield, 21 Vet. App. 505, 509-10 (2007). Disability evaluations are determined by comparing a Veteran's symptoms with criteria set forth in VA's Schedule for Rating Disabilities, which are based on average impairment in earning capacity. 38 U.S.C.A. § 1155 (West 2014); 38 C.F.R. Part 4 (2015). When a question arises as to which of two ratings applies under a particular diagnostic code, the higher of the two evaluations is assigned if the disability more closely approximates the criteria for the higher rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7 (2015). After consideration of the evidence, any reasonable doubt remaining is resolved in favor of the Veteran. 38 C.F.R. § 4.3 (2015). When evaluating musculoskeletal disabilities, VA must consider granting a higher rating in cases in which the Veteran experiences functional loss due to limited or excess movement, pain, weakness, excess fatigability, or incoordination (to include during flare-ups or with repeated use). See 38 C.F.R. §§ 4.40, 4.45 (2015); DeLuca v. Brown, 8 Vet. App. 202, 204-07 (1995). The provisions of 38 C.F.R. § 4.40 and 38 C.F.R. § 4.45 are to be considered in conjunction with the diagnostic codes predicated on limitation of motion. Johnson v. Brown, 9 Vet. App. 7 (1996). Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. In VA Fast Letter 06-25 (November 29, 2006), VA's Compensation and Pension Service noted that to properly evaluate any functional loss due to pain, examiners, at the very least, should undertake repetitive testing (to include at least three repetitions) of the joint's range of motion, if feasible. It was determined that such testing should yield sufficient information on any functional loss due to an orthopedic disability. In its rating decisions, the AOJ evaluated the Veteran's spondylosis and degenerative disc disease of the lumbar spine in accordance with the criteria set forth in the General Rating Formula for Diseases and Injuries of the Spine, 38 C.F.R. § 4.71a, Diagnostic Code 5242 (2015). Under the General Rating Formula for Diseases and Injuries of the Spine, in pertinent part, a 100 percent rating is warranted for unfavorable ankylosis of the entire spine. A 50 percent rating is warranted for unfavorable ankylosis of the entire thoracolumbar spine. A 40 percent rating is warranted for forward flexion of the thoracolumbar spine 30 degrees or less, or, favorable ankylosis of the entire thoracolumbar spine. 38 C.F.R. § 4.71a, Diagnostic Code 5242. Following the criteria set forth in the General Rating Formula for Diseases and Injuries of the Spine, Note (1) provides: evaluate any associated objective neurologic abnormalities, including, but not limited to, bowel or bladder impairment, separately, under an appropriate diagnostic code. Note (2) provides that, for VA compensation purposes, normal forward flexion of the thoracolumbar spine is zero to 90 degrees, extension is zero to 30 degrees, left and right lateral flexion are zero to 30 degrees, and left and right lateral rotation are zero to 30 degrees. The combined range of motion refers to the sum of the range of forward flexion, extension, left and right lateral flexion, and left and right rotation. The normal combined range of motion of the thoracolumbar spine is 240 degrees. The normal ranges of motion for each component of spinal motion provided in this note are the maximum that can be used for calculation of the combined range of motion. Note (3) provides that in exceptional cases, an examiner may state that because of age, body habitus, neurologic disease, or other factors not the result of disease or injury of the spine, the range of motion of the spine in a particular individual should be considered normal for that individual, even though it does not conform to the normal range of motion stated in Note (2). Provided that the examiner supplies an explanation, the examiner's assessment that the range of motion is normal for that individual will be accepted. Note (4) requires that each range of motion measurement be rounded to the nearest five degrees. Note (5) provides that for VA compensation purposes, unfavorable ankylosis is a condition in which the entire cervical spine, the entire thoracolumbar spine, or the entire spine is fixed in flexion or extension, and the ankylosis results in one or more of the following: difficulty walking because of a limited line of vision; restricted opening of the mouth and chewing; breathing limited to diaphragmatic respiration; gastrointestinal symptoms due to pressure of the costal margin on the abdomen; dyspnea or dysphagia; atlantoaxial or cervical subluxation or dislocation; or neurologic symptoms due to nerve root stretching. Fixation of a spinal segment in neutral position (zero degrees) always represents favorable ankylosis. Note (6) provides that disabilities of the thoracolumbar and cervical spine segments must be separately evaluated, except when there is unfavorable ankylosis of both segments, which will be rated as a single disability. For evaluation of intervertebral disc syndrome under Diagnostic Code 5243, with incapacitating episodes having a total duration of at least four weeks but less than six weeks during the past 12 months, a 40 percent rating is assignable. With incapacitating episodes having a total duration of at least six weeks during the past 12 months, a 60 percent rating is assignable. Id. For purposes of evaluations under Diagnostic Code 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. If intervertebral disc syndrome is present in more than one spinal segment, provided that the effects in each spinal segment are clearly distinct, each segment is to be evaluated on the basis of incapacitating episodes or under the General Rating Formula for Diseases and Injuries of the Spine, whichever method results in a higher evaluation for that segment. Id. Upon review of the evidence, the Board finds that a disability rating higher than 40 percent for the Veteran's service-connected spondylosis and degenerative disc disease of the lumbar spine is not warranted under the General Rating Formula for Diseases and Injuries of the Spine. In this connection, the Board notes that the Veteran's spondylosis and degenerative disc disease of the lumbar spine has been manifested by disability equating to no worse than a limitation on the range of motion consisting of flexion to no worse than 5 degrees even when pain on motion is taken into consideration as per DeLuca, supra. Ratings of 50 percent and 100 percent ratings are not warranted because the Veteran does not experience ankylosis of his spine. In reaching this conclusion, the Board notes in particular that each VA examiner has found the Veteran not to have ankylosis, and no treatment providers have made any such findings in his treatment records. Limitation of motion, even when severe, does not amount to ankylosis in the presence-as there is in this case-of any remaining motion in the spine. Therefore, the Board finds that a disability rating higher than 40 percent for spondylosis and degenerative disc disease of the lumbar spine is not warranted. See 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.3, 4.7, 4.71a, Diagnostic Code 5242 (2015). In reaching this decision, the Board acknowledges that the VA examiners have observed the Veteran to have pain throughout the range of motion and to report flare-ups that caused increased pain and limitation of motion. 38 C.F.R. §§ 4.40, 4.45, 4.59, 4.71, 4.71a, Diagnostic Codes 5003, 5242; DeLuca, 8 Vet. App. at 204-07. As discussed above, however, the functional impact of the Veteran's low back disability has been considered by his VA examiners, and when reporting the loss experienced by the Veteran there has been no indication that his ability to function is restricted beyond the limits of motion specifically described in the September 2011, September 2014, and November 2015 VA examination reports. The evidence reflects that the VA examiners considered the Veteran's pain on motion, including repetitive motion, when reporting on the range of motion of his lumbar spine. As noted above, the September 2014 and November 2015 examiners both specifically found no ankylosis, or disability tantamount to ankylosis, to be present. As such, there is simply no indication that the Veteran's disability, even with consideration of flare-ups due to pain, would approximate a 50 percent rating for unfavorable ankylosis of thoracolumbar spine, or a 100 percent rating for unfavorable ankylosis of the entire spine, at any point during the appeal period. See 38 C.F.R. §§ 4.40, 4.45; DeLuca, 8 Vet. App. at 204-07; see also Johnston v. Brown, 10 Vet. App. 80 (1997) (when receiving the maximum rating for limitation of motion, further analysis under DeLuca is not required). (Service connection is not in effect for disability of the entire spine.) The Board acknowledges the Veteran's statements to the effect that his low back disorder causes him pain and functional impairment. Here, however, the Board finds that the current 40 percent rating takes into consideration any interference with the Veteran's overall function of his lumbar spine due to his service-connected spondylosis and degenerative disc disease of the lumbar spine, including both pain on motion and flare-ups of the disability. The Board has also considered the Veteran's spondylosis and degenerative disc disease of the lumbar spine under the rating criteria for intervertebral disc syndrome. However, the evidence does not support a rating higher than 40 percent under those criteria. In that connection, the Board notes that although the September 2011 VA examiner diagnosed the Veteran with intervertebral disc syndrome, that examiner specifically found him not to have experienced any incapacitating episodes over the previous 12 months. (No other VA examiner or treatment provider has diagnosed intervertebral disc syndrome.) As such, the Board finds that consideration of the Veteran's spondylosis and degenerative disc disease of the lumbar spine under the rating criteria for intervertebral disc syndrome does not result in a rating higher than the 40 percent currently assigned. The Board notes particularly that the Veteran has not been found to have suffered from any incapacitating episodes to warrant a rating under Diagnostic Code 5243 for intervertebral disc syndrome at any time during the appeal period. The Board also finds that there are no other potentially applicable diagnostic codes by which to consider the Veteran's service-connected spondylosis and degenerative disc disease of the lumbar spine. In this case, while there is radiological evidence of degenerative changes of the lumbosacral spine, the Veteran is being rated for limitation of motion of the lumbosacral spine associated with such degenerative changes. Furthermore, the maximum rating otherwise allowable for arthritis in the absence of limitation of motion is 20 percent. See 38 C.F.R. § 4.71a, Diagnostic Codes 5003, 5010 (2015). The Board also notes, as discussed above, that there is no evidence that the Veteran's spondylosis and degenerative disc disease of the lumbar spine has resulted in disability comparable to ankylosis at any time during the appeal period, rendering higher ratings under the current General Rating Formula for Diseases and Injuries of the Spine inappropriate. The Board further acknowledges the Veteran's contentions of experiencing radiating pain and numbness into his lower extremities; however, the Veteran is currently service connected for lumbar radiculopathy of the lower extremities bilaterally, which has not been made a subject of this appeal; no other neurological disorder has been diagnosed at any time during the appeal period. Thus, the Board finds that no other separate rating for neurological disability is warranted. The Board is cognizant, as discussed above, that the Veteran has complained of painful motion of his lumbar spine. As noted above, in VA Fast Letter 06-25, VA has determined that repetitive testing of a joint should yield sufficient information on any functional loss due to an orthopedic disability. Most recently, testing of the Veteran's lumbar spine in November 2015 revealed flexion of the lumbar spine to 55 degrees, with pain on motion. At worst, the Veteran has been found to have forward flexion of the lumbar spine to 10 degrees, with pain beginning at 5 degrees. In this case, the Board has taken into consideration the Veteran's complaints of pain but finds, in light of the fact that he is being rated for limitation of motion of the lumbar spine under Diagnostic Code 5242, that any such pain and its effect on his range of motion is contemplated in the rating currently assigned. Therefore, the Board does not find that a disability rating higher than the 40 percent currently assigned for the Veteran's lumbar spine disability based on any additional functional loss under 38 C.F.R. §§ 4.40, 4.45, or 4.59 is warranted under the rating criteria. Regarding the Veteran's epidermophytosis of the feet, the Board notes that the disorder has been rated by the RO under the provisions of Diagnostic Code 7813 (which directs the disabilities to be rated as scars under Diagnostic Codes 7801-7805, or as dermatitis under Diagnostic Code 7806). Under Diagnostic Code 7806, regarding dermatitis or eczema, a 10 percent rating requires that at least 5 percent, but less than 20 percent, of the entire body, or at least 5 percent, but less than 20 percent, of exposed areas be affected; or intermittent therapy such as corticosteroids or other immunosuppressive drugs required for a total duration of less than six weeks during the past 12-month period. A 30 percent rating requires that 20 to 40 percent of the entire body or 20 to 40 percent of exposed areas affected; or systemic therapy such as corticosteroids or other immunosuppressive drugs required for a total duration of six weeks or more, but not constantly, during the past 12-month period. A 60 percent rating requires that more than 40 percent of the entire body or more than percent of exposed areas affected; or constant or near-constant systemic therapy such as corticosteroids or other immunosuppressive drugs required during the past 12-month period. 38 C.F.R. § 4.118, Diagnostic Code 7806 (2015). Diagnostic Code 7806 also provides for the disability to be rated as disfigurement of the head, face, or neck (Diagnostic Code 7800); or as scars (Diagnostic Code 7801-7805), depending upon the predominant disability. 38 C.F.R. § 4.118. The Board, however, finds that these Diagnostic Codes are inapplicable here. In that connection, Diagnostic Code 7800 is inapplicable in that the Veteran's epidermophytosis is not on his head, face, or neck. Diagnostic Code 7801 governs scars that are deep and nonlinear. Diagnostic Code 7802 governs scars that are superficial and nonlinear an affect an area or areas of at least 144 square inches. Diagnostic Code 7804 governs scars that are unstable or painful. Diagnostic Code 7805 provides that other scars and effects of scars evaluated under the above Diagnostic Codes require the evaluation of any disabling effect(s) not otherwise considered. 38 C.F.R. § 4.118. Here, however, as the evidence establishes that there is no scarring or disfigurement present but rather skin irritation, the Board finds that the Veteran's epidermophytosis of the feet is appropriately rated as dermatitis/eczema under Diagnostic Code 7806. Consequently, in order to warrant a disability rating higher than the 10 percent currently assigned, the Veteran's epidermophytosis of the feet would have to be manifested by at least 20 percent of the entire body, or at least 20 percent of exposed areas affected, or systemic therapy such as corticosteroids or other immunosuppressive drugs used for a total duration of at least six weeks during the previous 12-month period. Here, however, the May 2011, September 2011, September 2014, and November 2015 VA examination reports all show that the Veteran's epidermophytosis of the feet covers less than 5 percent of total body area, with no exposed area affected. To the contrary, the November 2015 examiner specifically considered the Veteran's contentions regarding symptoms on his legs, arms, hands, and back but found that the epidermophytosis is confined entirely to the Veteran's feet, with his complained-of additional symptoms being attributed not to epidermophytosis but to unrelated dry skin outbreaks. Additionally, although the Veteran reported that he has continuously treated the disability with topical antifungal cream and moisturizing lotion, there is no indication of any systemic therapy with corticosteroids or other immunosuppressive drugs. Accordingly, a disability rating higher than the 10 percent currently assigned is not warranted for the Veteran's epidermophytosis of the feet. The above determinations are based on consideration of the applicable provisions of VA's rating schedule. The Board finds that at no time during the period at issue has the Veteran's lumbar spine or skin disorder been shown to be so exceptional or unusual as to warrant the referral for consideration of any higher ratings on an extra-schedular basis. See 38 C.F.R. § 3.321(b)(1). Here, there is an absence of evidence of marked interference with employment (i.e., beyond that contemplated in the assigned evaluation), frequent periods of hospitalization, or evidence that the Veteran's spondylosis and degenerative disc disease of the lumbar spine or epidermophytosis of the feet, without consideration of other disabilities, has rendered impractical the application of the regular schedular standards. In that connection, the Board notes that the Veteran's symptoms are all specifically contemplated by the criteria discussed above. Thus, the criteria for invoking the procedures set forth in 38 C.F.R. § 3.321(b)(1) are not met. See Bagwell v. Brown, 9 Vet. App. 337, 338-39 (1996); Floyd v. Brown, 9 Vet. App. 88, 96 (1996); Shipwash v. Brown, 8 Vet. App. 218, 227 (1995). It bears emphasis that the schedule is intended to compensate for average impairments in earning capacity resulting from service-connected disability in civil occupations. 38 U.S.C.A. § 1155. Generally, the degrees of disability specified in the rating schedule are considered adequate to compensate for considerable loss of working time from exacerbations or illnesses proportionate to the severity of the several grades of disability. 38 C.F.R. § 4.1 (2015). Thus, based on the record before it, the Board does not find that the medical evidence demonstrates any unusual disability with respect to the claim that is not contemplated by the rating schedule. The very symptoms the Veteran experiences are all specifically addressed by the rating schedule. Thun v. Peake, 22 Vet. App. 111 (2008). As a result, the Board concludes that a remand for referral of the rating issue to the VA Central Office for consideration of extra-schedular evaluation is not warranted. Finally, the Board notes that under Johnson v. McDonald, 762 F.3d 1362 (Fed. Cir. 2014), a Veteran may be awarded an extraschedular rating based upon the combined effect of multiple conditions in an exceptional circumstance where the evaluation of the individual conditions fails to capture all the service-connected disabilities experienced. In this case, however, after applying the benefit of the doubt under Mittleider v. West, 11 Vet. App. 181 (1998), there are no additional symptoms that have not been attributed to a specific service-connected disability. Accordingly, this is not an exceptional circumstance in which extraschedular consideration may be required to compensate the Veteran for disability that can be attributed only to the combined effect of multiple conditions. In reaching these conclusions, the Board has considered the applicability of the benefit-of-the-doubt doctrine; however, because the preponderance of the evidence is against the Veteran's claims for higher ratings, that doctrine is not helpful to the Veteran. See 38 U.S.C.A. § 5107(b); 38 C.F.R. §§ 3.102, 4.3; Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). ORDER Entitlement to a disability rating higher than 40 percent for spondylosis and degenerative disc disease of the lumbar spine is denied. Entitlement to a disability rating higher than 10 percent for epidermophytosis of the feet is denied. ____________________________________________ JAMES L. MARCH Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs