Citation Nr: 1625901 Decision Date: 06/28/16 Archive Date: 07/11/16 DOCKET NO. 10-14 823 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Waco, Texas THE ISSUES 1. Entitlement to an initial disability rating in excess of 30 percent for postoperative residuals of a right thoracotomy resection apical bleb (claimed as a lung disorder). 2. Entitlement to a total disability rating based on individual unemployability (TDIU). REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD John Francis, Counsel INTRODUCTION The Veteran served on active duty from October 1967 to September 1970 and from October 1975 to October 1977. The Veteran's initial rating claim comes before the Board of Veterans' Appeals (Board) on appeal from a March 2009 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in North Little Rock, Arkansas, which granted service connection for postoperative residuals of a right thoracotomy resection apical bleb (pulmonary disability). The RO assigned an initial 30 percent rating, effective December 11, 2008, the date of the Veteran's service connection claim. The Veteran was afforded a Board videoconference hearing before the undersigned Veterans Law Judge (VLJ) in December 2010. A transcript of the hearing is currently of record. In April 2012, the Board remanded the claim for further development. During the December 2010 Board hearing, the Veteran testified that his service-connected pulmonary disability interfered with his employment such that he was unable to perform his previous employment duties. When the issue of unemployability is raised is raised in connection with an increased rating claim for a service-connected disability, the Board has jurisdiction over the issue of a TDIU because it is part of the claim for increased compensation. The Board added the claim for a TDIU to the Veteran's appeal consistent with Rice v. Shinseki, 22 Vet. App. 447 (2009). FINDINGS OF FACT 1. The Veteran's postoperative residuals of a right thoracotomy resection apical bleb is manifested by pulmonary function not worse than Forced Expiratory Volume in one second to Forced Vital Capacity (FEV-1/FVC) of between 56 and 70 percent with no evidence of pulmonary hypertension, cardiovascular complications, or the need for oxygen therapy. 2. Muscle and neurological complications from surgery for the pulmonary disorder were not found on clinical examination. 3. Residual scars from surgery for the pulmonary disorder are small, superficial, and stable, do not adhere to underlying tissue, and do not limit function; one of three scars is painful. 4. The Veteran is not precluded from securing or following gainful employment at any time during the period of the appeal because of his service-connected pulmonary disorder and associated scars. CONCLUSIONS OF LAW 1. The criteria for a rating in excess of 30 percent for postoperative residuals of a right thoracotomy resection apical bleb are not met. 38 U.S.C.A. §§ 1155, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.321, 4.1, 4.2, 4.3, 4.7, 4.10, 4.25, 4.73, Diagnostic Code 5321, 4.96, 4.97, Diagnostic Code 6844, 4.118, Diagnostic Codes 7802, 7804-05, 4.124a (2015). 2. The criteria for a TDIU due to service-connected pulmonary disorder and associated scars are not met. 38 U.S.C.A. §§ 1155, 5107 (West 2014); 38 C.F.R. §§ 3.340, 3.341, 4.16, 4.19 (2015). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. VA's Duty to Notify and Assist VA has a duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2014); 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a) (2015). Proper 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. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b)(1). The notice must be provided to a claimant before the initial AOJ decision on the claim for VA benefits. Pelegrini v. Principi, 18 Vet. App. 112 (2004). The notice requirements of 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) apply to all five elements of a service connection claim. Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). In January 2009, the RO provided notice that met the requirements for the Veteran's initial claim for service connection for the pulmonary disability. In this case, the Veteran's claim for service connection for his pulmonary disability was granted and an initial rating was assigned in the March 2009 rating decision on appeal. As the Veteran has appealed with respect to the initially assigned rating, no additional 38 U.S.C.A. § 5103(a) notice is required because the purpose that the notice is intended to serve has been fulfilled. Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007); Dunlap v. Nicholson, 21 Vet. App. 112 (2007); see also VAGCPREC 8-2003, 69 Fed. Reg. 25180 (May 5, 2004). Following the addition of the claim for a TDIU by the Board, in April 2012 the RO provided notice that met the requirements for this claim. Relevant to the duty to assist, the Veteran's service treatment records as well as post-service VA treatment records through July 2012 have been obtained and considered. The Veteran has not identified any additional, outstanding records that have not been requested or obtained including that any more recent records exist that demonstrate an increase in the degree of disability. There is no evidence that the diability has increased since the last VA examination. A Veterans Law Judge who chairs a hearing must fulfill two duties: (1) the duty to fully explain the issues and (2) the duty to suggest the submission of evidence that may have been overlooked. 38 C.F.R. 3.103(c)(2) (2015); Bryant v. Shinseki, 23 Vet. App. 488 (2010). Here, during the December 2010 Board hearing, the undersigned VLJ discussed the issues on appeal, the reasons for the initial rating, and the nature and severity of the Veteran's current symptoms and functional limitations. In addition, the VLJ sought to identify any pertinent evidence not currently associated with the claims folder that might have been overlooked or was outstanding that might substantiate the claim. In particular, the Veteran testified that he had undergone imaging studies earlier in the year 2010 that had not yet been considered. Therefore, the Board finds that, consistent with Bryant, the undersigned VLJ complied with the duties set forth in 38 C.F.R. 3.103(c)(2). In April 2012, the Board remanded the claims in part to permit the Veteran to identify any additional sources of relevant evidence and to obtain records of VA care cited by the Veteran during the hearing including VA computed tomography (CT) and positron emission tomography (PET) scans of his lungs dated in April 2010 and September 2010. The RO provided notice in April 2012 that requested the identification of new evidence from the Veteran. VA records through July 2012 were obtained and associated with the file including the April 2010 imaging reports. Studies in September 2010 could not be found, but studies in late July 2010 were included in the records and reviewed by examiners. Additionally, the Veteran was provided a comprehensive VA examination in June 2012. Therefore, the Board finds that there has been substantial compliance with the remand instructions. Stegall v. West, 11 Vet. App. 268 (1998); D'Aries v. Peake, 22 Vet. App. 97, 105 (2008). VA examinations in March 2009, February 2010, and June 2012 are adequate to decide the issues they are predicated on a review of the claims file, consideration of the Veteran's reported history, his available service treatment records, and post-service treatment record up to the date of the examination with clinical observations, functional test results and imaging studies that may be applied to the rating criteria. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). Accordingly, the Board finds that VA's duty to assist with respect to obtaining VA examinations and opinions has been met. Therefore, no further notice or assistance to the Veteran is required to fulfill VA's duty to assist him in the development of the claims on appeal. Smith v. Gober, 14 Vet. App. 227 (2000), aff'd 281 F.3d 1384 (Fed. Cir. 2002); Dela Cruz v. Principi, 15 Vet. App. 143 (2001); see also Quartuccio v. Principi, 16 Vet. App. 183 (2002). II. Initial Rating The Veteran served as a U.S. Army engineering vehicle mechanic including service in the Republic of Vietnam from March 1968 to March 1969. The Veteran also served as a U.S. Navy hull technician aboard an aircraft carrier from October 1975 to October 1977. In August 1977, a routine chest X-ray showed a right upper lung lobe cavitary lesion. The Veteran underwent screening for tuberculosis that was negative, but the lesion was diagnosed as a right apical cavity postinflammatory bleb and bilateral epical plural thickening. The disorders were not disqualifying, and the Veteran received an honorable discharge and release to inactive duty at the end of his obligated service. Ratings for service-connected disabilities are determined by comparing the Veteran's symptoms with criteria listed in VA's Schedule for Rating Disabilities, which is based, as far as practically can be determined, on average impairment in earning capacity. Separate diagnostic codes identify the various disabilities. 38 C.F.R. Parts 4. When rating a service-connected disability, the entire history must considered. Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Where there is a question as to which of two ratings shall be applied, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. Since the Veteran timely appealed the rating initially assigned for his disability, the Board must consider entitlement to "staged" ratings to compensate for times since filing the claim when the disability may have been more severe than at other times during the course of the appeal. See Fenderson v. West, 12 Vet. App. 119, 125-26 (1999). Restrictive lung diseases are rated either under the General Rating Formula for Restrictive Lung Disease. The restrictive lung diseases include Diagnostic Code 6843 (traumatic chest wall defect, pneumothorax, hernia, etc.), Diagnostic Code 6844 (post-surgical residual, e.g., lobectomy, pneumonectomy), and Diagnostic Code 6845 (chronic pleural effusion or fibrosis). The General Rating Formula for Restrictive Lung Disease provides that a 10 percent rating is warranted for Forced Expiratory Volume in one second (FEV-1) of 71- to 80-percent predicted value, or; the ratio of Forced Expiratory Volume in one second to Forced Vital Capacity (FEV-1/FVC) of 71 to 80 percent, or; Diffusion Capacity of the Lung for Carbon Monoxide by the Single Breath Method (DLCO (SB)) is 66- to 80-percent predicted. A 30 percent rating is warranted for FEV-1 of 56- to 70-percent predicted, or; FEV-1/FVC of 56 to 70 percent, or; DLCO (SB) 56- to 65-percent predicted A 60 percent rating is warranted for FEV-1 of 40- to 55-percent predicted, or; FEV-1/FVC of 40 to 55 percent, or; DLCO (SB) of 40- to 55-percent predicted, or; maximum oxygen consumption of 15 to 20 ml/kg/min (with cardiorespiratory limit. A 100 percent rating is warranted for FEV-1 less than 40 percent of predicted value, or; FEV-1/FVC less than 40 percent, or; DLCO (SB) less than 40-percent predicted, or; maximum exercise capacity less than 15 ml/kg/min oxygen consumption (with cardiac or respiratory limitation), or; cor pulmonale (right heart failure), or; right ventricular hypertrophy, or; pulmonary hypertension (shown by Echo or cardiac catheterization), or; episode(s) of acute respiratory failure, or; requires outpatient oxygen therapy. 38 C.F.R. § 4.97. Post-bronchodilator results are used for rating unless the pre-bronchodilator results are normal or the post-bronchodilator results are poorer. 38 C.F.R. § 4.96 (d) (4, 5). The medical records indicate that the Veteran may also have chronic obstructive pulmonary disease (COPD). However, ratings for coexisting respiratory conditions such as for diseases of the bronchi, interstitial, and restrictive lung disease will not be combined with each other. Moreover, a VA examiner in June 2012 determined that COPD is a separate disorder arising from a separate etiology from the service-connected pulmonary disease that is the subject of this appeal. A single rating will be assigned under the diagnostic code which reflects the predominant disability with elevation to the next higher evaluation where the severity of the overall disability warrants such elevation. 38 C.F.R. § 4.96 (a). When there is a disparity between the results of the PFT, the test result designated by the examiner as most accurately reflects the degree of disability is used. 38 C.F.R. § 4.96 (d)(6). The Veteran's claim and symptoms indicate potential involvement of muscle group XXI responsible for respiration. A noncompensable rating is warranted if the dysfunction is slight, a 10 percent rating if moderate, and a 20 percent rating if moderately severe or severe. 38 C.F.R. § 4.73, Diagnostic Code 5321. Ratings for scars, other than the head, face, or neck, that are superficial or that do not cause limited motion are provided in 38 C.F.R. § 4.118, Diagnostic Code 7802. Superficial scars that do not cause limited motion, in an area or areas of 144 square inches (929 sq. cm.) or greater, are rated 10 percent disabling. Note (1) to Diagnostic Code 7802 provides that a superficial scar is one not associated with underlying soft tissue damage. Note (2) provides that if multiple qualifying scars are present, or if a single qualifying scar affects more than one extremity, or a single qualifying scar affects one or more extremities and either the anterior portion or posterior portion of the trunk, or both, or a single qualifying scar affects both the anterior portion and the posterior portion of the trunk, assign a separate evaluation for each affected extremity based on the total area of the qualifying scars that affect that extremity, assign a separate evaluation based on the total area of the qualifying scars that affect the anterior portion of the trunk, and assign a separate evaluation based on the total area of the qualifying scars that affect the posterior portion of the trunk. The midaxillary line on each side separates the anterior and posterior portions of the trunk. Combine the separate evaluations under 38 C.F.R. § 4.25. Qualifying scars are scars that are nonlinear, deep, and are not located on the head, face, or neck. 38 C.F.R. § 4.118. Diagnostic Code 7804 provides a 10 percent rating for superficial unstable scars. Diagnostic Code 7804 provides that one or two scars that are unstable or painful are rated 10 percent disabling. Three or more scars that are unstable or painful are rated 20 percent disabling. Five or more scars that are unstable or painful are 30 percent disabling. Note (1) to Diagnostic Code 7804 provides that an unstable scar is one where, for any reason, there is frequent loss of covering of skin over the scar. Note (2) provides that if one or more scars are both unstable and painful, add 10 percent to the evaluation that is based on the total number of unstable or painful scars. Note (3) provides that scars evaluated under diagnostic codes 7800, 7801, 7802, or 7805 may also receive an evaluation under this diagnostic code, when applicable. Id. Diagnostic Code 7805 provides that any other scars (including linear scars) and other disabling effects of scars should be evaluated even if not considered in a rating provided under diagnostic codes 7800-04 under an appropriate diagnostic code. Id. Although the Veteran reported neurological symptoms of numbness, loss of strength and sensation in the right arm, none were noted during any VA outpatient encounters or in a comprehensive clinical examination in June 2012. Therefore, ratings for incomplete paralysis of the various nerve systems are not applicable in this case. 38 C.F.R. § 4.124a. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102; see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). The RO received the Veteran's claim for service connection for "lung problems" in December 2008. In a January 2009 statement, the Veteran reported that while working for a construction company, he sustained collapsed right lungs in February 2007 and again in March 2007. Following the second pneumothorax, the Veteran underwent a right thoracotomy, resection of the apical bleb due to extensive scarring and adhesions, and pleuroclesis at a private hospital. The surgeon noted no air leaks at the completion of the procedure. The Veteran established VA primary care in January 2009. A physician noted the history of X-ray in service, surgery in 2007, and the Veteran's report of shortness of breath on exertion, tenderness of the thoracotomy and chest tube scars, and occasional burning sensation in the right chest. In March 2009, a VA nurse practitioner (NP) noted a review of the claims file including the history of treatment for suspected tuberculosis in 1977, the diagnosis of an apical bleb, the two pneumothoraxes, and the subsequent surgery. The NP also noted that the Veteran had a history of tobacco smoking, one pack per day, from the age 13 to 52 but had quit eight years earlier. The Veteran reported work as an iron worker and denied the use of any medication. On examination, the NP noted a well-healed thoracotomy scar that was 24.0 by 1.0 centimeters (cm). There were no pulmonary abnormalities. A pulmonary function test (PFT) showed post- bronchodilator FEV-1 as 87 percent of predicted, FEV-1/FVC of 62 percent, and DLCO 83 percent of predicted. The physician evaluating the test noted that the Veteran had mild obstructive ventilatory impairment. In March 2009, the RO granted service connection for postoperative residuals of right thoracotomy resection apical bleb and assigned a 30 percent rating based on the FEV-1/FVC of 62 percent. Service connection and rating were effective December 11, 2008, the date of receipt of the claim for service connection. VA outpatient clinicians continued to monitor the status of the Veteran's pulmonary disability. In November 2009, a VA primary care physician referred to a chest X-ray and diagnosed chronic obstructive pulmonary disease (COPD) but recommended a follow-up scan. In December 2009, a CT scan showed probable bilateral apical pleural and parenchymal scarring likely from the previous surgery or old granulomatous disease. The evaluator also noted a partially calcified nodule in the right upper lobe. In January 2010, a VA physician noted the Veteran's report of dyspnea after walking one mile with no cough, sputum, or hemoptysis. The Veteran reported current work as a welder and possible asbestos exposure in the Navy. In February 2010, a VA physician noted a review of the electronic VA medical records and accurately summarized the history of pneumothorax and surgery and noted no history of heart disease. The Veteran reported that he had been working full time as a welder until being laid off three months earlier. He continued to report no use of medication. On examination, there were no abnormal breath sounds. An electrocardiogram was negative. The physician referred to the December 2009 CT scan and to the results of another concurrent PFT which a physician evaluated as very mild obstructive ventilatory impairment with no significant change in FEV-1 or FEV-1/FVC but a mild reduction in DCLO since the March 2009 testing. The physician noted that there was no effect of the disability on daily activities. In April 2010, the Veteran underwent a PET scan that showed the nodule to be smaller than predicted and likely benign. Another CT scan of the lungs was obtained in July 2010. The evaluator noted no changes since the December 2009 scan. During the December 2010 Board hearing, the Veteran testified that he experienced pain and a burning sensation on the front of the chest and around to the back in the vicinity of the surgical scars. He stated that he believed he sustained nerve damage from the surgery because he had difficulty lifting and had lost strength and sensation in his right arm. He stated that he had quit welding because of the smoke and asbestos in welding rod and was not able to climb ladders or use a hammer in his right hand. He stated that he had trouble breathing when moving at a fast pace or climbing stairs with a large object. He reported that he had used an inhaler with no effect and that his only current treatment was routine CT and PET scans of the right lung. He reported that the most recent scan was at some time between September and December 2010 and that he expected another series in March 2011. He acknowledged that the most recent PFT was in February 2010. As noted above, the Board located the record of a CT scan in late July 2010. In March 2011, a follow up CT scan showed no changes since July 2010 with stable volume loss in the right upper lobe, no suspicious masses, and no growth of the nodule. In April 2012, the Board added consideration for a TDIU because the Veteran reported that he could no longer work as a welder due to his pulmonary disability and remanded the claim for VA pulmonary, neurological, muscle, and scar examinations. In June 2012, a VA physician noted a review of the claims file, accurately summarized the history, and noted the November 2009 and December 2009 imaging studies that showed mild COPD and an unrelated and benign right upper lobe nodule that required watching. The Veteran reported that after a period of unemployment, he was working full time as a welder and sheet metal mechanic. He reported mild dyspnea with heavy repetitive work and right chest wall pain and a burning sensation at the surgical site. He also reported a loss of strength in the right arm and limitation of motion because of pulling at the surgical site. He denied any numbness or paralysis, and denied the use of any medication, inhalers, or oxygen. A PFT was performed in July 2012 that showed post-bronchodilator FEV-1 as 72 percent predicted, FEV-1/FVC of 61 percent, FVC of 94 percent, and DCLO of 77 percent predicted. The test evaluator noted that the FVC percent was the best reflection of the severity of the disability. However, the physician reviewed the test results and noted that the COPD was a separate disorder from the residuals of the service-connected bleb disorder and more likely attributable to smoking history. The physician found that the FEV-1 percentage best reflected the apical bleb disability and that the FEV-1/FVC best reflected the COPD. The physician also found that the service-connected disability did not impact the Veteran's ability to work. Regarding muscle and nerve injury, the physician noted that the affected muscle was group XXI associated with respiration. However the physician found no effect on muscle substance, tone, function, atrophy, weakness, or fatigue. Upper body including right arm strength, reflexes, and sensation were normal. The physician found no peripheral neurological deficits and determined that muscle group XXI injury, if any, had no impact on the Veteran's ability to work. The physician evaluated three surgical scars as follows: a 21.0 by 0.5 cm superficial non-linear thoracotomy scar on the right lateral chest wall; two thorascopic scars of 1.0 by 1.0 cm and 3.0 by 0.25 cm. The scars were slightly hyper-pigmented but not unstable, painful, adherent to the underlying tissue. The scars did not limit normal motion. Color photographs are of record and were reviewed. In June 2012, the RO granted service connection for the scars and assigned a 10 percent rating for the thoracotomy scar and noncompensable ratings for the smaller thorascopic scars, all effective December 11, 2008. Resolving all doubt in favor of the Veteran, the RO assigned the 10 percent rating to the thoracotomy scar because the Veteran reported chest wall pain in the vicinity of the scar. The Veteran has not expressed disagreement with the ratings or the effective date. The Board finds that a rating in excess of 30 percent for postoperative residuals of a right thoracotomy resection apical bleb is not warranted at any time during the period of the appeal. The Veteran is competent and credible to report his observable symptoms such as shortness of breath on exertion and chest pain in the vicinity of the thoracotomy scar. The pulmonary disorder is best rated under the criteria of Diagnostic Code 6844 pertaining to post-surgical residuals as this addresses the physiology of the apical bleb and residuals of surgery as well as the Veteran's symptoms of reduced lung function causing shortness of breath on exertion. Records show that the Veteran also experiences an interstitial disease from COPD that is not service-connected. The Veteran did report on one occasion that he was possibly exposed to asbestos in service. Even if some interstitial or restrictive disease is present from this exposure, the Veteran's pulmonary disorder is service-connected and only a single rating is available. Further, the physician performing the June 2012 assessment indicated that the FEV-1 percentage best reflected the apical bleb disability and that the FEV-1/FVC best reflected the COPD. PFTs in March 2009 and July 2012 show FEV-1 as 72 percent of predicted or greater with no change noted in between in February 2010. Therefore, this level of disability is less severe than that warranting a 10 percent rating. Considering the other test results, DCLO in June 2012 was 77 percent that warrants a 10 percent rating. Notwithstanding the opinion of the VA physician regarding the most representative test, FEV-1/FVC at 61 and 62 percent were between 56 and 70 percent. Resolving all doubt in favor of the Veteran, a 30 percent rating is warranted, but a higher rating is not warranted because none of the test results were not between 40-55 percent. The Veteran does not have pulmonary hypertension, cardiac involvement, or the need for oxygen therapy. Computed tomography scans showed a stable condition, and PET scans showed a stable and benign right upper lobe nodule; both imaging studies confirm that the Veteran's pulmonary function is not degrading. The Board acknowledges the Veteran's competent reports of loss of strength in the right arm and limitation of motion because of pulling at the surgical site weakness. However separate ratings for muscle and nerve damage or dysfunction are not warranted. The Board places greater probative weight on the clinical observations of the physician in June 2012 who noted no muscle or nerve deficits. The Board finds that ratings in excess of 10 percent for the thoracotomy scar and compensable ratings for the two thorascopic scars are not warranted. The scars were clinically assessed as small, non-linear, superficial, stable, not adherent to underlying tissue, and do not impair respiratory or motor function. The total area was 12.25 square centimeters, much less than 929 square centimeters for a 10 percent overall rating. Only the thoracotomy scar was painful, though that symptom was not expressed or observed during the June 2012 examination. The benefit of doubt was considered for the thoracotomy scar based on the Veteran's report of pain and burning sensation. Higher ratings are not warranted as the scars are not larger, unstable, or more than one is painful. None interfere with function. Additionally, the Board has contemplated whether the case should be referred for extra-schedular consideration. An extra-schedular disability rating is warranted if the case presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization that application of the regular schedular standards would be impracticable. 38 C.F.R. § 3.321(b)(1). The determination of whether a claimant is entitled to an extra-schedular rating under § 3.321 is a three-step inquiry. Thun v. Peake, 22 Vet. App. 111, 115-16 (2008). First, it must be determined whether the evidence presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. There must be a comparison between the level of severity and symptomatology of the claimant's service-connected disability with the established criteria found in the rating schedule for that disability. Under the approach prescribed by VA, if the criteria reasonably describe the claimant's disability level and symptomatology, then the claimant's disability picture is contemplated by the rating schedule, the assigned schedular evaluation is, therefore, adequate, and no referral is required. Second, if the schedular evaluation does not contemplate the claimant's level of disability and symptomatology and is found inadequate, the RO or Board must determine whether the claimant's exceptional disability picture exhibits other related factors such as "marked interference with employment" and "frequent periods of hospitalization." Third, when an analysis of the first two steps reveals that the rating schedule is inadequate to evaluate a claimant's disability picture and that picture has attendant thereto related factors such as marked interference with employment or frequent periods of hospitalization, then the case must be referred to the Under Secretary for Benefits or the Director of the Compensation and Pension Service to determine whether, to accord justice, the Veteran's disability picture requires the assignment of an extra-schedular rating. Id. Here, the rating criteria for the Veteran's restrictive pulmonary disease contemplate his reports of shortness of breath on exertion and provides comprehensive, targeted, and objective standards for the application of clinical, functional test results. The Veteran does not use medication or any form of therapy not considered in the criteria. Subjective rating criteria are available that contemplate the Veteran's claimed nerve and muscle deficits had they been confirmed in clinical examination. Rating criteria for scars contemplate the appearance, physiology, symptoms, and functional limitation, though none of the latter was shown during examination. Therefore the Board finds that the rating criteria for the pulmonary disability and its associated complications adequately contemplate all symptomatology and level of severity of the disabilities. As the preponderance of the evidence is against this claim, the "benefit of the doubt" rule is not for application, and the Board must deny the claim. See 38 U.S.C.A. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). III. TDIU In order to establish entitlement to TDIU due to a service-connected disability, there must be impairment so severe that it is impossible for the average person to secure and follow a substantially gainful occupation. See 38 U.S.C.A. § 1155; 38 C.F.R. §§ 3.340, 3.341, 4.16. In reaching such a determination, the central inquiry is "whether the veteran's service connected disabilities alone are of sufficient severity to produce unemployability." Hatlestad v. Brown, 5 Vet. App. 524, 529 (1993). Consideration may be given to the veteran's level of education, special training, and previous work experience in arriving at a conclusion, but not to his age or to the impairment caused by nonservice-connected disabilities. See 38 C.F.R. §§ 3.341, 4.16, 4.19; Van Hoose v. Brown, 4 Vet. App. 361 (1993). The regulatory scheme for TDIU provides both objective and subjective criteria. Hatlestad, supra; VAOPGCPREC 75-91 (Dec. 27, 1991), 57 Fed. Reg. 2317 (1992). The objective criteria provide for a total rating when there is a single disability or a combination of disabilities that result in a 100 percent schedular evaluation. Subjective criteria provide for a TDIU when, due to service-connected disability, a veteran is unable to secure or follow a substantially gainful occupation, and has a single disability rated 60 percent or more, or at least one disability rated 40 percent or more with additional disability sufficient to bring the combined evaluation to 70 percent. 38 C.F.R. §§ 3.340, 3.341, 4.16(a). In exceptional circumstances, where the veteran does not meet the percentage requirements, a total rating may nonetheless be assigned upon a showing that the individual is unable to obtain or retain substantially gainful employment. 38 C.F.R. § 4.16(b). Medical examiners are responsible for providing a full description of the effects of disability upon the person's ordinary activity, while the rating agency "is responsible for interpreting reports of examination in the light of the whole recorded history, reconciling the various reports into a consistent picture so that the current rating may accurately reflect the elements of the disability present. 38 C.F.R. §§ 4.2, 4.10; see Floore v. Shinseki, 26 Vet. App. 376, 381 (2013) In this case, the issue of employability was raised by the Veteran in conjunction with his claim for an increased rating for his pulmonary disorder, rated as 30 percent disabling with a scar rated as 10 percent disabling. The combined rating for the disabilities arising from the same etiology is 40 percent. In a March 2009 VA examination, the Veteran reported that he was employed as an iron worker. In a February 2010 examination, he reported that he was not working because he had been laid off. During the December 2010 Board hearing, the Veteran testified that he had quit welding because of the smoke and asbestos in welding rod. He was not able to climb ladders or use a hammer in his right hand. He stated that he had trouble breathing when moving at a fast pace or climbing stairs with a large object. However, in June 2012, the Veteran reported that after a period of unemployment, he was working full time as a welder and sheet metal mechanic. Following a VA examination, a VA physician assessed the degree of functional limitation imposed by the pulmonary disability and associated scars and found that the Veteran was capable of continuing to perform his skilled duties as a welder and sheet metal mechanic without work restrictions or accommodations. The Board finds that a TDIU is not warranted at any time during the period of the appeal because the Veteran was actually employed full time before and after a period of unemployment which was due to the unavailability of work and not because of degraded function due to his service-connected disability. All examiners noted that the pulmonary deficit did not impair daily activities and that the disability was stable. The June 2012 examiner noted specifically that the Veteran was able to perform his welder and mechanic duties. Therefore, the Board finds that the Veteran is able to secure or follow a substantially gainful occupation, and was able to do so throughout the period of the appeal. As the preponderance of the evidence is against this claim, the "benefit of the doubt" rule is not for application, and the Board must deny the claim. See 38 U.S.C.A. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). ORDER An initial disability rating in excess of 30 percent for postoperative residuals of a right thoracotomy resection apical bleb (claimed as a lung disorder) is denied. A total disability rating based on individual unemployability (TDIU) is denied. ____________________________________________ MARJORIE A. AUER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs