Citation Nr: 1612433 Decision Date: 03/28/16 Archive Date: 04/07/16 DOCKET NO. 09-18 682 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Nashville, Tennessee THE ISSUES 1. Entitlement to service connection for a cervical spine disability, including as secondary to lumbosacral spine disability and bilateral lower extremity radiculopathy. 2. Entitlement to service connection for a right shoulder disability, including as secondary to lumbosacral spine disability and bilateral lower extremity radiculopathy. 3. Entitlement to service connection for a ventral incisional hernia. 4. Entitlement to a rating in excess of 40 percent for lumbosacral spine disability with disc extrusion at L4-5 (lumbosacral spine disability). 5. Entitlement to a rating in excess of 10 percent for right lower extremity radiculopathy prior to December 13, 2011 and a rating in excess of 20 percent thereafter. 6. Entitlement to a rating in excess of 10 percent for left lower extremity radiculopathy prior to December 13, 2011 and a rating in excess of 20 percent thereafter. 7. Entitlement to a temporary total disability rating for ventral hernia repair surgery with convalescence. 8. Entitlement to a total disability rating based on individual unemployability due to service-connected disability (TDIU) prior to February 12, 2014. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD J. Rutkin, Counsel INTRODUCTION The Veteran served on active duty from November 1976 to August 1986. This appeal to the Board of Veterans' Appeals (Board) arises from August 2008 and September 2011 rating decisions of the Nashville, Tennessee Regional Office (RO) of the Department of Veterans Affairs (VA). The Board remanded this case in December 2013 for further development. It now returns for appellate review. In October 2012, a Board hearing was held in Washington, D.C. before the undersigned Veteran's Law Judge. A transcript is of record. In an April 2014 supplemental statement of the case, the agency of original jurisdiction (AOJ) adjudicated the issue of entitlement to an increased rating for service-connected bilateral sensorineural hearing loss. A June 2015 appellant brief lists this claim as being under appellate consideration. The Board, however, does not have jurisdiction of this claim. The August 2008 rating decision, in relevant part, denied entitlement to a higher rating for the Veteran's hearing loss. He expressly stated that he was not appealing this denial in his August 2008 notice of disagreement (NOD), which was submitted in response to this decision with regard to other claims adjudicated therein. See 38 U.S.C.A. § 7105(a) (West 2014); 38 C.F.R. §§ 20.200, 20.201 (2015). Entitlement to a higher rating for hearing loss was not subsequently adjudicated prior to the Board's December 2013 remand, and was not certified on appeal to the Board at that time. An April 2014 rating decision subsequently granted a 10 percent rating for hearing loss effective February 6, 2014, the date of a VA audiological examination. However, the Veteran did not submit a NOD in response to this decision. The June 2015 brief was received after the one-year time limit for submitting a NOD with respect to the April 2014 decision, and appears to assume that this issue was on appeal before the Board. 38 C.F.R. § 20.302(a) (2015) (providing, in pertinent part, that a NOD must be submitted within one year from the date that notice is mailed to the claimant of the determination by the AOJ). Accordingly, the issue of entitlement to a higher rating for service-connected bilateral hearing loss has been raised in the June 2015 appellant brief, but has not been adjudicated by the AOJ. Therefore, the Board does not have jurisdiction over it, and it is referred to the AOJ for appropriate action. See 38 C.F.R. § 19.9(b) (2015). FINDINGS OF FACT 1. The Veteran's degenerative disc disease of the cervical spine did not manifest during active service or within one year of service separation, was not caused by disease or injury incurred in or aggravated by active service, and was not caused or aggravated by his service-connected lumbosacral spine disability and bilateral lower extremity radiculopathy, including as a result of a fall injury in November 2010, which the credible evidence shows was due to vertigo and dizziness rather than service-connected disability. 2. The Veteran's current degenerative joint disease of the right shoulder did not manifest during active service or within one year of service separation, was not caused by disease or injury incurred in or aggravated by active service, including right shoulder pain diagnosed as tendonitis in June 1986 following heavy lifting, and was not caused or aggravated by his service-connected lumbosacral spine disability and bilateral lower extremity radiculopathy, including as a result of a fall injury in November 2010, which the credible evidence shows was due to vertigo and dizziness rather than service-connected disability. 3. The Veteran's ventral incisional hernia, which was surgically repaired in February 2008, was caused by surgery in January 2007 consisting of a small bowel resection to remove a carcinoid tumor; it was not caused or aggravated by service-connected disability, or a disease or injury incurred in or aggravated by active service. 4. The Veteran's service-connected lumbosacral spine disability is not manifested by favorable or unfavorable ankylosis, and has not required bed rest prescribed by a physician for a total duration of at least six weeks in any 12-month period during the pendency of this claim. 5. The Veteran's radiculopathy of the right lower extremity has been manifested by constant numbness with objective findings of loss of sensation, intermittent to constant pain, paresthesias, diminished or absent reflexes, and weakness, without atrophy, foot drop, or findings indicative of complete paralysis. 6. The Veteran's radiculopathy of the left lower extremity has been manifested by constant pain that is sometimes severe, paresthesias, diminished or absent reflexes, and weakness, without atrophy, foot drop, or findings indicative of complete paralysis. 7. The Veteran's service-connected disabilities and vocational and educational background have not prevented him from obtaining or maintaining substantially gainful employment in a sedentary capacity prior to February 12, 2014. CONCLUSIONS OF LAW 1. The criteria for entitlement to service connection for a cervical spine disability, including as secondary to lumbosacral spine disability and bilateral lower extremity radiculopathy, are not satisfied. 38 U.S.C.A. §§ 1112, 1113, 1131, 1137, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.307, 3.309, 3.310 (2015). 2. The criteria for entitlement to service connection for a right shoulder disability, including as secondary to lumbosacral spine disability and bilateral lower extremity radiculopathy, are not satisfied. 38 U.S.C.A. §§ 1112, 1113, 1131, 1137, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.307, 3.309, 3.310 (2015). 3. The criteria for entitlement to service connection for a ventral incisional hernia are not satisfied. 38 U.S.C.A. §§ 1131, 1137, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.303, 3.304 (2015). 4. The criteria for entitlement to a rating in excess of 40 percent for a lumbosacral spine disability have not been more nearly approximated at any point during the pendency of this claim. 38 U.S.C.A. §§ 1155, 5107 (West 2014); 38 C.F.R. § 3.102, 3.321, 4.3, 4.40, 4.45, 4.71a, Diagnostic Codes 5235-5243 (2015). 5. The criteria for entitlement to a rating of 40 percent, but no higher, for right lower extremity radiculopathy are satisfied for the entire period on appeal. 38 U.S.C.A. §§ 1155, 5107 (West 2014); 38 C.F.R. § 3.102, 3.321, 4.3, 4.124a, Diagnostic Code 8520 (2015). 6. The criteria for entitlement to a rating of 40 percent, but no higher, for left lower extremity radiculopathy are satisfied for the entire period on appeal. 38 U.S.C.A. §§ 1155, 5107 (West 2014); 38 C.F.R. § 3.102, 3.321, 4.3, 4.124a, Diagnostic Code 8520 (2015). 7. The criteria for entitlement to a temporary total disability rating for ventral hernia repair surgery with convalescence are not satisfied. 38 U.S.C.A. §§ 1155, 5107 (West 2014); 38 C.F.R. §§ 3.102, 4.3, and 4.30 (2015). 8. The criteria for entitlement to a total disability rating based on individual unemployability due to service-connected disability (TDIU) prior to February 12, 2014 are not satisfied. 38 U.S.C.A. §§ 1155, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.340, 3.341, 4.3, 4.15, 4.16, 4.19 (2015). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Procedural Due Process VA's duties to notify and assist under the Veterans Claims Assistance Act of 2000 (VCAA) have been satisfied. See 38 U.S.C.A §§ 5103, 5103A (West 2014); 38 C.F.R. §§ 3.159, 3.326(a) (2015). Letters dated in October 2007, January 2008, and January 2011 provided all notice required under the VCAA. They notified the Veteran of the elements of service connection, VA's general criteria for rating service-connected disabilities, and the criteria for entitlement to TDIU, the types of evidence that could support the claims, and the allocation of responsibilities between the Veteran and VA for obtaining relevant records and other evidence on his behalf. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473, 484 (2006); Quartuccio v. Principi, 16 Vet. App. 183, 187 (2002); 38 C.F.R. § 3.159(b). The letters were followed by adequate time for the Veteran to submit information and evidence before initial adjudication or readjudication of these claims in statements of the case and supplemental statements of the case. See Mayfield v. Nicholson, 444 F.3d 1328, 1333-34 (Fed. Cir. 2007) (VCAA notice must generally be provided prior to the initial rating decision); but see Mayfield v. Nicholson, 499 F.3d 1317, 1323 (Fed. Cir. 2007) (a timing delay in VCAA notice is harmless if followed by readjudication of the claim after the claimant has had an appropriate time to respond); accord Prickett v. Nicholson, 20 Vet. App. 370 (2006). Accordingly, VA's duty to notify is satisfied Concerning the duty to assist, the Veteran's service treatment records (STRs), VA treatment records, and Social Security Administration (SSA) records pertaining to an SSA disability claim have been associated with the claims file. See 38 U.S.C.A § 5103A; 38 C.F.R. § 3.159(c). He has not identified any other records or evidence he wished to submit or have VA obtain. With regard to the service connection claims for neck and right shoulder disabilities, VA examinations were performed, and medical opinions provided, in August 2011. See 38 C.F.R. §§ 3.159(c)(4), 3.326(a); McLendon v. Nicholson, 20 Vet. App. 79, 83 (2006). The examination reports and opinions are adequate to make a fully informed decision. See Barr v. Nicholson, 21 Vet. App. 303, 312 (2007) (holding that when VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate). The examiner reviewed the claims file and considered the Veteran's medical history, set forth the findings made on examination, and provided clear rationales in support of the conclusions reached that are sufficient to be weighed against any contrary opinions. See D'Aries v. Peake, 22 Vet. App. 97, 104 (2008) (holding that an examination is adequate when it is based on consideration of the claimant's medical history and describes the disability in sufficient detail so that the Board's evaluation of the disability will be a fully informed one); Stefl v. Nicholson, 21 Vet. App. 120, 124-25 (2007) (holding that an adequate opinion must support its conclusion with an analysis that can be weighed against contrary opinions); see also Monzingo v Shinseki, 26 Vet. App. 97, 107 (2012) (holding that "examination reports are adequate when, as a whole, they sufficiently inform the Board of a medical expert's judgment on a medical question and the essential rationale for that opinion even when the rationale does not explicitly 'lay out the examiner's journey from the facts to a conclusion'") (citing Acevedo v. Shinseki, 25 Vet. App. 286, 293 (2012) (noting that the law imposes no reasons-or-bases requirement on examiners)); Sickels v. Shinseki, 643 F.3d, 1362, 1365-66 (Fed. Cir. 2011) (holding that the Board is "entitled to assume" the competency of a VA examiner without "demonstrating why the medical examiners' reports were competent and sufficiently informed"). As the Board finds that the Veteran's November 2010 fall injury on which the claims are based was not due to his service-connected disabilities, and as there is no indication that his cervical spine and right shoulder conditions were otherwise caused or aggravated by his service-connected lumbosacral spine and lower extremity disabilities, further examination or opinion is not warranted. Cf. McLendon, 20 Vet. App. at 83. The Board notes that a June 1986 STR shows that the Veteran reported a two-week history of right shoulder pain after heaving lifting. The assessment was bicipital tendonitis. The Veteran does not state, and there is no indication, that the diagnosis of degenerative joint disease of the right shoulder decades after service may be related to the one-time treatment for right shoulder pain and tendonitis. As shown below in the discussion of the merits of the claim, the Veteran's in-service right shoulder pain resolved and he did not have any right shoulder symptoms for many years following service separation. Thus, a VA opinion is not necessary on this issue. See McLendon, 20 Vet. App. at 83 (holding, in pertinent part, that to trigger VA's duty to provide an examination or opinion, there must be an indication that the current disability may be related to the in-service disease, injury, or event). With regard to the Veteran's service connection claim for a ventral incisional hernia and entitlement to a temporary total convalescent rating for its surgical repair, a VA examination or opinion has not been provided. VA's duty to provide an examination or opinion is required when the following elements are satisfied: (1) evidence of a current disability, (2) evidence establishing an "in-service event, injury or disease," or a disease manifested in accordance with presumptive service connection regulations occurred which would support incurrence or aggravation, (3) an indication that the current disability may be related to the in-service event, and (4) insufficient evidence to decide the case. McLendon v. Nicholson, 20 Vet. App. 79, 83 (2006); 38 C.F.R. § 3.159(c)(4). Here, the second, third, and fourth McLendon elements are not satisfied. See McLendon, 20 Vet. App. at 83. The Veteran does not state, and the evidence of record does not otherwise suggest, that there was an in-service disease, injury, or event leading to the development of a ventral incisional hernia, or to the development of a carcinoid tumor, the surgical removal of which resulted in the incisional ventral hernia on which the claim is based. Thus, the second element is not satisfied. As the second element is not satisfied, the third element is moot with regard to a direct relationship to an in-service disease, injury or event. With regard to secondary service connection, there is no indication that the ventral incisional hernia may be related to the Veteran's service-connected irritable bowel syndrome (IBS), as the Veteran states without explanation or supporting evidence. See id.; see also Waters v. Shinseki, 601 F.3d 1274, 1278-79 (Fed. Cir. 2010) (holding that a claimant's "conclusory generalized statement that his service illness caused his present medical problems" was not sufficient to entitle him to a VA examination). There is no evidence or assertion that it may have been caused or aggravated by any other service-connected disability. Finally, the fourth element is not satisfied, as there is sufficient evidence to decide the case. See McLendon, 20 Vet. App. at 83. Specifically, the VA treatment records show that the incisional hernia was the result of surgical removal of a carcinoid tumor. As service connection has not been claimed or established for the carcinoid tumor, and as there is no information of record reasonably indicating that the carcinoid tumor itself may be associated with service or a service-connected disability, including IBS, there is sufficient competent evidence for the Board to find that the ventral incisional hernia is not service-connected on a direct or secondary basis. See id.; see also Delisio v. Shinseki, 25 Vet. App. 45, 54-55 (2011). Accordingly, because the McLendon elements have not been satisfied, an examination or opinion is not necessary to decide the claim. See McLendon, 20 Vet. App. at 83; 38 C.F.R. § 3.159(c)(4). Because service connection is not established for the ventral incisional hernia, entitlement to a temporary total convalescent rating based on recovery from its surgical repair may not be established as a matter of law. Accordingly, a VA examination or opinion is not warranted on this issue. See 38 C.F.R. § 3.159(d). With regard to the increased rating claims for the lumbosacral spine disability and bilateral lower extremity radiculopathy, as well as entitlement to TDIU, several VA examinations have been performed, including most recently in February 2014, which include consideration of the Veteran's medical history and set forth all pertinent findings, including the impact on occupational functioning, such that the Board is able to make a fully informed decision. See Stefl v. Nicholson, 21 Vet. App. 120, 123 (2007); 38 C.F.R. §§ 3.159(c)(4), 3.326(a), 3.327 (2015). There is no evidence indicating that there has been a material change in the severity of these disabilities since the last examination. See 38 C.F.R. § 3.327(a) (providing that reexaminations will be requested whenever VA needs to determine the current severity of a disability). Thus, further examination is not warranted. See Palczewski v. Nicholson, 21 Vet. App. 174 (2007) (holding that a new VA examination is not required simply because of the passage of time since an otherwise adequate examination was conducted); accord VAOPGCPREC 11-95 (April 7, 1995). In light of the above, the Veteran has had a meaningful opportunity to participate effectively in the processing of these claims, and no prejudicial error has been committed in discharging VA's duties to notify and assist. See Shinseki v. Sanders, 556 U.S. 396, 407, 410 (2009); Conway v. Principi, 353 F.3d 1369, 1374 (Fed. Cir. 2004); Arneson v. Shinseki, 24 Vet. App. 379, 389 (2011); Vogan v. Shinseki, 24 Vet. App. 159, 163 (2010). The Board remanded these claims in December 2013 for further development, to include obtaining additional records, requesting the Veteran to identify any outstanding records pertinent to the claims on appeal, and arranging for additional VA examinations. All of these actions have been accomplished. Accordingly, the Board finds there has been substantial compliance with its remand instructions. See Stegall v. West, 11 Vet. App. 268, 271 (1998) (holding that a remand by the Board confers upon the Veteran, as a matter of law, the right to compliance with its remand instructions, and imposes upon VA a concomitant duty to insure compliance with the terms of the remand); see also D'Aries v. Peake, 22 Vet. App. 97, 105 (2008) (holding that only substantial rather than strict compliance with the Board's remand directives is required under Stegall); accord Dyment v. West, 13 Vet. App. 141, 146-47 (1999). The Veteran testified at a hearing before the undersigned in October 2012. Under 38 C.F.R. § 3.103(c)(2) (2015), the hearing officer has the responsibility to explain fully the issues and suggest the submission of evidence which the claimant may have overlooked and which would be of advantage to the claimant's position. In Bryant v. Shinseki, 23 Vet. App. 488 (2010), the United States Court of Appeals for Veterans Claims (Court) held that the hearing officer has two duties under § 3.103(c)(2). First, the hearing officer must explain fully the issues still outstanding that are relevant and material to substantiating the claim by explicitly identifying them for the claimant. Id. at 496. Second, the hearing officer must suggest that a claimant submit evidence on an issue material to substantiating the claim when such evidence is missing from the record or when the testimony at the hearing raises an issue for which there is no evidence in the record. Id. at 496-97. At the hearing, the Veteran had an opportunity to provide testimony in support of the claims, facilitated by questioning from the undersigned and the representative of record. The Veteran did not raise any new issues at the hearing, and there is no indication that any outstanding evidence might exist that would provide additional support for the claims. See id. Moreover, the Board undertook additional development after the hearing was conducted, including obtaining additional records and arranging for VA examinations to evaluate the current level of severity of the Veteran's lumbosacral spine and lower extremity disabilities. See id. at 498-99 (finding that any deficiencies in discharging the hearing officer's duties under § 3.103(c)(2) were rendered harmless by otherwise developing the record). Given this development, in addition to the Veteran's testimony at the hearing and all the evidence in the claims file, the "clarity and completeness of the hearing record [is] intact" and there is no prejudicial error concerning the hearing officer's duties under § 3.103(c)(2). See Bryant, 23 Vet. App. at 498 (holding that the rule of prejudicial error applies to the hearing officer's duties); see also Sanders, 556 U.S. at 407, 410. II. Service Connection Service connection means that a veteran has a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303(a). Service connection may be granted for any disease diagnosed after discharge when the evidence shows that the disease was incurred in service. 38 C.F.R. § 3.303(d). Entitlement to service connection is established when the following elements are satisfied: (1) the existence of a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship or "medical nexus" between the current disability and the disease or injury incurred or aggravated during service. Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009); Shedden v. Principi, 381 F.3d 1163, 1166-67 (Fed. Cir. 2004); see 38 C.F.R. § 3.303(a). There is also a presumption of service connection for the chronic diseases listed in 38 C.F.R. § 3.309(a), including arthritis. See 38 C.F.R. § 3.303(b); Walker v. Shinseki, 708 F.3d 1331, 1338 (Fed. Cir. 2012) (holding that § 3.303(b) only applies to the chronic diseases listed § 3.309(a)). Under the presumption, if the chronic disease manifested in service, then service connection will be established for subsequent manifestations of the same chronic disease at any date after service, no matter how remote, without having to show a causal relationship or medical nexus, unless the later manifestations are clearly due to causes unrelated to service ("intercurrent causes"). When the condition noted during service is not shown to be chronic, or its chronicity may be legitimately questioned, then a continuity of symptoms after service must be shown to establish service connection under this presumption. Id.; Walker, 708 F.3d at 1338-39. To establish service connection based on a continuity of symptoms under § 3.303(b), the evidence must show: (1) a condition "noted" during service; (2) post-service continuity of the same symptoms; and (3) a nexus between the present disability and the post-service symptoms. Fountain v. McDonald, 27 Vet. App. 258, 263-64 (2015). In addition, where a veteran served continuously for 90 days or more during a period of war, or during peacetime service after December 31, 1946, there is a presumption of service connection for arthritis if the disease manifested to a degree of 10 percent or more within one year from the date of separation from service, even if there is no evidence of the disease during the service period itself. 38 U.S.C.A. §§ 1101, 1112, 1113; 38 C.F.R. §§ 3.307, 3.309(a). This presumption may be rebutted by affirmative evidence to the contrary. 38 C.F.R. § 3.307(d). Service connection may also be established on a secondary basis for a disability which is proximately due to, or the result of, a service connected disease or injury. 38 C.F.R. § 3.310(a). The Court has construed this provision as entailing "any additional impairment of earning capacity resulting from an already service connected condition, regardless of whether or not the additional impairment is itself a separate disease or injury caused by the service connected condition." Allen v. Brown, 7 Vet. App. 439, 448 (1995). In order to establish entitlement to service connection on a secondary basis, the evidence must show (1) that a current disability exists and (2) that the current disability was either (a) caused by or (b) aggravated by a service-connected disability. Id.; 38 C.F.R. § 3.310(a). The Board has an obligation to provide an adequate statement of reasons or bases supporting its decision. See 38 U.S.C.A. § 7104(d)(1) (West 2014); Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000); Allday v. Brown, 7 Vet. App. 517, 527 (1995). The Board must assess the credibility and weight of the evidence, accounting for evidence which it finds to be persuasive or unpersuasive, and providing reasons for rejecting any evidence favorable to the claimant. Caluza v. Brown, 7 Vet. App. 498, 506 (1995). A claimant is entitled to the benefit of the doubt when there is an approximate balance of positive and negative evidence on any issue material to the claim. See 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102 (providing, in pertinent part, that reasonable doubt will be resolved in favor of the claimant). When the evidence supports the claim or is in relative equipoise, the claim will be granted. See Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990); see also Wise v. Shinseki, 26 Vet. App. 517, 532 (2014). If the preponderance of the evidence weighs against the claim, it must be denied. See id.; Alemany v. Brown, 9 Vet. App. 518, 519 (1996). A. Cervical Spine and Right Shoulder Disabilities The Veteran states that his cervical spine and right shoulder conditions were caused or aggravated by his service-connected lumbosacral spine and lower extremity disabilities. Specifically, as reflected in his hearing testimony before the undersigned and in his November 2010 claim, he states that his cervical spine and right shoulder conditions were caused or aggravated by a fall injury in November 2010, and that the fall was triggered by his service-connected lumbosacral spine and lower extremity disabilities. At the August 2011 VA examination, he specified that he fell down several steps in November 2010 when his legs "gave out." For the following reasons, the Board finds that service connection is not established. The August 2011 VA examination reports show diagnoses of degenerative disc disease of the cervical spine, and degenerative joint disease of the right shoulder. VA treatment records dated in November 2010 show that the Veteran went to the emergency room and was then seen for follow-up treatment for cervical spine and right shoulder and arm pain after falling. The fall was not attributed to the Veteran's low back or lower extremity disabilities. Rather, a January 2011 VA treatment record reflects that the Veteran reported severe dizziness with vertigo, which in November 2010 "resulted in a fall injury to neck." A December 2010 VA treatment record also notes that the Veteran had been reporting dizziness since the beginning of November 2010. In the August 2011 VA examination report, the examiner concluded that the Veteran's cervical spine degenerative disc disease was less likely than not proximately due to or the result of the November 2010 fall injury. The examiner explained that there was evidence of degenerative disc disease of the cervical spine since 2004, which was not an acute finding but rather the result of "wear and tear." The changes noted on follow-up X-rays were most likely the natural progression of the disease, according to the examiner. The examiner also noted that the Veteran did not report striking his head or neck when he fell and that the exact type of fall was not clear. The Board notes that according to the November 2010 VA emergency room treatment record, the Veteran reported that he had fallen at night and "landed on outstretched hands." The next morning, he began having tenderness and pain of the right shoulder and neck, according to his report. Thus, the examiner's observation that it did not appear the Veteran struck his head or neck in the fall, which was a factor in the examiner's consideration, is borne out by the evidence of record. In essence, and in other words, the examiner found that the Veteran's cervical spine degenerative disc disease pre-existed the fall and was not due to an acute injury but rather due to cumulative "wear and tear" and the natural progression of the disease. With regard to the right shoulder, the August 2011 examiner concluded that the Veteran's degenerative joint disease of the right shoulder was less likely than not proximately due to or the result of the November 2010 fall injury. The examiner explained that a November 2010 X-ray of the right shoulder did not show an acute findings such as a fracture or dislocation. Rather, it showed degenerative joint disease ("DJD") changes which the examiner stated occur over a long period of time and thus do not represent "an acute finding." The examiner also noted that degenerative joint disease is "not uncommon" for the Veteran's age group. The August 2011 VA examiner's opinions explaining that clinical evidence and the history of the fall injury did not show pathology of the cervical spine or right shoulder indicative of injury, but rather gradual progressive degenerative changes over time weigh against a relationship to the fall injury. These opinions outweigh the Veteran's general lay assertions, as the examiner's conclusions are supported by complete explanations specific to the evidence of record and represent the informed findings of an objective medical professional. See King v. Shinseki, 700 F.3d 1339, 1345 (Fed. Cir. 2012) (the Board did not improperly discount the weight of a lay opinion in finding a medical expert's opinion more probative on the issue of medical causation); see also Madden v. Gober, 125 F.3d 1477, 1481 (Fed. Cir. 1997) (holding that the Board has the "authority to discount the weight and probity of evidence in the light of its own inherent characteristics in its relationship to other items of evidence"). The fact that the Veteran had an increase in symptoms after the fall does not alone support causation or aggravation of the Veteran's cervical spine and right shoulder conditions. Finally, and in the alternative, the probative evidence shows that the Veteran's fall injury in November 2010 was due to vertigo or dizziness rather than his service-connected low back and lower extremity disabilities. In this regard, the contemporaneous VA treatment records dated in December 2010 and January 2011 reflecting the Veteran's report of dizziness and of falling and injuring his neck in November 2010 due to severe dizziness and vertigo are more reliable than the Veteran's recent statements made in support of the present claim for benefits. See Curry v. Brown, 7 Vet. App. 59, 68 (1994) (contemporaneous evidence has greater probative value than history as reported by the claimant); see also White v. Illinois, 502 U.S. 346, 356, 112 S. Ct. 736 (1992) (statements made for the purpose of medical diagnosis or treatment are exceptionally trustworthy because the declarant has a strong motive to tell the truth in order to receive a proper diagnosis or treatment); Rucker v. Brown, 10 Vet. App. 67, 73 (1997) (observing that, although formal rules of evidence do not apply before the Board, recourse to the Federal Rules of Evidence may be appropriate if it assists in the articulation of the reasons for the Board's decision). Because the Veteran's recent statements made in support of a claim for benefits regarding his legs giving out and resulting in the fall is in conflict with the more probative contemporaneous treatment records showing that the fall occurred due to dizziness or vertigo, the Board concludes that such statements are not credible. See Caluza, 7 Vet. App. at 511 (holding that when determining whether lay evidence is satisfactory, the Board may properly consider, among other things, its consistency with other evidence submitted on behalf of the Veteran); Madden, 125 F.3d at 1480 (observing that "lay evidence which is in fundamental conflict with other lay evidence and is, for that reason, found not credible in a given case, is surely suspect"); see also Buchanan v. Nicholson, 451 F.3d 1331, 1337 (Fed. Cir. 2006) (holding that "the Board, as fact finder, is obligated to, and fully justified in, determining whether lay evidence is credible in and of itself, i.e., because of possible bias[.]"). Thus, as the November 2010 fall injury was not due to the Veteran's service-connected lumbosacral spine disability or radiculopathy, service connection on a secondary basis may not be established as a matter of law for the Veteran's cervical spine and right shoulder conditions on the basis of such fall. The Veteran has not stated, and there is no indication in the record, that his cervical spine or right shoulder conditions may have been caused or aggravated in any other manner by his service-connected lumbosacral spine and bilateral lower extremity disabilities. Accordingly, the criteria for service connection on a secondary basis are not satisfied. See 38 C.F.R. § 3.310; Allen, 7 Vet. App. at 448. The Veteran has not stated, and the record does not suggest, that cervical spine symptoms or pathology manifested during service or within one year of service separation. Thus, as arthritis of the cervical spine or cervical spine symptoms were not noted during service, and did not manifest to a compensable degree within one year of service separation, service connection on a presumptive basis for arthritis as a chronic disease is not warranted. See 38 C.F.R. §§ 3.303(b), 3.307(a); Walker, 708 F.3d at 1338. Since there is no evidence of in-service incurrence or aggravation of a cervical spine injury or disease, service connection on a direct basis is also not warranted, as the second element is not satisfied. See Holton, 557 F.3d at 1366; Shedden, 381 F.3d at 1166-67; 38 C.F.R. § 3.303(a). With regard to the right shoulder, service connection on a presumptive basis for degenerative joint disease of the right shoulder as a chronic disease is not warranted. Chronicity during service is not established. A June 1986 STR shows a report of right arm pain present for two weeks after heavy lifting. On examination, there was point tenderness of the right shoulder over the bicipital tendon. The assessment was right shoulder bicipital tendonitis. This is the only notation of a right shoulder condition in the STRs. A separation examination was not performed. In order to establish the existence of a chronic disease in service, the evidence must show a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time, as distinguished from merely isolated findings or a diagnosis including the word "chronic." 38 C.F.R. § 3.303(b). A manifestation of joint pain during service does not alone permit service connection of arthritis "first shown as a clearcut clinical entity[] at some later date." Id. Rather, for the showing of chronic disease during service, the evidence must show "a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time, as distinguished from merely isolated findings or a diagnosis including the word 'chronic.'" Id. The Veteran's right shoulder degenerative joint disease was not diagnosed until many years after service separation. He does not state, and there is no other indication, that he had ongoing right shoulder problems during service apart from the two weeks of right shoulder pain following heavy lifting, which was diagnosed as tendonitis and thus attributed to a tendon rather than bone. There is no evidence of right shoulder pain following the June 1986 STR, X-ray findings of arthritis or degenerative joint disease at the time, or other indicia of chronicity. Accordingly, the evidence weighs against chronicity during service. The evidence also weighst against a continuity of symptomatology after service. See 38 C.F.R. § 3.303(b); Walker, 708 F.3d at 1338. The Veteran has not stated that he had ongoing right shoulder symptoms following service separation. Although right shoulder pain was "noted" during service, the voluminous post-service treatment records in the file dated since the 1990's reflect no reports of right shoulder symptoms and no clinical findings pertaining to the right shoulder. A July 1998 VA treatment record shows orthopedic complaints involving the right hip, right knee, ankle, and low back, with no mention of the shoulder. An August 1999 VA treatment record reflects treatment for the left shoulder, a March 2001 VA treatment record shows that left shoulder surgery was performed, and a November 1999 VA treatment record shows complaints of right arm tingling and numbness after the Veteran hit his elbow on a sink in March or April 1999. The fact that the VA treatment records reflect various orthopedic complaints, including with regard to the left shoulder and right arm following an injury to the elbow, but make no mention of right shoulder problems, weighs against a continuity of symptoms after service, as they tend to show that the Veteran did not have right shoulder problems for many years after service. The Veteran does not state otherwise. Thus, there is every indication that the Veteran's in-service right shoulder pain, diagnosed as tendonitis at the time, was an acute injury that resolved. As a continuity of symptomatology after service is not established, and as there is no evidence of arthritis of the right shoulder within one year of service separation, service connection on a presumptive basis for arthritis of the right shoulder as a chronic disease is not warranted. See 38 C.F.R. § 3.303(b); Walker, 708 F.3d at 1338. Given the long period of time that elapsed between the Veteran's in-service shoulder symptoms, diagnosed as tendonitis, and the current diagnosis of degenerative joint disease, without evidence of any right shoulder problems for years following service separation, the preponderance of the evidence weighs against a medical nexus between the Veteran's current right shoulder joint disease and the in-service tenonitis. See Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000) (holding that a proper consideration for the trier of fact is the amount of time that has elapsed since military service, and that evidence of a prolonged period without medical complaint can be considered, along with other factors concerning the Veteran's health and medical treatment during and after military service, as evidence of whether a condition was incurred in service); see also Holton, 557 F.3d at 1366. Thus, the third service connection element is not satisfied; therefore service connection for the Veteran's right shoulder disability on a direct basis is not established. See Holton, 557 F.3d at 1366; Shedden, 381 F.3d at 1166-67; 38 C.F.R. § 3.303(a); Accordingly, the preponderance of the evidence is against the Veteran's claims. Consequently, the benefit-of-the-doubt rule does not apply, and service connection for disabilities of the cervical spine and right shoulder is denied. See 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). B. Ventral Incisional Hernia The Veteran states that a ventral incisional hernia is secondary to his service-connected irritable bowel syndrome (IBS). For the following reasons, the Board finds that service connection is not established. The VA treatment records show that the Veteran underwent surgery in January 2007 consisting of a small bowel resection to remove a carcinoid tumor. The carcinoid tumor was diagnosed in December 2006 on computerized tomography (CT) scan of the abdomen after the Veteran reported groin pain and hematuria. A February 2008 VA treatment record reflects that the Veteran developed a ventral incisional hernia six months after the January 2007 surgery. The Veteran underwent repair surgery of the ventral incisional hernia in February 2008. Service connection has not been claimed or established for the carcinoid tumor, and the record does not reasonably raise the issue of whether it may be related to service or a service-connected disability. See Delisio v. Shinseki, 25 Vet. App. 45, 54-55 (2011). Accordingly, the ventral incisional hernia resulting from surgical removal of the carcinoid tumor cannot be service-connected as a matter of law. See 38 C.F.R. § 3.310; Allen, 7 Vet. App. at 448. The Veteran submitted a March 2008 statement by his treating physician, D. Walters, MD, stating that the Veteran's infected ventral incisional hernia was "possibly related" to an in-service disease, injury, or event. This statement has no probative value, as it does not identify what occurred in service to which the ventral hernia may be related, and is not supported by any rationale. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008) (holding that the probative value of a medical opinion comes from its reasoning, and therefore is not entitled to any weight if it contains only data and conclusions). The treatment records showing that the ventral incisional hernia resulted from the January 2007 surgery to remove a carcinoid tumor, which itself is not service-connected, outweigh Dr. Walter's statement. Accordingly, the preponderance of the evidence is against the Veteran's claim. Consequently, the benefit-of-the-doubt rule does not apply, and service connection for a ventral incisional hernia is denied. See 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). II. Increased Ratings VA has adopted a Schedule for Rating Disabilities to evaluate service-connected disabilities. 38 U.S.C.A. § 1155; 38 C.F.R. § 3.321; see generally, 38 C.F.R. § Part IV. The basis of disability evaluations is the ability of the body as a whole, or of the psyche, or of a system or organ of the body to function under the ordinary conditions of daily life, including employment. 38 C.F.R. § 4.10 (2015). The percentage ratings in the Schedule for Rating Disabilities represent, as far as practicably can be determined, the average impairment in earning capacity resulting from service-connected diseases and injuries and their residual conditions in civilian occupations. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1 (2015). Generally, the degrees of disability 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 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 if the disability picture more nearly approximates the criteria required for that rating. 38 C.F.R. § 4.7 (2015). Otherwise, the lower rating will be assigned. Id. All reasonable doubt regarding the degree of disability will be resolved in favor of the claimant. 38 C.F.R. § 4.3; see also 38 C.F.R. § 3.102. Separate ratings for distinct disabilities resulting from the same injury or disease can be assigned so long as the symptomatology for one condition is not "duplicative or overlapping with the symptomatology" of the other condition. See Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994). However, the evaluation of the same disability or its manifestations under various diagnoses, which is known as pyramiding, is to be avoided. 38 C.F.R. § 4.14 (2015). Because the level of disability may have varied over the course of the claim, the rating may be "staged" higher or lower for segments of time during the period under review in accordance with such variations, to the extent the evidence shows distinct time periods where the service-connected disability has exhibited signs or symptoms that would warrant different ratings under the rating criteria. Hart v. Mansfield, 21 Vet. App. 505, 509-10 (2007); Fenderson v. West, 12 Vet. App. 119, 126 (1999). In initial-rating cases, where the appeal stems from a granted claim of service connection with respect to the initial evaluation assigned, VA assesses the level of disability from the effective date of service connection. See Fenderson, 12 Vet. App. at 125; 38 U.S.C.A. § 5110 (West 2014); 38 C.F.R. § 3.400 (2014). For increased-rating claims, where a claimant seeks a higher evaluation for a previously service-connected disability, it is the present level of disability that is of primary concern, and VA considers the level of disability for the period beginning one year prior to the claim for a higher rating to determine whether and when an ascertainable increase has occurred. See Hart, 21 Vet. App. at 509; Francisco v. Brown, 7 Vet. App. 55, 58 (1994); Hazan v. Gober, 10 Vet. App. 511, 519 (1992); 38 U.S.C.A. § 5110(b)(2) (West 2014); 38 C.F.R. § 3.400(o)(2) (2015). A claimant is entitled to the benefit of the doubt when there is an approximate balance of positive and negative evidence on any issue material to the claim. See 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102 (providing, in pertinent part, that reasonable doubt will be resolved in favor of the claimant). When the evidence supports the claim or is in relative equipoise, the claim will be granted. See Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990); see also Wise v. Shinseki, 26 Vet. App. 517, 532 (2014). If the preponderance of the evidence weighs against the claim, it must be denied. See id.; Alemany v. Brown, 9 Vet. App. 518, 519 (1996). In evaluating disabilities of the musculoskeletal system, consideration must be given to functional loss, including due to weakness and pain, affecting the normal working movements of the body in terms of excursion, strength, speed, coordination, and endurance. 38 C.F.R. § 4.40 (2015); see Mitchell v. Shinseki, 25 Vet. App. 32, 43 (2011) (holding that pain "must actually affect some aspect of 'the normal working movements of the body' [under] 38 C.F.R. § 4.40 in order to constitute functional loss" warranting a higher rating). With respect to disabilities of the joints, it must be considered whether there is less movement or more movement than normal, weakened movement, excess fatigability, incoordination, and pain on movement, as well as swelling, deformity, or atrophy of disuse. 38 C.F.R. § 4.45 (2015). These provisions thus require a determination of whether a higher rating may be assigned based on functional loss of the affected joint on repeated use as a result of the above factors, including during flare-ups of symptoms, beyond any limitation reflected on one-time measurements of range of motion. DeLuca v. Brown, 8 Vet. App. 202, 206-07 (1995) (holding that the provisions of 4.40 and 4.45 are not subsumed by the DC's applicable to the affected joint). However, a higher rating based on functional loss may not exceed the highest rating available under the applicable diagnostic code(s) pertaining to range of motion. See Johnston v. Brown, 10 Vet. App. 80, 85 (1997). Moreover, the intent of the schedule is to recognize painful motion with joint or periarticular pathology as productive of disability. See 38 C.F.R. § 4.59 (2015). Joints that are actually painful, unstable, or malaligned, due to healed injury, should be entitled to at least the minimum compensable rating for the joint. Id.; see also Burton v. Shinseki, 25 Vet. App. 1 (2011) (holding that section 4.59 applies to all forms of painful motion of joints, and not just to arthritis). A. Lumbosacral Spine The Veteran seeks entitlement to a rating greater than 40 percent for his service-connected lumbosacral spine disability. For the following reasons, the Board finds that entitlement to a higher rating is not established. The Veteran's service-connected lumbosacral spine disability has been rated under 38 C.F.R. § 4.71a, Diagnostic Code (DC) 5243. Diagnostic Code 5243 pertains to intervertebral disc syndrome (IVDS). The rating schedule provides for the evaluation of all disabilities of the spine under a General Rating Formula for Diseases and Injuries of the Spine (General Rating Formula), unless the disability is rated under the Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes (DC 5243). See 38 C.F.R. § 4.71a, Diagnostic Codes 5235-5243. The evaluation of IVDS will be discussed below. Under the General Rating Formula, evaluations are assigned as follows: A 10 percent rating is assigned for forward flexion of the thoracolumbar spine greater than 60 degrees but not greater than 85 degrees; or, combined range of motion of the thoracolumbar spine greater than 120 degrees but not greater than 235 degrees; or, muscle spasm, guarding, or localized tenderness not resulting in abnormal gait or abnormal spinal contour; or vertebral body fracture with loss of 50 percent or more of the height. A 20 percent rating is assigned for forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees; or, the 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 rating is assigned forward flexion of the thoracolumbar spine to 30 degrees or less; or, favorable ankylosis of the entire thoracolumbar spine. A 50 percent rating is assigned unfavorable ankylosis of the entire thoracolumbar spine. A 100 percent rating is warranted where unfavorable ankylosis of the entire spine is demonstrated. See id. The above criteria are to be applied irrespective of whether there are symptoms such as pain (whether or not it radiates), stiffness, or aching in the affected area of the spine. Id. In this regard, the criteria "are meant to encompass and take into account the presence of pain, stiffness, or aching, which are generally present when there is a disability of the spine." 68 Fed. Reg. 51, 454, 51,455 (August 27, 2003) (Supplementary Information). For VA compensation purposes, normal forward flexion of the thoracolumbar spine is from 0 to 90 degrees, extension is from 0 to 30 degrees, left and right lateral flexion are from 0 to 30 degrees, and left and right lateral rotation are from 0 to 30 degrees. 38 C.F.R. § 4.71a, Diagnostic Codes 5235-5243, Note (2). Unfavorable ankylosis is defined, in pertinent part, as "a condition in which the entire thoracolumbar spine is fixed in flexion or extension." Id., Note (5). Fixation of a spinal segment in neutral position (zero degrees) always represents favorable ankylosis. Id. The preponderance of the evidence shows that the Veteran's lumbosacral spine disability has not more nearly approximated the criteria for entitlement to a rating greater than 40 percent under the General Rating Formula. The VA examination reports, including most recently in February 2014, show diagnoses of IVDS and sacroiliac injury. They show that the Veteran does not have unfavorable ankylosis of the entire thoracolumbar spine or unfavorable ankylosis of the entire spine. Thus, the criteria for ratings of 60 or 100 percent are not satisfied. See 38 C.F.R. § 4.71a, DC's 5235-5243. Because the maximum evaluation has been assigned for a lumbosacral spine disability based on limitation of motion, a higher rating under the DeLuca criteria based on functional loss is not available. See Johnston, 10 Vet. App. at 85; DeLuca, 8 Vet. App. at 206-07; 38 C.F.R. § 4.40, 4.45. The General Rating Formula also provides that neurologic abnormalities associated with disabilities of the spine are to be separately evaluated under an appropriate diagnostic code. See 38 C.F.R. § 4.71a, General Rating Formula, Note (1). The evaluation of the Veteran's associated radiculopathy of the bilateral lower extremities is discussed below. The evidence does not show any other associated neurologic abnormalities, including bladder impairment. Under DC 5243, IVDS is to be evaluated either under the General Rating Formula 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 (2014). 38 C.F.R. § 4.71a, Note (6). Under the Formula for Rating IVDS set forth in DC 5243, a 10 percent rating is warranted if incapacitating episodes have a total duration of at least one week but less than 2 weeks during the past 12 months; a 20 percent evaluation is warranted if incapacitating episodes have a total duration of at least two weeks but less than four weeks; a 40 percent rating is warranted if the total duration is at least four weeks but less than six weeks; and a 60 percent rating is warranted if the total duration is at least six weeks. See 38 C.F.R. § 4.71a, DC 5243. An incapacitating episode is defined as 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. See 38 C.F.R. § 4.71a Note (1). Because the Veteran has not been prescribed bed rest by a physician for his low back disability for a total duration of at least six weeks in any 12-month period during the pendency of this appeal, a rating higher than 40 percent under DC 5243 is not available. See id. Accordingly, the preponderance of the evidence shows that the Veteran's lumbosacral spine disability more nearly approximates the criteria for a 40 percent rating under the General Rating Formula. See 38 C.F.R. § 4.71a. A higher or separate rating is not available under DC 5003 for degenerative arthritis of the spine, as the maximum rating for limitation of motion has already been assigned, and a separate rating for arthritis would contravene the express terms of DC 5003 and the rule against pyramiding. See 38 C.F.R. § 4.71a; see also 38 C.F.R. § 4.14. The evidence shows that the Veteran's lumbosacral spine disability has not met or more nearly approximated the criteria for a rating greater than 40 percent at any point during the pendency of this claim, for the reasons explained above. Rather, it has more nearly approximated the criteria for a 40 percent rating throughout this period. Thus, staged ratings are not appropriate for the time period under review. See Hart, 21 Vet. App. at 509-10; Fenderson, 12 Vet. App. at 126. The evaluation of the Veteran's lumbar spine disability does not warrant referral for extraschedular consideration. See 38 C.F.R. § 3.321(b); Thun v. Peake, 22 Vet. App. 111, 114 (2008); aff'd, Thun v. Shinseki, 572 F.3d 1366 (Fed. Cir. 2009). In this regard, because the ratings provided under the VA Schedule for Rating Disabilities are averages, it follows that an assigned rating may not completely account for each individual veteran's circumstances, but nevertheless would still be adequate to address the average impairment in earning capacity caused by the disability. Thun, 22 Vet. App. at 114. However, in exceptional situations where the rating is inadequate, it may be appropriate to refer the case for extraschedular consideration. Id. The governing norm in these exceptional cases is a finding that the disability at issue presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization as to render impractical the application of the regular schedular standards. Id. 38 C.F.R. § 3.321(b)(1). These criteria have been broken up into a three-step inquiry: (1) The schedular criteria must be inadequate to describe the claimant's disability level and symptomatology; (2) There must be related factors such marked interference with employment or frequent periods of hospitalization; (3) If so, then the case must be referred to the Under Secretary for Benefits or the Director of the Compensation and Pension Service for a determination of whether the claimant's disability picture requires the assignment of an extraschedular rating. Thun, 22 Vet. App. at 114. Here, a comparison of the Veteran's lumbosacral spine disability with the schedular criteria does not show "such an exceptional or unusual disability picture . . . as to render impractical the application of the regular schedular standards." 38 C.F.R. § 3.321(b). Specifically, his lumbosacral spine disability is manifested by IVDS or degenerative disc disease, sacroiliac injury, and spondylosis, with pain, spasms, limitation of motion, and associated functional impairment. These manifestations are specifically contemplated under 38 C.F.R. § 4.71a, DC's 5236 (sacroiliac injury and weakness) and 5243 (IVDS), and 5242 (degenerative arthritis of the spine), which are evaluated under the General Rating Formula or the Formula for Rating IVDS, and under sections 4.40 and 4.45 of the regulations, which contemplate functional impairment due to pain, deformity, weakness, instability, fatigability, and incoordination of the joint, including on repeated use and during flare-ups. See 38 C.F.R. § 4.71a; see also DeLuca, 8 Vet. App. at 206-07. By regulation, the 40 percent rating currently assigned under the schedular criteria is assumed to provide adequate compensation for "considerable loss of working time from exacerbation or illness proportionate to" the nature and severity of the Veteran's lumbar spine disability. See 38 C.F.R. § 4.1. Although not every diagnosis or specific clinical finding pertaining to the Veteran's lumbosacral spine condition may be mentioned in the rating criteria, the applicable diagnostic codes and regulations effectively contemplate all disabling effects from them as shown by the evidence of record discussed above, including loss of range of motion, symptoms such as radiating pain and spasms, and resultant functional impairment. See 38 C.F.R. § 4.71a, General Rating Formula; 38 C.F.R. §§ 4.40, 4.45. Just as separate ratings would not be warranted for different diagnoses or clinical findings resulting in the same disability, referral for extraschedular consideration is not warranted solely based on clinical findings that do not produce disability distinct from or in addition to what is already compensated under the schedular criteria. See 38 C.F.R. § 4.14 (the evaluation of the same disability under various diagnoses, known as pyramiding, is to be avoided). The fact that the Veteran occasionally uses assistive devices such as a walker does not indicate that the disability itself is exceptional or unusual, or more severe than that contemplated by the criteria. The issue of whether a disability is adequately captured by the schedular criteria is determined based on the manifestations of the disability and associated functional impairment, and not on external circumstances such as the means by which the claimant must cope with it, unless such means themselves produce additional disability not adequately captured by the rating schedule, such as the side-effects of medication, or when the external circumstances or coping mechanisms somehow indicate that the underlying disability itself is outside the schedular norms. Cf. VAOPGCPREC 6-96 (August 16, 1996) (holding that the fact that circumstances specific to a claimant may cause the effects of a service-connected disability to be more profound in that claimant's case does not in itself provide a basis for extraschedular referral). Moreover, the rating criteria already take into account functional loss and limitation of motion. They are cast in general terms and devoid of specific examples of the disabling effects of a disability of the spine in the context of daily life and employment. Rather, objective clinical findings such as loss of range of motion or spasms or guarding resulting in abnormal gait or spinal contour are used as markers for such disabling effects. Thus, use of a walker or specific challenges caused by the Veteran's lumbosacral spine disability cannot alone support an exceptional or unusual disability picture solely on the basis that these or other accommodations are not mentioned in the rating criteria. There is no indication that use of a walker is not contemplated by the rating criteria, that it is inconsistent with the disability picture being compensated under the rating criteria, or that this accommodation renders application of the schedular criteria impractical for evaluating the Veteran's lumbosacral spine disability. Accordingly, use of a walker or other assistive device is not a part of the Veteran's disability picture in terms of whether referral is warranted, or does not result in a disability picture so exceptional or unusual as to render application of the schedular standards impractical. In short, there are no manifestations of the Veteran's lumbar spine disability not accounted for in evaluating it under the schedular criteria. See Thun, 22 Vet. App. at 115; 38 C.F.R. § 3.321(b). Thus, the available schedular evaluations are adequate to rate this disability, and the first step of the inquiry is not satisfied. See id. In the absence of this threshold finding, the second step of the inquiry, namely whether there are "related factors" such as marked interference with employment or frequent periods of hospitalization, is moot. See Thun at 118-19. Therefore, the Board will not refer the evaluation of the Veteran's lumbosacral spine disability for extraschedular consideration. See id.; 38 C.F.R. § 3.321(b). When argued by the claimant or reasonably raised by the record, the combined effects of a veteran's service-connected disabilities must also be considered in determining whether extraschedular referral is warranted under § 3.321(b)(1). Johnson v. McDonald, 762 F.3d 1362, 1365 (Fed. Cir. 2014) (observing that "§ 3.321(b)(1) performs a gap-filling function [that] accounts for situations in which a veteran's overall disability picture establishes something less than total unemployability, but where the collective impact of a veteran's disabilities are nonetheless inadequately represented"); Yancy v. McDonald, __ Vet. App. __, __, 2016 WL 747304, at *9 (February 26, 2016). In this regard, consideration must be given to the "compounding negative effects that each individual disability may have on the veteran's other disabilities." Johnson, 762 F.3d at 1366. When considering whether referral is warranted based on the combined effects of a veteran's service-connected disabilities, the Board first must compare the Veteran's symptoms with the assigned schedular ratings. Yancy, __ Vet. App. __, __, 2016 WL 747304, at *9. "If the schedular evaluations reasonably contemplate the veteran's symptomatology-including any symptoms resulting from the combined effects of multiple service-connected disabilities-then the first Thun step is not satisfied, and referral is not warranted." Id. The Court has held that "[a]lthough the Board must consider any combined effects resulting from all of the Veteran service-connected disabilities insofar as they impact the disability picture of the disabilities on appeal, it lacks jurisdiction to consider whether referral is warranted solely for any disability or combination of disabilities not in appellate status[.]" Id. Here, the Veteran has not argued, and the record does not otherwise show, that his other service-connected disabilities impact his lumbosacral spine disability so as to produce symptoms or severity not reasonably described or contemplated by the applicable schedular criteria. His radiculopathy is separately compensated under the appropriate diagnostic code as explicitly provided under the General Rating Formula, which thus clearly takes into account the fact that a spine disability may be manifested by associated neurologic abnormality. There are no symptoms produced by the radiculopathy that have not already been compensated under the rating criteria applicable to the lumbosacral spine and the peripheral nerves of the lower extremities, including low back and lower extremity pain, spasms, limitation of range of motion of the lumbar spine, an abnormal gait, and resultant functional limitations, including with respect to standing and walking. The evidence does not show that the collective impact of these disabilities produces a disability picture not adequately compensated by the combined evaluation assigned under 38 C.F.R. § 4.25 (2015) based on their individual evaluations. The Veteran's other service-connected disabilities have not been shown to impact his lumbosacral spine disability in such a way as to produce symptoms or severity not captured by the schedular rating assigned, or the combined evaluation under § 4.25. Accordingly, the first Thun element is not satisfied, and thus referral for extraschedular consideration is not warranted. See Yancy, __ Vet. App. __, __, 2016 WL 747304, at *9. In sum, the preponderance of the evidence is against the Veteran's claim. Consequently, the benefit-of-the-doubt rule does not apply, and entitlement to a rating greater than 40 percent for service-connected disability of the lumbosacral spine is denied. See 38 U.S.C.A. § 5107; 38 C.F.R. §§ 3.102, 4.3; Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). B. Radiculopathy of the Lower Extremities The Veteran seeks entitlement to higher ratings for his bilateral lower extremity radiculopathy, with ratings assigned to each lower extremity of 10 percent prior to December 13, 2011 and 20 percent thereafter. For the following reasons, the Board finds that entitlement to ratings of 40 percent for each lower extremity is established for the entire period under review. The Veteran's radiculopathy of the lower extremities has been rated under DC 8520, which pertains to disease of the sciatic nerve. Under DC 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; a 40 percent evaluation is assigned for moderately severe incomplete paralysis; and a 60 percent evaluation is assigned for severe incomplete paralysis with marked muscular atrophy. Id. A maximum 80 percent evaluation requires complete paralysis of the sciatic nerve where the foot dangles and drops, there is no active movement possible of muscles below the knee, and flexion of the knee is weakened or (very rarely) lost. 38 C.F.R. § 4.124a. The term "incomplete paralysis," with peripheral nerve injuries, indicates a degree of lost or impaired function substantially less than the type pictured for complete paralysis given with each nerve, whether due to varied level of the nerve lesion or to the partial regeneration. When the involvement is wholly sensory, the rating should be for the mild, or at most, the moderate degree. 38 C.F.R. § 4.124a; Note prefacing DC's 8510 through 8730. A January 2007 VA treatment record reflects that an electromyography (EMG) test and nerve conduction velocity (NCV) test showed bilateral L5-S1 radiculopathy, along with right tibial neuropathy. A March 2008 VA examination report reflects that the Veteran complained of pain, paresthesias, and numbness in the left leg, and pain and numbness in the right leg. The pain in the left leg was continuous. The pain in the right leg was intermittent. There was a permanent numbness in the right lower lateral leg which extended down across the top of the foot into the toes, which the examiner noted was the area of the tibial nerve and superficial peroneal nerve. (The Board notes that although the examiner stated that the permanent numbness was in the left rather than the right lower extremity, this appears to be a typographic error, as the EMG findings above show that the Veteran had right (not left) tibial neuropathy, and the examination findings set forth in this report and in subsequent VA examination reports show decreased sensation in the right lower extremity rather than the left.) On examination, the Veteran was able to walk on his heels and toes. Deep tendon reflexes in the lower extremities were 1+ in the patellae and absent in the Achilles reflexes. There was a mild muscle weakness of 4/5 in the left lower extremity compared to the right. There was diminished sensation to light touch and sharp/dull discrimination in the right buttocks and right lower lateral leg and top of the right foot. A July 2009 VA treatment record reflects that the Veteran reported that radiculopathy caused his knees to buckle, resulting in near falls. The Veteran was issued knee braces. A December 2011 VA examination report reflects that the Veteran complained of recurring tingling and numbness of the left lower extremity, and a constant numb area on the right lower extremity. On examination, muscle strength testing was normal (5/5) with regard to bilateral hip flexion, knee extension, ankle plantar flexion, ankle dorsiflexion, and great toe extension. There was no muscle atrophy. The Veteran had zero or absent reflex of the right knee and hypoactive (1+) reflex of the left knee. He had hypoactive (1+) reflexes of the bilateral ankles. A sensory examination was normal in the bilateral upper anterior thighs and thighs and knees. Sensation was decreased in the right lower leg/ankle and foot/toes, and normal in the left lower leg/ankle and foot/toes. The Veteran had intermittent pain of a moderate nature in the left lower extremity, and intermittent severe pain in the left lower extremity. He had mild paresthesias and/or dysesthesias in the right lower extremity, and moderate paresthesias and/or dysesthesias in the left lower extremity. He had severe numbness of the right lower extremity, and moderate numbness of the left lower extremity. The examiner found that the Veteran's radiculopathy involved the sciatic nerves, and that it was moderate in severity in both extremities. A February 2013 SSA examination report reflects that on examination, the Veteran's strength was 5/5 and symmetric distally and proximally in the lower extremities. Muscle mass appeared normal without atrophy or hypertrophy. Sensation was decreased to the right lateral lower leg which crossed to the dorsum of the foot and went to the great toe dorsally. Otherwise, the Veteran's sensation was found to be normal. Deep tendon reflexes were 2+ and symmetric throughout. His toes were downgoing. The February 2014 VA examination report reflects that the Veteran had mild pain in the right lower extremity that was constant and could be excruciating at times. He had moderate constant pain in the left lower extremity that could be excruciating at times. He had moderate intermittent pain in both lower extremities that was usually of a dull nature. He had severe paresthesias and/or dysesthesias in both lower extremities. There was moderate numbness of the right lower extremity and no numbness of the left lower extremity. Muscle strength testing revealed 4/5 (active movement against some resistance) strength in bilateral knee extension, 5/5 (normal) strength in bilateral ankle flexion, and 4/5 strength in bilateral ankle dorsiflexion. The Veteran had absent reflexes in the knees and ankles. He had decreased sensation in the right lower leg/ankle and normal sensation in the left lower leg/ankle. He had absent sensation in the right foot/toes and normal sensation in the left foot/toes. The examiner found that the Veteran had mild incomplete paralysis of the sciatic nerve in both lower extremities. The examiner also found that the Veteran had mild incomplete paralysis of the internal popliteal (tibial) nerve on the right. The left was normal. With regard to the functional impact, the examiner stated that the Veteran had mild weakness of the lower extremities which prevented climbing or working around heights or near dangerous places. It also prevented extended walking or standing. The evidence is at least in equipoise as to whether the Veteran's radiculopathy of the bilateral lower extremities has more nearly approximated the criteria for moderately severe incomplete paralysis of the sciatic nerve, which is assigned a 40 percent rating under DC 8520. See 38 C.F.R. § 4.124a. Beginning with the March 2008 VA examination report, the evidence shows diminished or absent reflexes in both lower extremities, muscle weakness, constant pain in the left lower extremity that is excruciating at times, constant numbness of the right lower extremity with diminished sensation on sensory testing, intermittent pain of the right lower extremity, and paresthesias and/or dysesthesias such as tingling in both lower extremities. The evidence also shows that the Veteran has had an abnormal gait and was issued knee braces in July 2009 due to his report that his knees tended to buckle. Further, although not controlling on the Board, the Veterans Benefits Administration adjudication procedures manual (VBA Manual) advises that when evaluating incomplete paralysis of the peripheral nerves, including due to radiculopathy, severe incomplete paralysis would be described when more than sensory findings are demonstrated, such as atrophy, weakness and diminished reflexes. VBA Manual M21-1, III.iv.4.G.4.b; but see 38 C.F.R. § 19.5 (2015) (providing, in relevant part, that the Board is not bound by Department manuals, circulars, or similar administrative issues). Accordingly, resolving reasonable doubt, 40 percent ratings are assigned for each lower extremity based on moderately severe incomplete paralysis of the sciatic nerve. See id.; see also 38 U.S.C.A. § 5107; 38 C.F.R. §§ 3.102, 4.3. Although VA examiners have generally characterized the Veteran's sciatic nerve impairment as mild or moderate in severity, the determination as to whether it has satisfied the legal criteria under the rating schedule for a given level of severity is for the Board or rating specialist to make based on all the clinical findings and other evidence of record. Thus, the examiners' overall characterization of the level of severity of the Veteran's sciatic nerve impairment does not alter the Board's conclusion that the criteria for moderately severe incomplete paralysis are more nearly approximated in both lower extremities. The criteria for a rating of 60 percent or higher for paralysis of the sciatic nerve have not been more nearly approximated. The evidence consistently shows that the Veteran's radiculopathy has not been manifested by atrophy, let alone marked muscular atrophy, of either lower extremity, and is not manifested by complete paralysis of the sciatic nerve as described in DC 8520, such as the foot dangling and dropping with no active movement possible of muscles below the knee. See 38 C.F.R. § 4.124a. Accordingly, entitlement to a rating greater than 40 percent under DC 8520 is not established for either extremity. See id. A separate rating for involvement of the right internal popliteal (tibial) or external popliteal nerve (common peroneal) is not warranted, as it would result in compensating the Veteran twice for manifestations of the same disability under varying diagnoses, in violation of the rule against pyramiding. See 38 C.F.R. § 4.14; cf. VBA Manual M21-1, III.iv.4.G.4.d (providing that with regard to nerve impairment affecting the lower extremities, separate ratings are not warranted for symptoms arising from the same nerve branch, as this would constitute pyramiding); VBA Manual M21-1, III.iv.4.G.4.c (table listing the five nerve branches of the lower extremities, and indicating that the sciatic nerve, external popliteal nerve (common peroneal), musculocutaneous nerve (superficial peroneal), anterior tibial nerve (deep peroneal), and posterior tibial nerve) are all part of the sciatic branch). The Veteran's symptoms of pain, numbness, diminished sensation, diminished or absent reflexes, and weakness are all compensated by the 40 percent ratings assigned for each lower extremity. The evidence shows that the Veteran's bilateral radiculopathy has not met or more nearly approximated the criteria for ratings greater than the 40-percent evaluations assigned for each lower extremity at any point during the pendency of this claim, for the reasons explained above. Thus, staged ratings are not warranted for the time period under review. See Hart, 21 Vet. App. at 509-10; Fenderson, 12 Vet. App. at 126. Referral for extraschedular consideration of the radiculopathy is not warranted. See 38 C.F.R. § 3.321(b); Thun v. Peake, 22 Vet. App. 111, 114 (2008). The symptoms and severity of the Veteran's radiculopathy are reasonably described and contemplated by the schedular criteria applicable to diseases of the peripheral nerves, which take into account, in relevant part, loss of reflexes, muscle atrophy, sensory disturbances, constant pain, at times excruciating, and varying levels of paralysis of the nerve with associated clinical findings. See 38 C.F.R. § 4.123 (2015) (discussing ratings for peripheral neuritis); 38 C.F.R. § 4.124a, DC's 8520 (disease of the sciatic nerve) and DC 8620 (neuritis of the sciatic nerve). It must be assumed that resultant functional impairment such as difficulty walking and disturbances in gait are contemplated by the applicable diagnostic codes. See 38 C.F.R. § 4.1. Accordingly, a comparison of the Veteran's radiculopathy with the schedular criteria does not show that it presents such an exceptional or unusual disability picture as to render application of the rating schedule impractical. See id. In the absence of this threshold finding, the second step of the inquiry, namely whether there are "related factors" such as marked interference with employment or frequent periods of hospitalization, is moot. See Thun at 118-19. Therefore, the Board will not refer the evaluation of the Veteran's radiculopathy for extraschedular consideration. See id.; 38 C.F.R. § 3.321(b). For the reasons discussed above with regard to the Veteran's service-connected lumbosacral spine disability, referral for extraschedular consideration based on the collective impact of the Veteran's service-connected disabilities on his radiculopathy is not warranted. Johnson, 762 F.3d at 1366; Yancy, __ Vet. App. ___, 2016 WL 747304, at *9. In sum, resolving reasonable doubt, 40 percent ratings, but no higher, are assigned for left lower extremity radiculopathy and right lower extremity radiculopathy for the entire period under review. See 38 U.S.C.A. § 5107; 38 C.F.R. §§ 3.102, 4.3; Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). C. Temporary Total Rating for Ventral Hernia Repair Surgery with Convalescence Under 38 C.F.R. § 4.30, a temporary total rating for convalescence will be assigned from the date of hospital admission and continue for 1, 2, or 3 months from the first day of the month following hospital discharge when treatment of a service-connected disability results in (1) surgery necessitating at least one month of convalescence; (2) surgery with severe postoperative residuals such as incompletely healed surgical wounds, stumps of recent amputations, therapeutic immobilization of one major joint or more, application of a body cast, or the necessity for house confinement, or the necessity for continued use of a wheelchair or crutches (regular weight-bearing prohibited); or (3) immobilization by cast, without surgery, of one major joint or more. The termination of total ratings under this section are not subject to the notice and other procedural requirements under 38 C.F.R. § 3.105(e) (2015). An extension of 1, 2, or 3 months beyond the initial 3 months may be granted based on the factors enumerated above, and extensions of 1 or more months up to 6 months beyond the initial 6 months period may be made, upon approval of the Veterans Service Center Manager. Id. Because service connection has not been established for a ventral incisional hernia, entitlement to a temporary total rating under § 4.30 based on convalescence from its surgical repair may not be established as a matter of law. See id. As this claim must be denied as a matter of law, the benefit-of-the-doubt rule does not apply. Sabonis v. West, 6 Vet. App. 426, 430 (1994). D. TDIU The Veteran seeks entitlement to TDIU prior to February 12, 2014. For the following reasons, the Board finds that entitlement to TDIU prior to February 12, 2014 is not established. Total disability ratings for compensation may be assigned, where the schedular rating is less than 100 percent, when the disabled person is, in the judgment of the rating agency, unable to secure or follow a substantially gainful occupation as a result of one or more service-connected disabilities without regard to advancing age or nonservice-connected disability. See 38 C.F.R. §§ 3.340, 3.341(a), 4.16(a); Hatlestad v. Brown, 5 Vet. App. 524, 529 (1993) (holding that the central inquiry is whether the Veteran's service-connected disabilities alone are of sufficient severity to produce unemployability); see also 38 C.F.R. § 4.19 (unemployability associated with advancing age or intercurrent disability may not be used as a basis for a total disability rating). The claimant's service-connected disabilities, employment history, educational and vocational attainment, and all other factors having a bearing on the issue must be considered. 38 C.F.R. § 4.16(b). Total disability will be considered to exist when there is present any impairment of mind or body which is sufficient to render it impossible for the average person to follow a substantially gainful occupation. 38 C.F.R. § 4.15. While the rating is based primarily upon the average impairment in earning capacity, full consideration must be given to unusual physical or mental effects in individual cases, to peculiar effects of occupational activities, to defects in physical or mental endowment preventing the usual amount of success in overcoming the handicap of disability, and to the effect of combinations of disability. Id. Substantially gainful employment is defined as work which is more than marginal and which permits the individual to earn a living wage. 38 C.F.R. § 4.16(a); Moore v. Derwinski, 1 Vet. App. 356 (1991). Marginal employment shall generally be deemed to exist when a veteran's earned income does not exceed the amount established by the U.S. Department of Commerce, Bureau of the Census, as the poverty threshold for one person. 38 C.F.R. § 4.16(a). Marginal employment may also be established, on a facts found basis, when earned annual income exceeds the poverty threshold, including but not limited to employment in a protected environment such as a family business or sheltered workshop. Id. Consideration must be given in all claims to the nature of the employment and the reason for termination. Id. Although the Board must give full consideration to "the effect of combinations of disability" under 38 C.F.R. § 4.15, "neither the statute nor the relevant regulations require the combined effect to be assessed by a medical expert." Geib v. Shinseki, 733 F.3d 1350, 1354 (Fed. Cir. 2013). Indeed, regulation places responsibility for the ultimate determination of unemployability on the Board or rating agency, not a medical examiner. Id. (citing 38 C.F.R. § 4.16(a)). As part of this ultimate determination, VA is required to obtain a medical examination or opinion only when "necessary to make a decision on the claim." Id. (citing 38 U.S.C. § 5103A(d)(1)). Where separate medical opinions address the impact on employability resulting from independent disabilities, the Board is authorized to assess the aggregate effect of all disabilities. Id. Certain percentage requirements must be satisfied in order to qualify for schedular consideration of entitlement to TDIU. Specifically, if unemployability is the result of only one service-connected disability, this disability must be ratable at 60 percent or more. See 38 C.F.R. § 4.16(a). If it is the result of two or more service-connected disabilities, at least one must be ratable at 40 percent or more, with the others sufficient to bring the combined rating to 70 percent or more. Id. Disabilities of one or both upper extremities, or one or both lower extremities, including the bilateral factor, disabilities resulting from a common etiology or a single accident, and disabilities affecting a single body system such as orthopedic disabilities, will be considered as one disability for TDIU purposes. Id. The percentage requirements for schedular consideration of entitlement to TDIU are satisfied, as a combined evaluation of 70 percent or higher has been assigned the Veteran's service-connected disabilities since September 2007. In his January 2008 application for TDIU (VA Form 21-8940), the Veteran wrote that all of his service-connected disabilities prevented him from securing or following any substantially gainful employment. This form reflects that his employment history since 1993 included working as a Department of Corrections officer from 1993 to 2004, as a stocker for a store for a few months in 2004, as a customer care representative at a call center for several months from 2004 to 2005, and as a nursing assistant for several months from April 2007 to December 2007. He stated in this form that his most recent employment was terminated due to his missing work due to his service-connected disabilities. With regard to education, this form reflects that the Veteran completed one year of college. The Veteran's SSA records show that he also worked as a security guard from 2008 to 2011, as a cook from 2006 to 2007, and as a telemarketer from 2004 to 2006, and that he reported completing three years of college. The March 2008 VA examination report reflects that the Veteran stated he would be unable to work due to his lumbosacral spine and radiculopathy disabilities, without further comment. An October 2009 VA treatment record reflects that the Veteran reported missing work due to his service-connected irritable bowel syndrome (IBS), and that he had the flu the week before. A December 2010 VA treatment record reflects that the Veteran had sought excuses from work every weekend since the beginning of November 2010 due to dizziness. Another December 2010 VA treatment record reflects that the Veteran reported missing a month of work due to right arm and shoulder pain after a November 2010 fall injury. He stated that he was in such intense pain that he could not use the arm, sleep well, or function well in his daily life. A July 2011 VA treatment record reflects that the Veteran reported that he stopped working in his then present job because "he could no longer physically do it." He stated that he continued to struggle with chronic pain and health issues and had a very difficult time working due to these issues. The December 2011 VA examination report pertaining to the Veteran's lumbosacral spine disability and radiculopathy reflects the examiner's conclusion that these disabilities would prevent the Veteran from standing or walking for extended periods of time, and would prevent any physical employment, including heavy or repetitive lifting, pulling, pushing, or climbing. The examiner found that the Veteran could alternate sitting and standing and do sedentary work. A December 2011 VA examination report pertaining to the Veteran's service-connected irritable bowel syndrome (IBS) reflects the examiner's conclusion that the Veteran's IBS would prevent him from working in outlying areas and those jobs that require long distance driving or in which it would be difficult to locate a bathroom. The examiner stated that heavy lifting, pushing, or pulling should be avoided. The Veteran would be capable of sedentary work, according to the examiner. In a November 2012 SSA disability benefits application form, the Veteran stated he had trouble sitting as well as standing for more than thirty minutes at a time. He stated that sitting caused swelling to the point of pain in his lower legs and ankles. A February 2013 SSA examination report reflects the examiner's findings that the Veteran's chronic spine pain and radiating pain would restrict him to lifting, pushing, or carrying objects occasionally up to 20 or 25 pounds, and frequently up to 10 pounds. The examiner stated that he should be allowed to alternate his position sitting, standing, and walking as needed for comfort due to his spine pain. The examiner found that the Veteran would "do best at a sit down or sedentary job" or in a job in which he could stand or walk for up to 10 to 50 minutes for each hour of work. A January 2014 SSA disability determination reflects a finding of disability for SSA purposes since August 2011, with a primary diagnosis of disorders of the back (discogenic and degenerative) and a secondary diagnosis of obesity. In the January 2014 SSA decision granting SSA disability benefits, it was noted that the Veteran had a number of health conditions in addition to his service-connected disabilities, including asthma, sleep apnea, neck pain, and diabetes. It was found that the Veteran was an individual of advanced age, that he did not have acquired job skills that transferred to other occupations within his residual functional capacity (sedentary work), and that considering the Veteran's age, education, work experience, and residual functional capacity, there were no jobs existing in significant numbers in the national economy that he could perform. The decision concluded that in determining whether a successful adjustment to other work could be made, the Veteran's age was a factor. Indeed, the decision states that even if the Veteran could perform "the full range of sedentary work . . . a finding of disabled would be directed by Medical Vocational Rule 201.06." The Board notes that this rule directs a finding of disabled for an individual of advanced age with no transferable work skills. The corresponding rules for individuals of a younger age limited to sedentary work with no transferable work skills provide that they are not considered disabled for SSA purposes. See SSA Medical-Vocational Guidelines. In other words, the Veteran's age apparently played a significant role in this decision. A January 2014 VA examination report pertaining to mental disorders reflects the examiner's conclusion that the Veteran's service-connected depression was not severe enough to interfere with occupational functioning. A February 2014 VA audiological examination report reflects that the Veteran's hearing loss made it difficult for him to hear and understand speech. The Veteran's tinnitus did not impact ordinary conditions of daily life, including employment. The February 2014 VA spine examination report reflects that the Veteran stopped working in June 2011 due to pain in his back and legs. Prior to that time he was working as a security officer, according to the report. It was noted that he was required to perform extensive walking and stand for prolonged intervals in this job. In a February 2014 VA general examination report, the examiner opined that the Veteran's service-connected lumbosacral spine disability and radiculopathy would prevent any employment other than in a sedentary capacity. The examiner added that the Veteran "believe[d]" that the combination of these disabilities along with several other nonservice-connected conditions which the examiner listed, including diabetes, right carpal tunnel syndrome, right shoulder pain, arthritis of the cervical spine, and hemorrhoids, would prevent even sedentary work. In this regard, the examiner stated that the Veteran would need frequent breaks on the job and frequent absences from the job. The examiner also noted that the Veteran had recently been granted SSA disability benefits. The examiner concluded that the Veteran was "totally disabled and unable to be employed." The Board finds that the preponderance of the evidence weighs against unemployability prior to February 12, 2014. While the evidence clearly establishes that the Veteran's service-connected lumbosacral spine disability and radiculopathy prevent him from working in jobs involving prolonged standing or walking or more physically intensive work, his service-connected disabilities have not prevented sedentary employment, as consistently found by the VA and SSA examiners. Although the February 2014 VA examiner found that the Veteran was "totally disabled and unable to be employed," this conclusion was based on the Veteran's belief (as stated by the examiner) that a number of nonservice-connected disabilities prevented sedentary work. The examiner did not find that the Veteran's service-connected disabilities alone prevented even sedentary work. See Hatlestad, 5 Vet. App. at 529. Moreover, to the extent the examiner relied on SSA's grant of disability benefits to support the conclusion reached, such grant does not support unemployability for TDIU purposes, as explained in the next paragraph. Thus, the February 2014 VA examiner's opinion does not support unemployability due to service-connected disability prior to February 12, 2014, as it does not find that the Veteran's service-connected disabilities alone, without regard to age and nonservice-connected disability, prevent substantially gainful employment in a sedentary capacity for TDIU purposes. The January 2014 SSA decision and disability determination also do not support unemployability due to service-connected disability prior to February 12, 2014. While SSA decisions are relevant, they are not controlling on the Board. See Odiorne v. Principi, 3 Vet. App. 456, 461 (1992). In this regard, SSA's legal criteria for assessing disability for Social Security benefits purposes differs in important respects from VA's own framework for determining entitlement to TDIU. See Collier v. Derwinski, 1 Vet. App. 413, 417 (1991) (indicating that SSA's favorable determination, while probative evidence to be considered in a claim for VA benefits, is not dispositive or altogether binding on VA since the agencies have different disability determination requirements); see also White v. Principi, 243 F.3d 1378, 1380-81 (Fed. Cir. 2001) (discussing differences between SSA's criteria and VA's criteria for determining disability). As already explained, the Veteran's advanced age, as defined by SSA, was an important factor in the January 2014 decision. Age may not be considered for TDIU purposes. See 38 C.F.R. § 4.19. Moreover, even if the Veteran's age did not play a role in the decision, it does not otherwise explain why the Veteran's service-connected disabilities would prevent sedentary employment without regard to age and nonservice-connected disability, or why it was found he could no longer perform work as a telemarketer. The Board has reviewed the same evidence that was apparently available to SSA at the time of its decision, and finds that under VA law such evidence does not show unemployability for TDIU purposes prior to February 12, 2014, as it does not support a finding that the Veteran's service-connected disabilities alone are sufficiently incapacitating as to prevent him from obtaining or maintaining substantially gainful employment in a sedentary capacity without regard to age. The Board gives more weight to the VA and SSA examination reports showing that the Veteran is still able to engage in substantially gainful activity in a sedentary capacity, as these conclusions are based on clinical findings made on examination and supported by explanations. While the Veteran's other service-connected disabilities, including IBS, depression, hearing loss, tinnitus, and asthma may also significantly interfere with employment, the Veteran has not stated and the evidence does not otherwise indicate that these disabilities alone or in the aggregate, including along with his service-connected lumbosacral spine disability and radiculopathy, would render him unable to obtain or maintain substantially gainful activity in a sedentary occupation. In general, although in his applications for SSA disability benefits and TDIU the Veteran has cited all of his service-connected disabilities as preventing him from working, the VA treatment records show that the Veteran has only attributed unemployability due to pain from his back and radiculopathy. The February 2014 VA spine examination shows that the Veteran reported terminating his employment as a security officer in June 2011 due to back pain and radiculopathy. The December 2010 VA treatment record reflects that the Veteran had sought excuses from work every weekend since the beginning of November 2010 due to dizziness. Another December 2010 VA treatment record reflects that the Veteran reported missing a month of work due to right arm and shoulder pain after a November 2010 fall injury. He stated that he was in such intense pain that he could not use the arm, sleep well, or function well in his daily life. This evidence shows that the Veteran has generally not attributed unemployability to his other service-connected disabilities. There is no other evidence suggesting that they prevent sedentary work. The Veteran's education, work experience, and vocational background and attainment do not prevent a transition into sedentary work. Although most of his work experience has involved more physically active work as a medical assistant, security officer, or stocker, he has completed one to three years of college and also has experience as a telemarketer. The evidence does not show that he was unable to obtain or maintain substantially gainful activity in a sedentary capacity based on his educational and vocational background prior to February 2014. The observations in the December 2011 VA examination report and February 2013 SSA examination report that the Veteran would benefit from a job in which he could alternate sitting and standing or walking do not suggest that the Veteran was unable to perform sedentary work without such accommodations or that benefitting from such accommodations precluded sedentary work. Accordingly, the preponderance of the evidence is against the Veteran's claim. Consequently, the benefit-of-the-doubt rule does not apply, and entitlement to TDIU prior to February 12, 2014 is denied. See 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). ORDER Entitlement to service connection for a cervical spine disability, including as secondary to lumbosacral spine disability and bilateral lower extremity radiculopathy, is denied. Entitlement to service connection for a right shoulder disability, including as secondary to lumbosacral spine disability and bilateral lower extremity radiculopathy, is denied. Entitlement to service connection for a ventral incisional hernia is denied. Entitlement to a rating in excess of 40 percent for lumbosacral spine disability with disc extrusion at L4-5 is denied. Entitlement to a rating of 40 percent, but no higher, for right lower extremity radiculopathy is granted for the entire period on appeal, subject to the laws and regulations governing payment of monetary benefits. Entitlement to a rating 40 percent, but no higher, for left lower extremity radiculopathy is granted for the entire period on appeal, subject to the laws and regulations governing payment of monetary benefits. Entitlement to a temporary total disability rating for ventral hernia repair surgery with convalescence is denied. Entitlement to a total disability rating based on individual unemployability due to service connected disability prior to February 12, 2014 is denied. ______________________________________________ P. M. DILORENZO Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs