Citation Nr: 1634463 Decision Date: 09/01/16 Archive Date: 09/09/16 DOCKET NO. 07-14 290 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Indianapolis, Indiana THE ISSUES 1. Entitlement to higher initial ratings for depression with insomnia, rated 10 percent prior to January 12, 2010, 30 percent from January 12, 2010 through November 5, 2013, and 50 percent from November 6, 2013. 2. Entitlement to an increased rating for low back syndrome with degenerative changes, rated 10 percent prior to January 14, 2011 and 20 percent from January 14, 2011. 3. Entitlement to higher initial ratings for lumbar radiculopathy of the right lower extremity, rated 20 percent prior to November 6, 2013 and 40 percent from November 6, 2013. 4. Entitlement to higher initial ratings for lumbar radiculopathy of the left lower extremity, rated 20 percent prior to November 6, 2013 and 40 percent from November 6, 2013. 5. Entitlement to a total disability rating for compensation based upon individual unemployability (TDIU) prior to January 14, 2011, to include on an extraschedular basis. REPRESENTATION Appellant represented by: Ralph J. Bratch, Attorney WITNESSES AT HEARING ON APPEAL The Veteran and his wife ATTORNEY FOR THE BOARD M. Katz, Counsel INTRODUCTION The Veteran served on active duty from September 1982 to January 1983, and from September 1983 to April 1986. These matters come before the Board of Veterans' Appeals (Board) on appeal from March 2006, August 2008, and March 2009 rating decisions by the Department of Veterans Affairs (VA) Regional Office in Indianapolis, Indiana (RO). The Veteran testified at a hearing before the undersigned Veterans Law Judge in June 2010. A transcript of that hearing is associated with the claims file. In a November 2010 decision, the Board granted initial ratings of 20 percent each for lumbar radiculopathy of the right and left lower extremities, and denied entitlement to an initial rating in excess of 10 percent prior to January 12, 2010, and in excess of 30 percent from January 12, 2010, for depression with insomnia. The Board also remanded the issues of entitlement to service connection for acid reflux disease; entitlement to an increased rating for low back syndrome with degenerative changes; and entitlement to a TDIU. Thereafter, the Veteran appealed the Board's November 2010 decision to the U.S. Court of Appeal for Veterans Claims (Court). In May 2012, the Court issued an order granting a Joint Motion for Partial Remand (JMPR), and vacating the Board's decision regarding the initial ratings assigned for radiculopathy of the right and left lower extremities, as well as for depression with insomnia, and requesting additional reasons and bases. In April 2012, the RO assigned a 20 percent staged initial rating for the Veteran's low back syndrome with degenerative changes, effective January 14, 2011, and awarded TDIU effective January 14, 2011. In October 2012, the Board remanded all of the issues on appeal for additional development. In a March 2015 rating decision, the RO assigned an increased rating of 50 percent for depression with insomnia, effective November 6, 2013 and increased ratings of 40 percent each for right and left lower extremity radiculopathy, effective November 6, 2013. The case was then returned to the Board. The issues of entitlement to an increased rating for low back syndrome with degenerative changes, entitlement to increased ratings for lumbar radiculopathy of the right and left lower extremities, and entitlement to a TDIU prior to January 14, 2011, are addressed in the REMAND portion of the decision below, and are REMANDED to the Agency of Original Jurisdiction (AOJ). FINDINGS OF FACT 1. Since the initial grant of service connection effective November 15, 2007 through January 11, 2010, the Veteran's psychiatric disability has been manifested by symptoms productive of functional impairment comparable to occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks. 2. From January 12, 2010 to November 5, 2013, the Veteran's psychiatric disability has been manifested by symptoms productive of functional impairment comparable to occupational and social impairment with reduced reliability and productivity. 3. On and after November 6, 2013, the Veteran's psychiatric disability has been manifested by symptoms productive of functional impairment comparable to occupational and social impairment with reduced reliability and productivity. CONCLUSIONS OF LAW 1. The criteria for an initial evaluation of 30 percent, but no greater, for service-connected depression with insomnia have been met, prior to January 12, 2010. 38 U.S.C.A. §§ 1155, 5103A, 5107 (West 2014); 38 C.F.R. § 4.130, Diagnostic Code 9411 (2015). 2. The criteria for a staged initial evaluation of 50 percent, but no greater, for service-connected depression with insomnia from January 12, 2010 through November 5, 2013 have been met. 38 U.S.C.A. §§ 1155, 5103A, 5107 (West 2014); 38 C.F.R. § 4.130, Diagnostic Code 9411 (2015). 3. The criteria for a staged initial evaluation greater than 50 percent for service-connected depression with insomnia on or after November 6, 2013 have not been met. 38 U.S.C.A. §§ 1155, 5103A, 5107 (West 2014); 38 C.F.R. § 4.130, Diagnostic Code 9411 (2015). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS With respect to the issue of entitlement to higher initial and staged ratings for a service-connected psychiatric disability, VA has met all statutory and regulatory notice and duty to assist provisions. See 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126 (West 2014); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326 (2015). Prior to the initial adjudication of the Veteran's claim, a letter dated in February 2008 satisfied the duty to notify provisions. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b)(1); Quartuccio v. Principi, 16 Vet. App. 183, 187 (2002); Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). The issue of entitlement to an initial rating greater than 10 percent for an acquired psychiatric disability did not stem from an application for benefits, it stemmed from a notice of disagreement to the initial rating assigned by a VA rating decision. 38 C.F.R. § 3.159(b)(3) (effective May 30, 2008) provides that there is no duty to provide section 5103(a) (VCAA) notice upon the Veteran's filing of a notice of disagreement as to the initial rating assignment. 73 Fed. Reg. 23353-23356 (April 30, 2008) (as it amends 38 C.F.R. § 3.159 to add paragraph (b)(3), effective May 30, 2008). Rather, such notice of disagreement triggers VA's statutory duties under 38 U.S.C.A. §§ 5104 and 7105, as well as regulatory duties under 38 C.F.R. § 3.103. As a consequence, VA is only required to advise the Veteran of what is necessary to obtain the maximum benefit allowed by the evidence and the law. This has been accomplished here, as the Veteran was issued a copy of the rating decision, and a statement of the case which set forth the relevant diagnostic code rating criteria. Further, the purpose behind the notice requirement has been satisfied because the Veteran has been afforded a meaningful opportunity to participate effectively in the processing of his claim, to include the opportunity to present pertinent evidence. Simmons v. Nicholson, 487 F.3d 892, 896 (Fed. Cir. 2007); Sanders v. Nicholson, 487 F.3d. 881, 887 (Fed. Circ. 2007), rev'd on other grounds, Sanders v. Shinseki, 556 U.S. 396 (2009). The Veteran's service treatment records, VA medical treatment records, and identified private medical records have been obtained. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. Although the Veteran reported that he applied for disability benefits from the Social Security Administration (SSA), the SSA indicated that there were no records available for the Veteran. Id. The Veteran most recently was provided with a VA examination addressing the severity of his psychiatric disability in November 2013. The Board acknowledges the argument made by the Veteran's representative that the the November 2013 VA examination is inadequate because the examiner did not discuss the January 2010 VA examiner's assignment of a GAF score of 59 and the "seemingly conflicting conclusion that Appellant experienced reduced reliability and productivity due to mental disorder signs and symptoms . . . ." as noted in the JMPR. However, the Board finds that the November 2013 VA examination is adequate in this case. It provides a thorough history of the Veteran's depression, summarizing the symptoms found during the pertinent periods and concluding that "the medical evidence during the period March 2005 through January 13, 2011 shows that symptom levels and/or functional impairment was at a mild to moderate level with regard to depressive symptoms . . . ." Although the examiner did not specifically address the GAF score assigned in the January 2010 VA examination, the Board finds the November 2013 VA examiner's review of the pertinent evidence and ultimate conclusion to be in substantial compliance with its October 2012 Remand directives, and sufficient upon which to base an appellate decision. Additionally, the Board finds the November 2013 VA examination to be adequate, as it provides a clear picture of the Veteran's psychiatric disability status to rate the Veteran's disability under the pertinent rating criteria. Thus, the Board finds the VA examination conducted with regard to this issue to be adequate. 38 C.F.R. § 3.159(c)(4); Barr v. Nicholson, 21 Vet. App. 303, 307 (2007). In Bryant v. Shinseki, 23 Vet. App. 488 (2010), the Court held that 38 C.F.R. § 3.103(c)(2) requires that the Veterans Law Judge (VLJ) who conducts a hearing fulfill two duties to comply with the above the regulation. These duties consist of (1) the duty to fully explain the issues and (2) the duty to suggest the submission of evidence that may have been overlooked. The Veteran was afforded a hearing before the Board in June 2010. During the Board hearing, the VLJ noted that the Veteran needed to provide evidence of the current nature and severity of his psychiatric disability. The Veteran was assisted at the hearing by his attorney. The Veteran's representative and the VLJ both asked questions to ascertain the current symptomatology of the Veteran's psychiatric disability. No pertinent evidence that might have been overlooked and that might substantiate the claim was identified by the Veteran or the representative. The hearing focused on the elements necessary to substantiate the claim. Neither the representative nor the Veteran has suggested any deficiency in the conduct of the hearing. Therefore, the Board finds that, consistent with Bryant, the VLJ complied with the duties set forth in 38 C.F.R. § 3.103(c)(2). There is no indication in the record that any additional evidence relevant to the issue of entitlement to higher initial and staged ratings for an acquired psychiatric disability is available and not part of the claims file. See Pelegrini v. Principi, 18 Vet. App. 112 (2004). As there is no indication that any failure on the part of VA to provide additional notice or assistance reasonably affects the outcome of the case, the Board finds that any such failure is harmless. See Mayfield v. Nicholson, 20 Vet. App. 537 (2006); see also Shinseki v. Sanders/Simmons, 129 S. Ct. 1696 (2009). Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (Rating Schedule). 38 C.F.R. Part 4 (2015). The Rating Schedule is primarily a guide in the evaluation of disability resulting from all types of diseases and injuries encountered as a result of or incident to military service. The ratings are intended to compensate, as far as can practicably be determined, the average impairment of earning capacity resulting from such diseases and injuries and their residual conditions in civilian occupations. See 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1 (2015). Pertinent regulations do not require that all cases show all findings specified by the Rating Schedule, but that findings sufficient to identify the disease and the resulting disability and above all, coordination of the rating with impairment of function, will be expected in all cases. 38 C.F.R. § 4.21 (2015); see also Mauerhan v. Principi, 16 Vet. App. 436 (2002). In considering the severity of a disability, it is essential to trace the medical history of the Veteran. 38 C.F.R. §§ 4.1, 4.2, 4.41 (2015). Consideration of the whole-recorded history is necessary so that a rating may accurately reflect the elements of any disability present. 38 C.F.R. § 4.2; Peyton v. Derwinski, 1 Vet. App. 282 (1991). Although the regulations do not give past medical reports precedence over current findings, the Board is to consider the Veteran's medical history in determining the applicability of a higher rating for the entire period in which the appeal has been pending. Powell v. West, 13 Vet. App. 31, 34 (1999). With regard to the Veteran's appeal, the level of disability at and since the time that service connection was granted is of primary importance. Additional staged ratings are appropriate when the factual findings show distinct time periods in which a disability exhibits symptoms that warrant different ratings. Fenderson v. West, 12 Vet. App. 119, 126 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). The Veteran contends that he is entitled to an initial rating greater than 10 percent for his service-connected psychiatric disability prior to January 12, 2010; an initial staged rating greater than 30 percent from January 12, 2010 through November 5, 2013; and an initial staged rating greater than 50 percent on and after November 6, 2013. The claims file reflects that the Veteran filed a claim seeking service connection for a psychiatric disability in November 2007. In an August 2008 rating decision, the RO awarded service connection for depression with insomnia and assigned a 10 percent rating, effective November 15, 2007, under the provisions of 38 C.F.R. § 4.130, Diagnostic Code 9434. The Veteran filed a notice of disagreement with the assigned rating in August 2008, and in October 2009, he perfected his appeal. In a February 2010 rating decision, the RO assigned an initial staged rating of 30 percent for the Veteran's psychiatric disability, effective January 12, 2010. In a March 2015 rating decision, the RO assigned an initial staged rating of 50 percent for the Veteran's psychiatric disability, effective November 6, 2013. The current regulations establish a general rating formula for mental disorders. 38 C.F.R. § 4.130. Ratings are assigned according to the manifestation of particular symptoms. However, the use of the term "such as" in 38 C.F.R. § 4.130 demonstrates that the symptoms after that phrase are not intended to constitute an exhaustive list, but rather are to serve as examples of the type and degree of the symptoms, or their effects, that would justify a particular rating. See Vazquez-Claudio v. Shinseki, 713 F.3d 112 (Fed. Cir. 2013); see also Sellers v. Principi, 372 F.3d 1318, 1326-27 (Fed.Cir.2004); Mauerhan v. Principi, 16 Vet. App. 436, 442 (2002). However, because "[a]ll nonzero disability levels [in § 4.130] are also associated with objectively observable symptomatology," and the plain language of the regulation makes it clear that "the veteran's impairment must be 'due to' those symptoms," "a veteran may only qualify for a given disability rating under § 4.130 by demonstrating the particular symptoms associated with that percentage, or others of similar severity, frequency, and duration." Vazquez-Claudio, 713 F.3d at 116-17. For example, "in the context of a 70[%] rating, § 4.130 requires not only the presence of certain symptoms but also that those symptoms have caused occupational and social impairment in most of the referenced areas." Id. at 117. Thus, assessing whether a 70% evaluation is warranted requires a two-part analysis: "The ... regulation contemplates[: (1)] initial assessment of the symptoms displayed by the veteran, and if they are of the kind enumerated in the regulation[; and (2)] an assessment of whether those symptoms result in occupational and social impairment with deficiencies in most areas." Id. at 118. Pursuant to Diagnostic Code 9434, depression is rated as 10 percent disabling when there is occupational and social impairment due to mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress, or; symptoms controlled by continuous medication. A 30 percent rating contemplates occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), and chronic sleep impairment, mild memory loss (such as forgetting names, directions, or recent events). A 50 percent evaluation is warranted when there is occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; and difficulty in establishing and maintaining effective work and social relationships. 38 C.F.R. § 4.130, Diagnostic Code 9434. A 70 percent evaluation is warranted where there is objective evidence demonstrating occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to suicidal ideation; obsessional rituals which interfere with routine activities, speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately, or effectively; impaired impulse control, such as unprovoked irritability with periods of violence; spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances, including work or a work-like setting; and the inability to establish and maintain effective relationships. A maximum 100 percent evaluation is for application when there is total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; and memory loss for names of close relatives, own occupation, or own name. Id. In evaluating the evidence, the Board has considered the various Global Assessment of Functioning (GAF) scores that clinicians have assigned. The GAF is a scale reflecting the psychological, social, and occupational functioning on a hypothetical continuum of mental health illness. See Diagnostic and Statistical Manual of Mental Disorders (4th ed.) (DSM-IV); Carpenter v. Brown, 8 Vet. App. 240 (1995). The Board also notes, however, that the GAF scale was removed from the more recent DSM-V for several reasons, including its conceptual lack of clarity, and questionable psychometrics in routine practice. See DSM-V, Introduction, The Multiaxial System (2013). A GAF score of 61-70 reflects some mild symptoms (e.g., depressed mood and mild insomnia) or some difficulty in social, occupational, or school functioning (e.g., occasional truancy, or theft within the household), but generally functioning pretty well, and has some meaningful interpersonal relationships. A GAF score of 51-60 indicates moderate symptoms (e.g., flat affect and circumstantial speech, occasional panic attacks) or moderate difficulty in social, occupational, or school functioning (e.g., few friends, conflicts with peers or co-workers). A GAF score of 41-50 reflects serious symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent shoplifting) or any serious impairment in social, occupational, or school functioning (e.g., no friends, unable to keep a job). A GAF score of 31-40 reveals some impairment in reality testing or communication (e.g., speech is at times illogical, obscure, or irrelevant) or major impairment in several areas, such as work or school, family relations, judgment, thinking, or mood (e.g., depressed man avoids friends, neglects family, and is unable to work; child frequently beats up younger children, is defiant at home, and is failing at school). DSM-IV at 46-47. The evidence delineated below does not represent all of the extensive evidence in the claims file, but is representative of the evidence of record and encompasses or is fully representative of evidence that is favorable to the Veteran's claim. a. Prior to January 12, 2010 In a November 2007 statement, E. Schubert, M.D., the Veteran's VA treating physician, reported that the Veteran had "significant depression" while on medication, and that treatment included counseling. In July 2008, the Veteran underwent a VA psychiatric examination. The Veteran reported that he last worked in approximately 2000, and that he lived with his wife on a farm. He stated that he had been married three times. His first marriage resulted in two children, and ended in 1993. His second marriage lasted from 1998 to 2002, and he has two stepchildren from that marriage with whom he remains close. He noted that his second wife died in a motor vehicle accident, which ended their marriage. He remarried in 2006 to his present wife, who has three children. The Veteran indicated that he sees his mother on a weekly basis, when he attends church, but noted that his relationship with her was somewhat distant. He reported that he has four brothers, one sister, and three half-sisters. The Veteran reported a close and loving relationship with his wife, and noted that he and his wife were active at their church. He noted that they enjoyed teaching Sunday School through the youth ministry, and that they also enjoyed attending services twice per week, on a regular basis. The Veteran reported a close relationship with his children and grandchild. He also indicated that he was close with his youngest brother. The Veteran noted that there were several friends at church with whom he was close, and that he talked with them regularly. He indicated that he lived on a farm with his wife, and that they raised goats, rabbits, pheasants, and chickens. He stated that he sold chicken eggs and butchered chickens himself. He noted that he had not worked since 2000 due to his back pain and other physical problems. The Veteran stated that his hobbies included deer hunting, collecting guns, and target shooting. He noted that he enjoyed fishing, but that he had not fished that year. He also stated that he enjoyed gardening and dogs. The Veteran reported psychiatric symptoms including depressed mood due to worry and inability to work, and lack of enjoyment in things that he once enjoyed doing. He noted feelings of worry and irritation. The Veteran's wife indicated that he exhibited difficulty staying focused on tasks. The examiner stated that, "[o]verall, the veteran's mental health problems appear to be of mild severity, to occur at various intervals and to have been present over the last year." Mental status examination revealed the Veteran to be casually dressed with average grooming and hygiene. He was able to care for his personal hygiene and activities of daily living independently. He had good eye contact and no inappropriate behavior. He was alert and fully oriented with average memory and concentration. There was no evidence of memory impairment upon testing. Insight, judgment, and comprehension appeared to be average. Speech was fluent and of normal rate, and well-articulated. Speech patterns were logical, relevant, coherent, and goal-directed. He denied psychotic symptoms, such as hallucinations, delusions, and disorders of thought or communication. The Veteran was mildly depressed with appropriate affect. He denied any impulse control problems as well as suicidal or homicidal ideation. He did not report any panic attacks or panic-like symptoms. There was no evidence of obsessive or ritualistic behaviors that might interfere with routine activities. The diagnosis was depressive disorder, not otherwise specified. A GAF score of 65 was assigned. The examiner stated that, overall, the Veteran "reported mild signs and symptoms of depression, which appeared to have a mild impact on his occupational and social functioning." VA treatment records from November 2006 through 2009 reflect diagnoses of, and treatment, for a psychiatric disability. The evidence shows that the Veteran's marriage and family life were stable, and that his activities of daily living were relatively stable. Mental status examinations show that the Veteran was normally alert and fully oriented with appropriate behavior. Mood was usually subdued but characteristic, and affect was constricted, but congruent. Eye contact was reported to be good. There was no evidence of suicidal or homicidal ideation, and no evidence of physical or verbal aggression. No psychosis was present. Behavior was appropriate without tics, mannerisms, movement disturbances, or psychomotor extremes. Grooming and hygiene were good and the Veteran was neatly and appropriately attired. Speech and thought processes were linear, logical, and goal-directed, and the Veteran was cognitively intact. The diagnoses included depression and dysthymic disorder. A December 2006 record indicates that the Veteran communicated regularly with his children. A June 2007 record notes that there was some psychomotor slowing, characteristic of the Veteran's pain treatment. An August 2007 VA treatment record notes that the Veteran was divorced once and widowed three times, but currently married. There was decreased concentration, change in appetite, psychomotor slowing on examination. The examiner noted that the Veteran had fairly good response to his medication, but still exhibited some symptoms of depression. The physician suggested an increase in medication, but the Veteran declined, noting increased cognitive difficulties with more medication. In November 2007, the Veteran's VA physician indicated that the Veteran's depression had been "adequately treated" and that he had received counseling, but that the Veteran exhibited limitations in his response to treatment. The physician noted that the Veteran worked at home, mostly cutting wood, as he heated his home with a wood burning stove. A January 2008 record described the Veteran's depression as "significant." The record also indicates that the Veteran reported difficulty concentrating. He noted racing thoughts and decreased sleep. In February 2008, the Veteran endorsed some decrease in feelings of hopelessness since increasing his psychiatric medication. He noted difficulty sleeping due to anxiety and pain. A September 2008 record indicates that the Veteran's psychiatric disability resulted in sleep disturbance, and that he was able to sleep five to seven hours per night for four to six nights per week. A June 2009 VA treatment record notes that the Veteran experienced some visual misperceptions due to his pain medication, but no other psychosis. The Veteran's current 10 percent evaluation contemplates functional impairment comparable to occupational and social impairment due to mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress, or symptoms controlled by continuous medication. 38 C.F.R. § 4.130, Diagnostic Code 9434. As noted above, GAF scores are a scale reflecting the "psychological, social, and occupational functioning on a hypothetical continuum of mental health-illness." Carpenter, 8 Vet. App. at 242 . The Veteran's GAF score 65 indicates some mild symptoms or some difficulty in social, occupational, or school functioning, but generally functioning pretty well, and has some meaningful interpersonal relationships. See DSM-IV at 46-47. Although GAF scores are important in evaluating mental disorders, the Board must consider all the pertinent evidence of record and set forth a decision based on the totality of the evidence in accordance with all applicable legal criteria. See Carpenter, 8 Vet. App. at 242. Accordingly, an examiner's classification of the level of psychiatric impairment, by word or by a GAF score, is to be considered but is not determinative of the percentage VA disability rating to be assigned; the percentage evaluation is to be based on all the evidence that bears on occupational and social impairment. Id.; see also 38 C.F.R. § 4.126 (2015); VAOPGCPREC 10-95, 60 Fed. Reg. 43186 (1995). With consideration of the evidence in the claims file prior to January 12, 2010, the Board finds that the evidence more nearly approximates the criteria for the next higher disability rating of 30 percent prior to January 12, 2010. 38 C.F.R. §§ 4.7, 4.130, Diagnostic Code 9434 (2015). Since the initial grant of service connection, the Veteran has demonstrated symptoms including depression, anxiety, difficulty sleeping, irritability, lack of enjoyment in things once enjoyed, worry, and difficulty focusing. Although not all of the criteria for a 30 percent rating have been shown, the criteria are simply guidelines for determining whether the Veteran meets the dominant criteria. The dominant criteria for a 30 percent evaluation are occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal). The evidence of record demonstrates that this level of impairment is met prior to January 12, 2010. Accordingly, based on all the evidence of record, the manifestations of the Veteran's psychiatric disability meet the criteria contemplated for a 30 percent evaluation under the provisions of Diagnostic Code 9434 prior to January 12, 2010. However, the preponderance of the evidence is against a rating in excess of 30 percent prior to January 12, 2010. As noted above, since the initial grant of service connection, the Veteran's psychiatric disability has been manifested by symptoms including depression, hopelessness, anxiety, difficulty sleeping, irritability, lack of enjoyment in things once enjoyed, worry, and difficulty focusing. Additionally, the Veteran reported a close relationship with his wife and family, and noted significant participation at his church. He felt that he was close with several friends at church and reported enjoying deer hunting, collecting guns, target shooting, and teaching Sunday School. Mental status examinations showed him to have average grooming and hygiene, average memory and concentration, and average insight and judgment. Additionally, speech was logical, relevant, coherent, and goal-directed. There was no evidence of hallucinations, delusions, or disorders of thought or communication. Although some anxiety was noted, the Veteran did not report panic attacks. While there was some evidence of psychomotor slowing, this appears to have been attributed to the Veteran's pain medication. The Veteran stated that he worked at home, cutting wood. One record indicated that the Veteran experienced visual misperceptions, but found that this was also due to his pain medication. The medical evidence shows that the Veteran was alert and fully oriented. His mood was depressed. Thought process was normal. Eye contact was good. There was no evidence of obsessive or ritualistic behavior. There was no evidence of impulse control problems or inappropriate behavior. There was no history of suicidal or homicidal ideation. Additionally, the July 2008 VA examiner found that the Veteran's depression resulted in "mild signs and symptoms of depression, which appeared to have a mild impact on his occupational and social functioning." After a thorough review of the evidence of record, the Board concludes the preponderance of the evidence is against a finding that the Veteran's psychiatric disability is manifested by symptoms warranting a 50 percent or higher evaluation prior to January 12, 2010, as the evidence does not show functional impairment comparable to occupational and social impairment with reduced reliability and productivity. See 38 C.F.R. § 4.130, Diagnostic Code 9434; Vazquez-Claudio v. Shinseki, 713 F.3d 112 (Fed. Cir. 2013). In that regard, reduced reliability and productivity in occupational and social functioning are not shown, as the Veteran was active in his church community and participated at home by cutting wood. He reported a close social network of family and friends. Additionally, the Veteran was able to care for himself, communicate, and engage in activities that he enjoyed. While there is evidence of some impairment in mood and concentration, the majority of the evidence demonstrates that the Veteran's psychiatric disability did not more than mildly impact his social and occupational functioning. "[A] veteran may only qualify for a given disability rating under § 4.130 by demonstrating the particular symptoms associated with that percentage, or others of similar severity, frequency, and duration." Vazquez-Claudio, 713 F.3d at 116-17. Here, the preponderance of the evidence shows that the Veteran does not experience symptoms as listed for a 50 percent rating, or other symptoms of a similar severity, frequency, or duration, but rather that his symptoms are all reasonably contemplated by the symptoms set forth in the rating criteria for a rating of 30 percent, at any time prior to January 12, 2010. See Fenderson v. West, 12 Vet. App. 1 (1999). The Board acknowledges that the Veteran's VA psychiatrist, Dr. Schubert, reported that the Veteran's depression was "significant." However, the psychiatrist does not explain what is meant by "significant". While the Veteran's depression is most certainly significant and causes a considerable impact upon his life, such a finding does not suggest that an initial rating higher than 30 percent is warranted for the Veteran's depression. Moreover, all of Dr. Schubert's treatment records were considered in determining the appropriate initial rating for the Veteran's psychiatric disability, and the symptoms and assessments provided in those treatment records do not suggest that the Veteran's psychiatric disability warrants an initial rating greater than 30 percent prior to January 12, 2010. Although the evidence of record may demonstrate some of the symptoms contemplated in a 50 or a 70 percent evaluation, the Veteran's disability picture more closely corresponds to the requirements for a 30 percent evaluation prior to January 12, 2010. Thus, as the evidence does not more nearly approximate an evaluation greater than 30 percent, an initial evaluation in excess of 30 percent is not warranted for the Veterans psychiatric disability. b. From January 12, 2010 through November 5, 2013 On January 12, 2010, the Veteran underwent another VA psychiatric examination. The Veteran reported that he "really had no friends" aside from seeing some people on a regular basis at church. He also noted that he did not feel like going places. He noted that he was married for the third time, and indicated that his first marriage ended in divorce, and his second wife passed away in a motor vehicle accident. The Veteran indicated that he and his wife did not do very much, as he only left the house for doctor appointments. The Veteran's wife noted that the Veteran's pain contributed to his reluctance to leave the house. The Veteran indicated that he had several grandchildren, and that he saw them regularly. The Veteran stated that he had few or no friends, and did not see anyone regularly. He noted that he saw his father-in-law occasionally. The Veteran stated that he used to fish, but that now he only reads magazines and the Bible, or watches videos on television. He indicated that his sleep cycle was very irregular, and that he spent much of his day in his recliner. The Veteran reported symptoms including feeling sad and tearful, and lacking enjoyment of activities that he used to enjoy. He noted difficulty getting interested in anything. He also stated that he felt restless, had trouble making decisions, and lacked concentration. He reported feeling worthless and guilty. He also noted feeling irritable, decreased appetite, and less interested in sex. There was no evidence of panic attacks or generalized anxiety. The Veteran denied ritualistic or compulsive behaviors and did not appear to have problems controlling his impulses. Mental status examination revealed the Veteran to have adequate grooming and hygiene, although he reported difficulty maintaining personal hygiene, including some toileting activities, due to pain. He maintained good eye contact and interacted in a cooperative manner. He expressed feelings of frustration. Speech was slow and deliberate, punctuated occasionally by loud clearing of the throat. The Veteran's eyes appeared bloodshot. Although there was no evidence of hallucinations, delusions, or psychotic symptoms during the interview, the Veteran's wife reported one instance in which he appeared to be confused and thought that ashes had been spread in his driveway, which may have been a visual hallucination. The Veteran was alert and fully oriented, although he initially mis-reported the month. The Veteran's memory was intact, although he indicated having some problems with memory. Thought process was intact and goal-directed, and social judgment appeared to be good. There was some difficulty with concentration. Mood was somewhat dysphoric and frustrated. The diagnosis was depressive disorder, and a GAF score of 59 was assigned. The examiner noted that 59 was at the upper end of the range of moderate symptoms, or moderate difficulty in social, occupational, or school functioning. The examiner stated that the Veteran's prognosis was guarded, and that his mood was likely to improve only if his pain somehow improved. The examiner found there to be reduced reliability and productivity due to mental disorder signs and symptoms, and indicated that the Veteran's psychiatric medications, in addition to his depression, affected his cognition and contributed to problems with concentration, memory, and possibly alertness. The examiner noted that the Veteran isolated himself at home and avoided social contact; that his mood was often depressed; and that he got little enjoyment in life. Additionally, the examiner stated that the Veteran would have difficulty maintaining a normal pace in any kind of work due to distraction caused by pain. During a June 2010 hearing before the Board, the Veteran testified that his psychiatric symptoms included crying spells, nightmares, thoughts of death without suicidal intent, social isolation, and avoidance of people. He indicated that he spent most of his day in his recliner, and that he took antidepressant medication for his symptoms. He noted hallucinations on his medication, and reported that his depression had affected his relationships. He also endorsed feelings of frustration and lack of self-worth. The Veteran's wife noted that he hardly left the house, that he was forgetful, and that he lacked interest in doing things around the house. VA treatment records from January 2010 to November 2013 reflect continued diagnoses of and treatment for depression. Psychiatric examinations reveal the Veteran to be casually groomed and dressed, alert and fully oriented, with no evidence of psychosis. His thought process and thought content were within normal limits. His mood was stable and his affect was within normal limits. There was no evidence of any suicidal ideations and the Veteran was future-oriented. Diagnoses included depressive disorder and anxiety disorder. An August 2010 treatment record reflects that the Veteran had been stable on his psychiatric medication for some time, and the Veteran was referred to his primary physician for continued psychiatric medication treatment, as he was stable on his treatment at that time. A November 2010 note reveals that the Veteran telephoned the Suicide Prevention Lifeline. He denied suicidal ideation, but reported that he "freaked out" when he received a letter from the government stating that his compensation had been reduced. The Veteran reported feeling depressed with decreased sleep, weight loss, and decreased appetite. He reported poor hygiene, stating that his wife had to scrub his back and wipe his bottom because he could not reach. The Veteran seemed to be alert and oriented, and he denied psychotic symptoms. He seemed depressed with tangential thought processes. His speech was slow and drawn out. The Veteran was appropriately able to express his thoughts and feelings, and identified his wife as his primary support system, along with other family and friends. He seemed stable and forward thinking at the end of the telephone call. In May 2012, the Veteran reported increased forgetfulness, such as forgetting to eat and where he placed something. The Veteran's wife noted that the Veteran's anxiety seemed worse resulting in impaired sleep. In January 2013, the Veteran's wife reported that the Veteran seemed more depressed. She noted that he exhibited increased irritability and social isolation. He was forgetful of when he ate. The Veteran denied suicidal thoughts. He noted that he felt worthless but not hopeless. The Veteran's current 30 percent evaluation from January 12, 2010 through November 5, 2013 contemplates functional impairment comparable to occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal). 38 C.F.R. § 4.130, Diagnostic Code 9434. As noted above, GAF scores are a scale reflecting the "psychological, social, and occupational functioning on a hypothetical continuum of mental health-illness." Carpenter, 8 Vet. App. at 242. The Veteran's GAF score 59 shows moderate symptoms or moderate difficulty in social, occupational, or school functioning. See DSM-IV at 46-47. With consideration of the evidence in the claims file from January 12, 2010 through November 5, 2013, the Board finds that the evidence more nearly approximates the criteria for the next higher disability rating of 50 percent during that time period. 38 C.F.R. §§ 4.7, 4.130, Diagnostic Code 9434 (2015). During the time period from January 12, 2010 through November 5, 2013, the Veteran has demonstrated symptoms including increased social isolation, feeling sad and tearful, lack of interest in activities previously enjoyed, poor concentration, nightmares, frustration, irritability, decreased appetite, slow speech, and depressed mood. Additionally, the January 2010 VA examiner found there to be occupational and social impairment with reduced reliability and productivity as a result of the Veteran's psychiatric disability. The dominant criteria for a 50 percent evaluation are occupational and social impairment with reduced reliability and productivity due to psychiatric symptoms. The medical evidence of record demonstrates that this level of impairment is met from January 12, 2010 through November 5, 2013. Specifically, the evidence shows that the Veteran became more socially withdrawn during this time period and no longer participated in activities that he once enjoyed doing. The evidence also suggests that he began spending most of his time in his recliner during this time period, and was not participating in household chores. Accordingly, based on all the evidence of record, the manifestations of the Veteran's psychiatric disability meet the criteria contemplated for a 50 percent evaluation under the provisions of Diagnostic Code 9434 from January 12, 2010 through November 5, 2013. However, the preponderance of the evidence is against a rating in excess of 50 percent from January 12, 2010 through November 5, 2013. As noted above, since January 12, 2010, the Veteran's psychiatric disability has been manifested by symptoms including increased social isolation, feeling sad and tearful, lack of interest in activities previously enjoyed, poor concentration, nightmares, frustration, irritability, decreased appetite, slow speech, and depressed mood. Additionally, the evidence reflects that the Veteran was close with his wife and saw his grandchildren regularly. The Veteran maintained interest in reading magazines and the Bible. There was no evidence of anxiety or panic attacks, and the Veteran denied ritualistic or compulsive behavior and did not seem to have trouble controlling his impulses. The medical evidence demonstrates that the Veteran had adequate grooming and hygiene, although he required assistance with such as a result of the limitations caused by his back disability. He maintained good eye contact. Although his wife reported one instance of possible visual hallucination, the evidence does not show that the Veteran regularly experiences such distorted thinking. The Veteran was alert and fully oriented; thought process was intact; and insight and judgment were good. After a thorough review of the evidence of record, the Board concludes the preponderance of the evidence is against a finding that the Veteran's psychiatric disability is manifested by symptoms warranting a 70 percent or higher evaluation at any time from January 12, 2010 through November 5, 2013, as the evidence does not show functional impairment comparable to occupational and social impairment with deficiencies in most areas, such as work, school, family relations, thinking, or mood. See 38 C.F.R. § 4.130, Diagnostic Code 9434; Vazquez-Claudio v. Shinseki, 713 F.3d 112 (Fed. Cir. 2013). In that regard, although there is some evidence of deficiencies in thinking and mood, the evidence does not show deficiencies in family relations, judgment, or thinking. In that regard, the evidence shows that the Veteran remained close with his wife and family, and that his cognitive functioning was regularly good. While the Veteran reported symptoms of reduced concentration and memory, the mental status examination conducted in January 2010 showed normal memory, intact thought process, and good judgment. "[A] veteran may only qualify for a given disability rating under § 4.130 by demonstrating the particular symptoms associated with that percentage, or others of similar severity, frequency, and duration." Vazquez-Claudio, 713 F.3d at 116-17. Here, the preponderance of the evidence shows that the Veteran does not experience symptoms as listed for a 70 percent rating, or other symptoms of a similar severity, frequency, or duration, but rather that his symptoms are all reasonably contemplated by the symptoms set forth in the rating criteria for a rating of no more than 50 percent, at any time from January 12, 2010 through November 5, 2013. See Fenderson v. West, 12 Vet. App. 1 (1999). Although the evidence of record may demonstrate some of the symptoms contemplated in a 70 percent evaluation, the Veteran's disability picture more closely corresponds to the requirements for a 50 percent evaluation from January 12, 2010 through November 5, 2013. Thus, as the evidence does not more nearly approximate an evaluation greater than 50 percent, a staged initial rating in excess of 50 percent is not warranted for the Veterans psychiatric disability from January 12, 2010 through November 5, 2013. c. On and after November 6, 2013 On November 6, 2013, the Veteran underwent another VA psychiatric examination. The examiner noted that the Veteran's current social supports included his wife and family, but that he had less involvement in his community. The Veteran reported that he resided with his wife, stepson and his wife, and two granddaughters. The Veteran's wife indicated that they got along "okay" but that she became frustrated when he did not want to get out and do things. The Veteran stated that he enjoyed fishing, but only went once a few years ago. He identified his regular activities as watching television, reading, and reading to his grandchildren. He noted that it had been quite a while since he visited with friends and family. He stated that he stopped attending church, and only watched church on television. He reported that he requires help showering, and that an aid came to help him three days per week. He indicated that he spent much of his time in his recliner. The examiner noted that thinking and cognitive functioning are regularly reported to be within normal limits, with sporadic impairment in concentration. The Veteran reported that he was not working, primarily due to pain. The examiner also indicated that the Veteran takes psychiatric medication for his depression symptoms. The examiner noted that, although one of the medications description notes that it is for psychosis, the medical records did not document any symptoms of psychosis, such as delusions or hallucinations. Mental status examination showed the Veteran to be dressed in clean clothes. There was no observed agitation or excessive motor activity. Speech was slow in response, but all answers were relevant to the question asked and well-phrased. Eye contact was excellent and attitude was polite and cooperative. Affect was blunted most of the time. Mood was frustrated. He noted that he maintained interest in activities, but that he was not able to do them physically due to his physical limitations caused by pain. The Veteran noted that his level of enjoyment was "limited." He indicated that he was able to show affection for his wife. The Veteran's wife reported that she felt that the Veteran's range of interests was lower. The Veteran indicated that he was forgetful and sometime exhibited reduced appetite. The Veteran denied suicidal and homicidal ideation. There was evidence of sleep impairment with odd dreams. He reported worry and anxiety but denied having a temper or problems managing anger. Thought processes were logical and coherent, and thought content was normal. There was no evidence of delusions or hallucinations. The Veteran's wife reported impaired concentration and focus, although there was minimal impairment in concentration and attention during testing. The Veteran was oriented to month, year, place, and person, but reported that he did not know the date. Abstract reasoning was unimpaired, and there was slight reduction in immediate memory. Hygiene and grooming were reported to be excellent and there was no inappropriate behavior observed. Judgment was unimpaired and insight was good. The prognosis was fair to guarded, as it was highly dependent upon his physical pain. The diagnosis was depressive disorder, not otherwise specified, and a GAF score of 60 was assigned. The examiner reported that the Veteran exhibited occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although generally functioning satisfactorily, with normal routine behavior, self-care, and conversation. VA treatment records from November 6, 2013 through 2015 reflect continued diagnoses of and treatment for depression. Psychiatric examinations reveal the Veteran to be casually groomed and dressed, alert and fully oriented, with no evidence of psychosis. His thought process and thought content were within normal limits. His mood was stable and his affect was is within normal limits. There was no evidence of any suicidal ideations and the Veteran was future-oriented. Diagnoses included depressive disorder and anxiety disorder. A December 2013 note reflects that the Veteran had active clinical depression impacting his ability to care for himself. After a detailed review of the claims file, the Board finds that the preponderance of the evidence is against a staged initial rating in excess of 50 percent for service-connected psychiatric disability on and after November 6, 2013. The Veteran's current 50 percent evaluation contemplates functional impairment comparable to occupational and social impairment with reduced reliability and productivity due to psychiatric symptoms. 38 C.F.R. § 4.130, Diagnostic Code 9434. As noted above, GAF scores are a scale reflecting the "psychological, social, and occupational functioning on a hypothetical continuum of mental health-illness." Carpenter, 8 Vet. App. at 242. The Veteran's GAF score of 60 shows moderate symptoms or moderate difficulty in social, occupational, or school functioning. See DSM-IV at 46-47. Since November 6, 2013, the Veteran has demonstrated psychiatric symptoms including reduced involvement in the community, increased social isolation, sleep disturbance, poor concentration and focus, and increased depression. He stopped attending church, and only watched church on television. The evidence shows that he requires additional assistance with caring for himself as a result of his back disability. The medical evidence reflects that there was no evidence of psychosis, delusions, or hallucinations, and there was no agitation or excessive motor activity. Speech was slow, but relevant and well-phrased. Eye contact was good; mood was depressed or frustrated; and affect was blunted. There was no suicidal or homicidal ideation. The Veteran's thinking and cognitive functioning were found to be normal, with sporadic impairment in concentration. The Veteran indicated that he maintained interest in activities, but that he was unable to participate in them due to the pain caused by his back. The Veteran noted that he was sometimes forgetful. There was no evidence of poor impulse control or problems managing anger. Additionally, there was no evidence of delusions or hallucinations, and the Veteran was oriented to the month, year, place, and person, but did not know the date. Abstract reasoning was unimpaired. There was slight reduction in short-term memory. Hygiene and grooming were excellent and there was no inappropriate behavior. Thought processes were logical and coherent and thought content was normal. Judgment was unimpaired and insight was good. Additionally, the January 2013 VA examiner found that there was occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although generally functioning satisfactorily, with normal routine behavior, self-care, and conversation. After a thorough review of the evidence of record, the Board concludes the preponderance of the evidence is against a finding that the Veteran's psychiatric disability is manifested by symptoms warranting a 70 percent or higher evaluation on and after November 6, 2013, as the evidence does not show functional impairment comparable to occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood. In that regard, the evidence on and after November 6, 2013 does not demonstrate that the Veteran's psychiatric disability results in deficiencies in family relations, judgment, or thinking. See 38 C.F.R. § 4.130, Diagnostic Code 9434; Vazquez-Claudio v. Shinseki, 713 F.3d 112 (Fed. Cir. 2013). Although the Veteran reduced his participation in church activities due to his back pain, the evidence shows that he still maintained a close relationship with his wife and family. Additionally, thought processes were logical and coherent, and thought content was normal, and there was no evidence of hallucinations or delusions. Judgment was unimpaired and insight was good. "[A] veteran may only qualify for a given disability rating under § 4.130 by demonstrating the particular symptoms associated with that percentage, or others of similar severity, frequency, and duration." Vazquez-Claudio, 713 F.3d at 116-17. Here, the preponderance of the evidence shows that the Veteran does not experience symptoms as listed for a 70 percent rating, or other symptoms of a similar severity, frequency, or duration, but rather that his symptoms are all reasonably contemplated by the symptoms set forth in the rating criteria for a rating of no more than 50 percent, on and after November 6, 2013. See Fenderson v. West, 12 Vet. App. 119 (1999). Although the evidence of record may demonstrate some of the symptoms contemplated in a 70 percent evaluation on and after November 6, 2013, such as deficiencies in work and mood, the Veteran's disability picture more closely corresponds to the requirements for a 50 percent evaluation on and after November 6, 2013. Thus, as the evidence does not more nearly approximate an evaluation greater than 50 percent, an initial staged rating in excess of 50 percent on and after November 6, 2013 is not warranted for the Veteran's service-connected psychiatric disability. d. Other Considerations The Board has considered whether this case should be referred to the Director, Compensation and Pension Service, for extraschedular consideration for rating of the Veteran's service-connected psychiatric disability. The governing norm in such exceptional cases is: A finding that the case presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization as to render impractical the application of the regular schedular standards. 38 C.F.R. § 3.321(b). If the criteria reasonably describe the Veteran's disability level and symptomatology, then the disability picture is contemplated by the Rating Schedule, and the assigned schedular evaluation is, therefore, adequate and referral for an extraschedular rating is not required. Thun v. Peake, 22 Vet. App. 111, 115 (2008). As discussed at length above, the Veteran's symptomatology, as attributable to all diagnosed psychiatric disorders, is contemplated by the rating criteria for a 30 percent rating prior to January 12, 2010, and for a 50 percent rating on and after January 12, 2010. The Veteran's psychiatric disability does not more nearly approximate the symptoms set forth for a 50 percent rating, or any symptoms of similar severity, duration or frequency as those set forth for a 50 percent rating prior to January 12, 2010, or for a 70 percent rating, or any symptoms of similar severity, duration or frequency as those set forth for a 70 percent rating on and after January 12, 2010. Accordingly, referral for an extraschedular rating for the Veteran's psychiatric disability is not warranted. Finally, under Johnson v. McDonald, 762 F.3d 1362 (2014), a Veteran may be awarded an extra-schedular rating based upon the combined effect of multiple conditions in an exceptional circumstance where the evaluation of the individual conditions fails to capture all the service-connected disabilities experienced. However, in this case, after applying the benefit of the doubt under of Mittleider v. West, 11 Vet. App. 181 (1998), this is not an exceptional circumstance in which extra-schedular consideration may be required to compensate the Veteran for a disability that can be attributed only to the combined effect of multiple conditions. As the preponderance of the evidence is against a rating in excess of 30 percent for the service-connected psychiatric disability prior to January 12, 2010, and against a rating in excess of 50 percent for the service-connected psychiatric disability on and after January 12, 2010, the benefit of the doubt rule is not for application in resolution of the matter on appeal. See generally Ortiz v. Principi, 274 F. 3d 1361 (Fed. Cir. 2001); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). ORDER Entitlement to an initial rating of 30 percent, but no greater, prior to January 12, 2010, for service-connected depression with insomnia is granted, subject to the applicable regulations concerning the payment of monetary benefits. Entitlement to a staged initial rating of 50 percent, on and after January 12, 2010 for service-connected depression with insomnia is granted, subject to the applicable regulations concerning the payment of monetary benefits. Entitlement to a staged initial rating greater than 50 percent for depression with insomnia on and after January 12, 2010 is denied. REMAND The Veteran most recently underwent a VA examination to determine the current severity of his service-connected low back disability in November 2013. The VA examiner reported that there was flexion of the thoracolumbar spine to 40 degrees with pain at 0 degrees, that the Veteran was unable to perform repetitive use testing, and that he was not able to extend his back. However, it is unclear whether these findings indicate that the Veteran's low back disability more nearly approximates a finding of unfavorable ankylosis, as the examiner did not report whether there was any ankylosis of the spine. As the November 2013 VA examination does not provide all of the information necessary to properly rate the Veteran's service-connected low back disability under the pertinent rating criteria, the Board finds it to be inadequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007) (holding that once VA undertakes the effort to provide an examination for a service-connection claim, even if not statutorily obligated to do so, it must provide an adequate one). Accordingly, a new VA examination should be provided to determine whether there is any ankylosis of the thoracolumbar spine. With regard to the claims for entitlement to increased ratings for lumbar radiculopathy of the right and left lower extremities, the Board finds these claims to be intertwined with the claim for entitlement to an increased rating for a lumbar spine disorder. This is because a new VA examination addressing the severity of the Veteran's service-connected lumbar spine disorder may provide evidence relevant to the current severity of his service-connected lumbar radiculopathy of the right and left lower extremities. Accordingly, the claims for increased ratings for lumbar radiculopathy of the right and left lower extremities must also be remanded. Harris v. Derwinski, 1 Vet. App. 180, 183 (1991). Last, the claim for entitlement to a TDIU prior to January 14, 2011 must also be remanded. TDIU was granted by the RO in April 2012, effective January 14, 2011. Entitlement to a TDIU prior to January 14, 2011 was denied at that time because the Veteran did not meet the percentage requirements for a TDIU prior to January 14, 2011, and also because a September 2014 opinion from the Director of Compensation Service concluded that the evidence did not show that the Veteran was unemployable due to service-connected disability prior to January 14, 2011. The rationale for the opinion provided was based upon the Veteran's testimony during his June 2010 hearing before the Board in which he reported that his last job was terminated when he did not return to work following surgery for a hernia, and that he did not return to work due to respiratory issues caused by a medication, Vioxx. However, the opinion fails to consider the remainder of the Veteran's testimony, which is that he was prescribed Vioxx for his service-connected low back disability. As the Director's opinion is based upon the rationale that the Veteran was not unemployable prior to January 14, 2011 because he terminated his employment in 2001 as a result of respiratory problems associated with Vioxx, and because the Director did not address the evidence which indicates that the Veteran was taking Vioxx to treat his service-connected low back disability, the Board finds the September 2014 opinion to be inadequate. Additionally, the Board observes that there are numerous findings in the VA treatment records dated in 2007 and 2009 indicating that the Veteran was unemployable as a result of his service-connected low back disability, which were not addressed by the Director's opinion. This evidence should be considered in any opinion provided. Accordingly, the case is REMANDED for the following action: 1. Schedule the Veteran for a VA spine examination to determine the current severity of his service-connected lumbar spine disability. The claims file and a copy of this Remand must be provided to and reviewed by the examiner. All pertinent symptomatology and findings must be reported in detail. Any indicated diagnostic tests and studies must be accomplished. As to all information requested below, a complete rationale for all opinions must be provided. The examiner must determine the range of motion of the Veteran's thoracolumbar spine, in degrees, noting by comparison the normal range of motion of the thoracolumbar spine. The VA examiner must specifically state whether there is any favorable or unfavorable ankylosis in the thoracolumbar spine, and must also indicate the normal range of motion of the thoracolumbar spine for comparison. It must also be determined whether there is weakened movement, excess fatigability, or incoordination attributable to the service-connected lumbar spine disability, expressed in terms of the degree of additional range of motion loss or favorable or unfavorable ankylosis due to any weakened movement, excess fatigability, or incoordination. Finally, an opinion must be stated as to whether any pain found in the spine could significantly limit functional ability during flare-ups or during periods of repeated use, noting the degree of additional range of motion loss or favorable or unfavorable ankylosis due to pain on use or during flare-ups. The examiner must also report the nature and severity of all associated neurological complaints and findings attributable to the Veteran's service-connected lumbar spine disorder, to include service-connected radiculopathy of the left and right lower extremities. The examiner must perform any indicated tests, to include nerve conduction and/or electromyography studies, to evaluate any reported radiating pain. The examiner must also state whether the Veteran has intervertebral disc syndrome; if so, the examiner must state whether the Veteran experiences incapacitating episodes, as defined by 38 C.F.R. § 4.71a, and the frequency and total duration of such episodes over the course of the past 12 months. Finally, the examiner must provide an opinion as to whether the Veteran's subjective reports of his symptoms are consistent with the objective clinical findings and must describe functional limitations resulting from the Veteran's low back disorder. 2. Return the claims file to the Director of Compensation Service for consideration of entitlement to a TDIU prior to January 14, 2011 on an extraschedular basis under 38 C.F.R. § 4.16(b) (2015). The Director is requested to consider all of the evidence of record, to include the Veteran's testimony that he did not return to work in 2001 as a result of respiratory problems caused by Vioxx, which was prescribed for his service-connected low back disability, as well as the evidence in the VA treatment records noting that the Veteran was unemployable due to his service-connected low back disability. 3. The RO must notify the Veteran that it is his responsibility to report for all scheduled examinations and to cooperate in the development of the claims. The consequences for failure to report for a VA examination without good cause may include denial of the claim. 38 C.F.R. §§ 3.158, 3.655 (2015). 4. After completing the above actions, and any other development as may be indicated by any response received as a consequence of the actions taken in the paragraphs above, the Veteran's claims must be readjudicated. If any benefit sought on appeal remains denied, the Veteran and his representative must be furnished a supplemental statement of the case and be given the opportunity to respond thereto. The appeal must then be returned to the Board for appellate review. The appellant has the right to submit additional evidence and argument on the matter or matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West 2014). ______________________________________________ U. R. POWELL Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs