Citation Nr: 1735403 Decision Date: 08/25/17 Archive Date: 09/06/17 DOCKET NO. 09-46 051 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Roanoke, Virginia THE ISSUE Entitlement to an evaluation in excess of 20 percent for degenerative disc disease of the lumbar spine with intervertebral disc syndrome from May 23, 2008 to February 4, 2014. REPRESENTATION Veteran represented by: Disabled American Veterans ATTORNEY FOR THE BOARD Jeremy J. Olsen, Associate Counsel INTRODUCTION The Veteran served on active duty in the U.S. Army from March 1996 to June 2005. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a March 2009 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Roanoke, Virginia. In a November 2014 decision, the Board, in pertinent part, denied the appeal for an evaluation in excess of 20 percent for degenerative disc disease of the lumbar spine with intervertebral disc syndrome (hereinafter, "back disability") for the period from May 23, 2008 to February 4, 2014, and an evaluation in excess of 40 percent for the period beginning February 5, 2014. The Veteran then appealed to the United States Court of Appeals for Veterans Claims (Court). She appealed that portion, and that portion only, of the November 2014 Board decision that had denied an evaluation in excess of 20 percent for a back disability from May 23, 2008 to February 4, 2014. In June 2015, a Joint Motion for Partial Remand (JMPR) was issued by the parties. The Court then entered an Order vacating that pertinent portion of the 2014 Board decision that denied an evaluation in excess of 20 percent for a back disability from May 23, 2008 to February 4, 2014, and remanded the case for action consistent with the JMPR. In August 2015, the Board again denied the Veteran's appeal for an evaluation in excess of 20 percent for the back disability. Again, the Veteran appealed that decision to the Court. In March 2016, a Joint Motion for Partial Remand was issued by the parties. The Court then entered an Order vacating the Board's August 2015 decision, and remanded the case for action consistent with the JMPR. In May 2016, the Board again denied the Veteran's appeal for an evaluation in excess of 20 percent for the back disability. Again, the Veteran appealed that decision to the Court. In April 2017, the parties issued a Joint Motion for Remand (JMR). The Court then entered an Order vacating the Board's May 2016 decision, and remanded the case for action consistent with the JMR. This appeal was processed using the Veterans Benefits Management System (VBMS) and Virtual VA paperless, electronic claims processing systems. FINDING OF FACT From May 23, 2008, to February 4, 2014, the Veteran's lumbar spine disability does not approximate unfavorable ankylosis of the entire spine, unfavorable ankylosis of the entire thoracolumbar spine, favorable ankylosis of the entire thoracolumbar spine, forward flexion of 30 degrees or less, or incapacitating episodes having a total duration of at least 4 weeks but less than 6 weeks during any 12 month period, even considering additional functional loss. CONCLUSION OF LAW The criteria for an evaluation in excess of 20 percent for degenerative disc disease of the lumbar spine with intervertebral disc syndrome have not been met from May 23, 2008, to February 4, 2014. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.159, 4.1-4.14, 4.21, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5235-5243 (2016). REASONS AND BASES FOR FINDING AND CONCLUSION VA's Duties to Notify and Assist Upon receipt of a substantially complete application for benefits, VA must notify the claimant of what information or evidence is needed in order to substantiate the claim and it must assist the claimant by making reasonable efforts to get the evidence needed. 38 U.S.C.A. §§ 5103(a), 5103A (West 2014); 38 C.F.R. § 3.159(b) (2016); Quartuccio v. Principi, 16 Vet. App. 183, 187 (2002). The notice required must be provided to the claimant before the initial unfavorable decision on a claim for VA benefits, and it must (1) inform the claimant about the information and evidence not of record that is necessary to substantiate the claim; (2) inform the claimant about the information and evidence that VA will seek to provide; and (3) inform the claimant about the information and evidence the claimant is expected to provide. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b)(1); Pelegrini v. Principi, 18 Vet. App. 112, 120 (2004). With regard to claims for increased disability ratings for service-connected conditions, VA must notify the claimant that, to substantiate a claim, the claimant must provide, or ask VA to obtain, medical or lay evidence demonstrating a worsening or increase in severity of the disability. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b); Vazquez-Flores v. Peake, 22 Vet. App. 37 (2008), vacated and remanded sub nom. Vazquez-Flores v. Shinseki, 580 F.3d 1270 (Fed. Cir. 2009). The notice required by section 5103(a) need not be specific to a particular veteran's circumstances; that is, VA need not notify a veteran of alternative diagnostic codes that may be considered or notify a veteran of any need for evidence demonstrating the effect that the worsening of the disability has on the particular veteran's daily life. Id. The notice must be provided prior to an initial unfavorable decision by the agency of original jurisdiction. Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini, supra. In this case, the RO provided the Veteran with a notification letter in October 2008, prior to the initial decision on the claim in December 208. Therefore, the timing requirement of the notice as set forth in Pelegrini has been met and to decide the appeal would not be prejudicial to the claimant. Moreover, the requirements with respect to the content of the notices were met in this case. The letter notified the Veteran that she should provide, or ask VA to obtain, medical or lay evidence demonstrating the nature and symptoms, severity and duration, and impact of her condition on employment and daily life. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b); see also Vazquez-Flores v. Shinseki, supra. The letters provided examples of the types of medical and lay evidence that the Veteran may submit (or ask the VA to obtain) relevant to establishing entitlement to increased compensation. Additionally, the notice letters informed the Veteran of the division of responsibilities in obtaining the evidence to support her claim and how disability ratings and effective dates are determined. Therefore, the Board finds that the duty to notify has been satisfied in this appeal. In addition, the duty to assist the Veteran has also been satisfied in this case. The Veteran's service treatment records as well as all identified and available post-service medical records pertinent to the years after service are in the claims file and were reviewed by both the RO and the Board in connection with the Veteran's claim. She has not identified any available, outstanding records that are relevant to the claim being decided herein. The Veteran was also afforded a VA examination in November 2008. The Board finds the VA examination adequate, as it is predicated on an examination and fully addresses the rating criteria that are relevant to rating the disability in this case. These examinations also included the Veteran's subjective complaints about her disability and the objective findings needed to rate the disability. Moreover, there is no objective evidence indicating that there was a material change in the severity of the Veteran's service-connected disability for the remainder of the appeal period presently before the Board. 38 C.F.R. § 3.327(a) (2016). Although the examination took place in 2008, the duty to assist does not require that a claim be remanded solely because of the passage of time since an otherwise adequate VA examination was conducted. Palczewski v. Nicholson, 21 Vet. App. 174 (2007) (noting that the passage of time alone, without an allegation of worsening, does not warrant a new examination); VAOPGCPREC 11-95 (April 7, 1995). In addition, the examination is an adequate reflection of the Veteran's symptomology during the limited period of time on appeal. Based on the foregoing, there is adequate medical evidence of record to make a determination in this case. For these reasons, the Board concludes that VA has fulfilled the duty to assist the Veteran in this case. Hence, there is no error or issue that precludes the Board from addressing the merits of this appeal. Laws and Regulations Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities, found in 38 C.F.R., Part 4. 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. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating. 38 C.F.R. § 4.7. 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. Consideration of the whole-recorded history is necessary so that a rating may accurately reflect the elements of disability present. 38 C.F.R. § 4.2; Peyton v. Derwinski, 1 Vet. App. 282 (1991). While the regulations require review of the recorded history of a disability by the adjudicator to ensure a more accurate evaluation, the regulations do not give past medical reports precedence over the current medical findings. Where, as here, the question for consideration is a higher initial rating since the grant of service connection, evaluation of the medical evidence since the grant of service connection to consider the appropriateness of "staged rating" (assignment of different ratings for distinct periods of time, based on the facts found) is required. Fenderson v. West, 12 Vet. App. 119, 126 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). However, where a veteran appeals the denial of a claim for an increased disability rating for a disability for which service connection was in effect before she filed the claim for increase, the present level of the veteran's disability is the primary concern, and past medical reports should not be given precedence over current medical findings. Francisco v. Brown, 7 Vet. App. 55, 57-58 (1994). Disability of the musculoskeletal system is primarily the inability, due to damage or infection in the parts of the system, to perform the normal working movements of the body with normal excursion, strength, speed, coordination, and endurance. It is essential that the examination on which ratings are based adequately portray the anatomical damage, and the functional loss, with respect to all these elements. The functional loss may be due to absence of part, or all, of the necessary bones, joints and muscles, or associated structures, or to deformity, adhesions, defective innervation, or other pathology, or it may be due to pain, supported by adequate pathology and evidenced by visible behavior of the claimant undertaking the motion. Weakness is as important as limitation of motion, and a part which becomes painful on use must be regarded as seriously disabled. 38 C.F.R. §§ 4.10, 4.40, 4.45. VA must analyze the evidence of pain, weakened movement, excess fatigability, or incoordination and determine the level of associated functional loss in light of 38 C.F.R. § 4.40 , which requires the VA to regard as "seriously disabled" any part of the musculoskeletal system that becomes painful on use. DeLuca v. Brown, 8 Vet. App. 202 (1995). Although pain may be a cause or manifestation of functional loss, limitation of motion due to pain is not necessarily rated at the same level as functional loss where motion is impeded. See Mitchell v. Shinseki, 25 Vet. App. 32 (2011); cf. Powell v. West, 13 Vet. App. 31, 34 (1999); Hicks v. Brown, 8 Vet. App. 417, 421 (1995); Schafrath v. Derwinski, 1 Vet. App. 589, 592 (1991). Pursuant to 38 C.F.R. §§ 4.40 and 4.45, the possible manifestations of functional loss include decreased or abnormal excursion, strength, speed, coordination, or endurance, less or more movement than is normal, weakened movement, excess fatigability, and pain on movement (as well as swelling, deformity, and atrophy) that affects stability, standing, and weight-bearing. Thus, functional loss caused by pain must be rated at the same level as if the functional loss were caused by any of the other factors cited above. Therefore, in rating the severity of a joint disability, VA must determine the overall functional impairment due to these factors. The provisions of 38 C.F.R. § 4.14 do not forbid consideration of a higher rating based on greater limitation of motion due to pain on use, including during flare-ups. However, the provisions of 38 C.F.R. § 4.40 and 38 C.F.R. § 4.45, should only be considered in conjunction with the Diagnostic Code provisions predicated on limitation of motion. Johnson v. Brown, 9 Vet. App. 7 (1996). The intent of the Rating Schedule is to recognize painful motion with joint or periarticular pathology as productive of disability. It is the intention to recognize actually painful, unstable, or malaligned joints, due to healed injury, as entitled to at least the minimum compensable rating for the joint. 38 C.F.R. § 4.59. The Veteran's back disability has been evaluated as 20 percent disabling from May 23, 2008, to February 4, 2014, under Diagnostic Code 5242 for degenerative arthritis of the spine. This diagnostic code falls under the General Rating Formula for Diseases of the Spine. 38 C.F.R. § 4.71a, Diagnostic Code 5242. Under the General Rating Formula, an evaluation of 20 percent is warranted if forward flexion of the thoracolumbar spine is greater than 30 degrees, but not greater than 60 degrees; or the combined range of motion of the thoracolumbar spine is not greater than 120 degrees; or if there is muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. 38 C.F.R. § 4.71a, Diagnostic Codes 5235-5243. A 40 percent evaluation is warranted if forward flexion of the thoracolumbar spine is to 30 degrees or less; or, if there is favorable ankylosis of the entire thoracolumbar spine. 38 C.F.R. § 4.71a, Diagnostic Codes 5235-5243. A 50 percent rating is warranted if there is unfavorable ankylosis of the entire thoracolumbar spine and a 100 percent disability rating is warranted if there is unfavorable ankylosis of the entire spine. 38 C.F.R. § 4.71a, Diagnostic Codes 5235-5243. Note (1) to the General Rating Formula instructs VA to evaluate any associated objective neurologic abnormalities, including, but not limited to, bowel or bladder impairment, separately, under an appropriate diagnostic code. 38 C.F.R. § 4.71a, General Rating Formula, Note (1). For purposes of VA compensation, normal forward flexion of the thoracolumbar spine is 0 to 90 degrees, extension is 0 to 30 degrees, left and right lateral flexion are 0 to 30 degrees, and left and right lateral rotation are 0 to 30 degrees. The combined range of motion refers to the sum of the range of forward flexion, extension, left and right lateral flexion, and left and right rotation. The normal combined range of motion of the thoracolumbar spine is to 240 degrees. 38 C.F.R. § 4.71a, General Rating Formula, Note (2). Facts and Analysis Of record is an April 2008 military facility medical examination, which shows the Veteran reporting back pain. On examination there was full range of motion of the lumbar spine with pain elicited on motion and muscle spasms. The Veteran was assessed with back muscle spasms and lower back pain. There was no tenderness on palpation. Motor examination demonstrated no dysfunction and gait and stance were normal. In a May 2008 statement, the Veteran reported that due to her back and hip disabilities, she had trouble falling asleep, she was unable to sleep on her left side, sit or stand for long periods, and that the left lower side of her back was swollen. She reported that on several occasions she had to miss work due to heavy medication prescribed by her primary physician. An October 2008 private treatment note reported the Veteran had lumbar flexion "to ankles," extension to 30 degrees, and "side bending" to 45 degrees. The Veteran reported lower back pain. She denied bowel and bladder dysfunction. There was a normal gait with 5/5 lower extremity motor strength. VA afforded the Veteran an examination for her low back in November 2008. At that time, the Veteran received a diagnosis of degenerative disc disease lumbar spine. The Veteran's symptoms included stiffness and numbness and constant lower back pain. She reported pain at a level of eight out of ten that occurred spontaneously and was managed with pain medication. Regarding functional impairment, the Veteran reported that her life had changed due to her illness. She reported difficulty falling asleep and getting comfortable. She was unable to lift heavy objects, and had difficulty getting in and out of her car. The Veteran reported that she was unable to sit or walk for a long time due to pain and tingling. It was reported that her condition had not resulted in any incapacitation. She denied any bowel or bladder dysfunction. On physical examination the examiner noted that the Veteran required the use of a cane because of her back condition. Her gait was described as normal. There was no muscle spasm or lumbosacral motor weakness. There was paralumbar tenderness. Range of motion studies of the thoracolumbar showed that flexion ended at 45 degrees; extension ended at 30 degrees; bilateral lateral flexion ended at 30 degrees; and bilateral lateral rotation ended at 30 degrees, with pain throughout all motion. The combined range of motion was 195 degrees. The examiner noted intervertebral disc syndrome as well as sensory deficit of the left lateral leg, left dorsal foot, left lateral foot, and left back of thigh. The examiner reported that joint function of the spine was additionally limited after repetitive use by pain and that pain had a major functional impact. After repetitive use joint function of the spine was not additionally functionally limited by fatigue, weakness, lack of endurance and incoordination. The examiner reported that there was no additional limitation in degree. The examiner indicated that the established diagnosis of degenerative disc disease lumbar spine was changed to degenerative disc disease of lumbar spine with intervertebral disc syndrome affecting external cutaneous nerve of left thigh. The examiner remarked that the effect of the condition on the Veteran's daily activities was no limitations. The Veteran submitted a statement in support of her claim in December 2008. The Veteran described experiencing serious pain due to, among other injuries, her back spasms. She reported working with several different companies and having difficulty finding a long-term job. VA received various December 2008 buddy statements from the Veteran's mother, her friend, and a coworker regarding perceived pain and limitations due to the Veteran's low back disability. The Veteran's mother reported that the Veteran had chronic pain due to back and hip problems and that she moved to Virginia to assist her daughter with cooking, cleaning, washing clothes, and grocery shopping. A friend of the Veteran's reported that the Veteran reported chronic pain in the hip and low back. She reported the Veteran had limited mobility. The Veteran's co-worker reported that the Veteran showed back pain by a stiff unnatural gait while walking. The Board has reviewed VA medical records that document treatment for the Veteran's low back pain during the appeal period. These records show that the Veteran had low back pain. However, they do not otherwise provide insight into the severity of the Veteran's low back disability. Initially, the Board finds it necessary to discuss the June 2015 and March 2016 JMPRs. In both motions, the parties determined that the Board failed to provide adequate reasons and bases to support the conclusion that a higher 40 percent disability evaluation was not warranted because the Veteran's flexion was not limited to 30 degrees at any point during the period. 38 C.F.R. § 4.71a, DC 5242. In both motions, the parties found that the Board erred in failing to consider November 2008 VA findings indicating that joint function of the Veteran's spine was additionally limited by pain after repetitive use, and that "pain has the major functional impact." With the prior JMPRs noted, the Board again finds that from May 23, 2008, to February 4, 2014, an evaluation in excess of 20 percent of the Veteran's back disability is not warranted. From May 23, 2008, to February 4, 2014, the medical evidence shows the Veteran's complaints of lumbar pain, stiffness, and numbness. The Veteran described her low back affecting her sleep and mobility. Objectively, the most severe limitation of forward flexion was measured to end at 45 degrees. Repetitive use testing revealed additional functional limitation of the spine due to pain, and pain was described as having the "major functional impact." However, the Board concludes that the Veteran is not entitled to an increased evaluation in excess of 20 percent. See 38 C.F.R. § 4.7. Specifically, even with consideration of functional loss, the evidence of record does not reveal unfavorable ankylosis of the entire spine, unfavorable ankylosis of the entire thoracolumbar spine, favorable ankylosis of the entire thoracolumbar spine, or forward flexion to 30 degrees or less. In fact, there is no diagnosis of ankylosis at all in the evidence of record. Ranges of motion findings, although limited at times, do not reveal unfavorable ankylosis or even favorable ankylosis or forward flexion of the thoracolumbar spine 30 degrees or less. See 38 C.F.R. § 4.71a, Diagnostic Codes 5235-5243, Note (5); Dinsay v. Brown, 9 Vet. App. 79, 81 (1996) (noting that ankylosis is "stiffening or fixation of a joint as the result of a disease process, with fibrous or bony union across the joint," citing Stedman's Medical Dictionary 87 (25th ed. 1990)). Based on the range of motion findings of the lumbar spine throughout the appeal, it is apparent that the Veteran's lumbar spine is not fixated or immobile with fibrous or bony union. No VA or private examiner of record assessed ankylosis. The Board has considered the findings of the November 2008 examination, in which the Veteran was found to have flexion limited to 45 degrees. Particularly, the Board has considered the examiner's finding of additional functional limitation of the spine due to the pain, pain being described as having a major functional impact. The Board is unable to conclude that the examination report is sufficient to show that there was functional loss more nearly approximating flexion limited to 30 degrees or less after repetitive-use testing. 38 C.F.R. §§ 4.40, 4.45, 4.59; Mitchell, 25 Vet. App. 32; DeLuca, 8 Vet. App. 202. In making this finding, the Board notes that the Veteran had lumbar flexion sufficient to reach to her ankles only one month earlier, as evidenced by the October 2008 private treatment record discussed earlier. Such evidence tends to show that it is unlikely the Veteran had functional loss more nearly approximating limited flexion sufficient to merit a 40 percent evaluation under the General Formula for Rating Diseases and Injuries of the Spine. This finding is further corroborated by the April 2008 treatment record which documents full range of motion in the lumbar spine, despite objective evidence of painful motion. Essentially, the context of the record surrounding the November 2008 VA examination, as well as the contents of the November 2008 examination report, do not support a finding that the Veteran's low back disability resulted in functional limitation approximating forward flexion that is limited to 30 degrees or less after repetitive use testing. Although there is painful motion, which must be considered as seriously impaired, the evidence of record demonstrates that Veteran's back is adequately compensated by the 20 percent evaluation, even when considering other functional loss symptoms. In April 2008, the Veteran's gait was normal and there was no tenderness. In October 2008, there was a normal gait with 5/5 lower extremity motor strength. In November 2008, although there was stiffness and tenderness, the examiner found a normal gait despite the use of a cane, there was no muscle spasm or lumbosacral motor weakness. There was also no fatigability, weakness, lack of endurance, and incoordination. Furthermore, the examiner found that the effect of the condition on the Veteran's daily activities was no limitations. Accordingly, the Veteran has retained her lumbosacral strength and other factors such as endurance and coordination. Thus, although painful on use, the Veteran's lumbar spine manifestations do not more closely approximate the next level of impairment based on all the factors of additional functional loss. Regarding separate evaluations, the Veteran has consistently denied all bowel and bladder dysfunction for this time period, so no separate evaluations are warranted on this basis. Additionally, service connection has been granted for right and left leg radiculopathy; the Veteran has not appealed the effective dates of those grants. Thus, separate evaluations are not considered herein. See 38 C.F.R. § 4.71a, General Rating Formula, Note (1). Furthermore, the Board has considered all potentially applicable diagnostic codes. See Schafrath, 1 Vet. App. at 593. But the evidence does not show incapacitating episodes and the diagnostic code for arthritis does not permit a rating in excess of 20 percent. See 38 C.F.R. § 4.71a, Diagnostic Codes 5003, 5010, 5243. Additionally, the evidence of record does not indicate any incapacitating episodes. See 38 C.F.R. § 4.71a, Diagnostic Code 5243. Accordingly, an increased evaluation under alternative codes is not warranted. Therefore, there is no schedular basis for an evaluation in excess of 20 percent for the Veteran's low back disability from May 23, 2008, to February 4, 2014. Turning to the question of an extraschedular basis for an increased rating, the Board notes that in the April 2017 JMR, the parties determined that the Board erred in denying the Veteran entitlement to a referral for extraschedular consideration under Thun v. Peake, 22 Vet. App. 111 (2008). In the JMR, the parties found that the Board did not address specific functional limitations described by the Veteran at the November 2008 VA examination; specifically, the Veteran's reported inability to lift heavy objects, difficulty getting in and out of vehicles, and her inability to sit or walk for a long period of time. With the April 2017 JMR noted, the Board again finds that the symptoms of the Veteran's low back disability are adequately contemplated by the rating criteria and there exists no basis for a referral for extraschedular consideration. See 38 C.F.R. § 3.321(b)(1); Schafrath, 1 Vet. App. 589; see also Barringer v. Peake, 22 Vet. App. 242, 243-44 (2008). The threshold factor for extra-schedular consideration is a finding that the evidence before VA presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. Thun, supra. In this regard, there must be a comparison between the level of severity and symptomatology of the claimant's service-connected disability with the established criteria found in the rating schedule for that disability. If the criteria reasonably describe the claimant's disability level and symptomatology, then the claimant's disability picture is contemplated by the rating schedule and the assigned schedular evaluation is therefore adequate, and no extra-schedular referral is required. Id. at 111; VAOGCPREC 6-96 (Aug. 16, 1996). Otherwise, if the schedular evaluation does not contemplate the claimant's level of disability and symptomatology and is found inadequate, VA must determine whether the claimant's exceptional disability picture exhibits other related factors, such as those marked interference with employment and frequent periods of hospitalization. 38 C.F.R. § 3.321(b)(1). Here, the evidence in this case does not show a disability picture so exceptional that the assigned schedular evaluations are inadequate. The evidence indicates that the Veteran has a back disability objectively shown as limitation of motion, along with pain on motion of the spine. In addition, the medical and lay evidence indicates that as a result of her back disability, the Veteran uses a cane, has trouble sitting and standing, and she has problems getting comfortable in order to sleep. She also experiences trouble lifting objects and getting out of a car, and some trouble walking. After considering the evidence, the Board finds no basis to indicate that the Veteran's back disability presents such an exceptional disability picture that the applicable schedular criteria are inadequate, particularly as the rating criteria are thorough, and she does not manifest or describe symptomatology outside of such criteria. The Veteran's service-connected back disability has manifested primarily as non-incapacitating episodes with limited range of motion, including due to pain and interference with standing and weight bearing. See 38 C.F.R. § 4.45 ("interference with sitting, standing, and weight-bearing are related considerations"). The Board notes that painful limitation of motion, and interference with standing and weight-bearing, are specifically considered under the schedular rating criteria. See 38 C.F.R. §§ 4.40, 4.45, 4.59, and DeLuca, 8 Vet. App. at 205-206 (additional limitation of motion due to orthopedic factors are incorporated as part of the schedular rating criteria). The schedular rating criteria specifically include back pain, whether or not it radiates, as part of the General Formula for Diseases and Injuries of the Spine; the schedular rating criteria used here, Diagnostic Code 5242, specifically contemplate such symptomatology and functional impairment. The rating criteria in Diagnostic Code 5242 are premised upon limitation of motion with associated pain and/or discomfort, fairly accounting for the Veteran's symptoms as presented, to include all additional functional loss due to weakness, incoordination, excess fatigability, strength, speed, and endurance. Sleep deprivation is also considered part and parcel of the Veteran's service-connected left lateral femoral cutaneous nerve palsy. See August 2005 Rating Decision. Thus, the Board finds no referral for extraschedular consideration is required. Even if the Board were to assume that the Veteran's symptoms were not fully contemplated in the rating criteria, which it expressly does not, the Veteran's disability does not meet the second part of the Thun test irregardless. Specifically, the second part requires the Board to determine whether the case presents other indicia of an exceptional or unusual disability picture, such as marked interference with employment or frequent periods of hospitalization. As noted in a May 2008 statement, the Veteran reported missing work several times; at the November 2008 VA examination, she reported being unable to lift heavy objects, having difficulty getting in and out of a vehicle, and being unable to sit or walk for long periods of time. Collectively, she asserts, these symptoms have an effect on her employment as a clerk. The Board points out that the regulation states that the related factor is "marked" interference with employment and not just interference with employment. While "marked" is not defined in the regulations, according to 38 C.F.R. § 4.1, generally, the degrees of disability specified in the Rating Schedule are considered adequate to compensate for considerable loss of time working from exacerbations or illnesses proportionate to the severity of the several grades of disability. Thus, interference with employment alone is not tantamount to concluding there has been marked interference with employment, meaning above and beyond that contemplated by the assigned 20 percent rating. See also Van Hoose v. Brown, 4 Vet. App. 361, 363 (1993) (reiterating that the disability rating, itself, is recognition that industrial capabilities are impaired). Rather, "marked" interference is a level of impairment that exceeds slight, moderate, and even severe interference. Here, the Veteran's back disability and the reported associated symptoms would be expected to cause some interference with employment, as a 20 percent rating would not be justified otherwise. However, the evidence does not show marked interference with employment, i.e., above and beyond what is contemplated by the present rating, and of a manner that exceeds severe interference with employment. The Veteran reported that she had difficulty lifting, sitting and walking for long periods of time, and each of these tasks are presumably performed when employed as a clerk. However, these symptoms and their resulting interference with her employment, to include having to miss work, are fully contemplated by the 20 percent disability rating, which takes into account all additional functional loss due to weakness, incoordination, excess fatigability, strength, speed, and endurance. The Board specifically notes that the November 2008 examiner found that the Veteran's back disability had no effect on the performance of her daily activities. While the back disability symptoms she experiences do interfere with the Veteran's ability to work as a clerk, the evidence does not show that such interference is severe or worse; thus, they simply do not rise to the level of "marked" interference with her employment. Moreover, nothing in the evidence of record demonstrates any period of hospitalization due to the Veteran's degenerative disc disease of the lumbar spine, much less frequent hospitalization. As such, the Veteran's case does not present indicia of an exceptional or unusual disability picture and referral for extraschedular consideration is simply not warranted. In addition, a veteran may be awarded an extraschedular rating based upon the combined effect of multiple conditions in an exceptional circumstance where the evaluation of the individual conditions fails to capture all the service-connected disabilities experienced. Johnson v. McDonald, 762 F.3d 1362, 1365-66 (Fed. Cir. 2014). In this case, however, neither the Veteran nor the record has raised this contention. Yancy v. McDonald, 27 Vet. App. 484, 490 (2016). In conclusion, from May 23, 2008 to February 4, 2014, the Veteran's service-connected back disability does not approximate the criteria necessary for an evaluation in excess of 20 percent. There is no reasonable doubt to resolve in this matter. ORDER An evaluation in excess of 20 percent for degenerative disc disease of the lumbar spine with intervertebral disc syndrome from May 23, 2008 to February 4, 2014, is denied. ____________________________________________ R. FEINBERG Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs