Citation Nr: 1746941 Decision Date: 10/20/17 Archive Date: 10/31/17 DOCKET NO. 15-08 840A DATE THE ISSUES 1. Entitlement to an effective date prior to August 27, 2003, for service connection for degenerative arthritis of the lumbar spine. 2. Entitlement to an effective date prior to December 2, 2009, for service connection for radiculopathy of the right lower extremity. 3. Entitlement to an effective date prior to April 3, 2015, for service connection for radiculopathy of the left upper extremity. 4. Entitlement to an effective date prior to April 3, 2015, for service connection for radiculopathy of the left lower extremity. 5. Entitlement to an increased initial evaluation for degenerative arthritis of the cervical spine in excess of 10 percent prior to August 12, 2015, and in excess of 20 percent thereafter. 6. Entitlement to an initial compensable evaluation for degenerative arthritis of the lumbar spine prior to December 2, 2009; to an increased initial evaluation in excess of 10 percent beginning December 2, 2009, through August 12, 2015; and in excess of 20 percent thereafter. 7. Entitlement to an increased initial evaluation for dyspepsia in excess of 20 percent. 8. Entitlement to an increased initial evaluation for radiculopathy of the left upper extremity in excess of 20 percent. 9. Entitlement to an increased initial evaluation for radiculopathy of the right upper extremity in excess of 20 percent. 10. Entitlement to an increased initial evaluation for radiculopathy of the left lower extremity in excess of 10 percent. 11. Entitlement to an increased initial evaluation for radiculopathy of the right lower extremity in excess of 10 percent. 12. Entitlement to an extension of temporary total evaluation after January 1, 2014, due to treatment for service-connected cervical spine disability requiring convalescence. 13. Entitlement to service connection for chronic headaches, to include as secondary to service-connected degenerative arthritis of the cervical spine. 14. Entitlement to service connection for erectile dysfunction, to include as secondary to service-connected degenerative arthritis of the lumbar spine and/or radiculopathy of the right lower extremity. 15. Entitlement to a total disability evaluation based on individual unemployability (TDIU) for service-connected disabilities. ORDER An effective date prior to August 27, 2003, for service connection for degenerative arthritis of the spine is denied. An effective date of August 27, 2003, for service connection for radiculopathy of the right lower extremity is granted. An effective date prior to April 3, 2015, for service connection for radiculopathy of the left lower extremity is denied. An effective date prior of September 3, 2006, for service connection for radiculopathy of the left upper extremities is granted. An increased initial evaluation prior to August 12, 2015, for degenerative arthritis of the cervical spine is denied. An initial evaluation of 30 percent beginning August 12, 2015, for degenerative arthritis of the cervical spine is granted. Increased initial evaluations for degenerative arthritis of the lumbar spine, dyspepsia, and radiculopathy of the right and left upper and lower extremities are denied. Extension after January 1, 2014, of a temporary total evaluation (100 percent) for convalescence after cervical spine surgery is denied. Service connection for chronic headaches is denied. TDIU is granted, effective October 13, 2015, subject to the laws and regulations governing the payment of VA monetary benefits. FINDINGS OF FACT 1. The Veteran did not apply for service connection for degenerative arthritis of the lumbar spine within a year of separating from active duty service; he applied for such benefits on August 27, 2003, after a previous denial of service connection for degenerative arthritis of the lumbar spine became final. 2. The Veteran's claim for service connection for radiculopathy of the right lower extremity arose from his service connection claim for degenerative arthritis of the lumbar spine, and his application for such benefits occurred on August 27, 2003, after the date entitlement to benefits arose for radiculopathy of the right lower extremity. 3. The Veteran did not apply for service connection for radiculopathy of the left upper extremity within a year of separating from active duty service, and his earliest application for such benefits occurred on April 3, 2015; September 3, 2006 is the earliest objective evidence of this disability. 4. The Veteran did not apply for service connection for radiculopathy of the left lower extremity within a year of separating from active duty service, and his earliest application for such benefits occurred on April 3, 2015; this disability is not objectively shown prior to this date. 5. Prior to August 12, 2015, the service-connected degenerative arthritis of the cervical spine manifested in a combined range of motion of the cervical spine of 310 degrees; after August 12, 2015, pain on movement caused functional loss of the Veteran's cervical spine that most closely approximates forward flexion of 15 degrees or less. 6. Prior to December 2, 2009, the Veteran's lumbar spine measured a full range of motion without painful motion; examination revealed painful motion on December 2, 2009; and beginning on August 12, 2015, the evidence reflects a limited combined range of motion of the lumbar spine of 150 degrees. 7. Throughout the appeal period, the service-connected dyspepsia manifested in continuous, moderate symptoms. 8. Throughout the appeal period, the service-connected radiculopathy of the left upper extremity manifested in mild to moderate sensory symptoms, including numbness and pain. 9. Throughout the appeal period, the service-connected radiculopathy of the right upper extremity manifested in moderate sensory symptoms, including tingling, numbness, and pain. 10. Throughout the appeal period, the service-connected radiculopathy of the left lower extremity manifested in mild to moderate sensory symptoms, including intermittent dull pain and decreased sensation to light touch. 11. Throughout the appeal period, the service-connected radiculopathy of the right lower extremity manifested in moderate sensory symptoms, primarily intermittent dull pain. 12. Since January 1, 2014, there is no evidence of a period of convalescence related to the Veteran's cervical spine surgery that would warrant extension of a temporary total evaluation. 13. The evidence of record does not reflect a current diagnosis of chronic headaches. 14. As of October 13, 2015, the evidence of record indicates the Veteran is unable to secure or follow gainful employment due to the limitations on his ability to remain seated caused by his service-connected disabilities. CONCLUSIONS OF LAW 1. The criteria for an effective date prior to August 27, 2003, for service connection for degenerative arthritis of the lumbar spine have not been met. 38 U.S.C.A. § 5110 (West 2014); 38 C.F.R. § 3.400(q) (2016). 2. The criteria for an effective date prior to December 2, 2009, for service connection for radiculopathy of the right lower extremity have been met. 38 U.S.C.A. § 5110; 38 C.F.R. §§ 3.400(q), 3.400(b)(2)(i). 3. The criteria for an effective date prior to April 3, 2015, for service connection for radiculopathy of the left upper extremity have been met. 38 U.S.C.A. § 5110; 38 C.F.R. § 3.400(b)(2)(i). 4. The criteria for an effective date prior to April 3, 2015, for service connection for radiculopathy of the left lower extremity have not been met. 38 U.S.C.A. § 5110; 38 C.F.R. § 3.400(b)(2)(i). 5. The criteria for an increased evaluation for degenerative arthritis of the cervical spine prior to August 12, 2015, have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107(b); 38 C.F.R. §§ 3.400(o)(2), 4.1, 4.2, 4.3, 4.7, 4.10, 4.71a, Diagnostic Code (DC) 5242. 6. The criteria for an increased evaluation for degenerative arthritis of the cervical spine beginning August 12, 2015, have been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107(b); 38 C.F.R. §§ 3.400(o)(2), 4.1, 4.2, 4.3, 4.7, 4.10, 4.71a, DC 5242; DeLuca v. Brown, 8 Vet. App. 202 (1995). 7. The criteria for an increased evaluation for degenerative arthritis of the lumbar spine have not been met. 38 U.S.C.A. §§ 1155, 5107(b); 38 C.F.R. §§ 3.400(o)(2), 4.1, 4.2, 4.3, 4.7, 4.10, 4.71a, DC 5242. 8. The criteria for an increased evaluation for dyspepsia have not been met. 38 U.S.C.A. §§ 1155, 5107(b); 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.10, 4.114, DC 7305. 9. The criteria for an increased evaluation for radiculopathy of the left upper extremity have not been met. 38 U.S.C.A. §§ 1155, 5107(b); 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.10, 4.124, 4.124(a), DC 8712. 10. The criteria for an increased evaluation for radiculopathy of the right upper extremity have not been met. 38 U.S.C.A. §§ 1155, 5107(b); 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.10, 4.124(a), DC 8512. 11. The criteria for an increased evaluation for radiculopathy of the left lower extremity have not been met. 38 U.S.C.A. §§ 1155, 5107(b); 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.10, 4.124(a), DC 8520. 12. The criteria for an increased evaluation for radiculopathy of the right lower extremity have not been met. 38 U.S.C.A. §§ 1155, 5107(b); 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.10, 4.124(a), DC 8520. 13. The criteria for an extension of a temporary total evaluation after January 1, 2014, for convalescence from cervical spine surgery have not been met. 38 U.S.C.A. §§ 1155, 5107; 38 C.F.R. § 4.30, 4.71a, DC 5242. 14. The criteria for service connection for chronic headaches have not been met. 38 U.S.C.A. §§ 1110, 1154, 5103, 5103A, 5107(b); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.310(a). 15. The criteria for a TDIU have been met as of October 13, 2015, but not earlier. 38 U.S.C.A. §§ 1155, 5107(b); 38 C.F.R. §§ 3.340, 3.341, 4.16. INTRODUCTION The Veteran served on active duty with the United States Navy from August 1960 to July 1964. This matter comes before the Board of Veterans' Appeals (Board) on appeal from February 2013, March 2014, May 2015, and November 2015 rating decisions by the Department of Veterans Affairs (VA) Regional Office (RO) in Huntington, West Virginia. This case was previously before the Board in January 2013, when the Board granted service connection for cervical and lumbar spine disabilities. The case has been returned to the Board for appellate review of downstream issues and other, unrelated claims. The Board notes that the Veteran was awarded service connection for radiculopathy of the right upper extremity in an April 2016 rating decision. Although the Veteran filed a timely notice of disagreement with this decision, disputing the evaluation and effective date of the award, he did not file a substantive appeal of these issues after the statement of the case was issued. Although these issues would not typically be before the Board, the Board has taken jurisdiction over the issue of the evaluation for radiculopathy of the right upper extremity - as well as that of service-connected radiculopathy of the right lower extremity - as part and parcel of the claims for increased evaluations for the cervical and lumbar spine disabilities. See 38 C.F.R. § 4.71a, General Rating Formula for Diseases and Injuries of the Spine, Note 1. This appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2016). 38 U.S.C.A. § 7107(a)(2) (West 2014). The issue of service connection for erectile dysfunction is addressed in the REMAND portion of the decision below and is REMANDED to the AOJ. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Effective Dates Unless specifically provided otherwise in the statute, the effective date of an award based on an original claim for compensation benefits shall be the date of receipt of the claim or the date entitlement arose, whichever is later. 38 U.S.C.A. § 5110(a); 38 C.F.R. § 3.400(b)(2). The date of receipt is the date on which a claim, information, or evidence is received by VA. 38 C.F.R. § 3.1(r). Where a claim has been finally adjudicated and then reopened at a later date, the effective date of such an award shall be the date of receipt of the new claim or the date entitlement arose, whichever is later. 38 C.F.R. § 3.400(q)(2). If there is a prior final VA denial of the benefit sought, the effective date cannot be earlier than a subsequent claim to reopen. Leonard v. Principi, 17 Vet. App. 447 (2004); Sears v. Principi, 16 Vet. App. 244, 246-50 (2002). A claim received within one year of separation from active service will be assigned an effective date of the day following separation. 38 U.S.C.A. §5110(b)(1); 38 C.F.R. § 3.400(b)(2). Prior to March 24, 2015, VA defined a "claim" as "a formal or informal communication in writing requesting a determination of entitlement, or evidencing a belief in entitlement, to a benefit." 38 C.F.R. § 3.1(p) (2014); see also 79 Fed. Reg. 57,696 (Sept. 25, 2014) (effective March 24, 2015) (eliminating informal claims). An informal claim was defined as "[a]ny communication or action indicating an intent to apply for one or more benefits." 38 C.F.R. § 3.155(a). Thus, for the relevant time period for the appeal of an earlier effective date for degenerative arthritis of the lumbar spine and radiculopathy of the right lower extremity, the essential elements for a claim, whether formal or informal, were "(1) an intent to apply for benefits, (2) an identification of the benefits sought, and (3) a communication in writing." Brokowski v. Shinseki, 23 Vet. App. 79, 84 (2009). The Board first notes that the issue of an earlier effective date for the award of service connection for degenerative arthritis of the lumbar spine was addressed in a March 2015 statement of the case, although neither the Veteran nor his representative had raised it. As the Veteran appealed all issues listed on that statement of the case, the Board again addresses the issue here. However, although the RO certified the issue of an earlier effective date for the award of service connection for degenerative arthritis of the cervical spine, this issue was never raised by the Veteran or his representative prior to being before the Board, and was never adjudicated by the RO. Accordingly, the Board declines to take jurisdiction over a claim for an earlier effective date for the award of service connection for degenerative arthritis of the cervical spine. See 38 U.S.C.A. §§ 7104, 7105; 38 C.F.R. §§ 20.101, 20.200, 20.201, 20.202, 20.302; see also Percy v. Shinseki, 23 Vet. App. 37, 44-45 (2009) (time requirements for filing a notice of disagreement are jurisdictional in contrast to time requirements for filing a substantive appeal, which may be waived). Finally, the effective dates of the various evaluations for degenerative arthritis of the cervical and lumbar spine are addressed below in the context of increased evaluations for those disabilities. As for the Veteran's lumbar spine claim, the record establishes that the Veteran first applied for service connection in October 1998, which was denied in an April 1999 rating decision. The Veteran did not submit a notice of disagreement with that decision or any new evidence related to the claim within one year of its issuance; as such, the April 1999 rating decision became final. The Veteran next applied for service connection for his lumbar spine disability on August 27, 2003. The claim was denied in an April 2004 rating decision on the grounds that no new and material evidence had been submitted. The Veteran filed a timely appeal, and the Board reopened the lumbar spine claim in a September 2007 decision. In a January 2013 decision, the Board granted the service connection claim. The Veteran was subsequently awarded service connection for degenerative arthritis of the lumbar spine in a February 2013 rating decision, effective August 27, 2003, the date of his application to reopen the claim for service connection. This effective date, August 27, 2003, is not within a year of the Veteran's July 1964 separation from active service in the Navy. The Veteran asserted that his lumbar spine had been symptomatic since his time in service; as such, the date entitlement arose predates the date the Veteran applied for lumbar spine benefits. Therefore, the date of application must serve as the effective date for the Veteran's service connection for degenerative arthritis of the lumbar spine. As there was a prior final denial of the Veteran's claim for service connection for a lumbar spine disability, the effective date cannot under VA laws and regulations be earlier than the claim to reopen except when clear and unmistakable error (CUE) has been found. Review of the record indicates that there is not a pending CUE claim. The Veteran's claim to reopen was filed on August 27, 2003, which is the current effective date for his award of service connection. Thus, the request for an earlier effective date for service connection for degenerative arthritis of the lumbar spine must be denied. Regarding the Veteran's claim for an earlier effective date for service connection for radiculopathy of the right lower extremity, he was awarded service connection for this disability in a February 2013 rating decision, effective December 2, 2009. The initial claim arose from the Veteran's claim for service connection for degenerative arthritis of the lumbar spine; after the Board granted service connection for the lumbar spine disability, the RO raised the issue of radiculopathy as secondary to that disability and granted service connection effective as of the date a confirmed diagnosis of radiculopathy was noted in the record. The Veteran filed a notice of disagreement with the February 2013 rating decision, seeking an earlier effective date for the award of service connection for radiculopathy of the right lower extremity. As no formal or informal claim was submitted for radiculopathy of the right lower extremity, the Board finds that the date of claim coincides with that of the claim from which this claim arose - the August 27, 2003, application to reopen the claim for service connection for degenerative arthritis of the lumbar spine. The Veteran was not diagnosed with radiculopathy of the right lower extremity until December 2, 2009. However, a December 1997 private medical treatment record notes complaints of pain radiating from the Veteran's low back to the front of his pelvis. These were assessed to be "thoracic or lumbosacral neuritis or radiculitis, unspecified." A March 1998 private medical record noted these same pains, and further noted that similar pains radiated to the lower extremity with prolonged standing and walking. This note gave a possible diagnosis of neurogenic claudication. Later, a VA neurology consultation on May 4, 2004, diagnosed "chronic low back pain with occasional radiation to the lower extremities suspicious for mild radiculopathy." The Veteran was subsequently definitively diagnosed with radiculopathy on December 2, 2009. Although neuritis, neurogenic claudication, and radiculopathy have different causes, the symptoms, as reported by a lay person, are similar. As these symptoms of pain radiating to the lower extremities were later confirmed to be radiculopathy, the Board finds that the entitlement arose for radiculopathy of the right lower extremity arose in December 1997, prior to the Veteran's application to reopen the lumbar disability claim. As the date of the claim was later than the date entitlement arose, the date of the application to reopen is the appropriate effective date for the radiculopathy claim. Therefore, the effective date for service connection for radiculopathy of the right lower extremity is August 27, 2003. Finally, as for the Veteran's claims for radiculopathy of the left upper and lower extremities, he filed a formal claim for service connection for these disabilities on April 3, 2015. Again, this date is not within a year of his July 1964 separation from active service in the Navy. The Board does not find a basis for earlier grants of service connection under 38 C.F.R. § 3.400 as April 3, 2015 is the earliest claim. As to the left lower extremity, there is no objective diagnosis of lower extremity radiculopathy prior to the date currently assigned and therefore, the Board finds that an earlier date of service connection is also not warranted under Note (1) under the General Rating Formula for Diseases and Injuries of the Spine located in 38 C.F.R. § 4.71a. As to the left upper extremity, careful review of the record reveals a "probable" diagnosis in September 3, 2006. Resolving reasonable doubt, the Board finds this evidence sufficient under Note (1) to show that the disability in appellate status at that time, the rating for the cervical spine [in appellate status from January 26, 2004], development an objective neurologic abnormality - namely, the upper extremity radiculopathy. This is the earliest such objective evidence and therefore the earliest date for service connection for this disability associated with the service-connected cervical spine disability. II. Increased Evaluations Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (rating schedule). 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. Disabilities must be reviewed in relation to their history. 38 C.F.R. § 4.1. Other applicable, general policy considerations are interpreting reports of examination in light of the whole recorded history; reconciling the various reports into a consistent picture so that the current rating may accurately reflect the elements of disability, 38 C.F.R. § 4.2; resolving any reasonable doubt regarding the degree of disability in favor of the claimant, 38 C.F.R. § 4.3; where there is a question as to which of two evaluations apply, assigning a higher of the two where the disability picture more nearly approximates the criteria for the next higher rating, 38 C.F.R. § 4.7; and evaluating functional impairment on the basis of lack of usefulness, and the effects of the disabilities upon the person's ordinary activities, 38 C.F.R. § 4.10. See Schafarth v. Derwinski, 1 Vet. App. 589 (1991). Where the claimant has expressed dissatisfaction with the assignment of an initial evaluation following an award of service connection for that disability, separate ratings can be assigned for separate periods of time based on the facts found, a practice known as "staged" ratings. Fenderson v. West, 12 Vet. App. 119 (1999). The Veteran's claims for increased evaluations are evaluated separately below. A. Degenerative Arthritis of the Cervical Spine The Veteran's degenerative arthritis of the cervical spine is evaluated as 10 percent disabling from January 26, 2004, and 20 percent disabling from August 14, 2015. Additionally, the Veteran received a temporary total evaluation based on convalescence for the period from November 19, 2013, to January 1, 2014, due to treatment for this disability, which is discussed in more detail below. The Veteran is rated under Diagnostic Code 5242, which is assigned using the General Rating Formula for Diseases and Injuries of the Spine. Under the general rating formula, a 10 percent rating is warranted for forward flexion of the cervical spine greater than 30 degrees but not greater than 40 degrees; or, the combined range of motion of the cervical spine greater than 170 degrees but not greater than 335 degrees; or, muscle spasm, guarding, or localized tenderness not resulting in abnormal gait or abnormal spinal contour. 38 C.F.R. § 4.71a, DC 5242. A 20 percent rating is warranted for forward flexion of the cervical spine greater than 15 degrees but not greater than 30 degrees; or, the combined range of motion of the cervical spine not greater than 170 degrees; or, muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. Id. A 30 percent rating is warranted for forward flexion of the cervical spine 15 degrees or less; or, favorable ankylosis of the entire cervical spine. A 40 percent rating is warranted for unfavorable ankylosis of the entire cervical spine. A 100 percent rating is warranted for unfavorable ankylosis of the entire spine. Id. VA may consider functional loss due to a musculoskeletal disability, which may be due to pain where it is 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 body part which becomes painful on use must be regarded as disabled. See DeLuca v. Brown, 8 Vet. App. 202 (1995); 38 C.F.R. § 4.40; see also 38 C.F.R. § 4.45. In Mitchell v. Shinseki, the Court held that, although pain alone does not constitute functional loss, "pain may result in functional loss, but only if it limits the ability to perform the normal working movements of the body with normal excursion, strength, speed, coordination, or endurance." 25 Vet. App. 32, 38 (2011) (quoting 38 C.F.R. § 4.40). The Veteran underwent a VA spine examination on January 26, 2006, at which he reported mild spasms in the neck, mild stiffness in turning his head to the right, and no decreased motion. There was no ankylosis of the cervical spine, and no objective evidence found of spasm, atrophy, guarding, pain with motion, tenderness, or weakness in the cervical spine. The range of motion of the cervical spine was measured as 0 to 45 degrees in forward flexion; 0 to 35 degrees in extension; 0 to 45 degrees of left lateral flexion; 0 to 35 degrees of right lateral flexion; 0 to 80 of left lateral rotation; and 0 to 70 of right lateral rotation. The examiner noted pain beginning at 35 degrees in extension; at 35 degrees in right lateral flexion, and at 70 degrees in right lateral rotation; these same measurements were provided for the passive motion range of motion tests as well. X-ray imaging performed at this examination revealed reversed lordosis of the cervical spine, as well as a loss of disc space at every level. The examiner diagnosed these as advanced arthritic change. The Veteran's private treatment records contain an April 2012 examination that tested range of motion. Flexion, extension, and left and right lateral flexion and rotation were all noted as being "restricted," but the extent of the limitation was not noted. No notations were made regarding other cervical spine symptoms, such as muscle guarding or spasm, abnormal gait, or abnormal spinal contour. The Veteran next underwent a VA spine examination in October 2015. There was no localized tenderness, guarding or muscle spasm noted on this examination, and no ankylosis. The range of motion of the cervical spine was measured at this examination as 0 to 30 degrees in forward flexion; 0 to 25 degrees in extension; 0 to 15 degrees of left lateral flexion; 0 to 15 degrees of right lateral flexion; 0 to 15 of left lateral rotation; and 0 to 15 of right lateral rotation. The examiner noted pain on movement in each of these ranges of motion, and the Veteran was unable to perform repetitive testing due to pain. The examiner also noted that the limitations noted in the range of motion contributed to functional loss, in that the Veteran was unable to look right or left when driving, relying instead on side view mirrors. Throughout the Veteran's private and VA treatment records, he frequently reported stiffness and intermittent aching neck pain. In November 2013, the Veteran received surgery in his cervical spine to fuse the C4-C5 vertebrae, after which he was assigned a temporary total evaluation for his convalescence period. In a December 2013 follow-up visit, imaging showed reversed lordosis in the cervical spine, which the reviewer noted was chronic and had progressed since previous imaging in 2006. The diagnosis was multilevel degenerative changes and degenerative disc disease. After careful consideration of the foregoing evidence, the Board finds that the disability picture for the period between January 26, 2004, and August 12, 2015, does not warrant assignment of a 20 percent evaluation. The January 2006 examination resulted in forward flexion of 45 degrees and a combined range of motion of the cervical spine of 310 degrees. Although the Veteran reported mild muscle spasms, the examiner did not find any objective evidence of spasms or guarding, and noted that any muscle spasm was not severe enough to cause abnormal spinal contour. Further, the reversed lordosis identified at the examination was diagnosed as arthritic change, and not due to muscle spasm or guarding. This impression was later confirmed in the December 2013 imaging, which contributed the reversed lordosis to degenerative change. Finally, the examiner noted that the pain on motion did not limit the Veteran's range of motion. As the combined range of motion was 310 degrees, which is greater than 170 degrees but less than 335 degrees, a 10 percent evaluation is warranted, and no increase is assigned for this period. As for the period beginning August 12, 2015, although the Veteran made frequent and consistent reports of neck pain and stiffness after the January 2004 examination, unfortunately there are no notations detailed enough to constitute evidence warranting a higher evaluation until the October 2015 VA examination. The Veteran submitted a private April 2012 examination, but this reflected only that his range of motion was restricted without specifying to what extent. It further contained no information regarding other rating criteria such as abnormal gait or abnormal spinal contour. The October 2015 examination resulted in forward flexion of 30 degrees and a combined range of motion of the cervical spine of 115 degrees. The examiner did not find any objective evidence of spasms or guarding. As the forward flexion was not less than 15 degrees and there was no evidence of ankylosis, a 30 percent evaluation is not warranted. Rather, these measurements coincide with a 20 percent evaluation. However, the Veteran was unable to perform repetitive motion testing due to pain, and the examiner noted pain on movement in each range of motion test performed. Although the examination does not include range of motion measurements showing forward flexion of 15 degrees or less, when considering additional functional loss due to pain and pain on movement and affording the Veteran the benefit of the doubt, the Board finds that the symptomatology associated with the Veteran's cervical spine disability more nearly approximates forward flexion of 15 degrees or less. See 38 C.F.R. §§ 4.40, 4.45; DeLuca, 8 Vet. App. at 204-07. In this regard, the Board finds compelling that, according to the examiner, pain noted on examination caused functional loss with respect to each range of motion tested. Significantly, the Veteran was unable to complete repetitive motion testing due to pain, and reported difficulty looking to either side while driving on a regular basis. Accordingly, a 30 percent evaluation is warranted. The RO awarded the increase in evaluation from 10 percent to 20 percent effective on August 12, 2015, the date of the Veteran's application for TDIU. As the evidence prior to this date does not support the assignment of more than a 10 percent evaluation, the Board cannot find that the increase occurred earlier than August 12, 2015. As such, the 30 percent evaluation is effective August 12, 2015. B. Degenerative Arthritis of the Lumbar Spine The Veteran's degenerative arthritis of the lumbar spine is evaluated noncompensably from August 27, 2003, as 10 percent from December 2, 2009, and as 20 percent from August 12, 2015. Like the cervical spine disability, the lumbar spine disability is also rated under Diagnostic Code 5242, using the general rating formula. Under the formula, a 10 percent evaluation applies when forward flexion of the thoracolumbar spine is greater than 60 degrees but not greater than 85 degrees; the combined range of motion of the thoracolumbar spine is greater than 120 degrees but not greater than 235 degrees; muscle spasm, guarding or localized tenderness are present but not resulting in abnormal gait or abnormal contour; or, there exists vertebral body fracture with loss of 50 percent or more of the height. 38 C.F.R. § 4.71a, DC 5242. A 20 percent evaluation applies where the evidence shows 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, muscle spasm or guarding are severe enough to result in an abnormal gait or abnormal spinal contour, such as scoliosis, reversed lordosis, or abnormal kyphosis. Id. A 40 percent evaluation requires evidence of forward flexion of the thoracolumbar spine to 30 degrees or less; or, favorable ankylosis of the entire thoracolumbar spine. A 50 percent evaluation is warranted for unfavorable ankylosis of the entire thoracolumbar spine. Id. At the January 2006 VA spine examination, the Veteran reported mild occasional lower back pain that radiated down his right leg. The examiner noted no objective evidence of muscle spasm, atrophy, guarding, pain with motion, tenderness, or weakness in the lumbar region. The range of motion of the thoracolumbar spine was 0 to 90 degrees in flexion; 0 to 30 degrees in extension; 0 to 45 degrees in left lateral flexion; 0 to 45 degrees in right lateral flexion; 0 to 70 degrees in left lateral rotation; and 0 to 70 degrees in right lateral rotation. In passive motion, the range of motion was measured as 0 to 70 degrees in both right and left lateral motion. Pain was not noted in the range of motion, nor upon repetitive use. X-ray imaging revealed loss of normal lumbar lordosis and some loss of disc space, which were characterized as arthritic changes. The April 2012 private examination indicated restricted range of motion in extension and left lateral flexion, but again did not provide measurements as to the extent of these limitations. The flexion, right lateral flexion, and right and left rotation were not marked as either normal or restricted. The October 2015 VA examination resulted in range of motion measurements of 0 to 50 degrees in flexion; 0 to 20 degrees in extension; 0 to 30 degrees in left lateral flexion; 0 to 10 degrees in right lateral flexion; 0 to 20 degrees in left lateral rotation; and 0 to 20 degrees in right lateral rotation. The examiner noted pain on the examination, and remarked that the limitation in range of motion resulted in functional loss, including the inability to bend over to pick up objects and difficulty putting on socks and tying shoes. The Veteran also reported interference with prolonged sitting and standing. The pain was exhibited across all the ranges of motion. The Veteran was able to perform repetitive motion testing, and pain and other factors did not limit his functional ability with repeated use. No muscle guarding or spasm was noted. Similar to the cervical spine, the Veteran made consistent reports throughout his VA and private treatment records of low back pain and stiffness. For example, in November 2006, the Veteran reported chronic back pain with occasional radiation to the legs, and the neurologist noted November 2004 MRI results showing degenerative disc disease. In February 2007, the Veteran again reported chronic back pain with occasional radiation to the legs, and the neurologist noted a past medical history of degenerative disc disease of the lumbar spine. Similar reports were also made in November 2007, September 2007, June 2008, December 2008, April 2009, and June 2009. On December 2, 2009, the Veteran reported intermittent low back pain that had worsened over the previous six months, with more continuous pain radiating in the right leg. On examination, raising the knee to the chest elicited increased back pain, and standing back extension increased right sided lumbar pain. The physician noted that these symptoms and results were consistent with degenerative disc disease of the lumbar spine with intermittent radiculopathy. The Veteran's private treatment records also reflect a history of complaints of chronic back pain. Beginning in October 2010, until August 2013, the Veteran saw a chiropractor to treat his back pain. He reported increased pain in the evenings after activities during the day like digging in the yard, hunting and walking on uneven terrain, and playing with his grandchildren. However, in these reports, he did not mention pain while engaging in these activities. A May 2004 MRI scan revealed multilevel degenerative disease that was relatively stable in the lumbar spine compared with an April 1998 MRI. A June 2009 MRI scan revealed progression in loss of disc height and degenerative facet hypertrophy. September 2015 imaging showed mild to moderate disc space narrowing at L2-L4, moderate disc space narrowing at L4-L5, and severe disc space narrowing at L5/S1. The Veteran's lumbar disability is rated noncompensably for the period beginning August 27, 2003, to December 2, 2009. This assignment is based on the January 2006 examination resulting in a full range of motion, with no painful motion. The Veteran's lumbar disability is rated as 10 percent disabling for the period beginning December 2, 2009, based on the testing that day resulting in painful motion, despite the only contemporary range of motion measurements of record indicating a full range of motion. See 38 C.F.R. §§ 4.59, 4.71a, DC 5003 (requiring satisfactory evidence of painful motion). Finally, the Veteran's lumbar disability is rated as 20 percent disabling beginning August 12, 2015, based on the limitation of motion observed at the October 2015 examination. After considering the relevant evidence, the Board finds that increased evaluations and earlier effective dates are not warranted for the various stages. To begin with, the Veteran demonstrated a full range of motion at the January 2006 examination, so his forward flexion was greater than 85 degrees and his combined range of motion was greater than 235 degrees. Further, there was no evidence of muscle spasm or guarding, localized tenderness, or abnormal gait. The imaging revealed loss of the normal lumbar lordosis, but this was contributed to arthritic changes and not muscle spasm, guarding, or localized tenderness. Further, the Board notes that the general rating formula came into effect on September 26, 2003; prior to this, VA regulations rated lumbar disabilities based on slight, moderate, and severe limitation of motion. As the Veteran displayed a full range of motion in this period, a compensable rating is not appropriate for the period the degenerative arthritis of his lumbar spine was service-connected prior to the change in regulations. Next, although there were complaints of back pain in the record prior to December 2, 2009 - the date of the period in which the lumbar disability is rated as 10 percent disabling based on painful motion - these complaints are not accompanied by examination exhibiting painful motion, nor do they describe the pain as coinciding with motion. The examination in December 2009 was not a full range of motion study, but did detail two different tests during which the Veteran reported increased pain. Despite consistent reports of chronic back pain earlier than this December 2009 treatment record, these reports do not contain satisfactory evidence that the pain increased on motion. Accordingly, an earlier effective date for the 10 percent evaluation is not warranted. Finally, the October 2015 examination resulted in forward flexion of 50 degrees and a combined range of motion of 150 degrees. These results coincide with the rating criteria for a 20 percent evaluation. A 40 percent evaluation is not warranted unless the forward flexion of the thoracolumbar spine is 30 degrees or less, or the Veteran displays favorable ankylosis of the entire thoracolumbar spine, neither of which criteria the evidence meets. Further, when considering additional functional loss due to pain and pain on movement and affording the Veteran the benefit of the doubt, the Board finds that the 20 percent evaluation assigned adequately portrays any functional impairment that the Veteran experiences. The Veteran's complaints of difficulty bending over to pick up objects and put on socks and shoes are contemplated in the 20 percent evaluation, which specifically addresses limitation of range of motion. Most importantly, the examiner concluded that the pain reported across all ranges of motion did not limit the Veteran in his functional ability. Accordingly, increased evaluations and earlier effective dates for the current evaluations of degenerative arthritis of the lumbar spine are not warranted. C. Dyspepsia The Veteran's dyspepsia is currently evaluated as 20 percent disabling effective August 27, 2003, under Diagnostic Code 7305, which governs duodenal ulcers and most closely reflects the Veteran's predominant disability picture as relates to his stomach symptoms. 38 C.F.R. § 4.114. Under Diagnostic Code 7305, a 10 percent rating is assigned where the disability is mild, with recurring symptoms once or twice yearly. A 20 percent rating is assigned where the disability is moderate, with recurring episodes of severe symptoms two or three times a year averaging 10 days in duration, or with continuous, moderate manifestations. A 40 percent rating is assigned where the disability is moderately severe, with impairment of health manifested by anemia and weight loss, or recurrent incapacitating episodes averaging 10 days or more in duration at least four or more times a year. A 60 percent rating is assigned where the disability is severe, with pain only partially relieved by standard ulcer therapy, periodic vomiting, recurrent hematemesis or melena, with manifestations of anemia and weight loss productive of definite impairment of health. The words "mild," "moderate," and "severe," as used in the various diagnostic codes, are not defined in the rating schedule. The use of these terms by VA examiners and others, although an element of evidence to be considered by the Board, is not dispositive of an issue. 38 C.F.R. §§ 4.2, 4.6. Rather than applying a mechanical formula, the Board must evaluate all of the evidence to the end that its decisions are "equitable and just." 38 C.F.R. § 4.6. The Veteran first underwent a VA examination relevant to the dyspepsia disability in March 2004. At this examination, the Veteran reported a burning sensation in his stomach when it was empty, which improved after eating. He also reported experiencing distention approximately twice a week and some nausea, but no vomiting. The examiner found no signs of anemia at this examination. In January 2006, the Veteran underwent a second VA examination, at which the Veteran again reported experiencing the burning sensation on a daily basis. He reported esophageal pain several times a week. The examiner found no signs of anemia at this examination. In October 2015, the Veteran underwent a third VA examination, at which he reported experiencing episodes of dyspepsia symptoms more than four times a year. These episodes on average lasted less than one day, and none were incapacitating. The Veteran reported that his abdominal pain was only partially relieved by his course of treatment, and that he experienced nausea approximately three times a year. The Veteran did not report symptoms of anemia, weight loss, melena, or hematemesis. Throughout the Veteran's VA treatment records, he reported similar symptoms, such as bloating (distention), indigestion, and a burning sensation, on a regular basis and continued receiving treatment for them. No weight loss is noted in his records. The Board finds that an increased evaluation for dyspepsia is not warranted. The Veteran did not report any incapacitating episodes at any point, and there is no evidence of anemia or weight loss impairing his health, which constitute the criteria for a 40 percent evaluation. Rather, the 20 percent rating better describes the Veteran's dyspepsia, as he experiences continuous, moderate manifestations of the disability. The examinations and VA treatment records show a burning sensation on a regular basis, as well as abdominal and esophageal pain. The record does not indicate that the Veteran experiences any more severe symptoms, such as vomiting, weight loss, hematemesis, and melena. Accordingly, the claim for an increased evaluation for dyspepsia is denied. D. Radiculopathy of the Left and Right Upper Extremities The Veteran's radiculopathy of the left upper extremity is currently evaluated as 20 percent disabling effective April 3, 2015, under Diagnostic Code 8712, which governs neuralgia of the lower radicular group. 38 C.F.R. § 4.124(a), DC 8712. The Veteran's radiculopathy of the right upper extremity is also currently evaluated as 20 percent disabling effective August 22, 2014, under Diagnostic Code 8512, which governs paralysis of the lower radicular group. Neuralgia of the lower radicular group, characterized usually by a dull and intermittent pain, is rated on the scale provided for paralysis of the lower radicular group. 38 C.F.R. § 4.124. Diagnostic Codes 8512 and 8712 thus both provide that 20, 40, and 50 percent ratings are assigned depending on whether the incomplete paralysis of the extremity is mild, moderate, or severe, respectively. Complete paralysis of the extremity, in that all intrinsic muscles of the hand and some or all of the flexors of the wrist and fingers are paralyzed, warrants a 70 percent rating. 38 C.F.R. § 4.124(a), DC 8712. An introductory note to the rating schedule for diseases of the peripheral nerves indicates that where the involvement is wholly sensory, the rating should be for the mild, or at most moderate, degree. The words "mild," "moderate," and "severe," as used in the various diagnostic codes, are not defined in the rating schedule. The use of these terms by VA examiners and others, although an element of evidence to be considered by the Board, is not dispositive of an issue. 38 C.F.R. §§ 4.2, 4.6. Rather than applying a mechanical formula, the Board must evaluate all of the evidence to the end that its decisions are "equitable and just." 38 C.F.R. § 4.6. In April 2015, the Veteran underwent a VA peripheral nerves examination, which informed the RO's initial evaluation of the left upper extremity, as well as the left and right lower extremities. At this examination, the Veteran reported moderate intermittent dull pain, moderate paresthesias, and moderate numbness in the left arm. The muscle strength and reflexes were all normal in both the right and left arms, but the left hand and fingers demonstrated decreased sensation to light touch, as opposed to normal or absent sensation. All the upper extremity nerves were normal, as opposed to showing incomplete or complete paralysis. The examiner noted that electromyography (EMG) testing in November 2013 demonstrated abnormality in both the right and left upper extremity, but it is unclear whether the examiner reviewed these results or whether they were reported by the Veteran. This testing was performed by a private physician, and reported chronic left C5 radiculopathy with evidence of moderate ongoing axonal loss; evidence of chronic residual changes bilaterally in C6-C7; and evidence of right mild median mononeuropathy occurring at the wrist with demyelination. In an October 2015 VA cervical spine examination, the Veteran reported moderate intermittent dull pain, moderate paresthesias, and moderate numbness in the left and right upper extremities. The examiner considered the results of the radiculopathy testing during this examination to be mild radiculopathy in both the left and right upper extremities. In a separate October 2015 VA peripheral nerves examination, the Veteran reported no constant pain, but moderate intermittent dull pain, moderate paresthesias, and moderate numbness in the left and right arms. The sensation testing for light touch was all normal in the left and right shoulders, forearms, hands, and fingers. EMG testing was not noted on this examination. The examiner indicated that the severity of the radiculopathy affecting the left and right lower radicular group was a mild incomplete paralysis. The Veteran underwent imaging of his cervical spine in April and June 2014, which visits were in response to complaints of pain in his right hand and a tingling sensation in his right shoulder. A July 2014 physical therapy note indicated he was referred to physical therapy for right arm tingling; an August 2014 VA physical therapy note indicated that the Veteran reported reduced frequency of numbness in the arm. No other reports of radiculopathy symptoms in the upper extremities appear in the Veteran's VA treatment records during the period on appeal. As such, there is no evidence in the record that the radiculopathy of the left upper extremity is more severe than noted on the April and October 2015 examinations. These two examinations had similar results as to the left upper extremity, both resulting in reports of moderate intermittent dull pain, moderate paresthesias, and moderate numbness in the left arm. Although the April examination demonstrated decreased sensation to light touch, the October examination demonstrated normal results in this regard. Likewise, where the April examination showed normal results for the upper extremity nerves, the October examination indicated mild incomplete paralysis of the lower radicular group. Neither examination indicates a disability more severe than mild incomplete paralysis, as when taken together and with the Veteran's treatment records, they demonstrate relatively normal function of the left upper extremity, with no loss of strength or reflex and with occasional complaints of numbness and tingling. Accordingly, an increased initial evaluation for radiculopathy of the upper left extremity is not warranted. As for the right upper extremity, its symptoms were not addressed in the April 2015 examination, although the October 2015 examination recorded them as moderate intermittent dull pain, moderate paresthesias, and moderate numbness in the right arm. The right shoulder and forearm demonstrated normal results for sensation of light touch in the April 2015 examination, and the right shoulder, forearm, hand, and fingers all demonstrated normal results for sensation of light touch in the October 2015 examination. Although the Veteran reported pain and tingling in his right upper extremity in April and June 2014, these reports appear to have resolved somewhat with physical therapy, as by the April 2015 examination, the right lower radicular group was considered to be normal. At the October 2015 examination, the examiner considered the incomplete paralysis of the Veteran's right lower radicular group to be mild; this slight fluctuation, taken together with the 2014 success in physical therapy, appears to indicate an ebb and flow in the Veteran's condition, between intermittent and mild complaints of sensory impairment. Accordingly, the Board finds that the 20 percent evaluation best describes the Veteran's disability, and an increased evaluation is not warranted for radiculopathy of the right upper extremity. E. Radiculopathy of the Left and Right Lower Extremities The Veteran's radiculopathy of the left lower extremity is currently evaluated as 10 percent disabling effective April 3, 2015, under Diagnostic Code 8520, which governs paralysis of the sciatic nerve. 38 C.F.R. § 4.124(a), DC 8520. The Veteran's radiculopathy of the right lower extremity is also currently evaluated as 10 percent disabling under the same code, effective December 2, 2009. Diagnostic Code 8520 provides that 10, 20, 40, and 60 percent ratings are assigned depending on whether incomplete paralysis of the nerve is mild, moderate, moderately severe, or severe with marked muscular atrophy, respectively. Complete paralysis of the nerve, in that the foot dangles and drops, there is no active movement of the muscles below the knee possible, or flexion of the knee is weakened or lost, warrants an 80 percent rating. 38 C.F.R. § 4.124(a), DC 8520. An introductory note to the rating schedule for diseases of the peripheral nerves indicates that where the involvement is wholly sensory, the rating should be for the mild, or at most moderate, degree. The words "mild," "moderate," and "severe," as used in the various diagnostic codes, are not defined in the rating schedule. The use of these terms by VA examiners and others, although an element of evidence to be considered by the Board, is not dispositive of an issue. 38 C.F.R. §§ 4.2, 4.6. Rather than applying a mechanical formula, the Board must evaluate all of the evidence to the end that its decisions are "equitable and just." 38 C.F.R. § 4.6. At the April 2015 VA peripheral nerves examination, the Veteran reported mild intermittent dull pain, mild paresthesias, and mild numbness in the left lower extremity, and these at a moderate level in the right lower extremity. The muscle strength and reflexes were all normal, but the lower leg and ankle on both sides demonstrated decreased sensation to light touch, as opposed to normal or absent sensation. All the lower extremity nerves were recorded as normal, as opposed to showing incomplete or complete paralysis. The Board notes that, at this examination, the Veteran described his symptoms in the left leg as less severe than that of the right leg. In an October 2015 VA lumbar spine examination, the Veteran reported no constant pain, no paresthesias, no numbness, and moderate intermittent dull pain in the left and right legs. The examiner considered the results of the radiculopathy testing during this examination to be mild radiculopathy on both sides. In a separate October 2015 VA peripheral nerves examination, the Veteran again reported no constant pain, no paresthesias, no numbness, and moderate intermittent dull pain in the left and right lower extremities. The sensation testing for light touch was all normal in the left and right anterior thighs, knees, lower legs, ankles, feet, and toes. The examiner indicated that the severity of the radiculopathy affecting the sciatic nerve was a mild incomplete paralysis in the left and right lower extremities. A September 2015 treatment record notes a complaint of low back pain radiating to the Veteran's hips and down to his knees bilaterally after using a mechanical string trimmer to do some yardwork for a short period of time. No other reports of radiculopathy symptoms in the lower extremities appear in the Veteran's VA treatment records during the period on appeal. Although decreased sensation to light touch was noted on the April 2015 examination, all the lower extremity nerves were noted to be normal. The Veteran reported mild intermittent dull pain, paresthesias, and numbness in the left lower extremity and moderate levels of these sensations in the right lower extremity. In comparison, the October 2015 examination had similar and even somewhat improved results, showing a report of moderate intermittent dull pain but no paresthesias or numbness in either leg. Although the April examination demonstrated decreased sensation to light touch, the October examination demonstrated normal results in this regard. The September 2015 complaint of pain radiating from the Veteran's lower back to his hips and knees indicates a painful flare-up after exertion, but did not include reports of weakness or loss of use of the extremities. Neither examiner opined that the Veteran's left or right lower extremity radiculopathy was more severe than mild incomplete paralysis of the sciatic nerve, even considering the Veteran's report in the April examination that his symptoms were more significant in his right lower extremity than in his left. The Veteran's treatment records do not indicate complaints of symptoms of increased severity or any worsening of the condition in either side. Accordingly, increased initial evaluations for radiculopathy of the left and right lower extremities are not warranted. III. Temporary Total Evaluation The Veteran contends he is entitled to a longer duration of a temporary total evaluation after January 1, 2014, for convalescence related to a cervical spine surgery. A period of a temporary total evaluation (100 percent rating) under 38 C.F.R. § 4.30 for convalescence was awarded for the Veteran's service-connected cervical spine disability from November 19, 2013, to January 1, 2014. The applicable regulations provide that a total disability evaluation will be assigned without regard to other provisions of the rating schedule when it is established by report at hospital discharge (regular discharge or release to non-bed care) or outpatient release that entitlement is warranted. This rating is effective from the date of hospital admission or outpatient treatment and continuing for a period of one, two, or three months from the first day of the month following such hospital discharge or outpatient release. 38 C.F.R. § 4.30. Under section 4.30(a), a temporary total evaluation will be assigned if the hospital or outpatient treatment of a service-connected disability resulted in: (1) surgery necessitating at least one month of convalescence; (2) surgery with respect to postoperative residuals such as incompletely healed surgical wounds, stumps and recent amputations, therapeutic immobilization of one major joint or more, application of a body cast, the necessity for house confinement, or the necessity for continued use of a wheelchair or crutches (regular weight-bearing prohibited); or (3) immobilization by cast, without surgery, of one major joint or more. A temporary total rating may be extended one, two, or three months beyond the initial three month period. 38 C.F.R. § 4.30(b)(1). Here, the Veteran's service-connected cervical spine disability required surgery on November 19, 2013, to perform an anterior cervical discectomy and fusion of the C4-C5 vertebrae. The Veteran was discharged the same day as the surgery. The records reflect a phone call from the Veteran at home on November 22, 2013, to ask about treating the surgical site with ice. On December 23, 2013, the Veteran was seen for a follow-up appointment. The Veteran was restricted from lifting greater than 10 pounds, and he was referred to physical therapy. The records indicate that the Veteran had plans to leave town until March 2014, and was instructed to obtain exercises from the physical therapist that he could do on his own. There are no VA treatment records in the claims file indicating that the Veteran was treated between December 2013 and March 2014. The RO assigned the initial period of temporary total evaluation based upon the notation of the discectomy and fusion surgery. The RO assigned the temporary total evaluation for one month following the end of the month the Veteran was discharged from the hospital after surgery, resulting in a period from November 19, 2013, to January 1, 2014, of temporary total evaluation. A review of the Veteran's VA and private treatment records reveals no further indications of follow-up treatment amounting to convalescence related to the cervical spine surgery. Since January 1, 2014, there were no follow-up treatments that indicate an extended period of convalescence, bedrest, hospitalization, acute care, or any type of treatment that amounts to other than outpatient treatment for neck symptoms relating to the cervical spine surgery. There are no indications that the Veteran required use of a wheelchair or crutches, was immobilized, or was confined to his home in order to recover from this surgery. For instance, the first record of any neck treatment after the December 2013 follow-up visit was a March 2014 visit at which the physician noted of the cervical spine imaging, "graft is a little proud but pt [patient] asymptomatic." The physician indicated that the Veteran had completed a course of physical therapy and continued to do exercises at home. He further lifted the previous restriction on lifting greater than 10 pounds, after noting that the Veteran was "doing very well following ACDF [anterior cervical disc fusion]." The Veteran has not submitted any records indicating that in the period between January 1, 2014, and March 2014 he was under any type of care beyond the prescribed course of at-home physical therapy exercises. As such, without medical indication of continued convalescence relating to the November 19, 2013, cervical spine surgery, there is no basis for an extension of the temporary total evaluation. Here, the Board has considered the Veteran's lay statements, but finds that the preponderance of the evidence indicates that the convalescence did not extend beyond the current effective date as indicated by the medical follow-up. IV. Service Connection Service connection will be granted if the evidence demonstrates that a current disability resulted from an injury or disease incurred in or aggravated by active military service. 38 U.S.C.A. § 1131; 38 C.F.R. § 3.303(a). Establishing service connection generally requires (1) medical evidence of a current disability; (2) medical or, in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and (3) medical evidence of a nexus between the current disability and the disease or injury incurred or aggravated during service. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004); see also 38 C.F.R. § 3.303, Hickson v. West, 12 Vet. App. 247, 252-53 (1999). Service connection may be granted for any disease initially diagnosed after service, when all the evidence, including that pertinent to service, establishes the disease was incurred in service. 38 C.F.R. § 3.303(d). Service connection may be granted on a secondary basis for a disability that is shown to be proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310(a). Service connection on a secondary basis may not be granted without medical evidence of a current disability and medical evidence of a nexus between the current disability and a service-connected disability. See Wallin v. West, 11 Vet. App. 509, 512-14 (1998); see also Allen v. Brown, 7 Vet. App. 439, 488 (1995). The Veteran seeks service connection for chronic headaches secondary to his service-connected cervical spine disability. However, there is no evidence in the record of a diagnosis of chronic headaches. None of the active problem lists or reports of past medical history in the Veteran's VA treatment records list chronic headaches or migraines as something the Veteran was ever followed or treated for. The Veteran did report headaches in his November 2013 pre-operative history and physical work-up, but there is no accompanying indication of the persistence or frequency of these headaches. Throughout the rest of the Veteran's VA treatment records, there are several notations where the Veteran specifically denied having current headaches, and no accompanying notation that headaches occur chronically despite being free of them at that particular visit. An October 2014 VA treatment record noted that the Veteran reported having headaches when leaning over prior to a September 2014 coronary bypass procedure, but none since. Although the Veteran's representative contends that the Veteran experiences chronic headaches due to his cervical spine disability, the years of records from both private and VA providers regarding neck pain are silent as to headaches, even where the Veteran reported other symptoms related to his cervical spine, such as chronic neck pain and stiffness, and numbness and weakness in his arms and hands. As such, the Board finds there is no competent evidence of a recurrence or persistence of headache symptoms, and therefore no need for a VA examination in this case. See McLendon v. Nicholson, 20 Vet. App. 79, 83 (2006). In this determination, the Board has considered both the medical and lay evidence; although the Veteran asserts service connection is warranted, as summarized above, the Veteran's own statements (as recorded in treatment records) deny such symptoms. Without a current diagnosis, the Veteran's service connection claim for chronic headaches must be denied. See 38 C.F.R. §§ 3.102, 3.303; see also Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992) (existence of a current disability is the cornerstone of a claim for VA disability compensation). The preponderance of the evidence weighs against there being a comp V. TDIU VA will grant entitlement to TDIU when the evidence shows that the Veteran is precluded, by reason of his service-connected disabilities, from securing and following "substantially gainful employment" consistent with his education and occupational experience. 38 C.F.R. §§ 3.340, 3.341, 4.16; VAOPGCPREC 75-91; 57 Fed. Reg. 2317 (1992). The central inquiry is "whether the Veteran's service-connected disabilities alone are of sufficient severity to produce unemployability." Hatlestad v. Brown, 5 Vet. App. 524, 529 (1993). The sole fact that the Veteran was or is unemployed or has difficulty obtaining employment is not enough. A disability rating in itself is recognition that the impairment makes it difficult to obtain or keep employment, but the Board must evaluate whether there are circumstances in the Veteran's case, apart from any non-service-connected condition and advancing age, which would justify a total rating based on individual unemployability due solely to the service-connected conditions. See Van Hoose v. Brown, 4 Vet. App. 361, 363 (1993); see also Blackburn v. Brown, 5 Vet. App. 375 (1993). Marginal employment shall not be considered substantially gainful employment. 38 C.F.R. § 4.16(a). The regulations provide that if there is only one such disability, it must be rated at 60 percent or more; and if there are two or more disabilities, at least one disability must be rated at 40 percent or more, and sufficient additional disability must bring the combined rating to 70 percent or more. Disabilities resulting from common etiology or a single accident or disabilities affecting a single body system will be considered as one disability for the above purposes. 38 C.F.R. § 4.16(a). Moreover, because it is established VA policy that all Veterans who are unable to secure and follow a substantially gainful occupation by reason of service-connected disabilities shall be rated as totally disabled, the Board will submit to the Director of Compensation and Pension Services (Director) for extraschedular consideration all cases of veterans who are unemployable by reason of service-connected disabilities but who fail to meet the above percentage standards. 38 C.F.R. § 4.16(b). The Board cannot assign an extraschedular rating in the first instance, but must specifically adjudicate whether to refer a case to the Director for consideration of an extraschedular rating under section 4.16(b) when the issue is either raised by the claimant or is reasonably raised by the evidence of record. Barringer v. Peake, 22 Vet. App. 242 (2008) (citing Thun v. Peake, 22 Vet. App. 111, 115 (2008)). Section 4.16, in contrast to extraschedular evaluation under 38 CFR § 3.321(b)(1), does not require a finding that the schedular ratings are inadequate to compensate for the average impairments in earning capacity caused by particular disabilities, but requires only a finding that the service-connected disabilities render a particular veteran unemployable. VAOPGCPREC 6-96 (August 16, 1996). Here, the Veteran filed an application for a TDIU in August 2015, claiming that his service-connected dyspepsia, radiculopathy, lumbar spine, and cervical spine disabilities prevent him from securing or following a substantially gainful occupation. The Court has held that entitlement to TDIU is an element of all appeals of an initial rating. Rice v. Shinseki, 22 Vet. App. 447, 454-55 (2009). Therefore, as the appeals period for the Veteran's increased evaluation for degenerative arthritis of the lumbar spine claim began on August 27, 2003, the Board will evaluate whether the Veteran is entitled to a TDIU beginning on that date. The Veteran reported on his application that he completed high school and college, and earned a Masters of Business Administration in December 1975. He listed his employment as an accountant from September 1970 to July 1999. The Veteran's employer reported that he worked 40 hours a week during that period. The Veteran reported at the March 2004 VA dyspepsia examination that he took regular retirement when his employer was bought by another company. At the January 2006 VA spine examination, the examiner noted that the lumbar and cervical spine disabilities did not affect his ability to work or perform the activities of daily living. The examiner noted that the Veteran's back flared up about every three months if he lifted objects that were too heavy, and that the Veteran wore a back brace if he knew he would be engaging in strenuous activities. The examiner who performed the October 2015 spine and peripheral nerve examinations noted that the lumbar spine disability had an impact on the Veteran's ability to work. The examiner noted that the Veteran was unable to sit for more than twenty minutes without having to get up due to his lumbar pain and radiculopathy symptoms. Given the Veteran's education and work history of sedentary work, the Board finds that physical labor is unlikely to be an option for the Veteran. Further, there is evidence in the record reflecting that the Veteran's ability to lift heavy objects is limited by his service-connected lumbar and cervical spine disabilities. Although there is evidence as early as January 2006 that Veteran was limited in performing physical labor, the October 2015 examination is the earliest evidence in the appeal period indicating the Veteran's inability to sustain a sedentary occupation aligned with his training and education. Therefore, TDIU is warranted as of the date of that examination - October 13, 2015. The Veteran's service-connected disabilities have a combined evaluation of 70 percent beginning April 3, 2015. The Board's decision above granting an earlier effective date for radiculopathy of the right lower extremity does not affect the Veteran's eligibility for schedular TDIU, as the combined evaluation does not exceed 70 percent until the award of service connection for radiculopathy of the left lower and upper extremities on April 3, 2015. Likewise, the Board's decision above increasing the evaluation of the cervical spine disability does not affect the Veteran's eligibility, as that increase is effective August 12, 2015. As the date the Veteran's TDIU is effective, October 13, 2015, follows the date he became schedularly eligible for TDIU, there is no need to refer any portion of the Veteran's TDIU claim to the Director for extraschedular consideration. REMAND The Veteran seeks service connection for erectile dysfunction secondary to his service-connected lumbar spine disability and/or radiculopathy of the right lower extremity. To date, no VA examination has been afforded the Veteran relevant to this claim. In a June 2013 VA treatment record, the Veteran reported loss of erection and unsatisfactory sexual function during a review of his genitourinary system. The Veteran's report of such symptoms is competent evidence of recurrent or persistent symptoms. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007); Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009). Accordingly, a remand is necessary to obtain a VA examination to determine whether the Veteran's erectile dysfunction is secondary to his service-connected disabilities. See McLendon v. Nicholson, 20 Vet. App. 79, 83 (2006) (VA is obliged to provide an examination where the record contains competent evidence of a current disability or persistent or recurrent symptoms and an indication the disability may be related to service, but does not contain enough information to decide the claim). Accordingly, the case is REMANDED for the following action: (This appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c). Expedited handling is requested.) 1. Obtain any and all VA treatment records from the Huntington VA Medical Center, and/or any other VA medical facility that may have treated the Veteran, and associate those documents with the claims file. 2. Thereafter, schedule the Veteran for an examination with an appropriate clinician to determine whether any current erectile dysfunction is related to the Veteran's military service or service-connected disability. The claims file must be made available to and be reviewed by the examiner in conjunction with the examination. If the examiner identifies a diagnosis of erectile dysfunction or other sexual dysfunction, the examiner should opine whether it is at least as likely as not (50 percent or greater probability) that the disability began in or is otherwise caused by the Veteran's active service. The examiner should address the Veteran's lay statements regarding continuity of symptomatology since onset. The examiner should also address any other pertinent evidence of record. The examiner must also opine whether it is at least as likely as not (50 percent or greater probability) that the erectile dysfunction disability is (a) caused by; or (b) aggravated (i.e., worsened beyond the normal progression of the disease) by the Veteran's service-connected lumbar spine disability and/or radiculopathy of the right lower extremity, and/or the combined effects of those disabilities. All findings must be reported in detail and all opinions must be accompanied by a clear rationale. If any of the above issues cannot be resolved without resorting to speculation, then a detailed medical explanation as to why this is so must be provided. 3. Following the above indicated development, the AOJ should review the claims file and readjudicate the Veteran's claim. If the benefits sought on appeal remain denied, the Veteran and his attorney should be furnished a supplemental statement of the case and given the opportunity to respond thereto before the case is returned to the Board. The Veteran has the right to submit additional evidence and argument on the matter 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 remanded by the Board of Veterans' Appeals or the United States Court of Appeals for Veterans Claims for additional development or other appropriate action be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West 2014). ______________________________________________ Nathaniel J. Doan Veterans Law Judge, Board of Veterans' Appeals ATTORNEY FOR THE BOARD: K. Josey, Associate Counsel Copy mailed to: Virginia A. Girard-Brady, Esq. Department of Veterans Affairs