Citation Nr: 18145412 Decision Date: 10/29/18 Archive Date: 10/29/18 DOCKET NO. 09-26 185 DATE: October 29, 2018 ORDER Entitlement to service connection for asthma (characterized as a disability manifested by shortness of breath) is denied. Entitlement to a rating in excess of 10 percent for left lower extremity radiculopathy is denied. Entitlement to a rating in excess of 10 percent for right lower extremity radiculopathy is denied. FINDINGS OF FACT 1. The Veteran’s asthma (characterized as a disability manifested by shortness of breath) is not shown to be causally or etiologically related to any disease, injury, or incident during service, and did not manifest within one year of service discharge. 2. For the entire claim period, the Veteran’s lumbar radiculopathy of the left lower extremity has been manifested as subjective complaints of burning and pain without diminished or loss of reflexes, muscle atrophy, diminished or absent muscle strength and loss of muscle tone. 3. For the entire claim period, the Veteran’s lumbar radiculopathy of the right lower extremity has been manifested as subjective complaints of burning and pain without diminished or loss of reflexes, muscle atrophy or diminished or absent muscle strength and loss of muscle tone. CONCLUSIONS OF LAW 1. The criteria for service connection for asthma have not been met nor may asthma be presumed to have been incurred in active service. 38 U.S.C. § 1110, 1111, 5107 (2012); 38 C.F.R. § 3.102, 3.303, 3.304 (2017). 2. For the entire claim period, the criteria for an initial rating in excess of 10 percent for left lower extremity radiculopathy have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.102, 4.1-4.14, 4.120, 4.123, 4.124a, Diagnostic Code 8520 (2017). 3. For the entire appeal period, the criteria for an initial rating in excess of 10 percent for right lower extremity radiculopathy have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.102, 4.1-4.14, 4.120, 4.123, 4.124a, Diagnostic Code 8520 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served in active duty in the United States Army from November 1988 to June 1994. She received the Army Commendation medal. These matters come before the Board of Veterans’ Appeals (Board) on appeal from multiple rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in St. Petersburg, Florida. In March 2012, the Appeals Management Center (AMC) granted service connection for bilateral radiculopathy of the lower extremities and assigned separate initial 10 percent ratings for each extremity, both effective from September 23, 2010. In June 2014, the Board denied entitlement to an initial rating of greater than ten percent for bilateral radiculopathy of the lower extremities. The Veteran subsequently appealed this decision. In March 2015, the Court of Appeals for Veterans Claims (the Court) set aside the June 2014 decision, in part, and remanded the case for readjudication in compliance with directives specified in a February 2015 Joint Motion filed by counsel for the Veteran and VA. In pertinent part, the Joint Motion specified that the parties only sought remand as to that portion of the Board’s decision that denied entitlement to initial ratings higher than 10 percent for radiculopathy of the right and left lower extremities. This appeal was further remanded by the Board in April 2015 and August 2017. In June 2018, the Board remanded the Veteran’s claims for radiculopathy of the lower extremities and service connection for a respiratory condition, characterized as shortness of breath. The Board determined that additional examinations would be needed to fully and fairly evaluate the Veteran’s claims. The Board finds that the agency of original jurisdiction (AOJ) has substantially complied with the remand orders with regard to the instant claims and no further action is necessary in this regard. See D’Aries v. Peake, 22 Vet. App. 97, 105 (2008); Dyment v. West, 13 Vet. App. 141, 146-47 (1999) (remand not required under Stegall v. West, 11 Vet. App. 268 (1998), where the Board’s remand instructions were substantially complied with), aff’d, Dyment v. Principi, 287 F.3d 1377 (2002). Service Connection The Veteran asserts that she has asthma (manifested as shortness of breath) induced by exercise and walking up inclines. Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303 (a). Service connection may also be granted for any disease diagnosed after discharge, when all of the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Direct service connection may not be granted without evidence of a current disability; in-service incurrence or aggravation of a disease or injury; and a nexus between the claimed in-service disease or injury and the present disease or injury. Id; see also Caluza v. Brown, 7 Vet. App. 498, 506 (1995) aff’d, 78 F.3d 604 (Fed. Cir. 1996). For Veterans with service in the Southwest Asia Theater of Operations during the Persian Gulf War, service connection may also be established under 38 U.S.C. § 1117; 38 C.F.R. § 3.317. Under this law and regulation, service connection will be granted for a Persian Gulf veteran who exhibits objective indications of “a qualifying chronic disability” that became manifest during active military, naval or air service in the Southwest Asia theater of operations during the Persian Gulf War, or to a degree of 10 percent or more not later than not later than December 31, 2011. 38 C.F.R. § 3.317(a)(1). For purposes of 38 C.F.R. § 3.317, there are three types of qualifying chronic disabilities: (1) an undiagnosed illness; (2) a medically unexplained chronic multi- symptom illness; and (3) a diagnosed illness that the Secretary determines in regulations prescribed under 38 U.S.C. § 1117(d) warrants a presumption of service connection. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). 1. Entitlement to service connection for asthma (characterized as a disability manifested as shortness of breath) The Veteran is seeking service connection for asthma, characterized as a disability manifested as shortness of breath. The Veteran served in the Persian Gulf War, including deployments in Saudi Arabia and Egypt. Service treatment records are negative for any complaints of, or treatment for, symptoms of asthma or any respiratory disorder. When asked about her medical history on a DD Form 2246 in July 1995, the Veteran specifically stated that she did not have any history of asthma or respiratory problems. (It is worth noting that the certification block in Part III of this form emphasizes the importance of this statement as an official statement with severe penalties under federal law for making a false statement.) Another report of medical history signed by the Veteran in August of 1995 directly asks if the Veteran has or had asthma or shortness of breath. The Veteran responded that she did not have asthma or shortness of breath. An August 1995 separation exam also found the Veteran’s lungs and chest to be normal. The Board has first considered whether service connection is warranted on a presumptive basis. However, asthma is not a chronic condition included under 38 C.F.R. § 3.309(a). Additionally, the Veteran has not alleged a continuity of symptomology. As such presumptive service connection for asthma is not warranted. 38 U.S.C. §§ 1101, 1112; 38 C.F.R. §§ 3.307, 3.309. The Board also notes that the July 2018 VA examination report reflects a diagnosis of asthma. As the Veteran’s symptoms have been attributed to a known clinical diagnosis, service connection under the provisions of 38 C.F.R. § 3.317(a)(1) is not warranted. The preponderance of evidence is against the Veteran’s claims for service connection for asthma, characterized as a disability manifested by shortness of breath. In her August 2012 correspondence with the VA, the Veteran complained of shortness of breath “when climbing any type of incline.” In August 2013, the VA issued a rating decision denying the Veteran’s shortness of breath claim because there was no evidence for a diagnosis for shortness of breath “nor is there any complaints [sic] of shortness of breath noted.” The Veteran’s November 2015 spirometry report was within normal limits. A February 2016 VA examination and medical opinion determined that the Veteran’s shortness of breath was not due to an undiagnosed illness or medically unexplained chronic multi-symptom illness associated with service in the Persian Gulf. The same February 2016 examiner said that the Veteran’s respiratory condition started in approximately 2006, almost 12 years after the Veteran’s active service, and that is associated with exercise and walking). The February 2016 examiner restated the findings of the November 2015 spirometry report characterizing the Veteran as “within normal limits.” A December 2017 VA medical opinion specifically addressed the question of service connection for the Veteran’s asthma. The VA examiner opined that the Veteran does not have a diagnosis of shortness of breath that was likely incurred or caused by illness during service. The VA examiner noted that the Veteran was discharged from the military in 1994 and that she states she did not seek medical care until her first visit to the VA Women’s Health Clinic in December 2001. At that time, her review of systems for the pulmonary system was as follows: ‘Respiratory: Negative. Denies cough, hemoptysis, SOB, dyspnea, or wheezing in the chest.’ Thus, the symptoms of shortness of breath were not present when seen at the Women’s Health Clinic in 2001. The July 2018 VA examiner noted the Veteran’s claims that she did a road march and had trouble breathing; the Veteran also had trouble breathing during the birth of her daughter. The VA examiner also noted that the Veteran has not had any asthma attacks with episodes of respiratory failure in the past 12 months. The VA examiner opined that the Veteran’s asthma was less likely than not (less than 50 percent probability) incurred in or caused by the claimed in service injury, event or illness. The July VA examiner highlighted the Veteran’s increase in weight since 1999 and cited Centers for Disease Control (CDC) information addressing the correlation between obesity and asthma, which specifically addressed the fact that female gender is significantly associated with asthma and obesity. The VA examiner also cited to two articles explaining the correlation between exercise and asthma. He stated that there are no conclusive long-term studies that support a causal relationship between asthma and service in Southwest Asia and that the Veteran’s condition was diagnosed 18 plus years after separating military service. The examiner further reasoned that, per a review of the literature, the Veteran’s asthma is secondary to exercise-induced activity and/or obesity, a diagnosable condition. This opinion had clear conclusions and supporting data as well as a reasoned medical explanation connecting the two. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008); Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007) (“[A]medical opinion... must support its conclusion with an analysis that the Board can consider and weigh against contrary opinions”). There is no contrary etiology opinion of record. The Board notes that the Veteran has contended that her pulmonary disorder is the result of her service. Lay witnesses are competent to provide testimony or statements relating to symptoms or facts of events that the lay witness observed and is within the realm of his or her personal knowledge, but not competent to establish that which would require specialized knowledge or training, such as medical expertise. Layno v. Brown, 6 Vet. App. 465, 469-70 (1994). Lay evidence may also be competent to establish medical etiology or nexus. Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009). However, “VA must consider lay evidence but may give it whatever weight it concludes the evidence is entitled to” and a mere conclusory generalized statement that service event or illness caused the claimant’s current condition is insufficient to require the Secretary to provide an examination. Waters v. Shinseki, 601 F.3d 1274, 1278 (2010). In the instant case, the Board finds that the question regarding the etiology of the Veteran’s asthma to be complex in nature. Woehlaert v. Nicholson, 21 Vet. App. 456 (2007). Specifically, while the Veteran is competent to describe her current respiratory symptoms, the Board accords her statements regarding the etiology of such a disorder little probative value as she is not competent to opine on such a complex medical question. Specifically, where the determinative issue is one of medical causation, only those with specialized medical knowledge, training, or experience are competent to provide evidence on the issue. See Jones v. Brown, 7 Vet. App. 134, 137 (1994). In this regard, the question of causation involves a medical subject concerning an internal physical process extending beyond an immediately observable cause-and-effect relationship, and requires the administration and interpretation of diagnostic testing. That process took place with the July 2018 examination, and the examiner has opined that the etiology of the Veteran’s pulmonary symptoms is the result of her weight. In the instant case, there is no suggestion that the Veteran has had any medical training. As such, the question of etiology in this case may not be competently addressed by lay evidence, and the opinion of the Veteran is nonprobative evidence. Therefore, the Veteran’s pulmonary condition is not shown to be causally or etiologically related to any disease, injury, or incident in service. Consequently, service connection for such disorder is not warranted. In light of the foregoing, service connection must be denied. In reaching this decision, the Board has considered the applicability of the benefit of the doubt doctrine. However, the preponderance of the evidence is against the Veteran’s claim of entitlement to service connection for asthma. As such, that doctrine is not applicable in the instant claim, and her claim must be denied. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. Increased Rating Disability evaluations are determined by evaluating the extent to which a Veteran’s service-connected disability adversely affects his ability to function under the ordinary conditions of daily life, including employment, by comparing his symptomatology with the criteria set forth in the Schedule for Rating Disabilities (Rating Schedule). 38 U.S.C. § 1155; 38 C.F.R. §§ 4.1, 4.2, 4.10. Where the appeal arises from the original assignment of a disability evaluation following an award of service connection, the severity of the disability at issue is to be considered during the entire period from the initial assignment of the disability rating to the present time. See Fenderson v. West, 12 Vet. App. 119 (1999). In evaluating a disability, the Board considers the current examination reports in light of the whole recorded history to ensure that the current rating accurately reflects the severity of the condition. While the Veteran’s entire history is reviewed when making a disability determination, where service connection has already been established and an increase in the disability rating is at issue, it is a present level of disability that is of primary concern. Francisco v. Brown, 7 Vet. App. 55 (1994). The Court has held that, in determining the present level of a disability for any increased evaluation claim, the Board must consider the application of staged ratings. See Hart v. Mansfield, 21 Vet. App. 505 (2007). In other words, where the evidence contains factual findings that demonstrate distinct time periods in which the service-connected disability exhibited diverse symptoms meeting the criteria for different ratings during the course of the appeal, the assignment of staged ratings would be necessary. Consideration is given to the potential application of the various provisions of 38 C.F.R. Parts 3 and 4, whether or not they are raised by the Veteran, as required by Schafrath v. Derwinski, 1 Vet. App. 589 (1991). If there is a question as to which of two evaluations should apply, the higher rating is assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating is assigned. 38 C.F.R. § 4.7. In general, all disabilities, including those arising from a single disease entity, are rated separately, and all disability ratings are then combined in accordance with 38 C.F.R. § 4.25. Pyramiding, the evaluation of the same disability, or the same manifestation of a disability, under different diagnostic codes, is to be avoided when rating a Veteran’s service-connected disability. 38 C.F.R. § 4.14. It is possible for a Veteran to have separate and distinct manifestations from the same injury which would permit rating under several diagnostic codes, however, the critical element in permitting the assignment of several ratings under various diagnostic codes is that none of the symptomatology for any one of the conditions is duplicative or overlapping with the symptomatology of the other condition. See Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994). There is evidence of a neurologic impairment of the lower extremities associated with the Veteran’s service-connected low back disability. The Veteran’s radiculopathy is rated under diagnostic code 8520. Paralysis of the sciatic nerve is rated as follows: a 10 percent rating is assigned for mild incomplete paralysis of the sciatic nerve; a 20 percent rating is assigned for moderate incomplete paralysis of the sciatic nerve; a 40 percent rating is assigned for moderately severe incomplete paralysis; and a 60 percent rating is assigned for severe incomplete paralysis, with marked muscular atrophy. A maximum 80 percent rating is assigned for complete paralysis of the sciatic nerve; the foot dangles and drops, no active movement possible of muscles below the knee, flexion of knee weakened or (very rarely) lost. 38 C.F.R. § 4.124(a), Diagnostic Code 8520. The rating schedule provides guidance for rating neurologic disabilities. With regard to rating neurologic disabilities, cranial or peripheral neuritis, characterized by loss of reflexes, muscle atrophy, sensory disturbances, and constant pain, at times excruciating, is to be rated on the scale provided for injury of the nerve involved, with a maximum equal to severe, incomplete paralysis. 38 C.F.R. § 4.123. The maximum rating to be assigned for neuritis not characterized by organic changes will be that for moderate incomplete paralysis, or with sciatic nerve involvement, for moderately severe incomplete paralysis. Id. Cranial or peripheral neuralgia, usually characterized by a dull and intermittent pain, of typical distribution so as to identify the nerve, is to be rated on the same scale, with a maximum equal to moderate incomplete paralysis. 38 C.F.R. § 4.124. The term “incomplete paralysis” indicates a degree of lost or impaired function substantially less than the type pictured for complete paralysis given with each nerve, whether due to varied level of the nerve lesion or to partial regeneration. When the involvement is wholly sensory, the rating should be for the mild, or at most, the moderate degree. 38 C.F.R. § 4.124a. The words “slight,” “moderate,” and “severe” as used in the various diagnostic codes are not defined in the VA Schedule for Rating Disabilities. 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. It should also be noted that use of terminology such as “severe” by VA examiners and others, although an element of evidence to be considered by the Board, is not dispositive of an issue. All evidence must be evaluated in arriving at a decision regarding an increased rating. 38 C.F.R. §§ 4.2, 4.6. Radiculopathy of the right and left lower extremities The Board has carefully considered the directives of the February 2015 Joint Motion for Partial Remand in which there was a determination that the Board had “inadequate” reasons for denying the Veteran’s increased rating claim for radiculopathy. The Board will now revisit the reasons for which it has determined that a rating of 10 percent is appropriate. In January 2008, the Veteran denied experiencing any radiculopathy symptoms. However, in June 2008, Dr. M.A. diagnosed the Veteran with lumbar radiculopathy resulting from MRI revelations of minimal DJD of the spine. During an August 2011 examination, the Veteran reported radiating pain in her lower extremities measuring from 7 to 10 out of 10 with numbness and weakness. In a September 2011 VA examination of the spine, the Veteran explained that walking would cause pain in her right knee, hip, and foot. The Veteran said that she had pain that was sharp and burning in her right foot. Regarding symptoms of numbness and paresthesias in the legs and feet, the VA examiner specifically determined that these symptoms were unrelated to degenerative arthritis of the spine. The Veteran noted constant sharp and shooting pain of moderate severity that was distributed throughout her low back and into her legs. She also claimed to experience radiating pain into her legs, with both the radiating and shooting pain being worse in the Veteran’s right leg. Physical examination found the Veteran’s reflexes were found to be normal while sensory testing demonstrated a variable decrease in vibration sense and sensation to pain/pinprick and light touch in both lower extremities. Her sensory testing also revealed the presence of bilateral dysesthesias. The Veteran’s motor exams were normal. The Veteran did not have muscle atrophy. The September 2011 VA examiner did not attribute the Veteran’s pain to radiculopathy or any nerve damage related to her service-connected back injury. During her January 17, 2012 treatment at an Ambulatory Care Pain Clinic, the Veteran reported radiating pain at a severity of 7 out of 10 that affected her ability to do household chores or maintain a job. However, it is worth noting that the pain locations described include the head, low back, and “all over.” To this extent, the treatment note does not specifically discuss sciatic nerve pain or radiculopathy symptoms. During a December 2012 VA examination of the Veteran’s thoracolumbar spine, the Veteran had normal reflexes. Sensory exam results were not recorded. The Veteran did not have muscle atrophy. Her straight leg raising test was negative. The Veteran did not have radicular pain or symptoms due to radiculopathy. Furthermore, the examiner reported that the Veteran is “not affected” by radiculopathy on either side. During a December 2015 VA examination of the Veteran’s peripheral nerves, the Veteran stated that she had pain in the anterior and posterior aspect of both lower extremities and that the pain had worsened since her last VA examination. She also reported moderate constant pain in both lower extremities. She did not have intermittent pain, paresthesias, or numbness. She stated that she experienced cramping in both legs and difficulty using the bathroom due to problems sitting on the commode. In that examination, the Veteran’s reflexes were found to be hypoactive. Her sensory exams were normal. The Veteran did not have any muscle atrophy. The VA examiner noted that the Veteran had incomplete paralysis of the sciatic nerve of moderate severity for both lower extremities. The VA examiner also noted that the Veteran had mild pain with prolonged walking or standing that impacted her ability to do work. The Veteran also underwent an examination of her back condition in December 2015. The VA examiner reported normal findings for muscle strength, reflex, and sensory testing. The Veteran’s straight leg raising test was positive, but the VA examiner reported that the Veteran did not have radicular pain or any other signs or symptoms due to radiculopathy. No other neurologic abnormalities were noted. It is also significant that the Veteran’s back examination did not reveal any abnormal or hypoactive deep tendon reflexes. Most recently, in July 2018, the Veteran underwent another examination of her peripheral nerves. The Veteran reported falling, having weak legs, and experiencing burning and tingling in her feet. She claimed that the pain shoots up the back of her leg and is exacerbated by standing. The Veteran had normal reflex exams and normal sensory exams. The Veteran did not have muscle atrophy. Whereas the Veteran did not have intermittent pain, paresthesias, or numbness in her December 2015 examination, in July 2018, the Veteran had moderate intermittent pain and paresthesias. Whereas in December 2015, the Veteran had moderate constant pain, in July 2018, she had no constant pain. The July 2018 VA examiner also determined that the severity of the Veteran’s sciatic nerve paralysis was “mild” for both lower extremities. Based on the foregoing medical evidence pertaining to the severity of the Veteran’s radiculopathy, the Board finds that a higher rating for radiculopathy of the right and/or left lower extremities is not warranted. Aside from subjective statements regarding her pain, objective medical examinations do not demonstrate that the criteria for a higher rating are met. The Veteran has regularly complained of chronic pain throughout her body. However, the severity of her sciatic nerve paralysis, in particular, does not qualify as “moderate” based upon an overview of objective evidence. Lower extremity strength and muscle tone have consistently been found to be normal. Sensation testing in the September 2011 VA examination report demonstrated a variable decrease in vibration sense and sensation to pain/pinprick and light touch in both lower extremities. However, sensation testing during the December 2015 and July 2018 VA examinations were found to be normal. Reflexes were found to be normal in the September 2011 and July 2018 VA examinations but found to be hypoactive in December 2015. The objective evidence has not shown, and the Veteran has not alleged, muscle atrophy, loss of reflexes or loss of sensation. The Board has considered whether staged ratings under Hart, supra, are appropriate for the Veteran’s service-connected right and left lower extremity radiculopathy; however, the Board finds that her symptomatology does not adequately approximate an increased rating of “moderate” during the claim period. Therefore, assigning staged rating for such disability is not warranted. The Board has carefully reviewed and considered the Veteran’s statements regarding the severity of her right and left lower extremity radiculopathy. The Board acknowledges that the Veteran, in advancing her appeal, believes that the disability on appeal has been more severe than the assigned disability rating reflects. Moreover, the Veteran is competent to report observable symptoms. Layno v. Brown, 6 Vet. App. 465 (1994). In this case, however, the competent medical evidence offering detailed specific specialized determinations pertinent to the rating criteria are the most probative evidence with regard to evaluating the pertinent symptoms for the disability on appeal; the medical evidence also largely contemplates the Veteran’s descriptions of symptoms. The lay testimony has been considered together with the probative medical evidence clinically evaluating the severity of the pertinent disability symptoms. 2. Other considerations The issue of extra-schedular ratings was raised in the March 2015 Joint Motion for Partial Remand. The Board has contemplated whether the case should be referred for extra-schedular consideration. An extra-schedular disability rating is warranted if the case presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization that application of the regular schedular standards would be impracticable. 38 C.F.R. § 3.321(b)(1). In Thun v. Peake, 22 Vet. App. 111, 115-16 (2008), the Court explained how the provisions of 38 C.F.R. § 3.321 are applied. Specifically, the Court stated that the determination of whether a claimant is entitled to an extra-schedular rating under § 3.321 is a three-step inquiry. First, it must be determined whether the evidence presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. In this regard, the Court indicated that there must be a comparison between the level of severity and symptomatology of the claimant’s service-connected disability with the established criteria found in the rating schedule for that disability. Under the approach prescribed by VA, if the criteria reasonably describe the claimant’s disability level and symptomatology, then the claimant’s disability picture is contemplated by the rating schedule, the assigned schedular evaluation is, therefore, adequate, and no referral is required. Second, if the schedular evaluation does not contemplate the claimant’s level of disability and symptomatology and is found inadequate, the RO or Board must determine whether the claimant’s exceptional disability picture exhibits other related factors such as “marked interference with employment” and “frequent periods of hospitalization.” Third, when an analysis of the first two steps reveals that the rating schedule is inadequate to evaluate a claimant’s disability picture and that picture has attendant thereto related factors such as marked interference with employment or frequent periods of hospitalization, then the case must be referred to the Under Secretary for Benefits or the Director of the Compensation Service to determine whether, to accord justice, the Veteran’s disability picture requires the assignment of an extra-schedular rating. Id. The Board has carefully compared the level of severity and symptomatology of the Veteran’s service-connected right and left lower extremity radiculopathy with the established criteria found in the rating schedule. The Board finds that the Veteran’s symptomatology is fully addressed by the rating criteria under which such disability is rated. The rating criteria under Diagnostic Code 8520 contemplate the Veteran’s symptoms, to include lower extremity pain, burning, and tingling. The rating criteria also contemplate the impact of the Veteran’s symptoms. Moreover, there are no additional symptoms of her right and left lower extremity radiculopathy that are not addressed by the rating schedule. Therefore, the Board finds that the rating criteria reasonably describe the Veteran’s disability level and symptomatology of his service-connected disabilities. As such, the Board finds that the rating schedule is adequate to evaluate the Veteran’s disability picture for each disability. Therefore, the Board need not proceed to consider the second factor, viz., whether there are attendant thereto related factors such as marked interference with employment or frequent periods of hospitalization. Consequently, the Board concludes that referral of this case for consideration of an extra-schedular rating is not warranted Id.; Bagwell v. Brown, 9 Vet. App. 337, 338-39 (1996); Floyd v. Brown, 9 Vet. App. 88, 96 (1996). The Board notes that, pursuant to Johnson v. McDonald, 762 F.3d 1362 (Fed. Cir. 2014), a Veteran may be awarded an extra-schedular rating based upon the combined effect of multiple conditions in an exceptional circumstance where evaluation of the individual conditions fails to capture all the symptoms associated with service-connected disability experienced. However, on December 8, 2017, VA issued a Final Rule amending 38 C.F.R. § 3.321(b)(1), effective January 8, 2018, to clarify that extraschedular evaluation is to be applied in an individual service-connected disability when the disability is so exceptional or unusual that it makes application of the regular rating schedule impractical. The Board has determined that this is not an exceptional circumstance in which extra-schedular consideration may be required to compensate the Veteran for disability that can be attributed only to the combined effect of multiple conditions. Furthermore, there is no opinion of record that indicates that the Veteran’s service-connected right and left lower extremities render here unemployable. The Board notes that its June 2018 decision awarded entitlement to a total rating based on individual unemployability due to service-connected disabilities (TDIU) and that was implemented by the AOJ in a June 2018 rating decision. Moreover, a November 2015 letter from the Office of Personnel Management indicates that the Veteran was found to be too disabled to work due to posttraumatic stress disorder, major depressive disorder and anxiety only. As such, the Board finds that a claim for a TDIU is not raised in connection with the instant appeal. See Rice v. Shinseki, 22 Vet. App. 447 (2009). Neither the Veteran nor her representative has raised any other issues, nor have any other issues been reasonably raised by the record. See Doucette v. Shulkin, 28 Vet. App. 366 (2017) (confirming that the Board is not required to address issues unless they are specifically raised by the claimant or reasonably raised by the evidence of record). For the foregoing reasons, the Board finds that no higher or separate rating is warranted for the claim of entitlement to an increased rating for right and/or left lower extremity radiculopathy. In reaching this conclusion, the Board has considered the applicability of the benefit-of-the-doubt doctrine. However, as the preponderance of the evidence is against a higher or separate rating, that doctrine is not applicable. See 38 U.S.C. § 5107(b); 38 C.F.R. §§ 3.102, 4.3; Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). KRISTY L. ZADORA Acting Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD F. Lanton, Associate Counsel