Citation Nr: 18152460 Decision Date: 11/23/18 Archive Date: 11/21/18 DOCKET NO. 13-14 890 DATE: November 23, 2018 ORDER Entitlement to an initial rating in excess of 30 percent for residuals of a pulmonary mycobacterium tuberculosis infection (claimed as tuberculosis), with residual apical scarring and obstructive pulmonary disease (to include emphysema and bronchiectasis), is denied. FINDINGS OF FACT 1. Affording the Veteran with the benefit of the doubt, Bronchiectasis is the Veteran’s predominant disability. 2. The evidence does not indicate that the Veteran has experienced incapacitating episodes of infection of at least four to six weeks total duration per year, or; a near constant cough with purulent sputum associated with anorexia, weight loss, and frank hemoptysis, requiring almost continuous antibiotic usage, during the period on appeal. CONCLUSION OF LAW The criteria for an initial rating in excess of 30 percent for a pulmonary mycobacterium tuberculosis infection (claimed as tuberculosis), with residual apical scarring and obstructive pulmonary disease (to include emphysema and bronchiectasis) have not been met. 38 U.S.C. § 1155; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.10, 4.96, 4.97. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from June 1973 to September 1980. This matter is before the Board of Veterans’ Appeals (Board) on appeal of an April 2011 rating decision and a March 2013 rating decision. This appeal returns to the Board following a June 2018 Joint Motion for Remand. Entitlement to an initial rating in excess of 30 percent for residuals of a pulmonary mycobacterium tuberculosis infection, with residual apical scarring and obstructive pulmonary disease (to include emphysema and bronchiectasis), is denied. I. Legal Criteria Disability evaluations are determined by the application of a schedule of ratings that are based on average impairment of earning capacity. See 38 U.S.C. § 1155; Part 4. Separate diagnostic codes identify the various disabilities, and disabilities must be reviewed in relation to their history. See 38 C.F.R. § 4.1. Pertinent general policy considerations include: interpreting examination reports 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, resolving any reasonable doubt regarding the degree of disability in favor of the claimant, evaluating functional impairment on the basis of lack of usefulness, and evaluating the effects of the disability upon the veteran’s ordinary activity. See 38 C.F.R. §§ 4.2, 4.3, 4.10; Schafrath v. Derwinski, 1 Vet. App. 589 (1991). This analysis is undertaken with consideration of the possibility that different ratings may be warranted for different periods. See Hart v. Mansfield, 21 Vet. App. 505 (2007). Further, “[w]here there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned.” See 38 C.F.R. § 4.7. The evaluation of the same disability under various diagnoses, known as pyramiding, is to be avoided. See 38 C.F.R. § 4.14. The Board has the authority to consider the weight and probity of evidence in the light of its own inherent characteristics and its relationship to other items of evidence. See Madden v. Gober, 125 F.3d 1477, 1481 (Fed. Cir. 1997). In evaluating the probative value of competent medical evidence, the Court has stated that the probative value of a medical opinion is based on the medical expert’s personal examination of the patient, the physician’s knowledge and skill in analyzing the data, and the medical conclusion that the physician reaches. Further, the credibility and weight attached to these opinions are within the province of the adjudicator. See Guerrieri v. Brown, 4 Vet. App. 467, 470-71 (1993). As such, the Board may appropriately favor the opinion of one competent medical authority over another. See Owens v. Brown, 7 Vet. App. 429, 433 (1995); see also Wensch v. Principi, 15 Vet. App. 362, 367 (2001). In this case, the Veteran has been diagnosed with several co-existing respiratory conditions. The rating of the Veteran’s respiratory conditions is governed by 38 C.F.R. § 4.96(a), which states that “[r]atings under diagnostic codes 6600 through 6817 and 6822 through 6847 will not be combined with each other. Where there is lung or pleural involvement, ratings under diagnostic codes 6819 and 6820 will not be combined with each other or with diagnostic codes 6600 through 6817 or 6822 through 6847. A single rating will be assigned under the diagnostic code which reflects the predominant disability with elevation to the next higher evaluation where the severity of the overall disability warrants such elevation.” Respiratory disorders are rated under 38 C.F.R. § 4.97. Diseases of the lung and pleura (tuberculosis) are rated under different criteria according to when the rating was assigned. This section distinguishes between ratings for pulmonary tuberculosis rated prior to and on August 19, 1968 (Diagnostic Codes 6701 through 6724), and rated after August 19, 1968 (Diagnostic Codes 6730 through 6732). The Veteran was awarded compensation for residuals of pulmonary mycobacterium tuberculosis after August 19, 1968; therefore Diagnostic Codes 6730 through 6732 apply. Chronic, inactive, pulmonary tuberculosis is rated under Diagnostic Code 6731, and directs that the disability be rated based on residuals, such as interstitial lung disease, restrictive lung disease, or, when obstructive lung disease is the major residual, as chronic bronchitis under Diagnostic Code 6600. Under Diagnostic Code 6600, a 30 percent evaluation is assigned for FEV-1 of 56 to 70 percent predicted, or; FEV-1/FVC of 56 to 70 percent, or; DLCO (SB) 56 to 65 percent predicted. A 60 percent evaluation is assigned for FEV-1 of 40 to 55 percent predicted, or; FEV-1/FVC of 40 to 55 percent, or; DLCO (SB) of 40 to 55 percent predicted, or; maximum oxygen consumption of 15 to 20 ml/kg/min (with cardiorespiratory limit). A 100 percent evaluation is assigned for FEV-1 less than 40 percent of predicted value, or; FEV-1/FVC less than 40 percent, or; DCLO (SB) less than 40-percent predicted, or; maximum exercise capacity less than 15 ml/kg/min oxygen consumption (with cardiac or respiratory limitation), or; cor pulmonale (right heart failure), or; right ventricular hypertrophy, or; pulmonary hypertension (shown by Echo or cardiac catheterization), or; episode(s) of acute respiratory failure, or; when the veteran requires outpatient oxygen therapy. Bronchiectasis is rated under Diagnostic Code 6601. A 30 percent evaluation is assigned for incapacitating episodes of infection of two to four weeks total duration per year, or; a daily productive cough with sputum that is at times purulent or blood-tinged and that requires prolonged (lasting four to six weeks) antibiotic usage more than twice per year. A 60 percent evaluation is assigned for incapacitating episodes of infection of four to six weeks total duration per year, or; near constant findings of cough with purulent sputum associated with anorexia, weight loss, and frank hemoptysis and requiring antibiotic usage almost continuously. A 100 percent evaluation is assigned for incapacitating episodes of infection lasting at least 6 weeks total duration per year. See 38 C.F.R. § 4.97. A note following Diagnostic Code 6601 indicates that an incapacitating episode is one that requires bedrest and treatment by a physician. Bronchiectasis may alternately be rated according to pulmonary impairment under Diagnostic Code 6600. See 38 C.F.R. § 4.97. Diagnostic Code 6603 provides the rating criteria for pulmonary emphysema. A 60 percent rating is assigned for FEV-1 of 40- to 55-percent predicted, or; FEV-1/FVC of 40 to 55 percent, or; DLCO (SB) of 40- to 55-percent predicted, or; maximum oxygen consumption of 15 to 20 ml/kg/min (with cardiorespiratory limit). A 100 percent rating is assigned for FEV-1 less than 40 percent of predicted value, or; FEV-1/FVC less than 40 percent, or; Diffusion Capacity of the Lung for Carbon Monoxide by the Single Breath Method (DLCO (SB)) less than 40-percent predicted, or; maximum exercise capacity less than 15 ml/kg/min oxygen consumption (with cardiac or respiratory limitation), or; cor pulmonale (right heart failure), or; right ventricular hypertrophy, or; pulmonary hypertension (shown by Echo or cardiac catheterization), or; episode(s) of acute respiratory failure, or; when the veteran requires outpatient oxygen therapy. Interstitial Lung Disease is rated under Diagnostic Codes 6825 through 6833. A 30 percent rating is warranted if the FVC is 65 to 74 percent of predicted value or the DLCO (SB) is 56 to 65 percent of predicted value. A 60 percent rating is warranted where the FVC is 50 to 64 percent of predicted value; DLCO (SB) is 40 to 55 percent predicted value; or maximum exercise capacity is 15 to 20 ml/kg in oxygen consumption with cardiorespiratory limitation. A 100 percent rating is warranted if the FVC is less than 50 percent of predicted value; DLCO (SB) is less than 40 percent predicted value; maximum exercise capacity is less than 15 ml/kg in oxygen consumption with cardiorespiratory limitation or; cor pulmonale or pulmonary hypertension; or when the veteran requires outpatient oxygen therapy. Restrictive Lung Disease is rated under Diagnostic Codes 6840 through 6845. A 30 percent rating requires FEV-1 of 56 to 70 percent predicted, or; FEV-1/FVC of 56 to 70 percent, or; DLCO (SB) of 56 to 65 percent predicted. A 60 percent rating requires FEV-1 of 40 to 55 percent predicted, or; FEV-1/FVC of 40 to 55 percent, or; DLCO (SB) of 40 to 55 percent predicted, or; maximum oxygen consumption of 15 to 20 ml/kg/min (with cardiorespiratory limit). A 100 percent rating requires FEV-1 less than 40 percent predicted, or; FEV-1/FVC less than 40 percent, or; DLCO (SB) less than 40 percent predicted, or; maximum exercise capacity less than 15 ml/kg/min oxygen consumption (with cardiac or cardiorespiratory limitation), or; cor pulmonale (right heart failure), or; right ventricular hypertrophy, or; pulmonary hypertension (shown by Echo or cardiac catheterization), or; episode(s) of acute respiratory failure, or; when the veteran requires outpatient oxygen therapy. Pulmonary function tests (PFTs) are required to evaluate a disability under Diagnostic Codes 6600, 6603, 6825 through 6833, and 6840 through 6845, unless: (i) the results of a maximum exercise capacity test are of record and are 20 ml/kg/min or less, (ii) pulmonary hypertension, cor pulmonale, or right ventricular hypertrophy has been diagnosed, (iii) there have been one or more episodes of acute respiratory failure, or (iv) outpatient oxygen therapy is required. See 38 C.F.R. § 4.96(d). When evaluating a disability based on PFTs, post-bronchodilator results are used, unless the post-bronchodilator results were poorer than the pre-bronchodilator results. In those cases, the pre-bronchodilator results are used to determine the disability rating. Id. at (d)(5). In instances where the Veteran’s post-bronchodilator values were “poorer” than the pre-bronchodilator results, the Board will add “(pre-bronchodilator)” next to the PFT result to indicate that it has used the pre-bronchodilator value in accordance with 38 C.F.R. § 4.96(d)(5). When there is a disparity between the results of different PFTs, so that the level of evaluation would differ depending on which result is used, the test result that the examiner states most accurately reflects the level of disability is used to evaluate for rating purposes. Id. at (d)(6). II. Facts Turning to the facts of the case, a May 2010 private treatment record indicates that the Veteran’s lungs appeared “emphysematous,” and that he recorded a “[n]egative exam for air-space pneumonia with [chronic obstructive pulmonary disease (COPD)] and old scarring.” A separate private treatment record recorded that same month notes the Veteran as suffering from “weeks worth of productive cough[.] An October 2010 VA treatment record notes that the Veteran denied “a chronic cough.” A November 2010 VA treatment record notes that the Veteran underwent an x-ray examination in October 2010 that “showed some granulomatous scarring, but [was] otherwise unremarkable.” The record also notes that the Veteran suffered from “fairly significant emphysema.” During an April 2011 VA examination to determine the severity of the Veteran’s respiratory disability, the Veteran recorded the following PFT results: an FEV-1 of 83 percent, a FVC of 90 percent (pre-bronchodilator), a FEV-1/FVC of 94 percent, and a DLCO of 88 percent. The corresponding examination report notes a diagnosis of obstructive pulmonary disease (not meeting the standard criteria for COPD) and “residual[s] of active pulmonary mycobacterium tuberculosis infection,” resulting in a restrictive respiratory condition. A July 2012 VA treatment record indicates that the Veteran denied cough or wheezing. A December 2012 VA treatment record indicates that the Veteran denied cough, sputum, and shortness of breath on exertion. The April 2011 VA examination report, citing October 2010 imaging, notes the Veteran suffering from “severe pulmonary emphysema[.]” Diagnostic and clinical testing did not reveal “focal consolidation, bronchiectasis, or evidence of air trapping,” but did warrant a diagnosis of “Obstructive Pulmonary Disease (not meeting standard PFT criteria for Chronic Obstructive Pulmonary Disease)[.]” A June 2012 VA treatment record notes that the Veteran suffered from “[h]yperinflated lungs consistent with underlying chronic obstructive pulmonary disease.” A sperate treatment record recorded that same month indicates that the Veteran reported bronchitis and “some wheezing and cough . . . possible mild COPD exacerbation.” A December 2012 VA treatment record notes that the Veteran did not display “[shortness of breath (SOB)] during exertion, no cough or sputum or hemoptysis but he has SOB at night when he wakes up to urinate.” Several March 2013 VA treatment records indicates that the Veteran denied cough or shortness of breath. An August 2013 VA treatment record notes the Veteran as “breathing well, denies SOB.” In November 2013, the Veteran reported an increased cough. The VA treatment record also described the Veteran as suffering from significant change in sputum, and states that he was treated as having “tracheobronchitis.” Treatment records from that month indicate that the Veteran suffered from a cough with purulent sputum for approximately 3 weeks. Near the end of November 2013, the Veteran reported that he was “breathing well, denies SOB.” A March 2014 VA treatment record notes that the Veteran reported that he was “breathing well, denies SOB.” An August 2014 private medical opinion letter notes that April 2014 VA imaging of the Veteran’s lungs revealed “bilateral apical scarring with calcified nodules in the left upper lobe and the superior segment of the [left lower lobe (LLL)] (the regions which were abnormal in 1978 following his acute tuberculosis),” as well as “bronchiectasis limited to the superior segment of the left lower lobe and minimal emphysema which is most pronounced adjacent to the bronchiectasis in the superior segment of the LLL. There was minimal emphysema in other areas of the lung.” The author of the private medical opinion letter opined that “findings of ‘severe pulmonary emphysema’, and ‘hyperinflated lung consistent with underlying chronic obstructive lung disease’ were not substantiated by the chest CT performed in April 2014. Because emphysema does not resolve, the chest X-ray readings did not accurately reflect the pulmonary anatomy and I concluded that the more sensitive and specific CT scan did not show diffuse or severe emphysema. The CT scan did show chronic changes including scarring, calcified nodules, and localized bronchiectasis[.] . . . The spirometry is also relevant because there was no significant progression in his mild obstructive defect[.]” A November 2014 VA treatment record indicates that the Veteran suffered from cough with minimal production for “4-5 days” during the beginning of that month. Contemporaneous imaging of the Veteran’s lungs revealed “[h]yperinflation /emphysema appearance throughout the lung fields.” A May 2015 private treatment record indicates that the Veteran was treated for “weakness, cough, [and] yellow-green sputum production,” that began the week prior to his visit to the medical facility listed in the treatment record. He was diagnosed with acute COPD exacerbation and acute pneumonia by clinical history. The Veteran was discharged with medication to treat his respiratory condition. VA treatment records from that month indicate that the Veteran continued to experience congestion and coughing. A June 2015 VA examination report indicates that the Veteran suffered from a history of COPD and intermittent bronchitis. The Veteran reported that he suffered from “bronchitis about 3-4 times a year despite the time of year . . . usually treated with a course of antibiotics,” but added that “he really doesn't feel SOB. He reports that he will note wheezing at times and occasional sputum production that is either white or green. No oxygen or long[-]term antibiotics.” The Veteran recorded the following PFT results: an FEV-1 of 85 percent, a FVC of 93 percent, a FEV-1/FVC of 71 percent, and a DLCO of 57 percent, with the Veteran’s FEV-1 most accurately reflecting his level of disability. The corresponding examination report notes that the Veteran was prescribed “a one time course of antibiotics” for bronchitis, as well as an inhaler. A July 2015 VA treatment record notes that the Veteran denied “any chronic shortness of breath, chronic cough or history of hemoptysis,” though it appears that the Veteran suffered from a cough as a result of a cold earlier that same month. In a November 2015 notice of disagreement, the Veteran’s representative stated that the Veteran lost eight weeks from work that year and experienced “three-to-four incapacitating episodes per year, each lasting one-to-two weeks.” In an April 2016 letter, the Veteran described daily coughing with sputum and approximately three to four (or more) infections per year that last roughly one to three weeks. The Veteran also stated that he had “been off work for at least 4 weeks[,]” and that he used an inhaler on a daily basis. The Veteran added that he was “out sick five times in 2014, more times in 2015,” and that he “went to the VA Clinic [] twice in March 2015.” An October 2016 VA examination report indicates that the Veteran suffers from inactive pulmonary tuberculosis, resulting in emphysema and bronchiectasis. Emphysema was noted as the predominant respiratory condition. The Veteran recorded the following PFT results: an FEV-1 of 64 percent (pre-bronchodilator), a FVC of 74 percent (pre-bronchodilator), a FEV-1/FVC of 99 percent, and a DLCO of 57 percent, with the Veteran’s DLCO most accurately reflecting his level of disability. The corresponding examination report notes that the Veteran used an inhaler on an intermittent basis, and had four or more acute infections that required a prolonged course of antibiotics at least twice in the 12 months preceding the examination. The examination report also states that the Veteran did not experience anorexia, weight loss, frank hemoptysis, or incapacitating episodes due to his respiratory disability. The Veteran did suffer from an intermittent productive cough. [The Board notes that the examination report defined an “incapacitating episode” as “a period of acute symptoms severe enough to require prescribed bed rest and treatment by a physician.” The propriety of this definition is discussed below.] An October 2016 VA treatment record notes that the Veteran denied productive cough and shortness of breath. III. Analysis The Veteran’s respiratory disability may be evaluated under several diagnostic codes. The Board declines to provide overlapping ratings of the Veteran’s respiratory disability under various diagnoses. The Board may not assign combined ratings for disabilities rated under 6600 through 6817 and 6822 through 6847 (which govern the Veteran’s bronchitis, bronchiectasis, emphysema, COPD, and inactive tuberculosis as rated under the General Rating Formula for Intestinal Lung Disease and the General Rating Formula for Restrictive Lung Disease), the Board will assign a rating “under the diagnostic code which reflects the predominant disability with elevation to the next higher evaluation where the severity of the overall disability warrants such elevation.” 38 C.F.R. § 4.96. An analysis of the rules governing the Veteran’s respiratory disability reveals that the Veteran has not met the criteria for a rating in excess of 30 percent during the period on appeal. See Hart, 21 Vet. App. at 509-510. The Predominant Disability The Veteran’s respiratory disability is currently rated under Diagnostic Code 6731-6601. Hyphenated diagnostic codes are used when a rating under one diagnostic code requires use of an additional diagnostic code to identify the basis for the rating assigned. The additional code is shown after the hyphen. See 38 C.F.R. § 4.27. At issue is the nature of the Veteran’s predominant disability under 38 C.F.R. § 4.96. In this case, the medical evidence of record describes the Veteran as suffering from numerous respiratory conditions. The Board notes that a November 2010 VA treatment record describes the Veteran as suffering from “fairly significant emphysema.” The April 2011 VA examination report notes the Veteran suffering from “severe pulmonary emphysema[.]” The October 2016 VA examination report describes emphysema as the Veteran’s predominant respiratory condition. Conversely, the author of the August 2014 private medical opinion letter opined that the Veteran did not suffer from “diffuse or severe emphysema.” Emphysema is rated under Diagnostic Code 6603. The PFTs recorded by the Veteran during the period on appeal indicate that the Veteran is entitled to a rating of 30 percent, and no higher, under this code. A May 2010 private treatment record describes the Veteran as suffering from COPD, as do many other treatment records. On the contrary, the April 2011 VA examination report notes a diagnosis of “Obstructive Pulmonary Disease (not meeting standard PFT criteria for Chronic Obstructive Pulmonary Disease),” and the author of the August 2014 private medical opinion letter opined that a finding of “hyperinflated lung consistent with underlying chronic obstructive lung disease” was not substantiated by imaging performed in April 2014. The October 2016 VA examination report did not describe the Veteran as suffering from symptoms of COPD. COPD is rated under Diagnostic Code 6604. The PFTs recorded by the Veteran during the period on appeal indicate that the Veteran is entitled to a rating of 30 percent, and no higher, under this code. [The Board notes that Diagnostic Code 6731 allows for a rating under the criteria for interstitial lung disease, restrictive lung disease, or, when obstructive lung disease is the major residual, chronic bronchitis. It appears that the PFTs recorded by the Veteran during the period on appeal do not indicate that the Veteran is entitled to a rating in excess of 30 percent under the criteria for interstitial lung disease (Diagnostic Codes 6825-6833), restrictive lung disease (Diagnostic Codes 6840-6845), or chronic bronchitis (Diagnostic Code 6600).] As for the Veteran’s bronchiectasis, a November 2010 VA treatment record notes that the Veteran underwent an x-ray examination in October 2010 that “showed some granulomatous scarring, but [was] otherwise unremarkable.” Diagnostic and clinical testing performed as part of the April 2011 VA examination did not reveal bronchiectasis. But the author of the August 2014 private medical opinion letter opined that imaging of the Veteran’s lungs showed “chronic changes including scarring, calcified nodules, and localized bronchiectasis[.]” The Veteran’s treatment records, including the October 2016 VA examination report, indicate that he suffered from numerous acute infections due to his bronchiectasis. The Veteran argues that bronchiectasis is his predominant disability, and that he is entitled to a rating in excess of 30 percent under Diagnostic Code 6601. Moreover, the Veteran’s lay statements indicate that he has lost work due to infections caused by his bronchiectasis. Given the Veteran’s lay statements, frequency and symptoms of his acute infections, treatment records (including the August 2014 private medical opinion letter), and affording the Veteran the benefit of the doubt, the Board finds that bronchiectasis is the Veteran’s predominant disability under 38 C.F.R. § 4.96. The Propriety of an Increased Rating Under Diagnostic Code 6601 In order to obtain an increased rating under Diagnostic Code 6601, the evidence must demonstrate that the Veteran has suffered from “incapacitating episodes of infection of at least six weeks total duration per year,” as required for a 100 percent rating, or “incapacitating episodes of infection of four to six weeks total duration per year, or; near constant findings of cough with purulent sputum associated with anorexia, weight loss, and frank hemoptysis and requiring antibiotic usage almost continuously,” as required for a 60 percent rating. 38 C.F.R. § 4.97, Diagnostic Code 6601. The medical evidence of record indicates that the Veteran has not suffered from near constant cough with purulent sputum associated with anorexia, weight loss, and frank hemoptysis, requiring almost continuous antibiotic usage, during the period on appeal. At issue is whether the Veteran suffered from incapacitating episodes of infection of at least four to six weeks total duration during the period on appeal. As stated, Diagnostic Code 6601 defines an incapacitating episode as “one that requires bedrest and treatment by a physician.” 38 C.F.R. § 4.97. The interpretation of a regulation begins “with the plain language of the regulation.” Correia v. McDonald, 28 Vet. App. 158, 164 (2016) (citing Tropf v. Nicholson, 20 Vet. App. 317, 320 (2006) for the proposition that “if the meaning of the regulation is clear from its language, then that is ‘the end of the matter’”). The words analyzed should be given “their ‘ordinary, contemporary, common meaning,’ absent an indication Congress intended them to bear some different import.” Williams v. Taylor, 529 U.S. 420, 431, 120 S. Ct. 1479, 146 L. Ed. 2d 435 (2000) (quoting Walters v. Metropolitan Ed. Enterprises, Inc., 519 U.S. 202, 207, 117 S. Ct. 660, 136 L. Ed. 2d 644 (1997)). A regulation should be construed so that “‘no clause, sentence, or word shall be superfluous, void, or insignificant.’” Duncan v. Walker, 533 U.S. 167, 174, 121 S. Ct. 2120, 150 L. Ed. 2d 251 (2001) (quoting Market Co. v. Hoffman, 101 U.S. 112, 115, 25 L. Ed. 782 (1879)). In this case, the plain language of the definition provided for “incapacitating episodes,” as described in Diagnostic Code 6601, indicates that an incapacitating episode is comprised of two components: (1) symptoms of sufficient severity to require “bedrest,” and; (2) symptoms of sufficient severity to require “treatment.” The construction of the sentence indicates that a physician prescribes “bedrest” and provides “treatment.” The use of the conjunctive “and” in the construction of the definition of “incapacitating episodes” indicates that all criteria must be met to establish entitlement[.]” Camacho v. Nicholson, 21 Vet. App. 360, 366 (2007) (citing Watson v. Dep’t of the Navy, 262 F.3d 1292, 1299 (Fed. Cir. 2001)). Diagnostic Code 6601 does not provide a definition for the term “bedrest.” It appears that “bedrest” is an alternative spelling of the term “bed rest.” [The Board notes that “bed rest” is used in the definition of “incapacitating episodes” described in Diagnostic Codes 6510-6514.] Dorland’s Illustrated Medical Dictionary defines “bed rest” as the “confinement of a patient to bed.” Dorland’s Illustrated Medical Dictionary 1629 (32nd ed. 2012). Mosby’s Medical Dictionary defines “bed rest” as “the restriction of a patient to bed for therapeutic reasons for a prescribed period.” Mosby’s Medical Dictionary 191 (9th ed. 2009). Steadman’s Medical Dictionary defines “bed rest” as “maintenance of the recumbent position, in bed, to minimize activity and help recovery from disease; formerly used extensively in treatment of tuberculosis[.]” Steadman’s Medical Dictionary 1556 (27th ed. 2000). The Merriam-Webster’s Collegiate Dictionary defines “bed rest” as the “confinement of a sick person to bed.” Merriam-Webster’s Collegiate Dictionary 109 (11th ed. 2012). The above cited definitions of “bed rest” have a common theme: the confinement of a patient to a bed, ostensibly for treatment. Thus, the use of “bedrest” in the definition of “incapacitating episodes” implies that a veteran must suffer from symptoms that require prescribed confinement to bed and treatment provided by a physician. See Johnson v. Wilkie, No. 16-3808, 2018 U.S. App. Vet. Claims LEXIS 1253, at *16-17 (Vet. App. Sep. 19, 2018) (citing definitions of “characteristic” and “prostrating” found in Webster’s Third New International Dictionary of The English Language as part of a discussion of the plain meaning of 38 C.F.R. § 4.124a, Diagnostic Code 8100). At this point, the Board notes that “[t]he ordinary meaning of a term, however, ‘can be defeated by indications of legislative intent to the contrary or by obvious inferences from the structure and purpose of the statute.’” Correia, 28 Vet. App. at 166 (quoting United States v. Rodgers, 461 U.S. 677, 706, 103 S. Ct. 2132, 76 L. Ed. 2d 236 (1983)). The language contained in Diagnostic Code 6601 stems from 61 Fed. Reg. 46,720, the final rule for what became 38 C.F.R. § 4.97 (Sep. 5, 1996). The Supplementary Information portion of 61 Fed. Reg. 46,720 notes: We proposed criteria for bronchiectasis (DC 6601) that included “severe” hemoptysis, “chronic” antibiotic usage, and “chronic recurrent” pneumonia. One commenter said that the words “severe,” “chronic,” and “chronic recurrent” are not objective and that in fact they are unnecessary. VA agrees. However, simply eliminating those adjectives would not have left appropriate criteria, so we have revised the criteria to make them more objective. We have specified the required duration of incapacitating episodes of infection or frequency of antibiotic usage for each level of severity of bronchiectasis. At the 60- and 30-percent levels, we also provided alternative objective criteria based on such symptoms as cough, purulent sputum, and weight loss. Our change is to clarify the criteria for the evaluation of bronchiectasis. Id. While the Supplementary Information portion of 61 Fed. Reg. 46,720 is not part of the regulation, it does provide clarity as to meaning of “bedrest” as used in the definition of “incapacitating episodes.” The Supplementary Information portion of 61 Fed. Reg. 46,720 suggests that revisions made to Diagnostic Code 6601 were designed to provide “objective” criteria. In fact, “the words ‘severe,’ ‘chronic,’ and ‘chronic recurrent’,” were removed, and Diagnostic Code 6601 was redrafted, to “clarify the criteria for the evaluation of bronchiectasis.” 61 Fed. Reg. 46,720. The Board infers from the Supplementary Information portion of 61 Fed. Reg. 46,720 that Diagnostic Code 6601 is to be read in a manner that provides an objective assessment of the severity of a veteran’s bronchiectasis. See Buczynski v. Shinseki, 24 Vet. App. 221, 223 (2011) (discussing the difference between the objective assessment of a veteran’s disability, as based on the severity of a veteran’s medical symptoms, and the subjective assessment of a veteran’s disability, as based on words that “do not have a precise medical meaning”). The Board does not suggest that subjective, or lay evidence, cannot be used to support a rating under Diagnostic Code 6601, or that the criteria described in Diagnostic Code 6601 render 38 C.F.R. §§ 4.2, 4.3, 4.7, 4.96, or any other provision inapplicable. As Diagnostic Code 6601 was drafted to provide an objective assessment of bronchiectasis, it appears that the word “bedrest” should be read in a manner that fits into the objective criteria described. 38 C.F.R. § 4.97; see Correia, 28 Vet. App. at 166 (citing Holloway v. United States, 526 U.S. 1, 6, 119 S. Ct. 966, 143 L. Ed. 2d 1 (1999) for the proposition that language used in a regulation is considered not only based on the “bare meaning,” but also based on its “placement and purpose in the statutory scheme”). The common meaning of “bedrest,” as described above, provides the requisite objectivity. A nebulous reading of “bedrest” is counter to both the plain language of the regulation and the term’s “purpose in the statutory scheme.” See Holloway, 526 U.S. at 6. Thus, the inquiry before the Board remains whether the Veteran has suffered from symptoms of bronchiectasis that have required prescribed confinement to bed and treatment provided by a physician. The medical evidence of record, including the findings contained in the October 2016 VA examination report, indicate that the Veteran’s bronchiectasis has not produced symptoms of a sufficient severity to require his confinement to bed. The Veteran’s VA treatment records and private treatment records do not note the Veteran as requiring bedrest for his respiratory condition or otherwise state that a medical professional recommended bedrest for his respiratory condition. The Board notes the Veteran’s April 2016 letter, in which he stated that he was “out sick five times in 2014, more times in 2015,” and that he had “been off work for at least 4 weeks[.]” As discussed, the definition of “incapacitating episodes” described in Diagnostic Code 6601 indicates that a veteran must suffer from symptoms that require the veteran’s confinement to bed and treatment by a physician. The Veteran has received treatment for his respiratory disability during the period on appeal, but the Board finds that the Veteran’s descriptions of lost work time do not indicate that he was confined to his bed as a result of his bronchiectasis. To equate reports of lost work time to “bedrest” would render the term “bedrest” superfluous. See Duncan, 533 U.S. at 174. Though the Veteran’s lost periods of work reflect the severity of his disability, they do not indicate that he required bedrest, in addition to treatment by a physician, for at least four to six weeks total duration per year. For example, a May 2015 private treatment record that notes the Veteran as suffering from “weakness, cough, [and] yellow-green sputum production,” indicates that he was discharged with medication to treat his respiratory condition. It appears that the Veteran continued to suffer from these symptoms throughout the month of May 2015. Despite the Veteran’s symptoms, and recorded treatment, the evidence of record does not indicate that he required bedrest for the symptoms he reported in May 2015. It is possible that the Veteran lost work during May 2015, but it does not necessarily follow that the Veteran required bedrest as a result of his bronchiectasis during that month. The Board also notes the Veteran’s November 2015 notice of disagreement, in which the Veteran’s representative stated that the Veteran lost eight weeks of work that year and experienced “three-to-four incapacitating episodes per year, each lasting one-to-two weeks.” As stated, The Board declines to construe periods of lost work as equivalent to “incapacitating episodes.” In assessing the weight of the Veteran’s statement that he suffered “three-to-four incapacitating episodes per year, each lasting one-to-two weeks,” the Board notes that the Veteran is competent to offer lay testimony as to the frequency and severity of the observable symptoms of his respiratory condition. See Layno v. Brown, 6 Vet. App. 465, 469 (1994) (lay evidence competent to establish features or symptoms of injury or illness); Charles v. Principi, 16 Vet. App. 370, 374 (2002) (layperson competent to testify concerning symptoms capable of observation). The Veteran is competent to testify how often he received treatment from a physician, which is readily observable. He is not competent to opine as to whether his condition was an “incapacitating episode,” requiring “bedrest” and treatment by a physician to address an infection. See Grover v. West, 12 Vet. App. 109, 112 (1999). The Board finds the medical evidence more persuasive than the Veteran’s lay statements that discuss “incapacitating episodes,” insofar as the medical evidence of record indicates that the Veteran’s bronchiectasis did not manifest in symptoms that required prescribed confinement to bed and treatment provided by a physician. The Veteran argues that the above discussed definition of “bedrest” imposes a higher standard than required under Diagnostic Code 6601. The Veteran adds that an interpretation of Diagnostic Code 6601 that requires “bedrest” prescribed by a physician is not supported by the plain language of Diagnostic Code 6601, and compares the regulation at issue to 38 C.F.R. § 4.71a, Diagnostic Code 5243 (Intervertebral Disc Syndrome). Diagnostic Code 5243 describes an incapacitating episode as “a period of acute signs and symptoms due to intervertebral disc syndrome that requires bed rest prescribed by a physician and treatment by a physician,” which the Veteran argues is distinct from the definition of “incapacitating episodes” provided in Diagnostic Code 6601. See Jones v. Shinseki, 26 Vet. App. 56, 61 (2012); Buczynski v. Shinseki, 24 Vet. App. 221, 227 (2011); Tropf, 20 Vet. App. at 321 n.1. The Veteran suggests that “bedrest,” as required by the definition of “incapacitating episodes” provided in Diagnostic Code 6601, need not be prescribed by a physician. According to the Veteran, the construction of Diagnostic Code 6601, along with a lack of qualification of the term “bedrest,” implies that the Veteran’s reported infections, requiring a prolonged course of antibiotics lasting four to six weeks, at least twice a year, were of sufficient severity to warrant a 100 percent rating during the period on appeal. See 38 C.F.R. § 4.97, Diagnostic Code 6601. The interpretation of “incapacitating episodes” suggested by the Veteran ignores the plain language of Diagnostic Code 6601 and renders the term “bedrest” superfluous. See Duncan, 533 U.S. at 174. The Board declines to construe Diagnostic Code 6601 in a manner that both requires “bedrest” and allows the term to operate as a stand-in for miscellaneous symptoms, treatments, or other consequences of bronchiectasis. Such an interpretation would defeat the objective standard contemplated by Diagnostic Code 6601 because it would require a determination as to whether the proposed stand-in (i.e., lost periods of work due to periods of infection with prolonged antibiotic usage) is of sufficient severity to satisfy the meaning of “bedrest.” See 38 C.F.R. § 4.97. Moreover, the regulatory history of Diagnostic Code 5243 indicates that its definition of “incapacitating episode” is not so different from the definition contained in Diagnostic Code 6601. The language contained in Diagnostic Code 5243 stems from 62 Fed. Reg. 8,204, which proposed amendments to the criteria used to evaluate intervertebral disc syndrome (IVDS). The proposed rule defined an incapacitating episode as “a period of acute symptoms (orthopedic, neurologic, or both), requiring bed rest and treatment by a physician.” The Supplementary Information portion of 62 Fed. Reg. 8,204 notes: We propose to evaluate intervertebral disc syndromes that are primarily disabling because of periods of acute symptoms that require bed rest according to the cumulative amount of time over the course of a year that the patient is incapacitated, i.e., requires bed rest and treatment by a physician. Id (emphasis added). The language provided in 62 Fed. Reg. 8,204 was updated in 67 Fed. Reg. 54,345. The final rule defined an incapacitating episode as “a period of acute signs and symptoms . . . that requires bed rest prescribed by a physician and treatment by a physician.” The Supplementary Information portion of 67 Fed. Reg. 54,345 notes: [In 62 Fed. Reg. 8,204,] [w]e proposed to define the term ‘incapacitating episode of intervertebral disc syndrome’ to mean a period of acute symptoms (orthopedic, neurologic, or both), requiring bed rest prescribed by a physician and treatment by a physician. Such treatment by a physician would not require a visit to a physician's office or hospital but would include telephone consultation with a physician. One commenter suggested that we revise the definition to require bed rest “prescribed by a physician,” but eliminate the requirement for treatment. A physician prescribing bed rest will ordinarily prescribe treatment, e.g., analgesics, muscle relaxants, or traction, as well. In our view, the requirement for treatment by a physician makes the criteria clearer, more objective, and more likely to promote consistent evaluations. We therefore make no change in response to this comment. However, in order to clarify note (1), we have added “prescribed by a physician” following “bed rest.” Id (emphasis added). In summary, less than a year after the adoption of 38 C.F.R. § 4.97, Diagnostic Code 6601, it was proposed that IVDS be rated based on incapacitating episodes defined as “acute symptoms . . . requiring bed rest and treatment by a physician.” In August 2002, the Supplementary Information portion of 67 Fed. Reg. 54,345 noted that the phrase “requiring bed rest and treatment by a physician” contained in 62 Fed. Reg. 8,204 meant that an “incapacitating episode” required “bed rest prescribed by a physician and treatment by a physician.” The Supplementary Information portion of 67 Fed. Reg. 54,345 also noted that the phrase “prescribed by a physician” was added after the term “bed rest” to clarify the definition. Contrary to the Veteran’s argument, it does not appear that the phrase “prescribed by a physician,” contained in Diagnostic Code 5243, was added to create substantially different criteria than those discussed in the definition of “incapacitating episodes” provided in Diagnostic Code 6601. Rather, the definition contained in 38 C.F.R. § 4.71a, Diagnostic Code 5243, is derivative of the definition(s) provided in 38 C.F.R. § 4.97. [The Board notes that even if Diagnostic Code 6601 may be construed as requiring “bedrest” without prescription by a physician, a lay observer is not competent to opine as to whether such a treat is required. The medical evidence of record, including a medical opinion contained in the October 2016 VA examination report, indicates that the Veteran did not require “bedrest” to treat his bronchiectasis during the period on appeal, let alone for the periods contemplated under Diagnostic Code 6601.] It appears that the Veteran received treatment from a physician for his respiratory disability, but the record does not indicate that he required prescribed bedrest for this disability. Moreover, the PFTs recorded by the Veteran during the period on appeal do not indicate that an alternate rating in excess of 30 percent under Diagnostic Code 6600 is warranted, nor does it appear that the Veteran requires outpatient oxygen therapy, suffers from right heart failure, ventricular hypertrophy, pulmonary hypertension, or acute respiratory failure as a result of his respiratory disability. As such, a rating in excess of 30 percent under Diagnostic Code 6601 is not warranted. The Propriety of an Elevated Evaluation As the Veteran has been diagnosed with several co-existing respiratory disabilities, the Board must discuss whether the Veteran is entitled to the next higher evaluation due to the severity of his overall respiratory disability. 38 C.F.R. § 4.96. The Board will evaluate the Veteran’s coexisting service-connected respiratory conditions under the criteria enumerated in Diagnostic Code 6601. See Urban v. Shulkin, 29 Vet. App. 82 (2017) (finding reasonable VA’s interpretation of § 4.96(a) as referring to the next higher evaluation under the predominant disability Diagnostic Code, and that the criteria in that evaluation level are key to assessing the severity of the overall disability from all respiratory conditions). In order to obtain a 60 percent rating under Diagnostic Code 6601, the next higher rating, the evidence must demonstrate that the Veteran has suffered from “incapacitating episodes of infection of four to six weeks total duration per year, or; near constant findings of cough with purulent sputum associated with anorexia, weight loss, and frank hemoptysis and requiring antibiotic usage almost continuously.” 38 C.F.R. § 4.97, Diagnostic Code 6601. The evidence of record indicates that the Veteran requires inhaled medication to treat his emphysema, and, according to the Veteran, his emphysema renders him unable to walk more than two blocks or climb a single flight of stairs without suffering from shortness of breath. It appears that his use of medication and shortness of breath are not of the severity described at the 60 percent level of Diagnostic Code 6601, which, among other criteria, discusses symptoms that induce incapacitation or symptoms akin to incapacitation. The Veteran’s numerous PFTs suggest that he suffers from symptoms akin to no more than a 30 percent rating under Diagnostic Code 6601. The Veteran’s overall respiratory disability has not produced incapacitating episodes, as defined under Diagnostic Code 6601, and it does not appear that the Veteran’s coexisting respiratory conditions have manifested in symptoms of “near constant findings of cough with purulent sputum associated with anorexia, weight loss, and frank hemoptysis and requiring antibiotic usage almost continuously.” The Board notes the Veterans lost periods of work and visits to medical practitioners, but finds that the preponderance of the medical evidence of record does not suggest that his disability more nearly approximates a rating of 60 percent. As such, an elevated rating of 60 percent is not warranted. Extraschedular Consideration The Board has considered whether the Veteran is entitled to a greater level of compensation on an extraschedular basis. An extraschedular disability rating is warranted based upon a finding that the case presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization that would render impractical the application of the regular schedular standards. See 38 C.F.R. § 3.321 (2018). An exceptional case is said to include such factors as marked interference with employment or frequent periods of hospitalization as to render impracticable the application of the regular schedular standards. See Fanning v. Brown, 4 Vet. App. 225, 229 (1993). Under Thun v. Peake, 22 Vet. App. 111 (2008), there is a three-step inquiry for determining whether a veteran is entitled to an extraschedular rating. First, the Board must determine whether the evidence presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. With respect to the first prong of Thun, the evidence in this case does not describe such an exceptional disability picture that the available schedular evaluation for the Veteran’s service-connected bronchiectasis is inadequate. A comparison between the level of severity and symptomatology of the Veteran’s bronchiectasis with the established criteria indicates that the rating criteria reasonably describe his disability level and symptomatology. The Veteran suffers from shortness of breath and respiratory infections that require treatment with antibiotics. He also uses inhalational medication to treat his respiratory condition. The evidence of record indicates that the Veteran’s symptoms are described by the criteria listed under Diagnostic Code 6601. Those criteria consider antibiotic use, as well as other treatment prescribed by a physician. Moreover, Diagnostic Code 6601 allows for a rating based upon pulmonary impairment (i.e., symptoms related to the Veteran’s shortness of breath). As the Veteran’s respiratory condition does not presents such an exceptional disability picture that the available schedular evaluation is inadequate, referral of this case for extraschedular consideration is not warranted. M. H. HAWLEY Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD B. Moore, Associate Counsel