Citation Nr: 22018343 Decision Date: 03/29/22 Archive Date: 03/28/22 DOCKET NO. 17-48 464 DATE: March 29, 2022 ORDER Prior to February 26, 2018, entitlement to a higher initial rating, increased from 20 percent to 40 percent, but no higher, for intervertebral disc syndrome (IVDS) of the thoracolumbar spine is granted. On and after February 26, 2018, entitlement to a higher initial rating for IVDS of the thoracolumbar spine, evaluated as 40 percent disabling, is denied. On and after September 20, 2017, entitlement to an initial rating in excess of 20 percent for radiculopathy of the sciatic nerve of the left lower extremity is denied. From November 2, 2017, through August 9, 2020, entitlement to a separate rating of 20 percent, but no higher, for radiculopathy of the femoral nerve of the left lower extremity is granted. On and after August 10, 2020, entitlement to a higher initial rating, increased from 20 percent to 30 percent, but no higher, for radiculopathy of the femoral nerve of the left lower extremity is granted. Entitlement to a higher initial rating for radiculopathy of the sciatic nerve of the right lower extremity, rated as 10 percent disabling prior to September 7, 2017; as 60 percent disabling from September 7, 2017, through December 9, 2018; and as 40 percent disabling on and after December 10, 2018, is denied. From December 19, 2016, through October 28, 2017, entitlement to a separate rating of 10 percent, but no higher, for radiculopathy of the femoral nerve of the right lower extremity is granted. From October 29, 2017, through August 9, 2020, entitlement to a separate rating of 20 percent, but no higher, for radiculopathy of the femoral nerve of the right lower extremity is granted. On and after August 10, 2020, entitlement to an initial rating in excess of 30 percent for radiculopathy of the femoral nerve of the right lower extremity is denied. Entitlement to a total disability rating based on individual unemployability due to service-connected disabilities (TDIU) effective December 19, 2016 is granted. FINDINGS OF FACT 1. When considering functional impairment due to factors such as pain, weakness, fatigability, incoordination, pain on movement, flare up, or repetitive use over time, the Veteran's IVDS of the thoracolumbar spine has manifested in forward flexion to 30 degrees or less or favorable ankylosis of the entire thoracolumbar spine; it has not manifested in unfavorable ankylosis of the entire thoracolumbar spine or the functional equivalent thereof or in incapacitating episodes having a total duration of at least six weeks during a 12-month period. 2. On and after September 20, 2017, the Veteran's radiculopathy of the sciatic nerve of the left lower extremity manifests in no more than moderate, incomplete paralysis. 3. From November 2, 2017, through August 9, 2020, the Veteran's radiculopathy of the femoral nerve of the left lower extremity manifested in no more than moderate, incomplete paralysis. 4. On and after August 10, 2020, the Veteran's radiculopathy of the femoral nerve of the left lower extremity manifested in no more than severe, incomplete paralysis. 5. Prior to September 7, 2017, the Veteran's radiculopathy of the right sciatic nerve manifested in no more than mild, incomplete paralysis. 6. From September 7, 2017, through December 9, 2018, the Veteran's radiculopathy of the right sciatic nerve manifested in no more than severe, incomplete paralysis with marked muscle atrophy. 7. On and after December 10, 2018, the Veteran's radiculopathy of the right sciatic nerve has manifested in no more than moderately severe, incomplete paralysis. 8. From December 19, 2016, through October 28, 2017, the Veteran's radiculopathy of the femoral nerve of the right lower extremity manifested in no more than mild, incomplete paralysis. 9. From October 29, 2017, through August 9, 2020, the Veteran's radiculopathy of the femoral nerve of the right lower extremity manifested in no more than moderate, incomplete paralysis. 10. On and after August 10, 2020, the Veteran's radiculopathy of the femoral nerve of the right lower extremity has manifested in no more than severe, incomplete paralysis. 11. Resolving reasonable doubt in his favor, the Veteran's service-connected disabilities have been shown to prevent him from securing and following substantially gainful employment. CONCLUSIONS OF LAW 1. Prior to February 26, 2018, the criteria for entitlement to a higher initial rating, increased from 20 percent to 40 percent, but no higher, for IVDS of the thoracolumbar spine have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.1-4.14, 4.25, 4.27, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5243. 2. On and after February 26, 2018, the criteria for entitlement to a higher initial rating for IVDS of the thoracolumbar spine, evaluated as 40 percent disabling, have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.1-4.14, 4.25, 4.27, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5243. 3. On and after September 20, 2017, the criteria for entitlement to an initial rating in excess of 20 percent for radiculopathy of the sciatic nerve of the left lower extremity have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.123, 4.124, 4.124a, Diagnostic Codes 8520, 8525. 4. From November 2, 2017, through August 9, 2020, the criteria for entitlement to a separate rating of 20 percent, but no higher, for radiculopathy of the femoral nerve of the left lower extremity have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.123, 4.124, 4.124a, Diagnostic Codes 8526. 5. On and after August 10, 2020, the criteria for entitlement to a higher initial rating, increased from 20 percent to 30 percent, but no higher, for radiculopathy of the femoral nerve of the left lower extremity have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.123, 4.124, 4.124a, Diagnostic Codes 8526. 6. The criteria for entitlement to a higher initial rating for radiculopathy of the sciatic nerve of the right lower extremity, rated as 10 percent disabling prior to September 7, 2017; as 60 percent disabling from September 7, 2017, through December 9, 2018; and as 40 percent disabling on and after December 10, 2018, have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.123, 4.124, 4.124a, Diagnostic Codes 8520, 8525. 7. From December 19, 2016, through October 28, 2017, the criteria for entitlement to a separate rating of 10 percent, but no higher, for radiculopathy of the femoral nerve of the right lower extremity have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.123, 4.124, 4.124a, Diagnostic Code 8526. 8. From October 29, 2017, through August 9, 2020, the criteria for entitlement to a separate rating of 20 percent, but no higher, for radiculopathy of the femoral nerve of the right lower extremity, have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.123, 4.124, 4.124a, Diagnostic Code 8526. 9. On and after August 10, 2020, the criteria for entitlement to an initial rating in excess of 30 percent for radiculopathy of the femoral nerve of the right lower extremity have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.123, 4.124, 4.124a, Diagnostic Code 8526. 10. The criteria for entitlement to a total disability rating based on individual unemployability effective December 19, 2016 have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.340, 3.341, 4.15, 4.16, 4.18, 4.25, 4.26. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from October 2001 to July 2006. This matter comes before the Board on appeal from March 2017, December 2017, and April 2019 Regional Office (RO) rating decisions. In February 2020, the Veteran testified at a hearing before the undersigned Veterans Law Judge. Increased Rating Disability ratings are determined by comparing a veteran's symptoms with criteria listed in VA's Schedule for Rating Disabilities, which is based, as far as practically can be determined, on average impairment in earning capacity. 38 U.S.C. § 1155; 38 C.F.R. § Part 4. When there is a question as to which of two ratings to apply, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that rating; otherwise the lower rating shall be assigned. 38 C.F.R. § 4.7. "Staged ratings," or different percentage evaluations for separate periods based on the facts found, may also be awarded. Fenderson v. West, 12 Vet. App. 119, 126-7 (1999); Hart v. Mansfield, 21 Vet. App. 505, 509-10 (2007). The evaluation of the same disability under various diagnoses, known as pyramiding, is generally to be avoided. 38 C.F.R. § 4.14. 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 disabilities is duplicative or overlapping with the symptomatology of the other disability. See Esteban v. Brown, 6 Vet. App. 259, 261- 62 (1994). 1. Prior to February 26, 2018, entitlement to a higher initial rating, increased from 20 percent to 40 percent, but no higher, for IVDS of the thoracolumbar spine is granted. 2. On and after February 26, 2018, entitlement to a higher initial rating for IVDS of the thoracolumbar spine, evaluated as 40 percent disabling, is denied. Evaluation of a service-connected disability involving a joint rated on limitation of motion requires adequate consideration of functional loss due to pain under 38 C.F.R. § 4.40 and functional loss due to weakness, fatigability, incoordination, or pain on movement of a joint under 38 C.F.R. § 4.45. See generally DeLuca v. Brown, 8 Vet. App. 202 (1995). Pain must affect some aspect of "the normal working movements of the body" such as "excursion, strength, speed, coordination, and endurance," in order to constitute functional loss. Mitchell v. Shinseki, 25 Vet. App. 32, 38-43 (2011) (quoting 38 C.F.R. § 4.40). Actually painful, unstable, or malaligned joints due to healed injury are entitled to at least the minimum compensable rating for the joint. 38 C.F.R. § 4.59; Burton v. Shinseki, 25 Vet. App. 1 (2011). Joints are to be tested for pain on both active and passive motion, in weight-bearing and nonweight-bearing, and, if applicable, with the range of the opposite, undamaged joint. Correia v. McDonald, 28 Vet. App. 158, 168 (2016). Estimates of additional functional impairment during flare-ups, if any, are also to be recorded, or an explanation with adequate rationale must be given as to why such estimates are not possible. Sharp v. Shulkin, 29 Vet. App. 26 (2017). The Veteran's back disability is rated pursuant to 38 C.F.R. § 4.71a, Diagnostic Code 5242. This diagnostic code directs that the disability be rated under the General Rating Formula for Diseases and Injuries of the Spine. The General Rating Formula assigns a 10 percent evaluation for forward flexion of the lumbar spine greater than 60 degrees but not greater than 85 degrees; or, combined range of motion greater than 120 degrees but not greater than 235 degrees; or, muscle spasm, guarding, or localized tenderness not resulting in abnormal gait or abnormal spinal contour; or, vertebral body fracture with loss of 50 percent or more of the height. A 20 percent evaluation is warranted for forward flexion greater than 30 degrees but not greater than 60 degrees; or, combined range of motion not greater than 120 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. An evaluation of 40 percent is warranted when there is forward flexion to 30 degrees or less or favorable ankylosis of the entire thoracolumbar spine. An evaluation of 50 or greater requires unfavorable ankylosis of the entire thoracolumbar spine. Unfavorable ankylosis of the entire thoracolumbar spine warrants a 50 percent disability rating. Unfavorable ankylosis of the entire spine warrants a 100 percent disability rating. 38 C.F.R. § 4.71a, Diagnostic Codes 5235-5242. Ankylosis is stiffening or fixation of the joint as the result of a disease process, with fibrous or bony union across the joint. See Dinsay v. Brown, 9 Vet. App. 79, 81 (1996), citing Dorland's Illustrated Medical Dictionary at 86 (27th ed. 1988) (Ankylosis is "immobility and consolidation of a joint due to disease, injury, or surgical procedure."); see also Coyalong v. West, 12 Vet. App. 524, 528 (1999); Lewis v. Derwinski, 3 Vet. App. 259 (1992). Note (5) in Diagnostic Codes 5235-5242 provides that, for VA compensation purposes, unfavorable ankylosis is a condition in which the entire cervical spine, the entire thoracolumbar spine, or the entire spine is fixed in flexion or extension, and the ankylosis results in one or more of the following: difficulty walking because of a limited line of vision; restricted opening of the mouth and chewing; breathing limited to diaphragmatic respiration; gastrointestinal symptoms due to pressure of the costal margin on the abdomen; dyspnea or dysphagia; atlantoaxial or cervical subluxation or dislocation; or neurologic symptoms due to nerve root stretching. Fixation of a spinal segment in neutral position (zero degrees) always represents favorable ankylosis. Note (2) (see also Plate V) explains that, for VA compensation purposes, normal flexion of the thoracolumbar spine is from zero to 90 degrees, extension from 0 to 30 degrees, left and right lateral flexion from zero to 30 degrees, and left and right lateral rotation from zero to 30 degrees. The normal combined range of motion, then, is 240 degrees and refers to the sum of the range of forward flexion, backward extension, left and right lateral flexion, and left and right rotation. Because the General Formula is identical for all Diagnostic Codes pertaining to the spine other than for intervertebral disc syndrome (IVDS), consideration of other relevant diagnostic codes pertaining to the spine is not required. See 38 C.F.R. § 4.71a, Codes 5235, 5236, 5238, 5239, 5240, 5241, 5242; see also Schafrath v. Derwinski, 1 Vet. App. 589, 595 (1991). In the case at hand, the Veteran has also been diagnosed with IVDS. IVDS should be evaluated either under the General Formula or under the Formula for Rating IVDS Based on Incapacitating Episodes, whichever method results in the higher evaluation when all disabilities are combined under § 4.25 (VA's combined ratings table). Therefore, the Board will also determine whether a higher rating is available under 38 C.F.R. § 4.71a, Diagnostic Code 5243, based on incapacitating episodes. Under the Formula for Rating IVDS based on Incapacitating Episodes, a 10 percent disability evaluation is warranted for incapacitating episodes having a total duration of at least one week but less than two weeks during the past 12 months; a 20 percent disability evaluation is warranted for incapacitating episodes having a total duration of at least two weeks but less than four weeks during the past 12 months; a 40 percent disability evaluation is warranted for incapacitating episodes having a total duration of at least four weeks but less than six weeks during the past 12 months; and a 60 percent disability evaluation is warranted for incapacitating episodes having a total duration of at least six weeks during the past 12 months. Note (1) in Code 5243 for IVDS defines an incapacitating episode as a period of acute signs and symptoms due to IVDS requiring bed rest prescribed by a physician and treatment by a physician. "Bed rest" is defined as "confinement of a patient to a bed." Dorland's Illustrated Medical Dictionary, 1617 (32nd ed. 2012). As noted above, the Veteran is currently in receipt of a 20 percent rating for his back disability prior to February 26, 2018, and as 40 percent disabling on and after that date. He has described his limitations with everyday tasks, such as doing laundry, loading and unloading the dishwasher, standing over the sink washing dishes, and doing grocery shopping. (See September 2017 personal statement.) He reported that he has to lay down following these tasks and he has difficulty sleeping because of the pain. (See September 2017 personal statement.) These impairments are corroborated by his mother in a September 2017 statement. With respect to the period prior to February 26, 2018, the Board finds that the Veteran's VA and private medical records indicate a level of impairment that corresponds to the 40 percent rating criteria. That is, the Board finds that the evidence of record indicates a level of impairment of forward flexion to 30 degrees or less. The claims file contains records from the Veteran's private chiropractor reflecting that the Veteran received treatment for an exacerbation of his back condition five days in approximately one week immediately preceding the December 19, 2016, date of claim. (See private chiropractor records dated December 5-12, 2016.) In relevant part, these records note "intense lower back pain with limited mobility," "Active range of motion of lumbar spine is severely limited due to pain," "Severe exacerbation of his chronic lumbar spine injury," "Segmental range of motion abnormalities," "a lot of restrictions in mobility," "a lot of sitting ... seemed to aggravate it somewhat," "Active lumbar range of motion continues to be limited, especially forward flexion." These symptoms lasted several days in a row, and the December 12 record notes "Flareup is improving slowly." Treatment from this chiropractor consisted of: Electrical Muscle Stimulation (EMS), application of moist hot pack during his appointment, chiropractic adjustments, "Mobilization of the thoracic spine," and use of ice packs. An October 2017 disability benefits questionnaire (DBQ) from a private physician notes that the Veteran "can bend forward to touch knees with pain & wincing," but it does not provide a range of flexion in degrees. It notes functional limitation on flare-up in terms of limited ability to walk and sit comfortably. A November 2017 DBQ from the private chiropractor whose treatment records were discussed above notes flexion to approximately 45 degrees with pain at initiation. Flare-ups were noted to severely limit his ability to lift, stand, and walk. A November 2017 VA physical therapy consultation medical record notes that the Veteran has "Marked limitations in lumbar [active range of motion] due to guarding." Another November 2017 VA medical record notes that the Veteran has "Active Lumbar [range of motion] markedly limited and provocative into flexion at 30°." Context makes it unclear whether the Veteran's motion is limited to 30 degrees. Given, however, that both of these records note marked limitation of motion, the Board will consider them to most nearly approximate flexion to 30 degrees or less. The Board acknowledges that the only VA examination report of record from that period was a February 2017 record noting an initial range of motion of 60 degrees flexion, which would warrant a 20 percent rating. No additional loss of range of motion was found on three repetitions. It was noted that pain, weakness, fatigability, or incoordination do not significantly limit functional ability with repeated use over the period of time or on flare-up. However, the Board observes that musculoskeletal disabilities of this type tend to wax and wane over a period of time. Given the above indications of even greater limitation of motion that are most indicative of limitation of flexion to 30 degrees or less, to include immediately preceding and presumably at the beginning of the appeals period, the Board will resolve reasonable doubt in favor of the Veteran and find that entitlement to a rating of 40 percent based on the General Rating Formula is warranted for the entire period prior to February 26, 2018. The Board will now consider whether a rating in excess of 40 percent is warranted at any time during the appeals period. As noted above, under the General Rating Formula, an evaluation of 50 percent requires unfavorable ankylosis of the entire thoracolumbar spine, which requires both that the entire spine be fixed in flexion or extension and one or more of several enumerated conditions be met or the functional equivalent thereof. The VA back conditions examination reports (dated in February 2017, February 2018, December 2018, April 2019, and August 2020) and private DBQs (dated in October 2017 and November 2017) all expressly note no unfavorable ankylosis. None of the evidence of record, consisting of VA examination reports, VA medical records, and private medical records, reflect fixation in either flexion or extension, or the equivalent thereof, to include on repetitive motion, on flare-up, or during repetitive use over time. In making this finding, the Board acknowledges the Veteran's reports of severe limitation on flare-up. The medical records themselves also reflect that the Veteran does, at times, have severely limited range of motion. However, this limitation is properly compensated at the 40 percent rating, which contemplates flexion limited to no more than 30 degrees or favorable ankylosis. Therefore, the Veteran does not satisfy the criteria for a rating in excess of 40 percent under the General Rating Formula. Considering that the Veteran has had a diagnosis of IVDS throughout the appeals period, the Board has considered whether a higher initial rating is warranted based on incapacitating episodes at any point during the appeals period. The Veteran reported in a March 2019 statement that he only leaves his home when necessary and that, "while at home I am laying down and moving only when necessary." He reported that "For the periods of time in between I estimate 80% were partial days where my condition was aggravated by a movement or activity (standing too long, walking too long, bending, turning) causing me to have to lay down and minimize movement for the remainder of the day." Turning to the evidence of record, the February 2017, February 2018, December 2018, April 2019, and August 2020 VA examination reports all note that the Veteran has not had any episodes of acute signs and symptoms due to IVDS that required bed rest prescribed by a physician and treatment by a physician in the past 12 months. The Board notes that the October 2017 and November 2017 DBQs contain indications of bed rest having a total duration of at least six weeks over the past 12 months. The October 2017 DBQ is authored by a private physician who has been treating the Veteran since October 2016. When responding to Question 15A, he checked the "YES" box when asked "DOES THE VETERAN HAVE IVDS OF THE THORACOLUMBAR SPINE?" He checked neither the "YES" nor the "NO" box in response to Question 15B, which reads as follows: "IF YES TO QUESTION 15A ABOVE, HAS THE VETERAN HAD ANY INCAPACITATING EPISODES (a period of acute signs and symptoms due to IVDS that requires bed rest prescribed by a physician and treatment by a physician) OVER THE PAST 12 MONTHS?" Instead, he wrote out the following statement: "I am unaware of a period of bedrest prescribed by a physician for this patient." However, the physician also responded to Question 15C, which directs him as follows: "IF YES TO QUESTION 15B ABOVE, PROVIDE THE TOTAL DURATION OF ALL INCAPACITATING EPISODES OVER THE PAST 12 MONTHS." He checked the box indicating "At least 6 weeks," adding the written comment "based on patient's reporting of his symptoms." The Board has reviewed the potentially contradictory answers to Questions 15B and 15C, but finds that the October 2017 DBQ does not in fact support the assertion that the Veteran had at least six weeks of incapacitating episodes as defined by VA regulation in the past 12 months. The Board finds that the statement "I am unaware of a period of bedrest prescribed by a physician for this patient" clearly reflects an answer of "NO" to Question 15B, as he expressly denied awareness of a period of bedrest prescribed by a physician. Because a period of bedrest prescribed by a physician is a necessary element for an episode to be considered incapacitating, the absence of any such episode signifies that the Veteran has not had an incapacitating episode in the last 12 months. The Board next turns to Question 15C. As noted above, the examiner did check the box indicating that the Veteran has had "At least 6 weeks" of incapacitating episodes in the past 12 months. Resolving the inconsistencies between the answer to Questions 15B and 15C in the Veteran's favor would suggest that the criteria for assignment of a 60 percent rating have been met. However, the physician's explanation of his answer to Question 15C does not support an assertion that the Veteran has had "At least 6 weeks" of incapacitating episodes in the past 12 months as defined by VA regulation. Specifically, as noted above, the physician explained his answer to Question 15C by noting that his response is "based on patient's reporting of his symptoms." As noted above, however, the definition of an "incapacitating episode" is only partially based on the Veteran's symptoms. As noted above, an "incapacitating episode" is defined as "a period of acute signs and symptoms due to IVDS that requires bed rest prescribed by a physician and treatment by a physician." [Emphasis added.] Thus, the Veteran's own description of his symptoms alone, no matter the severity, is not sufficient to establish the occurrence of an incapacitating episode. As the Veteran's physician had just asserted in this same DBQ that he is unaware of the Veteran having had "a period of bedrest prescribed by a physician," the conclusion must follow that the physician is not, in fact, aware that the Veteran has suffered any incapacitating episodes during the prior 12-month period. Therefore, the Board must find that the October 2017 DBQ does not support an assertion that the Veteran has had at least six weeks of incapacitating episodes over the last 12 months. The Board will now turn to the two statements that have been submitted by the Veteran's private chiropractor. First, in September 2017, the private chiropractor submitted what he described as a "letter [that] is meant to serve as an update to the BACK (THORACOLUMBAR SPINE) CONDITIONS DISABILITY BENEFITS QUESTIONNAIRE signed by [a VA physician] on 2/24/2017." He then proceeds to "correct" that DBQ. (The Board notes that the private chiropractor himself has characterized this letter as a "correction" of the February 2017 VA examination report.) As relevant to his back claim, the chiropractor stated that: The other section that needs correction is on page 8 of 11, Section XI, item 11 B. In this section, the YES box should be checked and accordingly the last box which reads 'With episodes of bed rest having a total duration of at least 6 weeks during the past 12 months' should also be checked. Correction of these items more accurately describes [the Veteran's] lower back and right leg conditions. The Board finds that the private chiropractor's "correction" of the VA examiner's report does not diminish the probative value of the February 2017 VA back conditions examination report itself. Nor does the private chiropractor's September 2017 assertion, without any rationale other than that different boxes "should" be checked, render the February 2017 VA examiner's finding that the Veteran does not have incapacitating episodes any less probative. The medical evidence of record from the one-year period prior to the February 2017 VA examination report includes records dated from March 2016 through December 2016. These records described treatment from the private chiropractor himself. As described above, the treatment that the private chiropractor himself has prescribed during the December 2016 exacerbation describes extensive treatment that does not include bedrest. Likewise, the records from prior to that exacerbation do not include prescribed bedrest. Therefore, to the extent that this letter is intended to correct the findings of the February 2017 VA examination report, the Board notes that the records from the private chiropractor himself directly contradict the assertion that he makes in the September 2017 statement. The Board therefore finds that the September 2017 letter does not render the February 2017 VA examiner's findings less probative. The private chiropractor also submitted a November 2017 DBQ that again asserts that the Veteran has experienced at least six weeks of incapacitating episodes in the past 12 months. The Board finds that the medical evidence from that period does not support, and may in fact contradict, this estimate. As noted above, the December 2016 records from the private chiropractor himself reflect that no bedrest was prescribed for what the chiropractor himself characterized as "Severe exacerbation" of the Veteran's lumbar spine disability. Furthermore, the VA medical records from the 12-month period prior to the November 2017 DBQ describe the Veteran's treatment, including physical therapy and the issuance of a TENS unit, but do not reflect prescribed bedrest. The Veteran reported at a November 2017 VA peripheral nerves conditions examination that "once a day has to do bed rest after walking even going to clinic," and that "He has to lay down and rest for at least 30 to 60 minutes per 8 hour work day." The Board acknowledges that the Veteran described needing "bed rest." The Board finds, however, that the Veteran's lay use of the term "bed rest" does not satisfy the medical definition of "bed rest" that was noted above. Specifically, as noted above, "bed rest" is defined as "confinement of a patient to a bed." A need to lie down after certain activities does not constitute "confinement ... to a bed." Rather, voluntarily lying down in his bed, even if on a daily basis, while otherwise going about his regular activities, such as a work or going for a walk, does not constitute confinement to bed. The Board must thus find that the actual treatment records from the 12-month period prior to the November 2017 DBQ itself contradict the private chiropractor's assertion that the Veteran has required at least 6 weeks of treatment and bed rest prescribed by a physician during that period. Therefore, in light of contradictory evidence, the Board must find that the November 2017 DBQ from the Veteran's private chiropractor does not provide a probative assessment that the Veteran has had at least six weeks of incapacitating episodes during the period 12-month period. Next, at his Board hearing, the Veteran, through his accredited representative, acknowledged that he has not been prescribed bedrest by a physician for his IVDS. During the February 2020 Board hearing, the Veteran's accredited representative made the following contentions regarding incapacitating episodes: [W]e would consider those even just daily tasks of living whether it being dishes, doing his taxes, just trying to get anything done. The issues those present to him that he definitely meets the over six weeks of incapacitating episodes that would require the 60% or the next higher evaluation for his back disability and the intervertebral disc syndrome. So, we do believe that he has a valid argument to be made for that next higher evaluation on the back given that severity of it even if it doesn't mean you're necessarily going to the hospital to get treatment that you are essentially done for the day and need to go lay down which would make it very difficult to, you know, go to school or learn a new profession or even work if on a daily basis he needs to lay down to take the pressure off of back. (See Board hearing transcript, page 9.) The Board appreciates the impairment that the Veteran has due to his back disability. It must note, however, that the relevant regulation itself defines incapacitating episodes as requiring bed rest prescribed by a physician and treatment by a physician. Thus, the fact that the Veteran's need to go lie down is due to his own determination that lying down is necessary and is not prescribed by a physician signifies that, by definition, the above episodes as described by the Veteran's accredited representative do not satisfy the criteria to be considered incapacitating episodes. Thus, entitlement to an increased rating based on incapacitating episodes is not warranted at any point during the appeals period. Moreover, the Veteran is already in receipt of evaluations for the orthopedic manifestations of his back disability (under the General Rating Formula) and the neurologic manifestations of his back disability (under the diagnostic codes for Diseases of the Peripheral Nerves). The regulation does not permit a simultaneous evaluation under the Formula for Rating IVDS. To summarize, the Board finds that, prior to February 26, 2018, entitlement to an increased rating from 20 percent to 40 percent, but no higher, is warranted. The Board further finds that, on and after February 26, 2018, entitlement to a rating in excess of 40 percent is not warranted. To the extent that less than the maximum possible ratings are being assigned, the Board finds that the evidence is persuasively against the claim. As there is not an approximate balance of positive and negative evidence, the benefit-of-the-doubt doctrine is not applicable and additional benefits must be denied. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. Radiculopathy There are five separate nerve branches in the lower extremities that may be separately rated. Assigning separate ratings from within these nerve branches is not warranted as it would constitute impermissible pyramiding. In the case at hand, the competent medical evidence of record indicates that the Veteran has impairment of two nerves within the sciatic nerve branch, specifically, the sciatic nerve and the posterior tibial nerve. (Nerves within the sciatic nerve branch affect the foot and leg sensory and motor function of the buttock, leg, knee, muscles below the knee, lower leg, fibula, foot, muscles of the sole of the feet, plantar flexion, and toes.) The Veteran may only receive compensation for one of these two nerves (the sciatic nerve or the posterior tibial nerve) because the impact on his functioning is the same. The Board will determine which of these nerves warrants the higher rating and will assign that higher rating. There is no such conflict with the anterior crural nerve (femoral nerve), which is the only nerve at issue within the femoral nerve branch. (The femoral nerve branch affects the thigh and leg sensory motor function of the quadriceps muscle, front of thigh; medial calf; and medial thigh.) Therefore a rating may be assigned to the femoral nerve without regard to any rating that is assigned to the sciatic or posterior tibial nerves. Paralysis of the sciatic nerve is evaluated in accordance with the criteria set forth in 38 C.F.R. § 4.124a, Diagnostic Code 8520. Under these criteria, mild, incomplete paralysis is rated as 10 percent disabling. Moderate, incomplete paralysis is rated as 20 percent disabling. Moderately severe, incomplete paralysis is rated as 40 percent disabling. Severe, incomplete paralysis, with marked muscular atrophy, is rated as 60 percent disabling. Complete paralysis, when the foot dangles and drops, no active movement possible of muscles below the knee, flexion of knee weakened or (very rarely) lost is rated as 80 percent disabling. 38 C.F.R. § 4.124a. Paralysis of the posterior tibial nerve is evaluated in accordance with the criteria set forth in 38 C.F.R. § 4.124a, Diagnostic Code 8525. That diagnostic code assigns a 10 percent rating for mild or moderate, incomplete paralysis; a 20 percent rating for severe, incomplete paralysis; and a 30 percent rating for complete paralysis, paralysis of all muscles of the sole of the foot, frequently with painful paralysis of a causalgic nature; toes cannot be flexed; adduction is weakened; plantar flexion is impaired. Paralysis of the femoral nerve is evaluated in accordance with the criteria set forth in 38 C.F.R. § 4.124a, Diagnostic Code 8526. That diagnostic code assigns a 10 percent rating for mild, incomplete paralysis; a 20 percent rating for moderate, incomplete paralysis; a 30 percent rating for severe, incomplete paralysis; and a 40 percent rating for complete paralysis, with paralysis of the quadriceps extensor muscles. The words "mild," "moderate," and "severe" as used in the various Diagnostic Codes are not defined in the Rating Schedule. Ratings for peripheral neurological disorders are to be assigned based on the relative impairment of motor function, trophic changes (such as thin skin, absence of hair, or dystrophic nails, described at 38 C.F.R. § 4.104, Diagnostic Code 7115), or sensory disturbance. 38 C.F.R. § 4.120. Consideration is also given for loss of reflexes, pain, and muscle atrophy. See 38 C.F.R. §§ 4.123, 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. Left Lower Extremity Effective September 20, 2017, the Veteran's radiculopathy of the sciatic nerve of the left lower extremity has been rated as 20 percent disabling. Effective August 10, 2020, the Veteran's radiculopathy of the femoral nerve of the left lower extremity has been rated as 20 percent disabling. Because these claims are part and parcel of the Veteran's claim of entitlement to a higher initial rating for his back disability, which was received on December 19, 2016, the Board will consider whether separate compensable ratings are warranted from as early as that date. Turning to the evidence of record, review of the medical treatment records from the Veteran's private chiropractor through December 2016 reveals no complaints or findings of radiculopathy of the left lower extremity. The February 2017 VA back conditions examination report found that no diagnosis of left lower extremity radiculopathy was warranted. This determination was based on review of the record and interview and examination of the Veteran. The Veteran denied all symptoms of radiculopathy (constant pain, intermittent pain, paresthesias and/or dysthesias, and numbness) of the left lower extremity. Muscle strength and reflexes were normal, and straight leg raising test was negative. The Veteran had no other signs or symptoms of radiculopathy. A May 2017 VA medical record notes that there was some radiation into the right buttock and that the Veteran had new numbness in the right anterior thigh (which began last summer) and occasionally had a stabbing pain. No left lower extremity symptoms were noted. A June 2017 medical report from a VA physician notes a "Diagnosis and physical findings" of "Lumbar radicular low back pain." This form does not specify which of the lower extremities the radicular pain affects. In personal statements that were received on September 20, 2017, the Veteran and his mother described the Veteran's limitations with everyday tasks, such as doing laundry, loading and unloading the dishes, standing over the sink washing dishes, and doing grocery shopping. He reported that he has to lay down following these tasks and he has difficulty sleeping because of the pain. An October 2017 back conditions DBQ notes that muscle strength testing was full and the Veteran did not have muscle atrophy. Motor examination, reflex examination, and sensory examination were normal. The Veteran denied constant pain (at times excruciating). He reported moderate intermittent pain (subjective symptom). There was no response when asked about dull pain. It was noted that the Veteran has paresthesias and/or dysthesias, but no severity was noted. Severe numbness was present. There were no other objective findings due to radiculopathy. The physician noted that the Veteran has severe radiculopathy according to the Veteran's subjective report. The physician did not identify specific nerve roots involved because "subjective report of his leg pain makes it impossible to determine a specific dermatomal pattern of pain. He has non-dermatomal leg pain that does not correlate well with MRI findings." It was noted that the Veteran "needs EMG to further classify his leg symptoms as radiculopathy and to attribute to specific nerve roots." The November 2017 VA peripheral nerves conditions examination report estimates that the Veteran's left lower extremity sciatic nerve disability is of moderate severity. The Veteran reported moderate intermittent pain (usually dull), paresthesias and/or dysthesias, and numbness. He did not have constant pain (may be excruciating at times). Muscle strength and deep tendon reflexes were normal. Sensation was decreased in the thigh/knee, lower leg/ankle, and foot/toes. There were no trophic changes. Gait was antalgic, and the Veteran used a cane when walking. The examiner estimated that the Veteran had moderate, incomplete paralysis of the sciatic, the posterior tibial, and the anterior crural (femoral) nerves. A November 2017 VA medical record notes that the Veteran experiences intermittent stinging pains in the left lateral thigh and severe stabbing pains in the right lateral thigh. It was noted that he experiences numbness in one or the other posterior thigh, posterior calf, and foot after sitting for 15-20 minutes on a stool or hard folding chair. Left lower extremity sensation to light touch appeared to be intact. A November 2017 back conditions DBQ from the Veteran's private chiropractor notes that no muscle weakness was detected on examination and there was no muscle atrophy. Knee reflexes were full while ankle reflexes were hypoactive. Sensory examination was normal. Straight leg raising test was normal. The Veteran did not have constant pain, at times excruciating. He had moderate intermittent, sharp pains. He did not have dull pain. It was noted that he has paresthesias and/or dysthesias, but no severity was given. He had severe numbness in the thigh and the foot/calf. The examiner checked the boxes for both "Moderate" and "Severe" radiculopathy. It was noted that the Veteran has sciatic nerve impairment and involvement of the L5 nerve root. A January 2018 VA medical record notes that the Veteran has some numbness/tingling in his lower extremities with sitting/prolonged movements. A February 2018 VA medical record notes that the Veteran has bilateral lumbar radicular pain. A February 2018 VA back conditions examination report notes full muscle strength testing with no atrophy. Deep tendon reflexes were hypoactive. Sensory examination was normal and there was no radicular pain or other signs or symptoms of radiculopathy. A March 2018 VA medical record notes radicular symptoms and numbness/tingling bilaterally. The December 2018 VA back conditions examination report found normal deep tendon reflexes and normal sensory examination. Straight leg test was moderate. The Veteran denied constant pain (may be excruciating at times). He reported mild intermittent pain (usually dull). He reported moderate paresthesias and/or dysthesias and numbness. There were no other signs or symptoms of radiculopathy. The examiner determined that the sciatic nerve and femoral nerve were impacted and that the severity was mild. The April 2019 VA peripheral nerve conditions examination report notes that the Veteran reported mild, constant pain (may be excruciating at times), and moderate intermittent pain (usually dull), paresthesias and/or dysthesias, and numbness. Muscle strength testing was normal and there was no atrophy. Deep tendon reflexes were normal. There was decreased sensation in the upper anterior thigh, thigh/knee, and lower leg/ankle. Sensation in the foot/toes was absent. There were no trophic changes. There was moderate, incomplete paralysis of the sciatic nerve and moderate, incomplete paralysis of the anterior crural (femoral) nerve. The posterior tibial nerve was normal. A February 2020 VA medical record notes that the Veteran has pain radiating down his bilateral lower extremities and that he has some pain in the bottom of the left foot. It was noted that radiating symptoms were the likely cause of this pain. It was noted that he was limping due to these symptoms. The August 10, 2020, VA peripheral nerves conditions examination report reflects that the Veteran denied constant pain but reported moderate intermittent pain, paresthesias and/or dysthesias, and numbness. With respect to muscle strength testing, ankle plantar flexion and ankle dorsiflexion were normal, while knee extension was at 4/5 (active movement against some resistance). The Veteran did not have muscle atrophy. The Veteran's knee reflexes were hypoactive but his ankle reflexes were normal. Sensation testing for light touch was decreased in the upper anterior thigh and the thigh/knee, but it was normal in the lower leg/ankle and the foot/toes. There were no trophic changes. The examiner estimated that the Veteran's left sciatic nerve had moderate, incomplete paralysis, his posterior tibial nerve had moderate, incomplete paralysis, and his anterior crural nerve (femoral) had severe, incomplete paralysis. 3. On and after September 20, 2017, entitlement to an initial rating in excess of 20 percent for radiculopathy of the sciatic nerve of the left lower extremity is denied. As noted above, the Veteran is currently in receipt of separate ratings for radiculopathy of his left sciatic nerve (effective September 20, 2017) and of his left femoral nerve (effective August 10, 2020). These claims are considered to be part and parcel of his claim of entitlement to an increased rating for his low back claim, which arises from a December 19, 2016, service connection claim. The Board will therefore consider whether separate compensable ratings are warranted for these disabilities at any time from December 19, 2016. As also noted above, there is competent medical evidence of record that has identified a disability of the posterior tibial nerve. However, separate simultaneous ratings are not warranted for disabilities of the sciatic nerve and the posterior tibial nerve. The Board will therefore determine whether the Veteran's posterior tibial nerve may be assigned a higher rating than his sciatic nerve. For any portion of the appeals period during which a higher rating is warranted for his posterior tibial nerve, the Board will change the assigned rating to that of the posterior tibial nerve for that period. The Board will first consider whether a compensable rating is warranted for radiculopathy of the sciatic nerve prior to September 20, 2017. The Veteran's VA medical records from prior to September 20, 2017, contain no indication of left lower extremity radiculopathy. The only VA examination report from that period, dated in February 2017, reflects that the Veteran had no relevant complaints and found no clinical abnormalities on testing. Based on the results of this examination report, the VA examiner found that no diagnosis of radiculopathy of any nerve of the left lower extremity is warranted. Therefore, the Board finds that entitlement to a compensable disability rating is not warranted for either sciatic radiculopathy or posterior tibial radiculopathy prior to September 20, 2017. As noted above, a June 2017 VA medical record references radiculopathy but does not specify the affected extremity or extremities. Considering, however, that the Veteran had been diagnosed with radiculopathy of the right lower extremity at that time; that there had been no prior findings by treatment providers of left lower extremity radiculopathy; and that a VA examiner had found no left lower extremity radiculopathy four months earlier, the Board finds that this record does not establish the presence of left lower extremity radiculopathy in June 2017. Therefore, the Board finds that, prior to September 2017, entitlement to a separate compensable rating for left lower extremity radiculopathy of the sciatic nerve is not warranted. The Board will next determine whether a rating in excess of 20 percent is warranted for sciatic radiculopathy of the left lower extremity at any point on or after September 20, 2017. As noted above, a 20 percent rating reflects moderate, incomplete paralysis. Moderately severe, incomplete paralysis is rated as 40 percent disabling. Severe, incomplete paralysis, with marked muscular atrophy, is rated as 60 percent disabling. Complete paralysis, when the foot dangles and drops, no active movement possible of muscles below the knee, flexion of knee weakened or (very rarely) lost is rated as 80 percent disabling. Based on the above, the Board finds that, effective September 20, 2017, entitlement to a rating in excess of 20 percent for sciatic radiculopathy is not warranted. The VA peripheral nerve conditions examination reports from this period, dated in November 2017, April 2019, and August 2020, reflect that the Veteran has reported that his symptoms are no more than moderate (including constant pain (may be excruciating at times), intermittent pain (usually dull), paresthesias and/or dysthesias, and numbness). Muscle strength testing was mostly full, with slightly decreased strength (rated at 4/5) at the knee in August 2020. Deep tendon reflexes were mostly normal, with hypoactive knee reflexes at his August 2020 examination. There was no atrophy. Sensation was mostly noted to be decreased, with the April 2019 examination report noting that sensation in the foot/toes was absent. There were no trophic changes. The examiners summarized their findings by estimating that the Veteran's left lower extremity sciatic nerve disability is of moderate severity. The Board further notes that, while it is a back conditions examination report and contains less-detailed findings that the other reports, the December 2018 VA examination report does not indicate that any symptoms or findings are more severe than those that are described in the other examination reports. Given that symptoms were no more than moderate, motor and/or reflexes were mostly intact, and there was no atrophy, the Board finds that the VA medical evidence most accurately describes a level of disability corresponding to moderate, incomplete paralysis, which warrants a 20 percent rating. Nor do the private DBQs, dated in October 2017 and November 2017, justify a rating in excess of 20 percent. At both times, he reported severe numbness, but the remaining symptoms were either absent or moderate. Muscle strength, motor examination, reflex examination, and sensory examination were normal except for hypoactive reflexes at the time of the November 2017 DBQ. There was no muscle atrophy and no other symptoms of radiculopathy. The October 2017 DBQ author was unable to identify a specific nerve root or roots and did not provide a severity for any nerve root impairment. The November 2017 DBQ checks the boxes for both "moderate" and "severe" sciatic nerve impairment. Given that testing was largely normal at both times, the Board finds that the symptoms that were described in the DBQs are of no more than moderate severity. The Board notes that the Veteran has been consistently receiving treatment for his left lower extremity since September 20, 2017, and the Board has considered the lay contentions from the Veteran and his mother. It must note, however, that this evidence does not reflect symptoms of a greater severity than those that are noted in the evidence that was discussed above. In light of the above, the Board finds that entitlement to a rating in excess of 20 percent is not warranted based on sciatic nerve impairment at any point on or after September 20, 2017. The Board will next determine whether a higher rating may be assigned based on impairment of the posterior tibial nerve. The Board finds that a higher rating is not warranted based on such impairment. As discussed above, there is no medical evidence suggestive of left lower extremity radiculopathy prior to September 20, 2017. Therefore, for the same reason that the Board has not granted entitlement to a compensable rating for sciatic nerve impairment during that period, it must deny a compensable rating for impairment of the posterior tibial nerve during that period. The Board also finds that a rating in excess of 20 percent is not warranted for impairment of the posterior tibial nerve at any point on or after September 20, 2017. As noted above, paralysis of the posterior tibial nerve is evaluated in accordance with the criteria set forth in 38 C.F.R. § 4.124a, Diagnostic Code 8525. A 30 percent rating is assigned when there is complete paralysis, paralysis of all muscles of the sole of the foot, frequently with painful paralysis of a causalgic nature; toes cannot be flexed; adduction is weakened; plantar flexion is impaired. The Board notes that none of these specific symptoms is found in the above evidence, both in medical evidence and lay contentions. Therefore, the criteria for entitlement to a rating in excess of 20 percent for impairment of the posterior tibial nerve are not satisfied, and the Board will not change the diagnostic code under which the Veteran is rated. Accordingly, the evidence is persuasively against the claim. As there is not an approximate balance of positive and negative evidence, the benefit-of-the-doubt doctrine is not applicable, and the claim must be denied. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. 4. From November 2, 2017, through August 9, 2020, entitlement to a separate rating of 20 percent, but no higher, for radiculopathy of the femoral nerve of the left lower extremity is granted. 5. On and after August 10, 2020, entitlement to a higher initial rating, increased from 20 percent to 30 percent, but no higher, for radiculopathy of the femoral nerve of the left lower extremity is granted. The Board finds that, effective November 2, 2017, entitlement to a separate, 20 percent rating is warranted for radiculopathy of the femoral nerve of the left lower extremity. This date corresponds to the date of the November 2, 2017, VA examination, and is the date on which the Veteran was first noted to have a disability of the femoral nerve. Because no earlier evidence reflects any left lower extremity radiculopathy, including in a February 2017 VA examination report that expressly found no left lower extremity radiculopathy of any nerve, entitlement to a separate rating for impairment of the femoral nerve is not warranted. The Board finds that, from November 2, 2017, through August 9, 2020, entitlement to a rating of 20 percent, but no higher, is warranted for the same reasons that served as the basis for the 20 percent rating (also for moderate, incomplete paralysis) that have been cited for the assignment of a separate rating for impairment of the sciatic nerve under Diagnostic Code 8520. The VA peripheral nerve conditions examination reports from this period, dated in November 2017 and April 2019, reflect that the Veteran has reported that his symptoms are no more than moderate (including constant pain (may be excruciating at times), intermittent pain (usually dull), paresthesias and/or dysthesias, and numbness). Muscle strength testing was mostly full, and deep tendon reflexes were normal. There was no atrophy. Sensation was mostly noted to be decreased, with the April 2019 examination report noting that sensation in the foot/toes was absent. There were no trophic changes. The examiners summarized their findings by estimating that the Veteran's left lower extremity femoral disability is of moderate severity. The February 2018 VA back conditions examination report was normal other than noting hypoactive deep tendon reflexes. The Board further notes that, while it is a back conditions examination report and contains less detailed findings that the other reports, the December 2018 VA examination report does not indicate that any symptoms or findings are more severe than those that are described in the other examination reports. Given that symptoms were no more than moderate, motor was intact, reflexes were largely intact or were hypoactive but not absent in February 2018, and there was no atrophy, the Board finds that the 20 percent rating for moderate, incomplete paralysis most accurately describes the Veteran's level of disability for his left femoral nerve. Nor do the private DBQs, dated in October 2017 and November 2017, justify a rating in excess of 20 percent. At both times, he reported severe numbness, but the remaining symptoms were either absent or moderate. Muscle strength, motor examination, reflex examination, and sensory examination were normal except for hypoactive reflexes at the time of the November 2017 DBQ. There was no muscle atrophy and no other symptoms of radiculopathy. The October 2017 DBQ author was unable to identify a specific nerve root or roots and did not provide a severity for any nerve root impairment. The November 2017 DBQ checks the boxes for both "moderate" and "severe" sciatic nerve impairment. Given that testing was largely normal at both times, the Board finds that the symptoms that were described in the DBQs are of no more than moderate severity. The Board finds, however, that a 30 percent rating, but no higher, is warranted for the Veteran's impairment of the left femoral nerve on and after August 10, 2020. In assigning this rating, the Board notes that the August 2020 VA examiner, a qualified medical professional, determined that the level of impairment that is attributable specifically to the Veteran's left femoral nerve manifests in severe, incomplete paralysis. The Board notes that it is possible to award the 30 percent rating because the findings at this examination show impairment that is more than wholly sensory (specifically, that muscle strength was less than full on knee extension and that knee extension was hypoactive). The Board therefore finds that a rating of 30 percent, but no higher is warranted. In the absence of complete paralysis, paralysis of quadriceps extensor muscles, the Board finds that entitlement to a 40 percent rating is not warranted. In short, the Board finds that entitlement to a separate 20 percent rating for impairment of the left femoral nerve is warranted from November 2, 2017, through August 9, 2020. The Board also finds that entitlement to a higher initial rating, increased from 20 percent to 30 percent, is warranted effective August 10, 2020. To the extent that less than the maximum possible ratings are being assigned, the Board finds that the evidence is persuasively against the claim. As there is not an approximate balance of positive and negative evidence, the benefit-of-the-doubt doctrine is not applicable and additional benefits must be denied. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. Right Lower Extremity Effective December 19, 2016, the Veteran's radiculopathy of the sciatic nerve of the right lower extremity has been rated as 10 percent disabling. From September 7, 2017, through December 9, 2018, the Veteran was in receipt of a 60 percent rating. On and after December 10, 2018, the Veteran has been in receipt of a 40 percent rating. Effective August 10, 2020, the Veteran's radiculopathy of the femoral nerve of the right lower extremity has been rated as 30 percent disabling. Turning to the evidence of record, review of the medical treatment records through December 2016 from the Veteran's private chiropractor reveals no complaints or findings of radiculopathy of the right lower extremity. The February 2017 VA back conditions examination report found that the Veteran had mild radiculopathy of the right femoral nerve. No disability of the sciatic nerve was diagnosed. Muscle strength was full and there was no atrophy. Reflex examination was normal. On sensory examination, the Veteran's upper anterior thigh sensation to light touch was decreased, while the remaining sensory examination was normal. The Veteran denied constant pain, but he endorse mild intermittent pain, paresthesias and/or dysthesias, and numbness. A May 2017 VA medical record notes that there was some radiation into the right buttock and has new numbness in the right anterior thigh (which began last summer) and occasionally had a stabbing pain. A June 2017 medical report from a VA physician notes a "Diagnosis and physical findings" of "Lumbar radicular low back pain." This form does not specify which of the lower extremities the radicular pain affects, but given the findings of the February 2017 VA back conditions examination report, the Board presumes that this radiculopathy affects the right lower extremity. In personal statements that were received on September 20, 2017, the Veteran and his mother have described the Veteran's limitations with everyday tasks, such as doing laundry, loading and unloading the dishwasher, standing over the sink washing dishes, and doing grocery shopping. He reported that he has to lay down following these tasks and he has difficulty sleeping because of the pain. In September 2017, the Veteran's private chiropractor submitted what he described as a "letter [that] is meant to serve as an update to the BACK (THORACOLUMBAR SPINE) CONDITIONS DISABILITY BENEFITS QUESTIONNAIRE signed by [a VA physician] on 2/24/2017." He then proceeds to "correct" that DBQ. He stated that "Specifically, on page 7 of 11, Section VIII, item 8A should read INTERMITTENT PAIN (USUALLY DULL) in the right lower extremity as Severe, not Mild. Also the NUMBNESS section should read Moderate, not Mild." He concluded that "Correction of these items more accurately describes [the Veteran's] lower back and right leg conditions." An October 2017 back conditions DBQ notes that muscle strength testing was full and the Veteran did not have muscle atrophy. Motor examination, reflex examination, and sensory examination were normal. The Veteran denied constant pain (at times excruciating). He reported severe intermittent pain (subjective symptom). There was no response when asked about dull pain. It was noted that the Veteran has paresthesias and/or dysthesias, but no severity was noted. Severe numbness was present. There were no other objective findings due to radiculopathy. The physician noted that the Veteran has severe radiculopathy according to the Veteran's subjective report. The physician did not identify specific nerve roots involved because "subjective report of his leg pain makes it impossible to determine a specific dermatomal pattern of pain. He has non-dermatomal leg pain that does not correlate well with MRI findings." It was noted that the Veteran "needs EMG to further classify his leg symptoms as radiculopathy and to attribute to specific nerve roots." The November 2017 VA peripheral nerves conditions examination report noted no constant pain, but intermittent pain, paresthesias and/or dysthesias, and numbness were all reported to be severe. Muscle strength was full and deep tendon reflexes were normal. The examiner did not respond to the question concerning whether there was muscle atrophy. Sensation to light tough was normal in the upper anterior thigh but was decreased in the thigh/knee, lower leg/ankle, and foot/toes. There were no trophic changes. The examiner estimated that the Veteran had severe, incomplete paralysis in the right sciatic nerve with marked muscular atrophy. It was estimated that he had severe, incomplete paralysis in the right posterior tibial nerve, and severe, incomplete paralysis in the anterior crural (femoral) nerve. A November 2017 VA medical record notes that the Veteran experiences intermittent stinging pains in the left lateral thigh and severe stabbing pains in the right lateral thigh. It was noted that he experiences numbness in one or the other posterior thigh, posterior calf, and foot after sitting for 15-20 minutes on a stool or hard folding chair. Left lower extremity sensation to light touch appeared to be intact. A November 2017 back conditions DBQ from the Veteran's private chiropractor notes that no muscle weakness was detected on examination and there was no muscle atrophy. Knee reflexes were full while ankle reflexes were hypoactive. Sensation to light touch was decreased in the upper anterior thigh but was otherwise normal. Straight leg raising test was normal. The Veteran did not have constant pain, at times excruciating. He had severe intermittent, sharp pains. He did not have dull pain. It was noted that he has paresthesias and/or dysthesias in his thigh, and both the "Moderate" and "Severe" boxes were checked. He had severe numbness in the thigh and the foot/calf. The examiner checked the boxes for both "Moderate" and "Severe" radiculopathy. The chiropractor did not check the box indicating involvement of the femoral nerve. A January 2018 VA medical record notes that the Veteran has some numbness/tingling in his lower extremities with sitting/prolonged movements. A February 2018 VA medical record notes that the Veteran has bilateral lumbar radicular pain. The February 2018 VA back conditions examination report notes full muscle strength testing with no atrophy. Deep tendon reflexes were hypoactive. Sensory examination was normal and there was no radicular pain or other signs or symptoms of radiculopathy. In a May 2018 addendum to the November 2017 and February 2018 VA examination reports, the author of those reports clarified that the Veteran does, in fact, have signs and symptoms associated with a radiculopathy. He also noted that the Veteran's radiculopathy appears to be sensory in nature. It was noted that the Veteran "would to be re-examined to determine if marked muscular atrophy exists. I cannot remember this part of the exam, and failed to document the extent of any atrophy (if present)." A March 2018 VA medical record notes radicular symptoms and numbness/tingling bilaterally. The December 2018 VA back conditions examination report notes involvement of the femoral and sciatic nerves. On muscle strength testing, hip flexion strength was less than normal at 4/5, indicating active movement against some resistance, but was otherwise normal. There was no muscle atrophy. Deep tendon reflexes were normal. Sensory examination revealed that upper anterior thigh sensation was absent, thigh/knee sensation was decreased, and lower leg/ankle and foot/toes sensation were normal. There was no constant pain, while intermittent pain, paresthesias and/or dysthesias, and numbness were moderate. There were no other signs or symptoms of radiculopathy. The femoral and sciatic nerves were affected and were noted to be of moderate severity. The April 2019 VA peripheral nerve conditions examination report notes that the Veteran reported mild, constant pain (may be excruciating at times), and moderate intermittent pain (usually dull), paresthesias and/or dysthesias, and numbness. Muscle strength testing was normal and there was no atrophy. Deep tendon reflexes were normal. There was decreased sensation in the upper anterior thigh, thigh/knee, and lower leg/ankle. Sensation in the foot/toes was absent. There were no trophic changes. There was moderate, incomplete paralysis of the sciatic nerve and moderate, incomplete paralysis of the anterior crural (femoral) nerve. The posterior tibial nerve was normal. The August 10, 2020, VA peripheral nerves conditions examination report reflects that the Veteran denied constant pain but reported moderate intermittent pain, paresthesias and/or dysthesias, and numbness. Muscle strength testing and ankle plantar flexion were normal, while knee extension and ankle dorsiflexion were at 4/5 (active movement against some resistance). The Veteran did not have muscle atrophy. The Veteran's knee reflexes were hypoactive but his ankle reflexes were normal. Sensation testing for light touch was decreased in the upper anterior thigh, the thigh/knee, and the lower leg/ankle but was normal in the foot/toes. There were no trophic changes. The examiner estimated that the Veteran's right sciatic nerve had moderately severe, incomplete paralysis, his posterior tibial nerve had severe, incomplete paralysis, and his anterior crural nerve (femoral) had moderate, incomplete paralysis. 6. Entitlement to a higher initial rating for radiculopathy of the sciatic nerve of the right lower extremity, rated as 10 percent disabling prior to September 7, 2017; as 60 percent disabling from September 7, 2017, through December 9, 2018; and as 40 percent disabling on and after December 10, 2018, is denied. The Board will first consider whether a rating in excess of 10 percent is warranted for sciatic nerve radiculopathy prior to September 7, 2017. As noted above, a 10 percent rating is warranted for mild, incomplete paralysis. Moderate incomplete paralysis is rated as 20 percent disabling. Moderately severe incomplete paralysis is rated as 40 percent disabling. Severe incomplete paralysis, with marked muscular atrophy, is rated as 60 percent disabling. Complete paralysis, when the foot dangles and drops, no active movement possible of muscles below the knee, flexion of knee weakened or (very rarely) lost is rated as 80 percent disabling. 38 C.F.R. § 4.124a. The Board finds that a rating in excess of 10 percent is not warranted prior to September 7, 2017. As noted above, the record reflects complaints of radiculopathy symptoms. However, the February 2017 back conditions examination reports notes no specific diagnosis of sciatic radiculopathy, instead attributing the neurologic complaints to femoral nerve impairment. The remaining evidence from this period notes qualitative complaints but does not contain diagnostic findings that demonstrate more than mild severity. To the extent that the chiropractor himself was attempting to provide his own evaluation of the severity of the Veteran's right lower extremity radiculopathy in February 2017, the Board finds the chiropractor's September 2017 competing interpretation of an examination that was conducted outside of his presence in February 2017 is far less probative than the findings that are contained in the February 2017 VA examination report itself and were made by a trained medical professional who had personally examined the Veteran Based on the above, the Board finds that, prior to September 7, 2017, the criteria for a rating in excess of 10 percent for sciatic nerve radiculopathy are not met. The Board will next consider whether a rating in excess of 60 percent is warranted at any point during the period from September 7, 2017, through December 9, 2018. The 60 percent rating is assigned for severe, incomplete paralysis, with marked muscular atrophy. The only higher rating that is available for sciatic radiculopathy is for complete paralysis, when the foot dangles and drops, no active movement possible of muscles below the knee, flexion of knee weakened or (very rarely) lost. Review of the evidence from this period does not reflect complete paralysis of the sciatic nerve. None of this evidence indicates foot dangle and drop, and muscle strength was never noted to have active muscle movement of less than 4/5 (indicating active movement against some resistance). The Board find that, based on this evidence, entitlement to a rating of 80 percent is not warranted at any point during this period. The Board observes that the 60 percent rating from the preceding period is based on what appears to be an erroneous indication on the November 2017 VA peripheral nerve conditions examination report that the Veteran had severe, incomplete paralysis, with marked muscular atrophy. In a May 2018 addendum opinion, the author of this examination report noted that the Veteran's radiculopathy appears to be wholly sensory in nature. This level of impairment does not approach the level of impairment necessary in order for there to be complete paralysis. Therefore, the Board finds that entitlement to a rating in excess of 60 percent is not warranted at any point during the period from September 7, 2017, through December 9, 2018. The period on and after December 10, 2018, is currently assigned a 40 percent rating. The Board will now determine whether a rating in excess of 40 percent is warranted during any portion of that rating period. As noted above, a 60 percent rating requires severe, incomplete paralysis with marked muscular atrophy. In the case at hand, the evidence of record from this period reflects that the Veteran does not have muscle atrophy. Muscle strength was never found to be less than 4/5, indicating active movement against some resistance. Nor does this evidence reflect trophic changes. In addition, the Veteran's report of symptoms ranged from absent to moderate. Deep tendon reflexes were normal through the August 2020 VA examination, at which time his knee reflexes were hypoactive. This level of reflex impairment is contemplated by the moderately severe rating. Sensation in the thigh/knee were decreased throughout the appeals period, but this level of sensation impairment is contemplated by the 40 percent rating. Based on the above, the Board finds that entitlement to a rating in excess of 40 percent is not warranted at any point on and after December 10, 2018. The Board has also considered whether a higher rating may be assigned based on impairment of the posterior tibial nerve under Diagnostic Code 8525. The Board notes that the maximum disability rating that is available under this diagnostic code is 30 percent. Therefore, because this diagnostic code does not offer a rating in excess of 30 percent, the Board need not consider whether the Veteran may be assigned higher ratings under Diagnostic Code 8525 during the periods for which ratings of 60 percent or 40 percent have already been assigned under Diagnostic Code 8520. The Board will therefore consider whether a rating in excess of 10 percent is warranted prior to September 7, 2017, for impairment of the posterior tibial nerve under Diagnostic Code 8525. In order to receive a rating in excess of 10 percent, the evidence must demonstrate a level of impairment that reflects at least severe, incomplete paralysis. The Board finds that no such rating is warranted. As noted above, the February 2017 VA back conditions examination report reflects impairment of the femoral nerve. It does not suggest impairment of the posterior tibial nerve in particular. The remaining evidence from this period notes qualitative complaints but does not contain diagnostic findings that demonstrate more than mild severity. Therefore, the Board finds that, prior to September 7, 2017, the criteria for a rating in excess of 10 percent for posterior tibial radiculopathy are not met. Accordingly, the evidence is persuasively against the claim. As there is not an approximate balance of positive and negative evidence, the benefit-of-the-doubt doctrine is not applicable, and the claim must be denied. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. 7. From December 19, 2016, through October 28, 2017, entitlement to a separate rating of 10 percent, but no higher, for radiculopathy of the femoral nerve of the right lower extremity is granted. 8. From October 29, 2017, through August 9, 2020, entitlement to a separate rating of 20 percent, but no higher, for radiculopathy of the femoral nerve of the right lower extremity is granted. 9. On and after August 10, 2020, entitlement to an initial rating in excess of 30 percent for radiculopathy of the femoral nerve of the right lower extremity is denied. The claim of entitlement to a higher initial rating for radiculopathy of the femoral nerve of the right lower extremity is part and parcel of the initial rating of entitlement to service connection for a back disability, received on December 19, 2016. Therefore, the Board may consider whether a separate rating is warranted prior to August 10, 2020, and whether a rating in excess of 30 percent is warranted on and after that date. The Board notes that the February 2017 VA back conditions examination report expressly found that the Veteran had radiculopathy of the femoral nerve. Therefore, the Board finds that entitlement to a separate compensable rating is warranted effective from the December 19, 2016, date of claim. The Board finds that a rating of 10 percent, but no higher, is warranted prior to October 29, 2017, based on mild, incomplete paralysis of the right femoral nerve. The February 2017 VA examination report notes, in relevant part, decreased upper anterior thigh sensation to light touch and endorsement of mild intermittent pain, paresthesias and/or dysthesias, and numbness. Otherwise, the examination was normal. The remaining evidence from this period, including VA medical records, contain qualitative reports of mild symptomatology. The lay statements from the Veteran and his mother describe symptoms that are more severe than those described in the medical records. However, these descriptions focus on describing impairment of the back, which was significant, and do not indicate an increase in severity of the right femoral nerve, specifically, at the time of these letters. As noted above, the Board does not consider the September 2017 letter from the Veteran's private chiropractor, which offers "corrections" of the February 2017 VA examination report, to diminish the probative value of the findings that were made by the VA examiner in February 2017. To the extent that the chiropractor himself was attempting to provide his own evaluation of the severity of the Veteran's right lower extremity radiculopathy in February 2017, the Board finds the chiropractor's September 2017 competing interpretation of an examination that was conducted outside of his presence in February 2017 is far less probative than the findings that are contained in the February 2017 VA examination report itself and were made by a trained medical professional who had personally examined the Veteran. In short, the Board finds that the evidence of record reflects no more than mild, incomplete paralysis of the right femoral nerve prior to October 29, 2017. Therefore, entitlement to a rating of 10 percent, but no more, is warranted during that period. The Board also finds that, effective October 29, 2017, through August 9, 2020, entitlement to a separate rating of 20 percent, but no higher, is warranted for moderate, incomplete paralysis of the right femoral nerve. With respect to examination, the October 2017 back conditions DBQ notes that the Veteran reported paresthesias and/or dysthesias (of unspecified severity) as well as severe intermittent pain and numbness. However, no deficiencies in muscle strength, muscle atrophy, motor examination, reflex examination, and sensory examination were found on examination and there were no other objective findings of radiculopathy. The physician noted that there was "severe" radiculopathy according to the Veteran's subjective report. Given the severity of symptoms that were reported by the Veteran, which was greater than those that had been previously reported, the Board will resolve reasonable doubt in favor of the Veteran and find that entitlement to a rating of 20 percent, but no higher, is warranted beginning on October 29, 2017. As noted above, when the involvement is wholly sensory, the rating is for the mild, or at most, the moderate degree. 38 C.F.R. § 4.123. Given the absence of objective findings on testing, the Board finds that the Veteran's femoral radiculopathy of the right lower extremity is of no more than moderate severity. Therefore, a rating in excess of 20 percent is not warranted. Similarly, the November 2017 VA peripheral nerves examination report notes that the Veteran reported that his symptoms were severe and sensation to the thigh/knee was decreased. The Board finds that these findings, which were wholly sensory, warrant the maximum available rating for wholly sensory symptoms, and therefore a rating in excess of 20 percent is not warranted. The Board acknowledges that the VA examiner estimated that the Veteran had "severe, incomplete" paralysis of the femoral nerve. The Board notes, however, that, while the Veteran did report severe symptoms, diagnostic testing was largely normal with only one slight abnormality. The May 2018 addendum from the November 2017 VA examiner confirms the assessment that the November 2017 findings were wholly sensory in nature. The Board finds that the Veteran's reported severe symptomatology justifies an evaluation that his disability was "moderate" rather than "mild." The wholly sensory nature of his symptoms, however, means that a rating in excess of 20 percent may not be assigned. The notation in the February 2018 VA back conditions examination report of the single abnormality of hypoactive deep tendon reflexes on otherwise normal examination is adequately compensated by the 20 percent rating. Nor does the December 2018 VA back conditions examination report justify the assignment of a rating in excess of 20 percent. The Veteran reported moderate symptomatology, and the few deficiencies that were found on examination were mild in severity. The examination report did indicate that upper anterior thigh sensation was absent. However, the nature of this impairment does not raise the overall level of impairment of this disability from "moderate" to "severe." In addition, the April 2019 VA peripheral nerve conditions examination report reflects that no more than a 20 percent rating for mild, incomplete paralysis is warranted, as the impairment that was noted on that examination was also wholly sensory. With respect to the final portion of the appeals period, the Board finds that a rating in excess of 30 percent is not warranted at any point on and after August 10, 2020. The examination report from that date notes that the Veteran reported moderate symptomatology. Abnormalities on testing were not of significant grade, there was an absence of muscle atrophy or trophic changes. The Board finds that these symptoms do not represent complete paralysis. In short, the Board finds that, prior to October 29, 2017, entitlement to a separate rating of 10 percent, but no higher, is warranted for radiculopathy of the femoral nerve of the right lower extremity. From October 29, 2017, through August 9, 2020, entitlement to a separate rating of 20 percent, but no higher, is warranted. On and after August 10, 2020, entitlement to a rating in excess of 30 percent is not warranted. To the extent that less than the maximum possible ratings are being assigned, the Board finds that the evidence is persuasively against the claim. As there is not an approximate balance of positive and negative evidence, the benefit-of-the-doubt doctrine is not applicable and additional benefits must be denied. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. TDIU 10. Entitlement to a TDIU is granted. A total disability rating based upon individual unemployability due to service-connected disabilities is assigned when service-connected disabilities result in such impairment of mind or body that the average person would be precluded from following a substantially gainful occupation. 38 C.F.R. §§ 3.340, 4.15. If there is only one service-connected disability, it must be rated at 60 percent or more; if there are two or more service-connected disabilities, at least one must be rated at 40 percent or more and the combined rating must be at least 70 percent. 38 C.F.R. § 4.16(a). Pursuant to 38 C.F.R. § 4.16(b), when a claimant is unable to secure and follow a substantially gainful occupation by reason of service-connected disabilities but fails to meet the percentage requirements for eligibility for a total rating set forth in 38 C.F.R. § 4.16(a), such case shall be submitted for extraschedular consideration. A claim for a total compensation rating based upon individual unemployability, "presupposes that the rating for the [service-connected] condition is less than 100%, and only asks for TDIU because of 'subjective' factors that the 'objective' rating does not consider." Vettese v. Brown, 7 Vet. App. 31, 34-35 (1994). In evaluating a veteran's employability, consideration may be given to his or her level of education, special training, and previous work experience in arriving at a conclusion, but not to her age or to impairment caused by nonservice-connected disabilities. 38 C.F.R. §§ 3.341, 4.16, 4.19. In the case at hand, as discussed above, multiple increased or separate ratings have been awarded in the course of the decision herein. However, service connection has not been granted for any additional disabilities. Service connection is currently in effect for IVDS of the thoracolumbar spine; radiculopathy of the sciatic nerve of the right lower extremity; radiculopathy of the femoral nerve of the right lower extremity; radiculopathy of the sciatic nerve of the left lower extremity; radiculopathy of the femoral nerve of the left lower extremity; tinnitus; and varicocele surgical scar of the left groin. The Board notes that, prior to the increased rating grants herein, the Veteran satisfied the schedular criteria for a TDIU from September 7, 2017. With the new grants, the Veteran has now satisfied the schedular TDIU criteria throughout the appeals period. (See 38 C.F.R. §§ 4.25, 4.26.) Specifically, including the application of the bilateral factor, the Veteran's low back disability with lower extremity radiculopathy, combines to result in a single disability rated as 60 percent disabling. The Board will now consider whether these disabilities result in such impairment of mind or body that the average person would be precluded from following a substantially gainful occupation. Following review of the record, the Board finds that the Veteran's service-connected disabilities result in such impairment of mind or body that he is precluded from following a substantially gainful occupation. Turning to the evidence of record, the February 2017 VA back conditions examination report notes that the "Veteran is a pipefitter, currently on short term disability for low back pain as he is unable to perform his job duties. Since 5th Dec 2016." The November 2017 VA peripheral nerves conditions examination report notes functional impairment that impacts his ability to work in that he is "Unable to pursue his chosen vocation of pipe fitter. Unable to pursue any gainful employment." A November 2017 VA Form 28-1902b, Counseling Record- Narrative Report," from his vocational rehabilitation file notes that the Veteran has service-connected disability that contributes in substantial part to his vocational impairment. He has a serious employment handicap and has not overcome the effects of the vocational impairment. It was determined that achievement of the Veteran's vocational goal was at the time reasonably foreseeable. It was noted that the Veteran is currently employed and "He is a journeyman and he works for the union." It was determined that the Veteran's "disability factors preclude [his] ability to maintain or return to former employment." Current means of financial support consisted of "Work and VA disability payments." He was noted to have the following vocational impairments due to service-connected disabilities: Back- Inability/Limited/Guarded prolonged standing, walking, climbing, stooping, crouching, sitting without time to stand and walk, repetitive bending and lifting, and related activities. Lower Extremity- Inability/Limited/Guarded ability to perform activities that require prolonged standing, walking, climbing stairs, squatting, crouching, carrying, balancing, prolonged operation of machinery and equipment requiring foot controls, and related activities. Tinnitus- Inability/Limited/Guarded ability to comprehend verbal communication and follow verbal directives in loud / noisy environments. Condition distracts Veteran from concentration and gaining restful sleep thereby interfering with ability to maintain alertness and physical stamina. The vocational rehabilitation counselor determined that, based on the above impairments, the Veteran "is precluded from working in positions such as sedentary to light work." It was noted that the Veteran "is currently employed as a Pipefitter at Pipefitter Union." It was noted that the Veteran "has not overcome his impairments to employment, as this job is considered to be suitable. His disability conditions are aggravated by the job duties." The February 2018 VA back conditions examination report notes functional impairment in that the Veteran is "Unable to bend over at waist." The December 2018 VA back conditions examination report notes functional impairment on walking and range of motion. The Veteran reported on a January 2019 VA Form 21-8940, Veteran's Application for Increased Compensation Based on Unemployability, that he had last worked full-time on December 5, 2016. He reported that he was unemployable due to his back and lower extremities. He reported that he had worked as a pipefitter for approximately 50 hours per week since January 2007 and that he had lost approximately four weeks of work due to illness. He listed his employer as "Pipefitters Local [Number]." With respect to education, he indicated that he had finished one year of college. The Board notes that there was some confusion with respect to whether the Veteran was "employed" by the Pipefitters Union. A VA Form 21-4192, Request for Employment in Connection with Claim for Disability Benefits, that was completed by the Local Pipefitters Union in March 2019 notes that the Veteran last worked and his date of last payment were in November 2016. It was noted that: [The Veteran] is a member in good standing of UA Pipefitters Local Union [Number]. The Local serves as exclusive bargaining representative for all employees in our Trade or Work jurisdiction. Such employees are dispatched from our job referral list to signatory contractors. Local [Number] has not been the direct employer of [the Veteran]. A Welfare Fund record from the Pipefitters Union reflects that the Veteran received welfare payments for the maximum 26 weeks from mid-December 2016 to mid-June 2017. Multiple April 2019 VA examination reports note that the Veteran's thoracolumbar spine disability and bilateral radiculopathy of the lower extremities impacts his ability to work as follows: He is unable to pursue gainful employment and unable to pursue his chosen vocation due to his back and associated radiculopathies of the legs. He cannot sit, stand or walk for any prolonged periods. He cannot lift very heavy, heavy, moderate [or] light weight. He is unable to sit or stand long enough in one position to perform sedentary labor. He meets the criteria for "IU." [Individual Unemployability] The Veteran testified at his February 2020 Board hearing that his physical limitations would keep him from going to school. (See Board hearing transcript, page 8.) He also reported that he wishes to work but he is not physically able to do so, noting that "I have a considerable education in my vocation which I'm a pipe fitter with the [City] Pipe Fitters Union. I have numerous contacts and avenues into getting some some branch of that business, again, if the physical possibility was there, so I mean there's ample opportunity given my experience and relationships in that industry." (See Board hearing transcript, page 11.) However, as noted by his accredited representative, "it's not a matter of wanting to go back to work, that is definitely there, and the knowledge and skillset is there as well. It's strictly a physical limitation," and that "no method of treatment has been able to help you get to that point to where you could successfully go back to school to learn a new position or go back to your chosen profession." (See Board hearing transcript, page 11.) The Veteran added that his physical limitations leave him unable to work "even in the same chosen profession, just learning a new avenue within that same industry." (See Board hearing transcript, page 11.) He stated that there are "different types of administration or supervisory roles, too, which was kind of my goal set going into voc rehab." (See Board hearing transcript, page 11.) However, he noted that "That is what I wanted to do, but then I didn't physically recover to where that was going to work." (See Board hearing transcript, page 12.) He was unable "To attend the training schools or anything else for that." (See Board hearing transcript, page 12.) On the August 2020 VA peripheral nerves conditions examination report, which has been described in detail above, the VA examiner stated that the Veteran's peripheral nerve condition does impact his ability to work. Specifically, the examiner noted that "Veteran has radiculopathy bilateral lower extremities. Veteran is not able to work in an occupation[] requiring lifting, prolonged sitting or standing." The August 2020 VA back conditions examination report notes that, due to the Veteran's back disabilities, the "Veteran is not able to participate[] in employment requiring prolonged sitting, standing, and lifting." An October 2020 email from the Pipefitters Union explains their hiring practices, elaborating on the information that was provided on the March 2019 VA Form 21-4192. It notes that "Members that are available for work are listed as such at the union hall and are dispatched to signatory employees when they request manpower." It states that "Members are not employed by Local [Number], only referred to our signatory employers." It notes that the Veteran "was last added to the list in November 2016. [The Veteran] was not subsequently dispatched. He notified the union that he was not physically able to perform work as a Pipefitter in December 2016." It was noted that the Veteran "was then listed as unavailable for work until his request for minimum dues beginning in June 2018." It was further explained that "As a minimum dues member [the Veteran] is no longer eligible for referral." The Board finds that, resolving reasonable doubt in favor of the Veteran, the above evidence reflects that the Veteran has been unable to follow a substantially gainful occupation due to his service-connected back disability, radiculopathy of the bilateral lower extremities, tinnitus, and left varicocele site scar. Specifically, the above evidence demonstrates that the Veteran's low back and bilateral lower extremity disabilities, in particular, prevent him from feasibly performing his duties as a pipefitter and from returning to school to train for a more sedentary role within the same industry. The evidence contains ample examples of limitations of activities that are essential to his work as a pipefitter, such as prolonged standing, walking, climbing, stooping, crouching, sitting without time to stand and walk, repetitive bending and lifting, and related activities. VA's vocational rehabilitation counselor determined that the Veteran's service-connected disabilities contribute in substantial part to his vocational impairment and that the Veteran has a serious employment handicap and has not overcome the effects of the vocational impairment. While the vocational rehabilitation counselor determined that achievement of the Veteran's vocational goal was reasonably foreseeable at the time of the evaluation, the Board finds that the evidence of record reflects that the Veteran's back and lower extremity disabilities prevented him from completing the necessary training. The evidence reflects that the Veteran has not worked since the December 19, 2016, date of claim. Specifically, it reflects that, while the Veteran is still a member of his Union, he was last available to be sent out to a job in November 2016. The evidence reflects that he had notified the Union in December 2016 that he was medically unable to work. Therefore, the Board finds that the criteria for entitlement to a TDIU are met effective December 19, 2016. TANYA SMITH Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Elizabeth Jalley, Counsel The Board's decision in this case is binding only with respect to the instant matter decided. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.