Citation Nr: 0926251 Decision Date: 07/14/09 Archive Date: 07/22/09 DOCKET NO. 05-34 154 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Phoenix, Arizona THE ISSUES 1. Entitlement to an increased disability evaluation for service-connected edentulous mandible with rampant caries and periodontal disease, currently rated as 10 percent disabling. 2. Entitlement to an increased disability evaluation for service-connected recurrent plasmacytoma, status post removal right sixth rib, status post-operative left mandibular lesion with recurrent left thoracic paraspinal region, currently rated as 10 percent disabling. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESSES AT HEARING ON APPEAL Appellant and his spouse. ATTORNEY FOR THE BOARD April Maddox, Counsel INTRODUCTION The Veteran served on active duty from February 1976 to April 1991. This matter comes before the Board of Veterans' Appeals (Board) on appeal of a February 2005 rating decision of the Department of Veterans Affairs (VA), Phoenix, Arizona, Regional Office (RO) that, in part, denied the claims for an increased rating for service-connected edentulous mandible with rampant caries and periodontal disease, and entitlement to an increased rating for service-connected recurrent plasmacytoma, status post removal left sixth rib, status post-operative left mandibular lesion with recurrent left thoracic paraspinal region. In January 2008 the Veteran testified before the undersigned Veteran's Law Judge at a Travel Board hearing. A transcript of this proceeding has been associated with the claims file. This case was previously before the Board in April 2008 at which time it was remanded for further development. The Board is satisfied that there has been substantial compliance with the remand directives and the Board may proceed with review of the issue decided herein. Stegall v. West, 11 Vet. App. 268 (1998). The issue of entitlement to a disability rating greater than 10 percent for edentulous mandible with rampant caries and periodontal disease is addressed in the REMAND portion of the decision below and is REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. FINDINGS OF FACT 1. The Veteran was treated for a plasmacytoma in is right 6th rib in 1989, a plasmacytoma in the left mandible in 1990, and a plasmacytoma in the soft tissue of the back in 1992. There gave been no recurrences of plasmacytoma since 1992. 2. The Veteran is in receipt of a separate 10 percent disability rating for chemosis and posterior subcapsular cataract, left eye as a residual of service-connected plasmacytoma and ophthalmology examinations have shown corrected visual acuity of 20/30 or better in both eyes. 3. The Veteran is in receipt of a separate 10 percent disability rating for right shoulder with long thoracic nerve palsy as a residual of service-connected plasmacytoma manifested by no more than moderate incomplete paralysis of the long thoracic nerve and noncompensable loss of motion. 4. The Veteran's right rib resection scars are superficial, do not cause limited motion, and have an area or areas of less than 144 square inches. 5. The Veteran retains a partial sense of taste and does not suffer from complete loss of taste. 6. The Veteran has not been diagnosed with a respiratory disorder to include as a residual of the Veteran's service- connected plasmacytoma. CONCLUSION OF LAW The criteria for a disability rating greater than 10 percent for service-connected recurrent plasmacytoma, status post removal right sixth rib, status post-operative left mandibular lesion with recurrent left thoracic paraspinal region have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 4.1, 4.2, 4.7, 4.10, 4.71a, Diagnostic Code 5012 (2008). REASONS AND BASES FOR FINDINGS AND CONCLUSION Factual Background The Veteran's service treatment records show that, after 15 years of active military service, he was seen in mid 1988 for right-sided low rib cage pain followed by growing mass. Evaluation revealed solitary plasmacytoma of the right sixth rib. Evaluation for multiple cytoma was negative. Resection was done in January 1989 with the Veteran doing well until four to five months later when a growth on the left mandible was noted. A biopsy was performed in August 1990 which revealed recurrent solitary plasmacytoma. The Veteran received radiation therapy to the left facial area from November to December 1990. Upon discharge from military service in April 1991 the Veteran submitted a claim for service connection for a bilateral knee disorder, a bilateral ankle disorder, chest rib removal, a right shoulder disorder, dryness in the right eye, bad taste in mouth, left ear hearing loss, dryness in left eye, loss of facial hair on the left side, and floating teeth. By rating decision dated in May 1991 the RO granted service connection for solitary plasmacytoma, right sixth rib, postoperative with disfigurement and recurrent solitary plasmacytoma, left mandible and assigned a 100 percent disability rating effective April 22, 1991. He was subsequently afforded VA examinations for the other claimed conditions. In November 1991 the RO proposed to reduce the Veteran's disability rating for plasmacytoma from 100 percent to 10 percent and by rating decision dated in February 1992 the RO decreased the Veteran's disability rating for plasmacytoma from 100 percent to 10 percent beginning June 1, 1992. In the February 1992 rating decision the RO also granted service connection for right shoulder with long thoracic nerve palsy (10 percent disabling), sicca syndrome (10 percent disabling), traumatic arthritis of the right knee with pain on motion (10 percent disabling), degenerative arthritis, left knee, X-ray evidence only (noncompensably disabling), and degenerative arthritis, right ankle, X-ray evidence only (noncompensably disabling). Subsequently, in March 1992, the Veteran indicated that he was undergoing treatment for another plasmacytoma tumor located in the soft tissue of his back. By rating decision dated in May 1992 the RO continued the original 100 percent disability rating assigned for the Veteran's plasmacytoma from April 22, 1991 (the date after the Veteran's discharge from military service) based on evidence of recurrence of plasmacytoma involving the thoracic and cervical spine. By rating decision dated in October 1993 the RO proposed to decrease the Veteran's disability rating for plasmacytoma from 100 percent to 10 percent and by rating decision dated in February 1994 the RO decreased the Veteran's disability rating for plasmacytoma from 100 percent to 10 percent effective May 1, 1994. Subsequently, in January 1994 correspondence the Veteran indicated that he suffered from a new cancerous tumor every three years which resulted in extensive dental work, pain in chest/back, as well as continuous headaches, shortness of breath, and memory loss. By rating decision dated in June 1997 the RO granted service connection for missing teeth 19, 20, and 21, hypersensitivity and gum recession teeth numbers 22, 23, and 26 assigning a 10 percent disability rating. In December 2004 the Veteran submitted a claim for an increased rating for his right knee disorder and also requested service connection for low jaw, teeth, and eye damage. By rating decision dated in February 2005 the RO granted a temporary 100 percent disability rating for right knee surgery from November 8, 2004 to January 1, 2005. The RO also granted service connection for tinnitus (10 percent disabling), chemosis and posterior subcapsular cataract, left eye (10 percent disabling), right knee traumatic arthritis (10 percent disabling), a right knee disorder due to laxity and patellar dislocation (10 percent disabling). Finally, the February 2005 rating decision continued 10 percent disability ratings for the Veteran's dental and plasmacytoma disorders and denied service connection for hearing loss. Legal Criteria Disability evaluations are determined by the application of a schedule of ratings, which are based on the average impairment of earning capacity. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. Separate diagnostic codes identify the various disabilities. The governing regulations provide that the higher of two evaluations will be assigned if the disability more closely approximates the criteria for that rating. Otherwise, the lower rating is assigned. 38 C.F.R. § 4.7. In every instance where the schedule does not provide a zero percent evaluation for a diagnostic code, a zero percent evaluation shall be assigned when the requirements for a compensable evaluation are not met. 38 C.F.R. § 4.31. Furthermore, when an evaluation of a disability is based on limitation of motion, the Board must also consider, in conjunction with the otherwise applicable diagnostic code, any additional functional loss the veteran may have sustained by virtue of other factors as described in 38 C.F.R. §§ 4.40 and 4.45. DeLuca v. Brown, 8 Vet. App. 202, 206 (1995). Such factors include more or less movement than normal, weakened movement, excess fatigability, incoordination, pain on movement, swelling, and deformity or atrophy of disuse. 38 C.F.R. § 4.45. Also, the VA General Counsel held in VAOPGCPREC 9-98 after reiterating its holding in VAOPGCPREC 23-97 that pain as a factor must be considered in the evaluation of a joint disability with arthritis and that the provisions of 38 C.F.R. § 4.59 are for consideration. Analysis The Veteran's service-connected recurrent plasmacytoma, status post removal right sixth rib, status post-operative left mandibular lesion with recurrent left thoracic paraspinal region, is currently rated as 10 percent disabling under 38 C.F.R. § 4.71a, Diagnostic Code (DC) 5012. Under DC 5012, malignant new growths of bones will be assigned a 100 percent rating continued for one year following the cessation of surgical, X-ray, antineoplastic chemotherapy or other therapeutic procedure. After the one year, if there has been no local recurrence or metastases, the rating will be made on residuals. 38 C.F.R. § 4.71a, DC 5012, and note. The evidence shows that the Veteran was treated for a plasmacytoma in the right 6th rib in 1989, a plasmacytoma in the left mandible in 1990, and a plasmacytoma in the soft tissue of the back in 1992. There gave been no recurrences of plasmacytoma since 1992. Therefore, the Veteran is not entitled to a disability rating greater than 10 percent under DC 5012 based on recurrences. Under the principles of DC 5012, service connection has been granted and disability ratings have been awarded for tinnitus (10 percent disabling), chemosis and posterior subcapsular cataracts of the left eye (10 percent disabling), and an edentulous mandible with rampant caries and periodontal disease, as residuals of the Veteran's service-connected plasmacytoma (10 percent disabling). Service connection is also in effect for several other disabilities that were granted based upon x-ray evidence of degenerative arthritis at the time of the Veteran's separation from service. At his January 2008 Board hearing, the Veteran identified several other physical complaints that he believes are associated with his service-connected plasmacytoma. These include tenderness in his rib area, diminishing lung function, loss of motion in his right arm, a loss of jaw function, and an irritation and swelling of the eye. The Veteran was afforded VA examinations specific to the joints, eyes, and dental in January 2005. Also, pursuant to the Board's April 2008 remand the Veteran was afforded VA examinations in October 2008 to address each of the claimed residuals regarding the Veteran's service-connected plasmacytoma. Also, VA treatment records dated through January 2009 were obtained and associated with the claims file. 1. Left Eye As above, by rating decision dated in February 2005, the RO granted service connection for chemosis and posterior subcapsular cataract, left eye. The Veteran's chemosis and posterior subcapsular cataract, left eye is currently rated as 10 percent disabling under 38 C.F.R. § 4.84a, DC 6028- 6018. Visual acuity is rated based upon the best distant vision obtainable after correction by glasses. 38 C.F.R. § 4.75. Evaluations for visual acuity range from non-compensable to 100 percent based on the degree of impairment. 38 C.F.R. § 4.84a, DCs 6061-6079. The percentage evaluation will be found from Table V by intersecting the horizontal row appropriate for the Snellen index for one eye and the vertical column appropriate to the Snellen index of the other eye. 38 C.F.R. § 4.83a. Vision in both eyes correctable to 20/40 warrants a non-compensable evaluation. 38 C.F.R. § 4.84a, DC 6079. A 10 percent rating requires vision in one eye correctable to 20/50 and vision in the other eye correctable to 20/40. 38 C.F.R. § 4.84a, DC 6078. A 20 percent rating requires vision in one eye correctable to 20/70 and vision in the other eye correctable to 20/50. 38 C.F.R. § 4.84a, DC 6078. Conjunctivitis is rated under 38 C.F.R. § 4.84a, Diagnostic Codes (DC) 6017 and 6018. A 10 percent rating is warranted under DC 6018 for chronic conjunctivitis that is active, with objective symptoms. Ten percent is the maximum rating under DC 6018. For an increase, the veteran's symptoms must show chronic trachomatous conjunctivitis that is active, which would warrant a 30 percent rating unless the condition is such that it can be rated based upon the impairment of visual acuity. 38 C.F.R. § 4.84a, DC 6017. During a January 2005 VA eyes examination the Veteran reported that every two to three months he has a flare-up in his left eye where the white part of the eye swells up and gets red and feels dry, scratchy, and irritated. He stated that he had cancer and received radiation to the left side of the face. He has been told that lymph ducts which drain the eye on the side of the face were damaged from radiation. The first episode was November 2003 and the most recent episode began ten days prior to the examination and was about over. The Veteran stated that his vision was fine. The examiner noted that the Veteran was first seen in November 2003 complaining of irritated red eye. The diagnosis was chemosis of unknown etiology. The Veteran had been seen repeatedly since then for recurrent swelling irritation of left eye. Extensive workup including computed tomography (CT) and magnetic resonance imaging (MRI) of orbit found no ocular or orbital pathology to account for episodes of chemosis. At last ophthalmology visit in November 2003 the assessment was "plasmacytome of left mandible, status- post radiation with sclerosis of lymph ducts to submandibular/preauricular and deep cervical nodes." The Veteran denied ocular pain or diplopia. The Veteran stated that when his eye flares up, he uses Tobradex TID until his eye starts to clear up and then taper. The Veteran denied a family history of glaucoma or macular degeneration. Examination of visual acuity revealed the following: distance uncorrected, OD 20/20-2 and OS 20/20-1; near uncorrected OD 20/70, and OS 20/60; near corrected OD 20/25 and OS 20/25; best corrected visual acuity with refraction OS 20/20-1 +0.75 DS and OS 20/20-1 Plano DS, add +2.00 and 20/20. During an October 2008 VA eyes examination the Veteran reiterated that he experienced left eye swelling/irritation about three to four times per year. He also reported using Tobradex for the swelling. On examination, the Veteran denied ocular pain or diplopia. The examiner diagnosed the Veteran with recurrent chemosis, left eye, most likely secondary to stenosis of lymph flow due to residuals of radiation therapy. Examination of visual acuity revealed the following: distance uncorrected, OD 20/40+2, PH 20/25+2 and OS 20/30, PH 20/25; near uncorrected OD 20/200, and OS 20/200; distant corrected visual acuity with refraction OD 20/20, +0.75 + 0.75 x 135 and OS 20/25+, +0.75 DS; near corrected visual acuity with refraction, ADD +2.00, OD 20/20 and OS 20/25. In this case, the Board finds that a disability rating greater than 10 percent for chemosis and posterior subcapsular cataract, left eye is not warranted. First, a 10 percent rating is the highest rating assignable under DC 6018. Thus, the Veteran may not receive a higher rating under DCC 6018. As for the potential for an increased rating based on visual acuity, the ophthalmology examinations have shown corrected visual acuity of 20/30 or better in both eyes. Thus, the Veteran does not meet the criteria for a higher rating based on decreased visual acuity. 2. Limited Range of Motion and Pain of the Right Shoulder As above, by rating decision dated in February 1992, the RO granted service connection for right shoulder with long thoracic nerve palsy. The Veteran's right shoulder disorder is currently rated as 10 percent disabling under 38 C.F.R. § 4.124a, DC 8519. Under DC 8519 the long thoracic nerve is evaluated on the basis of the extent of paralysis. The Veteran's right arm is his dominant (major) upper extremity, though the evidence shows the left side is now his dominant side due to loss of function in the right. Under Diagnostic Code 8519, evaluation of the major side provides for a noncompensable disability rating for mild incomplete paralysis of the long thoracic nerve, a 10 percent disability rating for moderate incomplete paralysis of the long thoracic nerve, and a 20 percent disability rating for severe incomplete paralysis of the long thoracic nerve. A 30 percent disability rating is warranted for "complete paralysis; inability to raise the arm above shoulder level, winged scapula deformity." The term "incomplete paralysis" with peripheral nerve injuries indicates a degree of loss or impaired function substantially less than the type pictured for complete paralysis given with each nerve, whether due to the varied level of the nerve lesion or to partial regeneration. When the involvement is wholly sensory, the rating should be for mild, or at most, the moderate degree. See note at "Diseases of the Peripheral Nerves" in 38 C.F.R. § 4.124(a). During the October 2008 VA joints examination the Veteran reported that since he underwent radiation therapy for plasmacytoma to the right suprascapular area he has had limited range of motion and pain of the suprascapular area. The Veteran reported that he was right-hand dominant. He reported pain and stiffness in the right shoulder joint but denied weakness, episodes of dislocation or sublaxation, and locking episodes. The examiner noted that there was no deformity, no giving way, effusion, flareups of joint disease, or inflammation. Range of motion testing revealed flexion to 140 degrees with pain from 120 degrees, extension to 60 degrees, abduction to 130 degrees with pain from 120 degrees, internal rotation from 90 degrees, and external rotation from 85 degrees with pain from 70 degrees. With regard to DeLuca, the examiner noted that there was pain on range of motion as reported above and specifically noted that there was no additional limitation following repetitive range of motion. There were no recurrent shoulder dislocations and there was no inflammatory arthritis. X-ray examination of the right shoulder revealed mild AC joint degenerative findings with no significant abnormality of the scapula noted. The diagnosis was radiation therapy to right scapular with residual loss of range of motion of the right shoulder. With regard to the effect of this disorder regarding occupational activities the examiner noted that the Veteran had problems with lifting and carrying, difficulty reaching, and pain and may need to take extra breaks when doing lifting or reaching overhead activities. After carefully reviewing the evidence of record, the Board finds no basis to grant a disability rating higher than 10 percent for the Veteran's right shoulder with long thoracic nerve palsy. The Veteran's right shoulder complaints reflect no more than moderate incomplete paralysis, thereby precluding a disability rating higher than 10 percent under DC 8519. The relevant evidence for consideration includes numerous VA treatment records dated through January 2009 as well as the October 2008 VA joints examination report, all of which show no significant neurological findings in the Veteran's right upper extremity. Looking to other related diagnostic codes, under 38 C.F.R. § 4.71A, Diagnostic Code (DC) 5200, for the major extremity, a 30 percent rating is assigned for favorable ankylosis of the scapulohumeral articulation with abduction to 60 degrees. A 40 percent rating is assigned for intermediate ankylosis between favorable and unfavorable, and a 50 percent rating is assigned with unfavorable ankylosis and abduction limited to 25 degrees from the side. Under 38 C.F.R. § 4.71a, DC 5201, (limitation of motion of the arm), limitation of motion at shoulder level, or midway between the side and shoulder level warrants a 20 percent for both the major and minor arms. A 30 percent evaluation (major) is also in order with limitation of the arm midway between side and shoulder level. A 40 percent evaluation (major) is in order with limitation of the arm to 25 degrees from the side. If there are x-ray findings of degenerative arthritis, such findings will be rated on the basis of limitation of motion under the appropriate diagnostic codes for the specific joint or joints involved. 38 C.F.R. § 4.71a, DC 5003. According to 38 C.F.R. § 4.71a, DC 5202 (impairment of the humerus), a 20 or 30 percent rating is assigned for the major arm if there is malunion of the humerus with moderate (20 percent) or marked (30 percent) deformity, with findings of moderate deformity, with recurrent dislocation of the scapulohumeral joint with infrequent episodes and guarding movement at only the shoulder level, or with infrequent (20 percent) or frequent (30 percent) episodes and guarding of all arm movements warrants. A 50 percent rating is assigned if there is evidence of fibrous union of the humerus. A 60 percent rating requires evidence of nonunion of the humerus (false flail joint), and an 80 percent rating is assigned for evidence of loss of the head of the humerus (flail shoulder). Under 38 C.F.R. § 4.71a, DC 5203 (impairment of the clavicle or scapula), nonunion of the clavicle or scapula (major) with loose movement warrants a 20 percent rating. Dislocation of the clavicle or scapula also warrants a 20 percent rating. Impairment of the clavicle or scapula may also be evaluated based upon impairment of function of the contiguous joint. In this case, the Board finds that a disability rating greater than 10 percent for a right shoulder disorder is not warranted. There is no evidence of ankylosis of the scapulohumeral articulation to warrant a higher rating under DC 5200 (ankylosis of the scapulohumeral articulation). As above, range of motion testing of the right shoulder in October 2008 revealed flexion to 140 degrees with pain from 120 degrees, extension to 60 degrees, abduction to 130 degrees with pain from 120 degrees, internal rotation from 90 degrees, and external rotation from 85 degrees with pain from 70 degrees. Additionally, a rating higher than 10 percent under DC 5201 requires limitation of motion of the arm to 25 degrees from the side. As reported above, the Veteran had more than 25 degrees of motion in the right shoulder in October 2008. Additionally, a higher rating under DC 5202 requires fibrous union of the humerus, nonunion of the humerus (false flail joint), or loss of the head of the humerus (flail shoulder). However, there was no indication of a fibrous union of the humerus, a false flail joint, or a flail shoulder in the October 2008 VA examination report. Therefore, there is no basis for a higher schedular rating under either DC 5200, 5201, 5202, or 5203. The Board also considered whether a higher rating is warranted based on findings of pain and functional loss. However, the Board finds that the 10 percent rating adequately contemplated the level of disability in the Veteran's right shoulder, including pain and functional loss due to pain. In that regard, as described above, the medical evidence indicates that although the Veteran had some painful motion, the pain did not in effect limit his motion to degree such that it was analogous to ankylosis. Cf. 38 C.F.R. § 4.71a, DC 5200. Additionally, there was no evidence that the Veteran guarded his right arm due to pain, or was only able to slightly lift his arm from his side without pain. Cf. 38 C.F.R. § 4.71a, DC 5202, DC 5201. In short, the Board finds that the Veteran's right shoulder disability is properly rated as 10 percent disabling, and the preponderance of the evidence is against a higher rating. 3. Pain at the site of the rib resection During the October 2008 VA examination the Veteran reported that he experienced right lateral rib pain, mid-chest level, due to the absence of the 6th rib. He reported that he takes extra breaks in his work as a postal distribution clerk when he develops right rib pain after handling mail. The rib pain has a moderate effect on the Veteran's activities of daily living including: exercise and sports and a mild effect of his performance of chores and recreational activities. It does not affect his other usual daily activities. The examiner noted an increased gap between mid-level ribs, consistent with the absence of the 6th right rib. The examiner also noted scars from the Veteran's 6th right rib resection. There was a scar from the 6th right rib resection, extending from mid-chest level to right paraspinoud around to near costochondral margin anteriorly. The scar was 41 centimeters (cm) x 0.8 cm. It was a well- healed scar, with no pain or tenderness on examination, no adherence or underlying tissue, no history of ulceration or breakdown, and no disfigurement or functional limitations. There was also a scar on the right upper back just medial of midline from biopsy or rhomboid scapular plasmacutoma recurrence in 1991. It measured 21 cm x 0.5 cm and was well- healed with no evidence of pain or tenderness on examination, no adherence to underlying tissue, no history of ulceration or breakdown, no disfigurement, and no functional limitations. There was mild numbness to light touch along the scar. Under 38 C.F.R. § 4.118, Diagnostic Code (DC) 7801-7805 a noncompensable evaluation is assigned for superficial scars that do not cause limited motion and have an area or areas of less than 144 square inches. See 38 C.F.R. § 4.118, DC 7805. As above, during the October 2008 VA examination the examiner noted two scars measuring 41 cm x 0.8 cm and 21 cm x 0.5 cm with no evidence of pain or tenderness on examination, no adherence to underlying tissue, no history of ulceration or breakdown, no disfigurement, and no functional limitations. Consequently, while the Veteran's right rib resection scars are obviously related to his service-connected plasmacytoma, the Board finds that the preponderance of the evidence is against the assignment of a separate compensable disability rating for these scars are they are superficial, do not cause limited motion, and have an area or areas of less than 144 square inches. Esteban v. Brown, 6 Vet. App. 259 (1994). 4. Loss of Taste During the October 2008 VA examination the Veteran noted that his sense of taste has been affected by radiation therapy for plasmacytoma. The examiner noted that the Veteran had a loss of taste on the left lateral 2/3 of his mouth after radiation to the jaw for plasmacytoma but the Veteran's sense of taste was intact elsewhere. Specifically, the Veteran was able to taste everything on the unaffected side. Loss of sense of taste is rated under 38 C.F.R. § 4.87a, Diagnostic Code 6276. Under DC 6276, a 10 percent evaluation, the maximum schedular rating, is assigned for complete loss of sense of taste. 38 C.F.R. § 4.87a. As above, during the October 2008 VA examination the Veteran indicated that he had a loss of taste on the left lateral 2/3 of his mouth but the Veteran's sense of taste was intact elsewhere. Thus, the evidence indicates that the Veteran retains a partial sense of taste and does not suffer from complete loss of taste. Consequently, while the Veteran's partial loss of taste is obviously related to his service-connected plasmacytoma, the Board finds that the preponderance of the evidence is against the assignment of a separate compensable disability rating for loss of taste as the Veteran retains a partial sense of taste and does not suffer from complete loss of taste. Esteban v. Brown, 6 Vet. App. 259 (1994). 5. Loss of lung function During the October 2008 VA examination the examiner conducted a respiratory examination to determine whether the Veteran has a respiratory disability as a residual of his radiation therapy for plasmacytoma. The Veteran reported progressive shortness of breath with activities over the past several years. He attributed this condition to the rib resection as the Veteran recalled being told that after his lung was re- expanded, it would not expand to 100 percent of its previous volume. He reported no trauma, history of neoplasm to the respiratory system or hospitalizations. There was no history of emphysema, asthma, cough, hemoptysis (spitting of blood), wheezing, anorexia, chest pain, or severe exertion. The Veteran reported that he stopped smoking about a year prior to the examination. X-ray examination revealed no evidence of active pulmonary disease or pulmonary lesions. Pulmonary function tests showed normal spirometry and diffusion, without obstruction or restriction. The examiner was unable to diagnose a respiratory condition or identify diminished lung function. The examiner also opined that diminished exertional ability is not due to limited lung capacity. In this case, the Board finds that a separate disability rating for loss of lung function is not in order. While the Veteran's service treatment records show plasmacytoma with resulting 6th right rib resection, there is no evidence of a current diagnosis of a lung disorder. As above, the October VA examiner was unable to diagnose a respiratory condition or identify diminished lung function. The examiner also opined that diminished exertional ability is not due to limited lung capacity. Current disability is required in order to establish service connection. Boyer v. West, 210 F.3d 1351, 1353 (Fed. Cir. 2000); Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). The Veteran's claim for service connection implicitly includes the assertion that he has a respiratory disorder, but his personal opinion as a lay person not trained in medicine is not competent evidence needed to establish a diagnosis of a respiratory disorder or its relationship to his service-connected plasmacytoma. Grottveit v. Brown, 5 Vet. App. 91, 93 (1993); Espiritu v. Derwinski, 2 Vet. App. 492, 494 (1992). Accordingly, the Board finds that the preponderance of the evidence is against entitlement to a disability rating greater than 10 percent for service-connected recurrent plasmacytoma, status post removal right sixth rib, status post-operative left mandibular lesion with recurrent left thoracic paraspinal region. 38 C.F.R. § 4.3. Extraschedular Consideration VA may consider an extraschedular rating in cases that are exceptional, such that the standards of the rating schedule appear to be inadequate to evaluate a disability. 38 C.F.R. § 3.321(b)(1). Extraschedular ratings under 38 C.F.R. § 3.321(b)(1) are limited to cases in which it is impractical to apply the regular standards of the rating schedule because there is an exceptional or unusual disability picture, with such related factors as frequent hospitalizations or marked interference with employment. In determining whether an extraschedular rating is necessary, VA must compare the level of severity and the symptomatology of the claimant's disability with the established criteria provided in the rating schedule for that disability. Thun v. Peake, 22 Vet. App. 111 (2008). The Board does not have the authority to assign, in the first instance, higher ratings on an extraschedular basis under 38 C.F.R. § 3.321(b)(1). When an extraschedular rating may be warranted, the Board must refer the case to designated VA officials. Bagwell v. Brown, 9 Vet. App. 377 (1996). The Veteran is currently employed as a postal distribution clerk and the Board finds that the rating criteria considered in this case reasonably describe the Veteran's disability level and symptomatology. The Veteran's disability picture is contemplated by the rating schedule, the assigned schedular evaluations for his service-connected disorders are adequate and referral is not required. Thun v. Peake, 22 Vet. App. 111 (2008). Notice and Assistance Upon receipt of a complete or substantially complete application for benefits and prior to an initial unfavorable decision on a claim by an agency of original jurisdiction, VA is required to notify the appellant of the information and evidence not of record that is necessary to substantiate the claim. In the notice, VA will inform the claimant which information and evidence, if any, that the claimant is to provide to VA and which information and evidence, if any, that VA will attempt to obtain on behalf of the claimant. See 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159; Pelegrini v. Principi, 18 Vet. App. 112 (2004); Quartuccio v. Principi, 16 Vet. App. 183 (2002); Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). For an increased-rating claim, VA must, at a minimum, notify a claimant that, (1) to substantiate an increased-rating claim, the evidence must demonstrate "a worsening or increase in severity of the disability and the effect that worsening has on the claimant's employment and daily life" and (2) that if an increase in the disability is found, the rating will be assigned by applying the relevant Diagnostic Codes (DC) based on "the nature of the symptoms of the condition for which disability compensation is being sought, their severity and duration, and their impact upon employment and daily life." The notice must also provide examples of the types of medical and lay evidence that may be obtained or submitted. Vazquez-Flores v. Peake, 22 Vet. App. 37 (2008). Complete notice was sent in December 2004, March 2006, October 2006, and June 2008 and the claim was readjudicated in a March 2009 supplemental statement of the case. Mayfield v. Nicholson, 499 F.3d 1317 (Fed. Cir. 2007). Specifically, the March 2006 letter addressed the rating criteria or effective date provisions that are pertinent to the appellant's claim pursuant to Dingess v. Nicholson, 19 Vet. App. 473 (2006) and the June 2008 letter met the requirements of Vazquez-Flores. Moreover, the record shows that the appellant was represented by a Veteran's Service Organization and its counsel throughout the adjudication of the claims. Overton v. Nicholson, 20 Vet. App. 427 (2006). VA has obtained service treatment records, assisted the Veteran in obtaining evidence, afforded the Veteran physical examinations, obtained medical opinions as to the etiology and severity of disabilities, and afforded the Veteran the opportunity to give testimony before the Board. All known and available records relevant to the issues on appeal have been obtained and associated with the Veteran's claims file; and the Veteran has not contended otherwise. VA has substantially complied with the notice and assistance requirements and the Veteran is not prejudiced by a decision on the claim at this time. ORDER A disability rating greater than 10 percent for service- connected recurrent plasmacytoma, status post removal right sixth rib, status post-operative left mandibular lesion with recurrent left thoracic paraspinal region is denied. REMAND In its April 2008 remand the Board noted that, with respect to the Veteran's service-connected edentulous mandible with rampant caries and periodontal disease, the Veteran has argued that although he has been fitted with a prosthesis (dentures), the deterioration of his jaw is such that it does not fit properly, requiring that he remove it frequently. In light of these complaints, the Board noted that the question arose as to whether the Veteran's prosthesis is such that he would be as well served without one, which by analogy to the amputation rule for orthopedic disabilities could provide a higher disability rating under DC 9913. It was also noted that the Veteran's jaw disability could potentially be rated under other analogous dental codes, such as DC 9914 or DC 9915, which provide disability ratings from 0 percent to 100 percent based upon loss of the maxilla, and whether it is replaceable by prosthesis. 38 C.F.R. § 4.150, DCs 9914 and 9915. The examiner was specifically requested to provide an opinion as to whether the Veteran's prosthesis is such that he would be just as well served without one and was also requested to provide an opinion as to whether the Veteran's dental disability represents or approximates a loss of the maxilla, and if so, what percentage of the maxilla is lost. The Veteran was afforded a VA dental examination pursuant to the April 2008 Board remand in October 2008. In an October 2008 report, the VA examiner noted that the Veteran's mandibular complete denture was necessary for him to masticate his food as he had no remaining teeth on the mandibular arch. Bone loss on the maxillary arch was limited to the bone supporting his remaining teeth. The examiner opined that the Veteran had lost 20 percent of this bone support as a result of his periodontal disease exacerbated by his dry mouth which was a direct cause of the radiotherapy he has received. The examiner also noted that there was no appreciable bone loss to the maxilla or mandible as a result of the radiotherapy other than the bone lost due to periodontal disease. Compliance with the April 2008 remand has not been accomplished. The April 2008 remand specifically requested to provide an opinion as to whether the Veteran's prosthesis is such that he would be just as well served without one and also requested an opinion as to whether the Veteran's dental disability represents or approximates a loss of the maxilla, and if so, what percentage of the maxilla is lost. While the October 2008 VA examiner commented on the percentage of maxilla lost the examiner did not provide an opinion as to whether the Veteran's prosthesis is such that he would be just as well served without one. A remand by the Board confers on the claimant, as a matter of law, the right to compliance with the remand orders. Stegall, 11 Vet. App. at 268. Where the remand orders of the Board are not fully implemented, the Board itself errs in failing to insure compliance. As such, the Board finds that this case is not ready for appellate review and must be remanded for further development. Accordingly, the case is REMANDED for the following action: 1. The AMC/RO should return the claims folder to the October 2008 VA examiner so that examiner can supplement his report and specifically opine whether the Veteran's prosthesis is such that he would be just as well served without one. If the October 2008 VA examiner is unavailable or another examination is needed, the AMC/RO should schedule the Veteran for a new VA examination and direct the new examiner to include an opinion as to whether the Veteran's prosthesis is such that he would be just as well served without one. 2. After completing any additional necessary development the AMC/RO should readjudicate the appeal. If the claim is still denied the AMC/RO must furnish the Veteran and his representative with a Supplemental Statement of the Case (SSOC) and allow the Veteran an opportunity to respond. The appellant has the right to submit additional evidence and argument on the matter the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2008). ______________________________________________ M. E. LARKIN Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs