Citation Nr: 1107288 Decision Date: 02/23/11 Archive Date: 03/04/11 DOCKET NO. 07-21 138 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in San Diego, California THE ISSUES 1. Entitlement to an increased initial evaluation for squamous cell carcinoma of the right vocal cord, currently rated 30 percent disabling. 2. Entitlement to a total disability rating based upon individual unemployability (TDIU). REPRESENTATION Appellant represented by: Veterans of Foreign Wars of the United States WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD S. Lipstein, Associate Counsel INTRODUCTION The Veteran had active duty service from July 1954 to May 1957. This matter came to the Board of Veterans' Appeals (Board) from an April 2006 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO). The Board remanded this claim in February 2010. As addressed more fully below, a review of the record shows that the RO has substantially complied with all remand instructions to the extent possible. Stegall v. West, 11 Vet. App. 268 (1998). The Veteran testified at a hearing before the RO in January 2007. The Veteran requested a Board hearing, however, he withdrew that request in September 2007. In an Informal Hearing Presentation dated October 2009, the Veteran's representative raised the issue of entitlement to service connection for emphysema. This issue raised by the record has not been adjudicated and developed by the Agency of Original Jurisdiction (AOJ) for appellate review. Therefore, the Board does not have jurisdiction over this claim which, therefore, is referred to the AOJ for appropriate action. The issue of entitlement to TDIU is addressed in the REMAND following this decision and is REMANDED to the RO, via the Appeals Management Center (AMC) in Washington, D.C., for further development. FINDINGS OF FACT 1. The Veteran last underwent radiation treatment for his service-connected laryngeal cancer in May 2002; there has been recurrence or metastasis of laryngeal cancer since that time. 2. The Veteran is service-connected for laryngeal cancer effective March 28, 2003; the mandatory 6 month 100 percent rating period following radiation treatment for laryngeal cancer, which includes the procedural protections of 38 C.F.R. § 3.105(e), do not apply. 3. The Veteran's residuals of laryngeal cancer, status post radiation therapy, include chronic laryngitis, reflux laryngitis, recurrent cerumen impaction and mucosal edema with nasal obstruction. 4. The Veteran's chronic laryngitis does not result in complete organic aphonia with constant inability to speak above a whisper. 5. The Veteran's reflux laryngitis is manifested by dysphagia, pyrosis and regurgitation, but absent considerable impairment of health, laryngeal stenosis, or moderate laryngeal stricture. 6. The Veteran's recurrent cerumen impaction does not result in any significant impairment of earning capacity. 7. For the time period prior to June 3, 2010, the Veteran's nasal obstruction secondary to radiation therapy was not shown to result in greater than 50 percent nasal obstruction on both sides, incapacitating sinusitis episodes, or at least three non- capacitating sinusitis episodes during a 12-month period. 8. For the time period beginning on June 3, 2010, the Veteran's nasal obstruction secondary to radiation therapy demonstrated greater than 50 percent nasal obstruction on both sides, but has not been shown to result in incapacitating sinusitis episodes, or more than six non-capacitating sinusitis episodes during a 12- month period. CONCLUSION OF LAW The criteria for a disability rating in excess of 30 percent for voice hoarseness as a residual of squamous cell carcinoma of the right vocal cord have not been met, but a separate 10 percent disability rating for reflux laryngitis residuals have been met for the entire appeal period and a separate 10 percent rating for nasal obstruction has been met effective June 3, 2010. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.321(b), 4.1-4.14, 4.97, 4.118, Diagnostic Codes (DCs) 6510-14, 6516, 6519, 6522-24, 6819, 7203, 7346 (2010). REASONS AND BASES FOR FINDINGS AND CONCLUSION Veterans Claims Assistance Act of 2000 Before addressing the merits of the Veteran's claim on appeal, the Board is required to ensure that VA's "duty to notify" and "duty to assist" obligations have been satisfied. See 38 U.S.C.A. §§ 5103, 5103A (West 2002); 38 C.F.R. § 3.159 (2010) Quartuccio v. Principi, 16 Vet. App. 183, 187 (2002); Pelegrini v. Principi, 18 Vet. App. 112 (2004). The notification obligation was accomplished by way of a letter from the RO to the Veteran dated in October 2005. In June 2006, the Veteran was provided with notice of the types of evidence necessary to establish a disability rating and the type of evidence necessary to establish an effective date. Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). In cases where service connection has been granted and an initial disability rating and effective date have been assigned, the typical service connection claim has been more than substantiated, it has been proven, thereby rendering 38 U.S.C.A. § 5103(a) notice no longer required because the purpose that the notice is intended to serve has been fulfilled. Dingess, 19 Vet. App. at 473; Dunlap v. Nicholson, 21 Vet. App. 112 (2007). The appellant bears the burden of demonstrating any prejudice from defective notice with respect to the downstream elements. Goodwin v. Peake, 22 Vet. App. 128 (2008). That burden has not been met in this case. The Veteran's post-service VA and private medical records are on file, as are multiple VA examination reports. The case was remanded, in part, in February 2010 for additional examination of laryngeal cancer residuals. The examination report obtained, dated June 2010, contains all findings necessary to decide this claim and fully complies with the Board's February 2010 remand directive. The Board notes that this claim was remanded in February 2010, in part, upon the Veteran's report of being in receipt of Social Security Administration (SSA) disability benefits. A June 2010 VA Memorandum reflects a formal finding on the unavailability of Social Security records. A request was faxed to SSA in March 2010. This request was forwarded to the Office of Central Operations (OCO), Office of Disability Operations (ODO) Special Workgroup, and a response from OCO ODO Special Workgroup stated that they had no medical records or were unable to locate medical records. Given the unsuccessful attempts, evident from the record, by VA to obtain these records, the Board finds that additional attempts to obtain these records would be futile. In any event, the Veteran testified in January 2007 that he began receiving Social Security Benefits in 1989, which is many years before his laryngeal cancer was diagnosed and treated. As such, the relevance of these records is not demonstrated. See Golz v. Shinseki, 590 F.3d 1343 (Fed. Cir. 2010) (finding that VA's duty to assist "is not boundless in scope" and does not require a search for irrelevant records). Overall, the Board finds that the RO has substantially complied with its February 2010 remand directives pertaining to SSA records. The Veteran and his representative have not made the RO or the Board aware of any additional evidence that needs to be obtained in order to fairly decide this appeal, and have not argued (nor does the evidence show) any notice deficiency, or that any error or deficiency in the accomplishment of the duty to notify and duty to assist has prejudiced him in the adjudication of his appeal. Mayfield v. Nicholson, 19 Vet. App. 103 (2005), rev'd on other grounds, 444 F. 3d 1328 (Fed. Cir. 2006). Therefore, the Board finds that duty to notify and duty to assist have been satisfied. Criteria & Analysis Disability evaluations are determined by the application of the Schedule for Rating Disabilities, which assigns ratings based on the average impairment of earning capacity resulting from a service-connected disability. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4. Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. In order to evaluate the level of disability and any changes in condition, it is necessary to consider the complete medical history of the veteran's condition. Schafrath v. Derwinski, 1 Vet. App. 589, 594 (1991). Where, as in the instant case, the appeal arises from the original assignment of a disability evaluation following an award of service connection, the severity of the disability at issue is to be considered during the entire period from the initial assignment of the disability rating to the present time. See Fenderson v. West, 12 Vet. App. 119 (1999). In Fenderson, the Court also discussed the concept of the "staging" of ratings, finding that in cases where an initially assigned disability evaluation has been disagreed with, it was possible for a veteran to be awarded separate percentage evaluations for separate periods based on the facts found during the appeal period. Fenderson at 126-28; see also Hart v. Mansfield, 21 Vet. App. 505 (2007). Pyramiding, which is the evaluation of the same disability or the same manifestation of a disability under different diagnostic codes, is to be avoided when rating a veteran's service-connected disabilities. 38 C.F.R. § 4.14. However, it is possible for a veteran to have separate and distinct manifestations from the same injury, which would permit rating under several diagnostic codes. The critical element in permitting the assignment of several ratings under various diagnostic codes is that none of the symptomatology for any one of the conditions is duplicative or overlapping with the symptomatology of the other condition. See Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994). Where the particular disability is not listed, it may be rated by analogy to a closely related disease in which not only the functions affected, but also the anatomical location and symptomatology are closely analogous. 38 C.F.R. §§ 4.20, 4.27; see also Lindeman v. Principi, 3 Vet. App. 345 (1992); Pernorio v. Derwinski, 2 Vet. App. 625 (1992). The claimant bears the burden of presenting and supporting his/her claim for benefits. 38 U.S.C.A. § 5107(a). See Fagan v. Shinseki, 573 F.3d 1282 (Fed. Cir. 2009). In its evaluation, the Board shall consider all information and lay and medical evidence of record. 38 U.S.C.A. § 5107(b). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Board shall give the benefit of the doubt to the claimant. Id. Another way stated, VA has an equipoise standard akin to the rule in baseball that "the tie goes to the runner." Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Notably, the benefit of the doubt doctrine is not applicable based on pure speculation or remote possibility. See 38 C.F.R. § 3.102. A lay claimant is competent to provide testimony concerning factual matters of which he or she has firsthand knowledge (i.e., reporting something seen, sensed or experienced). Barr v. Nicholson, 21 Vet. App. 303 (2007); Washington v. Nicholson, 19 Vet. App. 362 (2005). Under certain circumstances, lay statements may serve to support a claim for service connection by supporting the occurrence of lay-observable events or the presence of disability, or symptoms of disability, susceptible of lay observation. Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009); Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). In Barr, the United States Court of Appeals for Veterans Claims (Court) emphasized that when a condition may be diagnosed by its unique and readily identifiable features, the presence of the disorder is not a determination "medical in nature" and is capable of lay observation. In such cases, the Board is within its province to weigh that testimony and to make a credibility determination as to whether that evidence supports a finding of service incurrence and continuity of symptomatology sufficient to establish service connection. However, there are clearly limitations regarding the competence of a lay claimant to speak to certain matters, such as those involving medical diagnosis and etiology. See Jandreau, 492 F.3d at 1377 (Fed. Cir. 2007) (noting that a layperson not competent to diagnose a form of cancer). As reflected in Fed.R.Evid 701, lay witness testimony is permissible in the form of opinions or inferences when (a) rationally based on the perception of the witness and (b) helpful to a clear understanding of the witness' testimony or the determination of a fact in issue. Otherwise, in matters involving scientific, technical or other specialized knowledge, Fed.R.Evid 702 requires that an opinion be provided by a witness qualified as an expert by knowledge, skill, experience, training or education. The present appeal involves the Veteran's claim that the severity of his service-connected squamous cell carcinoma of the right vocal cord warrants a higher initial disability rating. Historically, the Veteran was diagnosed with laryngeal cancer by VA in February 2002. Notably, he weighed 174 pounds at that time. Thereafter, the Veteran underwent radiation therapy, involving a total dose of 6600 Centigray in 53 fractions over 48 days. The last treatment was on May 7, 2002. The Veteran filed his service connection claim on March 28, 2003. An April 2006 rating decision granted service connection for squamous cell carcinoma of the right vocal cord and assigned a 30 percent disability rating effective March 28, 2003. The RO rated this disability as 30 percent disabling under 38 C.F.R. § 4.97, DC 6819-6516. See 38 C.F.R. § 4.27 (hyphenated diagnostic codes are used when a rating under one diagnostic code requires use of an additional diagnostic code to identify the basis for the evaluation assigned, the additional code is shown after the hyphen). DC 6819 governs malignant neoplasms of any specified part of the respiratory system. The Board finds it appropriate that the Veteran's larynx has been evaluated as part of the respiratory system. See generally 38 C.F.R. § 4.97, DCs 6515-18 (evaluating larynx disabilities within the framework for diseases and disabilities of the respiratory system). Under DC 6819, a rating of 100 percent continues for beyond the cessation of any surgical, x-ray, antineoplastic chemotherapy or other therapeutic procedure. Six months after the discontinuance of such treatment, the appropriate disability rating is determined by mandatory VA examination. Any change in evaluation based upon that or any subsequent examination shall be subject to the provisions of 38 C.F.R. § 3.105(e). If there has been no local recurrence or metastases, the rating is based on residuals. 38 C.F.R. § 4.97, DC 6819. At the outset, the Board notes that, following the cessation of radiation therapy on May 7, 2002, the Veteran has not undergone any further therapeutic treatment for laryngeal cancer. While some clinical records record impressions of laryngeal cancer, these records merely reflect a past history of laryngeal cancer and do not contain any actual findings of recurrence based upon clinical evidence. The record does not show, and the Veteran does not contend, that he has had a recurrence of laryngeal cancer since May 2002. See generally LeShore v. Brown, 8 Vet. App. 406, 409 (1995) (the recording of a past medical history does not equate with a current medical diagnosis). The medical records also reflect routine monitoring of abnormal nodules in the Veteran's lungs, liver and neck for potential metastases or malignancies. Fortunately, there has been no evidence of laryngeal cancer recurrence or metastasis. See, e.g., VA computerized tomography (CT) scan dated June 2004 (monitoring a 9 millimeter soft tissue attenuation on the right side of the vocal cord and the supraglottic space); CT scans of the chest dated November 2003, January 2004, November 2004 and October 2006); and CT scan of the head January 2008. As indicated above, the RO has granted service connection for laryngeal cancer effective March 28, 2003, which is beyond the mandatory 6 month 100 percent rating period. As this rating has never been applied, the procedural protections of 38 C.F.R. § 3.105(e) referenced in the note to DC 6819 also have no application in the case. The Veteran's private physician has identified the Veteran's residuals of laryngeal cancer, status post radiation therapy, to be 1) chronic laryngitis secondary to radiation therapy; 2) reflux laryngitis and 3) recurrent cerumen impaction secondary to radiation therapy. Notably, in January 2006, a VA examiner provided opinion that the Veteran's laryngeal cancer unlikely caused a currently manifested septal deviation. However, this examiner indicated that radiation treatment residuals included mucosal edema and nasal obstruction. Thus, the Board will adjudicate this claim to ensure that all residual symptomatology involving chronic laryngitis, reflux laryngitis, recurrent cerumen impaction and mucosal edema with nasal obstruction are adequately compensated. See Esteban, 6 Vet. App. at 261-62. The Board will not evaluate, however, aspects of disability related to septal deviation. DC 6516 provides a maximum 30 percent rating for chronic laryngitis manifested by hoarseness, with thickening or nodules of cords, polyps, submucous infiltration or pre-malignant changes on biopsy. See 38 C.F.R. § 4.97, DC 6516. Since this is the maximum rating available under DC 6516, the only other potentially applicable code is DC 6519, which provides a 60 percent disability rating when there is complete organic aphonia with constant inability to speak above a whisper. Also, a 100 percent disability rating is warranted when there is a constant inability to communicate by speech. See 38 C.F.R. § 4.97, DC 6519. DC 6510 (pansinusitis), 6511 (ethmoid sinusitis), 6512 (frontal sinusitis), 6513 (maxillary sinusitis), and 6514 (sphenoid sinusitis) are to be rated under the General Rating Formula for Sinusitis. The General Rating Formula for Sinusitis provides a 10 percent rating for one or two incapacitating episodes per year of sinusitis requiring prolonged (lasting four to six weeks) antibiotic treatment, or; three to six non-incapacitating episodes per year of sinusitis characterized by headaches, pain, and purulent discharge or crusting. Under the General Rating Formula for Sinusitis, a 30 percent rating for three or more incapacitating episodes per year of sinusitis requiring prolonged (lasting four to six weeks) antibiotic treatment, or; more than six non-incapacitating episodes per year of sinusitis characterized by headaches, pain, and purulent discharge or crusting. A 50 percent rating is assigned following radical surgery with chronic osteomyelitis, or; near constant sinusitis characterized by headaches, pain and tenderness of affected sinus, and purulent discharge or crusting after repeated surgeries. A Note to the General Rating Formula for Sinusitis provides that an incapacitating episode of sinusitis means one that requires bed rest and treatment by a physician. 38 C.F.R. § 4.97. DC 6522 provides ratings for allergic or vasomotor rhinitis. A 10 percent rating is warranted for allergic or vasomotor rhinitis without polyps, but greater than 50-percent obstruction of nasal passage on both sides or complete obstruction on one side. Allergic or vasomotor rhinitis with polyps is rated 30 percent disabling. 38 C.F.R. § 4.97. DC 6523 provides ratings for bacterial rhinitis. A 10 percent rating is warranted for permanent hypertrophy of turbinates and with greater than 50-percent obstruction of nasal passage on both sides, or complete obstruction on one side. A 50 percent rating is warranted for rhinoscleroma. 38 C.F.R. § 4.97. DC 6524 provides ratings for granulomatous rhinitis. Wegener's granulomatosis, lethal midline granuloma, is rated 100 percent disabling. 38 C.F.R. § 4.97. Other types of granulomatous infections are rated as 20 percent disabling. The regulations provide that there are diseases of the digestive system, particularly within the abdomen, which, while differing in the site of pathology, produce a common disability picture characterized in the main by varying degrees of abdominal distress or pain, anemia and disturbances in nutrition. Consequently, certain coexisting diseases in this area, as indicated in the instruction under the title "Diseases of the Digestive System," do not lend themselves to distinct and separate disability evaluations without violating the fundamental principle relating to pyramiding as outlined in § 4.14. See 38 C.F.R. § 4.113. Ratings under diagnostic codes 7301 to 7329, inclusive, 7331, 7342 and 7345 to 7348 inclusive will not be combined with each other. A single evaluation will be assigned under the diagnostic code which reflects the predominant disability picture, with elevation to the next higher evaluation where the severity of the overall disability warrants such elevation. 38 C.F.R. § 4.114. Gastroesophageal reflux disease (GERD) may be appropriately rated by analogy to hiatal hernia, pursuant to 38 C.F.R. § 4.114, DC 7346. Under this diagnostic code, symptoms of pain, vomiting, material weight loss and hematemesis or melena with moderate anemia; or other symptom combinations productive of severe impairment of health warrants a 60 percent evaluation. A 30 percent evaluation is warranted where there is persistently recurrent epigastric distress with dysphagia, pyrosis and regurgitation, accompanied by substernal or arm or shoulder pain, productive of considerable impairment of health. Finally, a 10 percent evaluation is warranted with two or more of the symptoms for the 30 percent evaluation of less severity. Under DC 7203, stricture of esophagus, a 30 percent rating requires moderate stricture, a 50 percent rating requires severe stricture, permitting liquids only, and an 80 percent rating requires passage of liquids only, with marked impairment of general health. 38 C.F.R. § 4.114, Diagnostic Code 7203. The rating schedule provides guidance in the evaluation of gastrointestinal disorders. In particular, 38 C.F.R. § 4.112 highlights the importance of weight loss in the evaluation of the impairment resulting from gastrointestinal disorders. For purposes of evaluating conditions in 38 C.F.R. § 4.114, the term "substantial weight loss" means a loss of greater than 20 percent of the individual's baseline weight, sustained for three months or longer; and the term "minor weight loss" means a weight loss of 10 to 20 percent of the individual's baseline weight, sustained for three months or longer. 38 C.F.R. § 4.112. The term "inability to gain weight" means that there has been substantial weight loss with inability to regain it despite appropriate therapy. "Baseline weight" means the average weight for the two-year-period preceding onset of the disease. There is no specific diagnostic code evaluating cerumen impaction. Notably, the Veteran is currently in receipt of a 40 percent rating for bilateral hearing loss. Thus, the criteria of DC 6100 pertaining to hearing loss are not applicable to the current claim at hand. The only potential applicable diagnostic code pertains to chronic otitis media. Under DC 6210, a 10 percent rating is warranted for chronic otitis media manifested by dry and scaly swelling or serous discharge, and itching requiring frequent and prolonged treatment. 38 C.F.R. § 4.87. Following the cessation of radiation treatment in March 2002, the pertinent VA outpatient treatment records include a February 2004 visitation which reported the Veteran as having a voice change "with excessive use only." In June 2004, the Veteran complained of sore throat, hoarseness and right nasal obstruction. Physical examination demonstrated a right larynx cord which was slightly thickened as well as a right obstructive caudal deflection at the columella. A septoplasty was advised. A CT scan in June 2004 revealed a 9 millimeter soft tissue attenuation on the right side of the vocal cord and the supraglottic space which showed no interval change. In January 2005, the Veteran's vocal cords were found to be mobile with mild erythema. The Veteran denied symptoms of dysphagia or dyspnea. He had an episode of voice change the prior month which returned spontaneously. In August 2005, the Veteran was observed to have a slightly hoarse voice. In December 2005, multiple CT scans resulted in an impression of low probability of malignancy with mild asymmetry in the right larynx. In December 2005, the Veteran was also diagnosed with status post radiation squamous cell carcinoma of the right vocal cord with no evidence of recurrence. Furthermore, the Veteran was prescribed Omeprazole due to an assessment of reflux manifested by burning sensation of his soft palate, heartburn and regurgitation. A September 2005 report of medical history for Riverside Community Hospital included the Veteran's report of a dry/burning sensation of the throat which had been worsening over the last 6- 8 months. He described pain with talking, and having his voice quit within 30 to 60 minutes. On January 12, 2006, the Veteran underwent VA Compensation and Pension (C&P) internal medicine examination. At that time, the Veteran reported hoarseness, dry mouth, dry throat, difficulty swallowing solids, difficulty with swallowing and breathing simultaneously, constant sore throat, and popping/ringing of the ears. He denied any recurrence of cancer. On examination, the Veteran appeared well-developed, and well-nourished. He weighed 183.5 pounds. There was no evidence of nasal obstruction or sinus tenderness. The pharynx was normal without exudates or tonsillar involvement. There was no evidence of thyromegaly or compression of the trachea or larynx. The examiner indicated that the Veteran was status post radiation treatment for right vocal cord squamous cell carcinoma with no current evidence of radiation-induced dermatitis changes. The ENT examination was unremarkable with adequate saliva. However, the Veteran did report having residual hoarseness, dry mouth, and dysphagia from the radiation treatment. The Veteran underwent VA ENT examination on January 20, 2006. At that time, the Veteran reported laryngeal cancer residuals of difficulty swallowing, hoarseness, and difficulty breathing. He denied loss of work due to these symptoms. Examination of the nose revealed nasal obstruction with a 50 percent obstruction in the right nostril, and a 0 percent obstruction in the left nostril. The nose was deviated to the right. The findings were mild right septal deviation with hypertrophic turbinates, right greater than left. The examiner indicated that the rhinitis was believed to be allergic in origin due to sneezing and clear rhinorrhea. Examination of the larynx revealed voice hoarseness, inflammation of mucous membranes and inflammation of the cords on both sides. The findings were chronic post-radiation changes to the larynx. Vocal cord mobility was normal bilaterally, but the cords were inflamed. Examination of the pharynx revealed no paralysis, no stricture and no obstruction. The Veteran had speech impairment. The VA examiner reported a diagnosis of "laryngeal cancer" with subjective factors of hoarseness, dysphagia and dyspnea and objective factors of biopsy. In an addendum opinion, the examiner indicated that the Veteran's cancer was unlikely to cause septal deviation but may cause mucosal edema and nasal obstruction. A January 2006 VA clinical record noted that the Veteran's turbinates were without erythema, edema or discharge. There were no polyps. A February 2006 VA clinical record noted the Veteran's report of difficulty swallowing both liquids and solids. He described a sensation of having something stuck in his throat as well as having a "funny sensation" when eating. He was unsure whether he had heartburn, but denied loss of weight. It was noted that a January 2006 fluoroscopic image of the esophagus showed a filling defect along the right wall of the cervical esophagus. The Veteran was noted to have a hoarse voice upon examination. He was also advised to avoid cold liquids, and to drink warm sips for oesophageal spasms. An April 2006 VA clinical evaluation, noting the prior esophogram findings, noted that the Veteran denied GERD symptoms such as nausea, vomiting, diarrhea, abdominal pain, melena, and hematochezia. The Veteran was given an assessment of hiatal hernia treated with simethicone for gas as well as Omeprazole and Rantidine for reflux. That same month, a VA ENT consultation found no evidence of recurrent laryngeal tumor following a laryngoscopy. He did report difficulty with swallowing, coughing and catching his breath. An August 2006 treatment record from G.M.F., M.D., F.A.C.S., noted that the Veteran was having breathing difficulties due to an abscess of the right nostril. A September 2006 private examination report from J.P., M.A., C.C.C.-S.L.P., reported the Veteran's progressive difficulties with voice production, as well as pain and burning along the hyoid bone and palate, following his radiation treatment. Examination demonstrated that the Veteran had inadequate breath support for connected speech, below optimal pitch use (speaking at low end of register), decreased vocal intensity and complaints of pain with prolonged voice use. Palpation of larynx revealed elevated position of hyoid and laryngeal tension. The Veteran had lost laryngeal mobility and, due to pain, increased laryngeal tension. These problems were related to the previous radiation treatment. The Veteran underwent speech therapy in September 2006 to November 2006. His intake evaluation noted that the Veteran had poor breath control being able to phonate /a/ for an average of 6 seconds. He reported pain with digital manipulation of the larynx. He described occasional choking during swallow of liquid or saliva. His voice quality was hoarse, strained and gravelly. He further reported pain, tingling, and discomfort to the roof of mouth. A private examination report from G.M.F., M.D., F.A.C.S., dated in October 2006, reflected an assessment that the Veteran suffered from chronic laryngitis with inability to speak for prolonged periods. Dr. G.M.F. diagnosed laryngeal cancer, chronic laryngitis secondary to radiation therapy, reflux laryngitis, and recurrent cerumen impaction secondary to radiation therapy. Another private otolaryngology examination in October 2006 included an impression of "larynx cancer." However, a fiberoptic nasopharyngolaryngoscopy demonstrated a clear nasopharynx, normal appearing epiglottis and larynx, no evidence of lesions or ulcerations, mobile vocal cords, and minimal evidence of reflux. The oropharynx, base of tongue and vallecula also appeared normal, but there were retained secretions in the vallecula absent lesions. In the piriform sinuses, there was no evidence of lesions or ulcerations. A statement from the Veteran's spouse, received in October 2006, reported that the Veteran's daughter had observed his loss of voice at night after attempting to talk. The Veteran was described as having a low voice which required 45 minutes to an hour to regain full strength. A letter from J.P., M.A., C.C.C.-S.L.P., dated in November 2006, reflected that the Veteran made minimal progress during his speech therapy treatment sessions and did not appear to be practicing his vocal exercises at home. The Veteran required frequent redirections and was resistant to practicing voice exercises during treatment. A December 2006 treatment record from G.M.F., M.D., F.A.C.S., noted the Veteran's report of being unable to perform speech exercises secondary to severe throat pain. A CT scan of the mastoids revealed minimal bilateral anterior ethmoiditis with minimal left inferomedial frontal sinusitis. The Veteran testified at a hearing before a Decision Review Officer (DRO) in January 2007. He reported pain that ran from his neck up and around his ear. He stated that he constantly had pain upon speaking. He stated that his voice had never gotten to the point where he did not have the physical capacity to speak. However, during the hearing, the Veteran stopped speaking and had to be asked 'yes' or 'no' questions so he could either nod or shake his head to answer. The Veteran underwent another VA examination on January 23, 2007. He reported that he could no longer talk like he used to with his voice becoming rugged, rough, and unclear. He stated that his voice disappeared after talking for a while. He could no longer raise his voice like he used to, and had pain in the throat which occasionally prevented him from swallowing. He further reported breathing difficulty due to severe septal deformity. Upon physical examination, the Veteran's voice was rough and rugged. He talked with a strained voice which had not been improved with physical therapy. The Veteran did not look emaciated but, rather, was somewhat overweight. He apparently had been having some good oral nutrition. Examination of the nose demonstrated septal deviation on both sides, moderate congested nasal mucosa, and limited airway passage on both sides. The throat demonstrated an irritated posterior pharyngeal wall with very significant gag reflex. The uvula was of normal size. The tonsils and both tonsillar pillars were within normal range. The tongue and mouth were normal. The neck was supple. There were no palpable nodes. The trachea was midline. Direct fiberoptic examination passed through the left side of the nose with slight difficulty but showed normal epiglottis, aryepiglottic fold, arytenoids, post arytenoid area and vocal cords. The examiner did not see any evidence of residual tumor or recurrent tumor. Both vocal cords moved well and proximally midline. When the Veteran talked in a relaxed fashion, his voice improved. The examiner did not see any nodules or polyps. Both piriform sinuses appeared clear. The examiner diagnosed voice change, post radiation therapy for carcinoma of the vocal cords, with no evidence of residual recurrence. The examiner stated that voice changed due to improper vocalization and improper habitual phonation. There was no residual or recurrent cancer of the vocal cords. In an addendum, the examiner indicated that the Veteran had been able to speak above a whisper, and that he could talk above a whisper after talking for a period of time. The Veteran underwent another VA examination in July 2007 related to hearing loss and balance complaints (which have been addressed in separate RO rating decisions). In pertinent part, an intraoral examination was normal. The tongue was normal. Mobility of the tongue was normal. The flow of the mouth appeared to be normal. The hard palate and soft palate were normal. The uvula was in the midline. The tonsils appeared to be surgically removed. There was no exudate. The tongue base was normal. An indirect laryngoscopy was performed. Vallecular area was clear. Epiglottis appeared to be normal. Intrinsic larynx was visualized and there was some thickness and scarring of the right vocal cord. There was no lesion noted in the larynx. A VA clinic examination in August 2007 showed that the Veteran's turbinates were without erythema, edema or discharge. A VA ENT clinician in December 2007 commented that the Veteran's radiation treatment had affected his larynx with good vocal cord mobility and some telangectasis. The remaining VA clinical records contain no pertinent findings to the issues on appeal. An October 2009 Informal Hearing Presentation asserted that the Veteran could barely talk, had difficulty swallowing, had episodes of coughing, had difficulty catching breath, and had pain upon talking. It was reported that the Veteran could not speak for more than 20 to 55 minutes maximum per day. The Veteran underwent VA nose and sinus examination in May 2010. At that time, the Veteran denied a history of neoplasm. He reported a history of malignant tumor and perennial nasal allergy. He denied a history of osteomyelitis and sinusitis. He reported nasal congestion, excess nasal mucous, watery eyes, sneezing, purulent nasal discharge, weekly headaches, and sinus pain. He stated that he had frequent breathing difficulty and hoarseness. On physical examination, the Veteran weighed 174 pounds. There was no evidence of sinus disease or soft palate abnormality. There was zero percent left nasal obstruction and 30 percent right nasal obstruction. No nasal polyps were present. There was septal deviation which was not due to trauma. There was no permanent hypertrophy of turbinates from bacterial rhinitis. There was no rhinoscleroma present. There was no tissue loss or scarring or deformity of the nose. There was no evidence of Wegener's granulomatosis or granulomatous infection. The Veteran had not undergone a laryngectomy. There were no residuals of an injury to the pharynx, including nasopharynx. The examiner diagnosed status post adeno carcinoma treated with radiation. This disability had significant effects on usual occupation, with the impact being speech difficulty. The disability had no effect on feeding, bathing, dressing, toileting, and grooming. The disability had mild effects on shopping, exercise, sports, recreation, and traveling. The Veteran underwent VA ENT examination in June 2010. At that time, the Veteran denied interference with breathing through the nose and purulent discharge. He reported hoarseness which started after radiation therapy. He stated that speech therapy did not help significantly. He denied chronic sinusitis. He reported dry throat with burning sensation in the area which started after radiation therapy. He denied effects on occupational functioning, as he is retired. He stated that effects on daily activities were inability to talk that much and pain in the throat which affected his sleep. Upon physical examination, there was no allergic or vasomotor rhinitis. There was no bacterial rhinitis. There was 80 percent obstruction of the right nostril and 65 percent obstruction on the left nostril. There was septal deviation. There was no tissue loss, scarring, or deformity of the nose. There was no sinusitis. There was no disease affecting the soft palate. A fiberoptic laryngoscopy showed no lesions or edema of the nasopharynx down to the larynx. The right vocal cord was slightly erythematous; however, the cords were mobile and no lesions were seen. There were no residuals of injury or disease of the pharynx. There was no stenosis of the larynx. There was no facial disfigurement. The examiner diagnosed cancer of the larynx treated in 2002, and radiation therapy residuals including chronic mild inflammation of the right vocal cord, hoarseness, and pain of the throat. Additional evidence includes medical treatise documents which report that side effects of radiation therapy include severe pain, reduced salivary flow/dryness, edema, restricted movement, nausea and vomiting, reduced appetite, reduced senses of taste and smell, dental problems, and limited mobility of structures required for successful speech, voice or swallowing functions. With respect to the medical treatise documents, the Board has specifically identified 4 separate disease residuals which is consistent with the types of residual disorders identified in the medical treatise documents. To this extent, these documents have significant probative value and have assisted the Board in identifying potential disease characteristics. However, with respect to evaluating the current nature and severity of those residuals, these medical treatise documents have limited probative value and need not be further discussed. See generally Sacks v. West, 11 Vet. App. 314 (1998) (a generic medical treatise evidence that does not specifically opine to the particular facts of the appellant's case holds little probative value). Voice hoarseness Applying the criteria to the facts of this case, the Board finds that the Veteran is not entitled to an initial rating greater than 30 percent for his residual chronic laryngitis for any time during the appeal period. In this respect, the credible lay and medical evidence shows that the Veteran's chronic laryngitis does not result in complete organic aphonia with constant inability to speak above a whisper. The Veteran credibly reports hoarseness of voice following his radiation treatment for laryngeal cancer which is recognized by the current 30 percent rating assigned. This rating is consistent with his January 2007 hearing testimony which alleged as follows: POWER OF ATTORNEY: ... Approximately how long can on average you carry on a conversation before your voice breaks and fades away on you? VETERAN: It fluctuates. It will go anywhere from 20 minutes to 45, 55 minutes or so. And for it to recover I would imagine it takes about half that length of time. Clearly, the Veteran's own testimony in and of itself establishes that his chronic laryngitis does not result in complete organic aphonia with constant inability to speak above a whisper. Nonetheless, the Veteran seeks entitlement to a rating greater than 30 percent for his chronic laryngitis residuals. The Veteran has asserted an inability to speak for more than 20 to 55 minutes maximum per day. But, this in and of itself, also does not constitute complete organic aphonia with a constant inability to speak above a whisper. The Veteran and his spouse have also clearly described periods of time wherein he temporarily loses his voice due to a need of rest and recovery. This testimony and observation generally constitutes credible evidence in support of this claim, and is consistent with his RO hearing wherein he was unable to speak after a period of time testifying. However, this evidence does not establish that the Veteran has a "constant inability to speak above a whisper." Rather, the Veteran and his lay witnesses generally describe a hoarse voice which is lost after use, and requires a period of time for full recovery. Notably, the Veteran's own speech therapist found that the Veteran had functional loudness in close proximity. He had a low range pitch which dropped into glottal fry frequently, and he demonstrated markedly improved vocal quality when he maintained adequate breath support. A VA examiner in January 2007 specifically provided opinion that the Veteran had been able to speak above a whisper, and that he could talk above a whisper after talking for a period of time. Overall, the Board is entirely persuaded that the credible lay and medical evidence establishes that the Veteran's chronic laryngitis does not result in complete organic aphonia with constant inability to speak above a whisper. This finding is consistent with the credible and medical descriptions of disability. Other diagnostic codes that are remotely relevant include DC 6518 for total laryngectomy and DC 6520 for stenosis of the larynx. None of these diagnostic codes apply, however, as the medical evidence does not show any such impairment. As noted above, the May 2010 VA examiner noted that the Veteran had not undergone a laryngectomy. Moreover, the June 2010 VA examiner noted that there was no stenosis of the larynx. In this case, the Board acknowledges the Veteran's argument of entitlement to higher rating still. However, the Board places greater probative value to the private and VA clinicians who have described the Veteran's overall voice quality and characteristics, as these clinicians possess greater expertise and training than the Veteran and his lay witnesses in evaluating the characteristics of his chronic laryngitis. As the preponderance of the evidence is against this aspect of the claim, the issue of entitlement for further compensation related to chronic laryngitis residuals must be denied. 38 U.S.C.A. § 5107(b). Reflux laryngitis Applying the criteria to the facts of this case, the Board finds that the Veteran is entitled to a separate 10 percent rating, but no higher, for reflux laryngitis residuals for the entire appeal period. In this respect, the credible lay and medical evidence shows that the Veteran's reflux laryngitis has been manifested by dysphagia, pyrosis and regurgitation, but absent considerable impairment of health, laryngeal stenosis, or moderate laryngeal stricture. The medical evidence establishes that the Veteran manifests reflux laryngitis as secondary to service-connected laryngeal cancer status post radiation treatment. The Veteran has credibly reported symptomatology involving dysphagia, pyrosis and regurgitation which has been treated with anti-acid medications. These symptoms, in and of themselves, warrant an initial 10 percent rating under DC 7346. To this extent only, the claim is granted. However, the Board has carefully reviewed the record and does not find any instances wherein the Veteran has reported substernal, arm or shoulder pain related to reflux laryngitis origin. Furthermore, it is not argued or reasonably shown that the Veteran has demonstrated considerable impairment of health, laryngeal stenosis, or moderate laryngeal stricture. To the contrary, the Veteran's weight has remained stable since the onset of reflux laryngitis, and there has been no lay or medical evidence of compromised nutritional status. The Veteran himself has described intermittent dysphagia symptoms, which are used to support the 10 percent rating assigned. He does not report an inability to swallow liquids or foods. Absent lay or medical evidence relating to the factors for a higher rating still, the Board finds that the lay and medical evidence is against a rating greater than 10 percent rating for reflux laryngitis residuals for any time during the appeal period. There is no doubt of material fact to be resolved in the Veteran's favor. 38 U.S.C.A. § 5107. Recurrent cerumen impaction Applying the criteria to the facts of this case, the Board finds that the Veteran is not entitled to a separate compensable rating for recurrent cerumen impaction residuals for any time during the appeal period. In this respect, the credible lay and medical evidence shows that the Veteran recurrent cerumen impaction does not result in any significant impairment of earning capacity. The Veteran's private physician has identified recurrent cerumen impaction as a residual of radiation therapy to treat service- connected laryngeal cancer. However, this examiner did not identify any particular impairment of earning capacity or functional impairment caused by this abnormality. The Board has carefully reviewed the record, and fails to find any credible lay and medical evidence suggesting that the Veteran's recurrent cerumen impaction results in any significant impairment of earning capacity and/or functional impairment. One potential residual could involve decreased hearing acuity, but the Veteran is already in receipt of compensation benefits for hearing loss. Another potential residual involves symptoms analogous in degree to chronic otitis media. However, the Board has found no lay or medical evidence of ear symptomatology involving dry and scaly swelling or serous discharge and/or itching requiring frequent and prolonged treatment. Absent lay or medical evidence relating to these factors, the Board finds that the lay and medical evidence is against a compensable rating for recurrent cerumen impaction for any time during the appeal period. There is no doubt of material fact to be resolved in the Veteran's favor. 38 U.S.C.A. § 5107. Nasal obstruction Applying the criteria to the facts of this case, the Board finds that, for the time period prior to June 3, 2010, the criteria for a compensable rating for residuals of nasal obstruction have not been met for any time during the appeal period. In this respect, the credible lay and medical evidence did not show that the Veteran's nasal obstruction secondary to radiation therapy resulted in greater than 50 percent nasal obstruction on both sides, incapacitating sinusitis episodes, or at least three non- capacitating sinusitis episodes during a 12-month period. For the time period beginning on June 3, 2010, the Board finds that the criteria for a 10 percent rating, but no higher, for residuals of nasal obstruction have been met. In this respect, the credible lay and medical evidence establishes that the Veteran's nasal obstruction secondary to radiation therapy demonstrated greater than 50 percent nasal obstruction on both sides, but has not been shown to result in incapacitating sinusitis episodes, or more than six non-capacitating sinusitis episodes during a 12-month period. As indicated above, a January 2006 VA examiner provided opinion that the Veteran's radiation treatment resulted in residuals of mucosal edema and nasal obstruction. The mucosal edema is part of the criteria for supporting a 10 percent rating under DC 6516. These criteria, however, do not contemplate symptomatology involving nasal obstruction. The medical evidence of record prior to June 3, 2010 included a December 2006 CT scan of the mastoids which demonstrated minimal bilateral ethmoiditis and minimal left frontal sinusitis. Otherwise, VA C&P examination reports dated January 2006, January 2007, July 2007 and May 2010 failed to demonstrate nasal obstruction on both sides greater than 50 percent, incapacitating sinusitis episodes, or at least three non-capacitating sinusitis episodes during a 12-month period. Similarly, clinical evaluations in January 2006 and August 2007 returned essentially normal findings. The Board has carefully reviewed the record, and also finds no lay descriptions of nasal obstruction on both sides greater than 50 percent, incapacitating sinusitis episodes, or at least three non-capacitating sinusitis episodes during a 12-month period for the time period prior to June 3, 2010. In short, for the time period prior to June 3, 2010, the credible lay and medical evidence shows that the Veteran's nasal obstruction secondary to radiation therapy did not result in greater than 50 percent nasal obstruction on both sides, incapacitating sinusitis episodes, or at least three non- capacitating sinusitis episodes during a 12-month period. On VA C&P examination on June 3, 2010, the Veteran demonstrated an 80 percent obstruction of the right nostril and a 65 percent obstruction of the left nostril. This meets the criteria for a compensable rating under DC 6522. As addressed above, the Board can find no lay or medical evidence of record demonstrating that such symptoms had been present prior to this date. Nonetheless, the credible lay and medical evidence of record establishes that the Veteran has not demonstrated any clinical findings since June 3, 2010 which would entitle him to a higher rating still. Notably, the Veteran has not reported, and the evidence does not show, incapacitating sinusitis episodes, or more than six non-capacitating sinusitis episodes during a 12- month period. Furthermore, the medical evaluations found no evidence of polyps, rhinoscleroma or Wegener's granuloma to potentially warrant consideration of a higher rating still under DCs 6522-24. To the extent the Veteran argues entitlement to higher ratings still, the Board places greater probative value to the private and VA clinicians who have described the Veteran's overall nasal obstruction characteristics, as these clinicians possess greater expertise and training than the Veteran and his lay witnesses in evaluating the characteristics of this type of disability. As the preponderance of the evidence is against this aspect of the claim, the issue of entitlement for further compensation related to chronic laryngitis residuals must be denied. 38 U.S.C.A. § 5107(b). Extraschedular consideration To accord justice in an exceptional case where the scheduler standards are found to be inadequate, the field station is authorized to refer the case to the Chief Benefits Director or the Director, Compensation and Pension Service for assignment of an extraschedular evaluation commensurate with the average earning capacity impairment. 38 C.F.R. § 3.321(b)(1). The provisions of 38 C.F.R. § 3.321(b) state as follows: Ratings shall be based as far as practicable, upon the average impairments of earning capacity with the additional proviso that the Secretary shall from time to time readjust this schedule of ratings in accordance with experience. To accord justice, therefore, to the exceptional case where the schedular evaluations are found to be inadequate, the Under Secretary for Benefits or the Director, Compensation and Pension Service, upon field station submission, is authorized to approve on the basis of the criteria set forth in this paragraph an extra-schedular evaluation commensurate with the average earning capacity impairment due exclusively to the service- connected disability or disabilities. The governing norm in these exceptional cases is: A finding that the case presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization as to render impractical the application of the regular schedular standards. In Thun v. Peake, 22 Vet. App. 111 (2008), the Court clarified the analytical steps necessary to determine whether referral for extraschedular consideration is warranted. The Court stated that the RO or the Board must first determine whether the schedular rating criteria reasonably describe the Veteran's disability level and symptomatology. Id. at 115. If the schedular rating criteria do reasonably describe the Veteran's disability level and symptomatology, the assigned schedular evaluation is adequate, referral for extraschedular consideration is not required, and the analysis stops. Id. If the RO or the Board finds that the schedular evaluation does not contemplate the Veteran's level of disability and symptomatology, then either the RO or the Board must determine whether the Veteran's exceptional disability picture includes other related factors such as marked interference with employment and frequent periods of hospitalization. Id. at 116. If this is the case, then the RO or the Board must refer the matter to the Under Secretary for Benefits or the Director of the Compensation and Pension Service for the third step of the analysis, determining whether justice requires assignment of an extraschedular rating. Id. VA's General Counsel has stated that consideration of an extra- schedular rating under 3.321(b)(1) is only warranted where there is evidence that the disability picture presented by the Veteran would, in that average case, produce impairment of earning capacity beyond that reflected in the rating schedule or where evidence shows that the Veteran's service-connected disability affects employability in ways not contemplated by the rating schedule. See VAOPGCPREC 6-96 (Aug. 16, 1996). In Thun, the Court further explained that the actual wages earned by a particular veteran are not considered relevant in the calculation of the average impairment of earning capacity for a disability, and contemplate that veterans receiving benefits may experience a greater or lesser impairment of earning capacity than average for their disability. The Thun Court indicated that extraschedular consideration cannot be used to undo the approximate nature of the rating system created by Congress. The Board is precluded by regulation from assigning an extraschedular rating under 38 C.F.R. § 3.321(b)(1) in the first instance. However, the Board is not precluded from raising this question, see Floyd v. Brown, 9 Vet. App. 88 (1996), and addressing referral where circumstances are presented which the Director of VA's Compensation and Pension Service might consider exceptional or unusual. Shipwash v. Brown, 8 Vet. App. 218, 227 (1995). The Board is aware of the Veteran's complaints as to the effects of his service-connected residuals of laryngeal cancer have had on his activities of work and daily living. In the Board's opinion, all aspects of these disabilities are adequately encompassed in the assigned schedular ratings. Notably, the medical evidence has identified residual symptomatology involving voice hoarseness, reflux laryngitis, recurrent cerumen impaction and nasal obstruction. The Board has specifically addressed these varied symptoms under numerous diagnostic codes, providing separate disability ratings where such symptomatology has not overlapped. See 38 C.F.R. § 4.14. As addressed in each analysis, there are higher schedular evaluations assignable for greater levels of severity, but the Veteran does not meet or more closely approximate those criteria. Overall, the Board finds no unusual aspects of these disabilities which are credibly established which are not addressed in the schedular criteria. As the assigned schedular evaluations are adequate, there is no basis for extraschedular referral in this case. See Thun, 22 Vet. App. 111, 114-15 (2008). Therefore, referral by the RO to the Chief Benefits Director of VA's Compensation and Pension Service, under 38 C.F.R. § 3.321, is not warranted. See Bagwell v. Brown, 9 Vet. App. 337 (1996). ORDER An evaluation in excess of 30 percent for voice hoarseness as a residual of squamous cell carcinoma of the right vocal cord is denied, but a separate 10 percent disability rating for reflux laryngitis residuals for the entire appeal period and a separate 10 percent rating for nasal obstruction effective June 3, 2010 are granted. REMAND During the appeal period, the Veteran has raised a claim of entitlement to TDIU. In May 2009, the Court held that a request for TDIU, whether expressly raised by a Veteran or reasonably raised by the record, is not a separate claim for benefits, but rather involves an attempt to obtain an appropriate rating for a disability or disabilities which is part of a pending claim for increased compensation benefits. Rice v. Shinseki, 22 Vet. App. 447, 453-54 (2009). See also Comer v. Peake, 552 F.3d 1362, 1366 (Fed. Cir. 2009) (the issue of entitlement to TDIU is not a free- standing claim which must be pled with specificity). In light of the decision in Rice, the Board finds that the issue of entitlement to TDIU is currently before the Board. It would be fundamentally unfair to the Veteran to decide this aspect of the claim without further development and adjudication by the RO. See Bernard v. Brown, 4 Vet. App. 384 (1993). In order to comply with precedential Court opinion, the Board has listed the TDIU aspect of the claim as a separate issue for administrative purposes, and remands the issue for further development. Accordingly, the case is REMANDED for the following action: 1. Provide the Veteran notice consistent with 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) regarding the claim of entitlement to TDIU. 2. Obtain the Veteran's clinical records of treatment at the Loma Linda VA Medical Center since November 2008. 3. After completion of any necessary notice, assistance (to include obtaining pertinent VA treatment records), and other development which may be deemed necessary, the RO should adjudicate the Veteran's claim of entitlement to TDIU in a separate rating action. If the benefit sought on appeal remains denied, the Veteran and his representative should be furnished a supplemental statement of the case and an appropriate period of time 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). ____________________________________________ T. MAINELLI Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs