Citation Nr: 1103802 Decision Date: 01/31/11 Archive Date: 02/08/11 DOCKET NO. 08-37 656 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Seattle, Washington THE ISSUES 1. Entitlement to service connection for a psychiatric disorder, to include as secondary to service-connected idiopathic central nervous system hypersomnolence syndrome (narcolepsy). 2. Entitlement to an increased rating for narcolepsy, to include whether a December 2006 reduction from 60 percent to 20 percent for narcolepsy was proper. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD Jennifer Hwa, Counsel INTRODUCTION The Veteran served on active duty from August 1984 to March 1991. This matter comes before the Board of Veterans' Appeals (Board) from December 2006 rating decisions of a Department of Veterans Affairs (VA) Regional Office (RO) that denied service connection for an acquired psychiatric disorder and reduced the rating for narcolepsy from 60 percent to 20 percent, effective March 1, 2007. The Veteran testified before the Board in October 2010. The issue of service connection for sleep apnea, to include as secondary to service-connected idiopathic central nervous system hypersomnolence syndrome, has been raised by the record, but has not been adjudicated by the Agency of Original Jurisdiction (AOJ). Therefore, the Board does not have jurisdiction over that issue, and it is referred to the AOJ for appropriate action. FINDINGS OF FACT 1. In an August 2010 communication and at his October 2010 hearing before the Board, the Veteran withdrew his appeal concerning entitlement to service connection for a psychiatric disorder. 2. Since March 1, 2007, the Veteran's idiopathic central nervous system hypersomnolence syndrome has not demonstrated sustained improvement because the evidence shows that the Veteran has continued to experience 9 to 10 minor attacks of narcolepsy per week. 3. The Veteran's idiopathic central nervous system hypersomnolence syndrome has been manifested by 9 to 10 minor attacks of narcolepsy per week. CONCLUSIONS OF LAW 1. The criteria for withdrawal of a substantive appeal of the issue of entitlement to service connection for a psychiatric disorder have been met. 38 U.S.C.A. § 7105(b)(2) (West 2002); 38 C.F.R. §§ 20.202, 20.204 (2010). 2. The December 2006 reduction of the rating for idiopathic central nervous system hypersomnolence syndrome from 60 percent to 20 percent was not proper. 38 U.S.C.A. § 5112(b)(6) (West 2002); 38 C.F.R. §§ 3.105, 3.344 (2010). 3. The criteria for an increased rating for idiopathic central nervous system hypersomnolence syndrome have not been met. 38 U.S.C.A. §§ 1155, 5107(b) (West 2002); 38 C.F.R. §§ 4.7, 4.31, 4.124, 4.124a, Diagnostic Codes 8108, 8911 (2010). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Withdrawal A substantive appeal may be withdrawn in writing at any time before the Board promulgates a decision. 38 C.F.R. §§ 20.202, 20.204(b) (2010). Withdrawal may be made by the appellant or by his authorized representative. 38 C.F.R. § 20.204(c) (2010). In December 2008, the Veteran submitted a substantive appeal perfecting his appeal as to the issue of entitlement to service connection for a psychiatric disorder, as identified in the October 2008 statement of the case. In an August 2010 written communication and at his October 2010 hearing before the Board, the Veteran stated that he wanted to withdraw his pending claim of entitlement to service connection for a psychiatric disorder. The Veteran's written statement indicating his intention to withdraw the appeal satisfies the requirements for the withdrawal of a substantive appeal. Additionally, the Veteran's testimony indicating his intention to withdraw the appeal as to this issue, once transcribed as a part of the record of his hearing, also satisfies the requirements for the withdrawal of a substantive appeal. Tomlin v. Brown, 5 Vet. App. 355 (1993). As the appellant has withdrawn his appeal as to the issue of entitlement to service connection for a psychiatric disorder, there remain no allegations of errors of fact or law for appellate consideration concerning this issue. The Board therefore has no jurisdiction to review this issue. Accordingly, the issue of entitlement to service connection for a psychiatric disorder is dismissed. Reduction and Increased Rating The Veteran argues that his narcolepsy has not improved since March 1, 2007, and that it has actually worsened to the point where it has had a profound effect on his employment. A Veteran's disability rating shall not be reduced unless an improvement in the disability is shown to have occurred. 38 U.S.C.A. § 1155 (West 2002). Prior to reducing a Veteran's disability rating, VA is required to comply with several VA regulations applicable to all rating-reduction cases, regardless of the rating level or the length of time that the rating has been in effect. Generally, when reduction in the rating of a service-connected disability is contemplated and the lower rating would result in a reduction or discontinuance of compensation payments, a rating proposing the reduction or discontinuance will be prepared setting forth all material facts and reasons. The beneficiary must be notified at his latest address of record of the contemplated action and furnished detailed reasons therefore. The beneficiary must be given 60 days for the presentation of additional evidence to show that compensation payments should be continued at the present level. 38 C.F.R. § 3.105(e) (2010). In the advance written notice, the beneficiary will be informed of the right to a pre-determination hearing, and if a timely request for hearing is received within 30 days, benefit payments shall be continued at the previously established level pending a final determination. 38 C.F.R. § 3.105(i)(1) (2010). The record shows that in an April 2006 letter, the Veteran was notified of a proposal to reduce the rating assigned for his narcolepsy. He was notified that he had 60 days for the presentation of additional evidence to show that compensation payments should be continued at the present level, and that if he did not respond within those 60 days, his disability rating would be reduced, effective no earlier than June 1, 2006. The record shows that the Veteran responded to the April 2006 letter by requesting a pre-determination hearing and submitting additional evidence in the form of a letter from his treating VA physicians. Evaluating the chronology of the actions described above, the Board finds that the RO complied with the procedures required under 38 C.F.R. § 3.105(e) for reducing the Veteran's rating by notifying him of his rights and giving him an opportunity for a pre-determination hearing and time to respond. In certain rating reduction cases, VA benefits recipients are to be afforded greater protections. 38 C.F.R. § 3.344(a)(b) (2010). Those regulations provide that rating agencies will handle cases affected by change of medical findings or diagnosis, so as to produce the greatest degree of stability of disability evaluations consistent with the laws and VA regulations governing disability compensation and pension. However, the those considerations are applicable only for ratings which have continued for long periods, five years or more, at the same level, and do not apply to disabilities which have not become stabilized and are likely to improve. 38 C.F.R. § 3.344(c) (2010). Reexaminations disclosing improvement, physical or mental, in disabilities will warrant a reduction in rating. Similar protections are afforded to Veterans who have been awarded a total rating based on unemployability. 38 C.F.R. § 3.343 (2010). Under the criteria regarding reductions, the RO must find the following: (1) based on a review of the entire record, the examination forming the basis for the reduction is full and complete, and at least as full and complete as the examination upon which the rating was originally based; (2) the record clearly shows a finding of material improvement; and (3) it is reasonably certain that the material improvement found will be maintained under the ordinary conditions of life. 38 C.F.R. § 3.344(a),(b) (2010); Kitchens v. Brown, 7 Vet. App. 320 (1995); Brown v. Brown, 5 Vet. App. 413 (1993). In this case, however, the 60 percent rating for narcolepsy was in effect for less than five years, from June 3, 2004, to March 1, 2007. Therefore, the provisions of 38 C.F.R. § 3.344(a) and 38 C.F.R. § 3.344(b) are not applicable. 38 C.F.R. § 3.344(c) (2010). An examination disclosing improvement will warrant reduction in the rating. 38 C.F.R. § 3.344(c) (2010). The question is thus whether an examination showed an improvement warranting reduction in the rating. Ratings for service-connected disabilities are determined by comparing the Veteran's symptoms with criteria listed in VA's Schedule for Rating Disabilities, which is based, as far as practically can be determined, on average impairment in earning capacity. Separate diagnostic codes identify the various disabilities. 38 C.F.R. Part 4 (2010). When rating a service- connected disability, the entire history must be borne in mind. Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Where there is a question as to which of two ratings shall be applied, the higher rating 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 (2010). The Board will consider entitlement to staged ratings to compensate for times since filing the claim when the disability may have been more severe than at other times during the course of the claim on appeal. Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). The Veteran is currently rated under Diagnostic Code 8108-8911 for his narcolepsy. 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. 38 C.F.R. § 4.27 (2010). Diagnostic Code 8108 pertains to narcolepsy, which is to be rated as epilepsy, petit mal. 38 C.F.R. § 4.124a, Diagnostic Code 8108 (2010). Diagnostic Code 8911 pertains to epilepsy, petit mal. 38 C.F.R. § 4.124a, Diagnostic Code 8911 (2010). The Rating Schedule does not contain a specific diagnostic code for idiopathic central nervous system hypersomnolence syndrome. However, where an unlisted condition is encountered it is permissible to rate it under a closely related disease or injury, in which not only the functions affected, but the anatomical localization and symptomatology are closely analogous. 38 C.F.R. § 4.20 (2010). In this case, the Board finds that Diagnostic Code 8108, which pertains to narcolepsy and directs the rater to rate the disability as petit mal epilepsy under Diagnostic Code 8911, is the most closely analogous diagnostic code. 38 C.F.R. § 4.84 (2010). Under Diagnostic Code 8911, for petit mal epilepsy, both the frequency and type of seizures a Veteran experiences are considered in determining the appropriate rating. A major seizure is characterized by generalized tonic-clonic convulsion with unconsciousness. A minor seizure consists of a brief interruption in consciousness or conscious control associated with staring or rhythmic blinking of the eyes or nodding of the head (pure petit mal), or sudden jerking movements of the arms, trunk, or head (myoclonic type) or sudden loss of postural control (akinetic type). 38 C.F.R. § 4.124a (2010). To warrant a rating the seizures must be witnessed or verified at some time by a physician, and regarding the frequency of epileptiform attacks, competent, consistent lay testimony emphasizing convulsive and immediate post-convulsive characteristics may be accepted. It is also provided that the frequency of seizures should be ascertained under the ordinary conditions of life while not hospitalized. 38 C.F.R. § 4.121 (2010). Under the general formula for major and minor epileptic seizures, both the frequency and type of seizure a Veteran experiences are considered in determining the appropriate rating. A 10 percent rating is assigned for a confirmed diagnosis of epilepsy with a history of seizures. A 20 percent rating is assigned when there has been at least one major seizure in the last two years or at least two minor seizures in the last six months. A 40 percent rating is assigned when there is at least one major seizure in the last six months or two in the last year; or averaging at least five to eight minor seizures weekly. A 60 percent rating is assigned when there is an average of at least one major seizure in four months over the last year; or nine to 10 minor seizures per week. An 80 percent rating is assigned when there is an average of at least one major seizure in three months over the last year; or more than 10 minor seizures weekly. A 100 percent rating is warranted when there is an average of one major seizure per month over the last year. 38 C.F.R. § 4.124a, Diagnostic Code 8911 (2010). When continuous medication is shown necessary for the control of epilepsy, the minimum rating will be 10 percent. This rating will not be combined with any other rating for epilepsy. In the presence of major and minor seizures, the predominating type of epilepsy is to be rated. There will be no distinction between diurnal and nocturnal major seizures. 38 C.F.R. § 4.124a, General Rating Formula for Major and Minor Epileptic Seizures, Notes (1)-(3) (2010). In a June 3, 2004, VA medical report, the Veteran reported that his symptoms had worsened because he felt more tired lately and was falling asleep more easily at his job, especially when his work was finished and he had some down time. His medications were increased. VA medical records dated from July 2004 to February 2005 show that the Veteran requested a medical letter to his employer in July 2004 explaining his condition and assistance in applying for Family Medical Leave in September 2004 for times when he was unable to go to work due to hypersomnolence. The Veteran complained that he continued to fall asleep at work while doing paperwork. An April 2005 letter from the Veteran's treating VA physicians indicated that despite being on medication, the Veteran still required two to three naps at work each day and a nap when he got sleepy on the drive back from work. He was also noted to need to take a three to four hour nap on his first day off from work. The Veteran was found to struggle to maintain wakefulness both at work and home despite being on medication. On VA examination in October 2005, the Veteran reported having worked as an airline mechanic for the same company for the previous five years. He stated that he was doing fine at work except for in June 2004 when he fell asleep and missed an important deadline, causing him to nearly get fired. He maintained that since September 2004, he had increased his medication both prior to and after work so that he was safe to drive. At a March 2006 VA examination, the Veteran described a typical narcoleptic attack as one where he fell asleep very easily often at inappropriate times. He stated that the sleep was evoked by lack of sleep or inactivity. He reported experiencing 100 attacks in the previous two years and averaging four attacks per month. He complained of frequently falling asleep while sitting in church, reading, or watching television. He maintained that he often had to pull over while driving in order to take a nap. He stated that he had not fallen asleep while driving but that he had to take a nap at work. He complained that the symptoms occurred intermittently as often as daily with each occurrence lasting for 30 minutes. The examiner found that the Veteran's ability to perform daily functions during flare-ups was significantly impaired. The examiner noted that the Veteran was functionally impaired by sometimes oversleeping and missing work and that because he sometimes had to stop while driving, he would be late to work or other appointments. The examiner stated that the Veteran's narcolepsy had resulted in him missing work eight times per year. Neurological examination of the Veteran's upper and lower extremities was within normal limits. In a May 2006 letter, the Veteran's treating VA physicians reported that the Veteran continued to have uncontrolled sleep episodes despite being on two different medications to control his hypersomnolence. The physicians stated that the Veteran was fortunately in a van pool to get to work, where he drove his own vehicle 32 miles to get to the van and then traveled the remaining 33 miles in the van. The Veteran reported that he still fell asleep up to a few times a day, including in church every Sunday, in the van going to work at least twice a week, and in the van on the way home from work every day. The Veteran stated that because he was able to sleep in the van, he was able to stay awake when he drove himself home and avoid taking as much Ritalin to stay awake as he did when he was driving the entire way to the airport. On a typical work day, the Veteran would take a Modafinil pill when he arrived at work and then nap during his meal break. He would oversleep during his meal break about once a week. He took one to two Ritalin pills on his days off and one Ritalin pill on his work days. He took two to four Ritalin pills if he worked overtime. The Veteran had to call in sick about 12 times in the past year due to sleepiness. On the Veteran's days off, he had to shift his sleep cycle from daytime sleeping to nighttime sleeping in order to see his family, and this would contribute to his sleep problems. He would thereafter fall asleep three to four times a day on his days off. The physicians concluded that the Veteran continued to struggle to maintain wakefulness both at work and home despite his medication. A July 2006 statement from the Veteran's technical training instructor at work indicated that the Veteran was an airframe and power plant certified technician with Alaska Airlines and that he would have worked at the company for six years at the end of October 2006. The instructor reported that during the classroom portion of the qualification training for engine run and taxi procedures, he had observed the Veteran having difficulty staying alert. He stated that he had been made aware that the Veteran was being treated for a sleep disorder and that due to the inherent risks in engine run and taxi procedures, it had been determined that the Veteran would not be qualified for those responsibilities. At a July 2006 pre-determination hearing, the Veteran testified that his narcoleptic episodes occurred every day. He testified that he participated in a van pool to and from work and that he fell asleep in the van both to and from work. He reported that due to being able to nap in the van, he was usually able to stay awake for the drive home although he sometimes had to keep himself awake by turning up the music very loud, rolling down the windows, or slapping his face. He stated that he had to pull over to the side of the road to take a nap quite frequently, especially if he worked overtime. He maintained that if he was in a situation where he felt comfortable, he would often fall asleep without realizing it. He testified that once at work, he did not go out to work on his airplane when it had arrived because he had fallen asleep for four hours. He reported that due to his sleepiness, he had also been in several car accidents where he ran into a freeway barrier and a tree. He stated that before the van pool, he would have to pull over and stop driving at least 50 percent of the time. He maintained that he took two different types of medications, one that was long-term and another that was more short-term. The Veteran's wife testified that over the course of the previous month, the Veteran had probably fallen asleep in the middle of a conversation about 20 to 30 times. She reported that he fell asleep in church every week. She stated that she had to do most of the driving if they were in the car together because otherwise, he would fall asleep while driving. Post-service VA and private medical records dated from April 2005 to August 2010 show that the Veteran received intermittent treatment for his hypersomnolence syndrome. His hypersomnolence was noted by treating providers to be severe. In May 2006, a VA treating physician found that the Veteran's daytime sleepiness was unchanged from before, as he continued to require daily naps. The evidence revealed that despite taking medication before work, during his shift, and before driving home from work, the Veteran still had to pull over while driving and take a nap. In a September 2007 VA treatment report, it was noted that the Veteran was taking up to seven or eight pills of Ritalin in addition to two pills of Modafinil a day in order to control his narcolepsy and that his disability was thus found to be poorly controlled. A March 2009 VA treatment report found that there had been no change in the Veteran's narcolepsy symptoms. The Veteran reported still having to pull over to nap once or twice while driving to and from work. On VA examination in May 2010, the Veteran described a typical narcoleptic attack as being one where he became drowsy and finds it hard to keep his eyes open. He reported that during the past two years, he had experienced 800 such attacks and averaged 30 attacks each month. He complained that he was functionally impaired due to his disability because he was unable to perform all of his duties with his employment, including engine run and taxiing of aircraft. He also maintained that his commute to and from work required him to pull over several times to take naps. Neurological examination of the upper and lower extremities as well as mental examination were found to be within normal limits. The Veteran submitted an October 2010 letter from an automobile insurance company showing that the Veteran had been involved in a May 2010 at fault car accident where he struck a parked and unoccupied vehicle. The Veteran testified before the Board at an October 2010 hearing. Testimony revealed that the Veteran fell asleep at work once while he was waiting for his assigned aircraft to arrive and that he was almost fired as a result. The Veteran testified that since that incident, he took extra steps to prevent himself from falling asleep at work again. He reported that he always carries a radio and his cell phone at work so that his friends can contact him when he dozes off. He stated that on his days off from work, his wife always had to drive and that he would fall asleep literally as she was trying to talk to him. He maintained that he still had to pull over and take a nap on the way to work about once a week and that he had to pull over and take a nap about twice a week when coming home from work. He further testified that when he tried to get engine room qualified to allow him to perform ground operation of the aircraft, he fell asleep both while he was training in the simulator and while in the classroom. He reported that the engine room qualification instructor informed him that due to his sleep disorder, it was too much of a liability to get him engine room qualified and taxi qualified. He stated that he lost a bid for an available job with better hours at an airport closer to his house because the job required him to be engine room qualified and taxi qualified. He maintained that he got into a car accident in May 2010 when he fell asleep and hit a parked car just a few feet away from his house. He testified that taking public transportation was not a viable alternative to driving because it would take three hours to get to work. He reported that his company was no longer reimbursing its employees for half the cost of the van pool that he had been taking, which caused him to stop taking the van pool in January 2007 due to the expensive cost. As an initial matter, the Board finds that although the Veteran's narcoleptic attacks involve loss of consciousness, they are not characterized by generalized tonic-clonic convulsions. Therefore, the Board finds that they do not rise to the level and severity of incapacitation of major seizures. 38 C.F.R. § 4.124a (2010). Therefore, the Veteran's narcoleptic attacks will be considered as minor seizures for purposes of analysis. The Board notes that in an August 2005 rating decision, the RO increased the Veteran's rating for idiopathic central nervous system hypersomnolence from 10 percent to 60 percent, effective June 3, 2004, because the Veteran's disability was found to be no longer controlled by medication and was equivalent to an average of 9 to 10 minor seizures a week. 38 C.F.R. § 4.124a, Diagnostic Code 8911 (2010). Subsequently, in a December 2006 rating decision, the Veteran's rating was reduced from 60 percent to 20 percent disabling, effective March 1, 2007, because his disability was found to be controlled with less medication, he was able to drive 32 miles without pulling over to take a nap, and he did not need to invoke family medical leave at work due to his naps. The Board acknowledges that during the period of time when the Veteran participated in the van pool to and from work, he was able to drive the 32 miles to and from his house without having to pull over to take a nap. However, the Board finds that the Veteran's lack of naps during the 32 miles to and from his house did not show actual improvement in his narcolepsy disability because the Veteran still required naps while riding as a passenger in the van pool both to and from work each day. The Veteran's disability remained present during his participation in the van pool. Indeed, because the Veteran required naps during the 33 mile drive in the van pool, that indicates that he would have had to pull over to nap had he been driving those 33 miles. The Veteran's treating physicians have also consistently stated both that the Veteran continued to have uncontrolled sleep episodes despite being on two different medications to control his hypersomnolence and that there had been no change in his condition. In fact, the medical evidence demonstrates that despite taking medication before work, during his shift, and before driving home from work, the Veteran still had to pull over while driving and take a nap. In a September 2007 VA treatment report, it was also noted that the Veteran's disability was poorly controlled, as he was taking up to seven or eight pills of Ritalin in addition to two pills of Modafinil a day in order to control his narcolepsy. Furthermore, the evidence shows that the Veteran had been involved in car accidents due to falling asleep while driving. Therefore, the Board finds that the complete evidence reveals that the Veteran's disability has not shown actual improvement since he was granted a 60 percent rating for his narcolepsy in an August 2005 rating decision. Accordingly, resolving all reasonable doubt in the Veteran's favor, the Board finds that a reduction in the 60 percent rating was not warranted because actual improvement was not shown. Therefore, he is entitled to a restoration of the 60 percent rating for idiopathic central nervous system hypersomnolence, effective March 1, 2007, the effective date of the reduction. While the Veteran was able to drive the 32 miles to and from his house without having to take a nap during his period of participation in the van pool for work, the Board finds that sustained improvement was not demonstrated because the Veteran's disability was still present, as he continued to need to take daily naps while riding in the van as a passenger. Therefore, the evidence does not conclusively establish improvement such that the 60 percent rating is no longer warranted. In sum, the weight of the credible evidence shows that the December 2006 reduction of the disability rating from 60 percent to 20 percent was not proper because actual sustained improvement was not shown. Therefore, restoration of the 60 percent rating, effective March 1, 2007, is warranted. With respect to whether the Veteran is entitled to a rating higher than 60 percent disabling for his narcolepsy during the pendency of the appeal, the Board finds that he is not. A 60 percent rating is warranted when there is an average of at least one major seizure in 4 months over the last year; or nine to 10 minor seizures per week. An 80 percent rating is warranted when there is an average of at least one major seizure in three months over the last year; or more than 10 minor seizures weekly. A 100 percent rating is warranted when there is an average of one major seizure per month over the last year. 38 C.F.R. § 4.124a, Diagnostic Code 8911 (2010). The evidence of record shows that the Veteran's reports of the frequency of his narcoleptic attacks have varied. His attacks were reported as occurring quite frequently in a June 2004 VA medical record (two to three times at work each day and once on the drive back from home each day) and in a May 2006 VA medical record (a few times each day). However, the narcoleptic attacks were reported as occurring only four times a month at a March 2006 VA examination and as occurring only 30 times a month at the Veteran's most recent VA examination in May 2010. Therefore, the Board finds that the Veteran's condition most nearly approximates the criteria for a 60 percent rating under Diagnostic Code 8911 of nine to 10 minor seizures per week. Therefore, an increased rating is not warranted for the Veteran's idiopathic central nervous system hypersomnolence syndrome. The Board finds the evidence does not show that the Veteran's service-connected idiopathic central nervous system hypersomnolence syndrome presents such an unusual or exceptional disability picture at any time so as to require consideration of an extra-schedular rating. 38 C.F.R. § 3.321(b)(1) (2010). The objective medical evidence of record shows that manifestations of the Veteran's service-connected idiopathic central nervous system hypersomnolence syndrome do not result in a marked functional impairment to a degree other than that addressed by VA's Rating Schedule. The schedular rating criteria are designed to compensate for average impairments in earning capacity resulting from service-connected disability in civil occupations. 38 U.S.C.A. § 1155 (West 2002). Generally, the degrees of disability specified in the rating schedule are considered adequate to compensate for considerable loss of working time from exacerbations or illnesses proportionate to the severity of the several grades of disability. 38 C.F.R. § 4.1 (2010). The Board finds that the evidence does not show frequent hospitalization due to the idiopathic central nervous system hypersomnolence syndrome. Furthermore, the Board finds that the evidence does not show marked interference with employment beyond that envisioned by the schedular rating already assigned. While the Board acknowledges that the Veteran's disability interferes with his employment to some degree, the interference primarily relates to the Veteran's ability to be promoted and occasional absences. The Veteran may be prevented from being engine room qualified and taxi qualified, but he is still able to perform his job with employer accommodations and help from his co-workers. The Veteran has also reported missing work around eight to 12 times a year due to his disability, but the Board finds that the Veteran's current degree of disability as specified in the rating schedule adequately compensates him for that loss of working time. Additionally, the schedule provides for higher ratings for idiopathic central nervous system hypersomnolence syndrome, but that is not shown here. Consequently, the Board concludes that referral of this case for consideration of an extra-schedular rating is not warranted. Thun v. Peake, 22 Vet. App. 111 (2008); Bagwell v. Brown, 9 Vet. App. 337 (1996); Floyd v. Brown, 9 Vet. App. 88 (1996). Duties to Notify and Assist the Appellant Upon receipt of a complete or substantially complete application, VA must notify the claimant and any representative of any information, medical evidence, or lay evidence not previously provided to VA that is necessary to substantiate the claim. This notice requires VA to indicate which portion of that information and evidence is to be provided by the claimant and which portion VA will attempt to obtain on the claimant's behalf. See 38 U.S.C.A. §§ 5103, 5103A, 5107 (West 2002 & Supp. 2009); 38 C.F.R. § 3.159 (2010). The notice must: (1) inform the claimant about the information and evidence not of record that is necessary to substantiate the claim; (2) inform the claimant about the information and evidence that VA will seek to provide; and (3) inform the claimant about the information and evidence the claimant is expected to provide. Pelegrini v. Principi, 18 Vet. App. 112 (2004). Here, the RO sent correspondence in March 2005 and July 2008; rating decisions in August 2005, April 2006, December 2006, September 2007, and November 2007; and a statement of the case in October 2008. These documents discussed specific evidence, the particular legal requirements applicable to the claim, the evidence considered, the pertinent laws and regulations, and the reasons for the decisions. VA made all efforts to notify and to assist the appellant with regard to the evidence obtained, the evidence needed, the responsibilities of the parties in obtaining the evidence, and the general notice of the need for any evidence in the appellant's possession. The Board finds that any defect with regard to the timing or content of the notice to the appellant is harmless because of the thorough and informative notices provided throughout the adjudication and because the appellant had a meaningful opportunity to participate effectively in the processing of the claim with an adjudication of the claim by the RO subsequent to receipt of the required notice. There has been no prejudice to the appellant, and any defect in the timing or content of the notices has not affected the fairness of the adjudication. See Mayfield v. Nicholson, 19 Vet. App. 103 (2005), rev'd on other grounds, 444 F.3d 1328 (Fed. Cir. 2006) (specifically declining to address harmless error doctrine); see also Dingess v. Nicholson, 19 Vet. App. 473 (2006). Thus, VA has satisfied its duty to notify the appellant and had satisfied that duty prior to the final adjudication in the September 2010 supplemental statement of the case. In addition, all relevant, identified, and available evidence has been obtained, and VA has notified the appellant of any evidence that could not be obtained. The appellant has not referred to any additional, unobtained, relevant, available evidence. VA has also obtained medical examinations in relation to this claim. Thus, the Board finds that VA has satisfied both the notice and duty to assist provisions of the law. ORDER The appeal concerning the issue of entitlement to service connection for an acquired psychiatric disorder is dismissed. The reduction of the rating for the Veteran's idiopathic central nervous system hypersomnolence syndrome, from 60 percent to 20 percent, effective March 1, 2007, was not proper; the Veteran is entitled to restoration of the 60 percent rating for idiopathic central nervous system hypersomnolence syndrome, effective March 1, 2007. An increased rating, greater than 60 percent, for idiopathic central nervous system hypersomnolence syndrome is denied. ____________________________________________ Harvey P. Roberts Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs