Citation Nr: 1451816 Decision Date: 11/21/14 Archive Date: 11/26/14 DOCKET NO. 09-00 233 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Nashville, Tennessee THE ISSUES 1. Entitlement to an initial compensable rating for Sjogren's syndrome with bilateral dry eye syndrome. 2. Entitlement to an initial rating in excess of 10 percent for Hashimoto's thyroiditis. 3. Entitlement to an initial compensable rating for sinusitis, claimed as headaches. REPRESENTATION Appellant represented by: Veterans of Foreign Wars of the United States ATTORNEY FOR THE BOARD R. Dodd, Associate Counsel INTRODUCTION The Veteran had military service from August 1984 to October 1989 and from July 1991 to December 2006, with verified active duty from July 1985 to October 1989. This matter initially came to the Board of Veterans' Appeals (Board) on appeal from an April 2007 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Winston-Salem, North Carolina, that, in pertinent part, granted service connection for Hashimoto's thryoiditis, Sjogren's syndrome with bilateral dry eye syndrome, sinusitis, and irritable bowel syndrome (IBS), and assigned an initial 10 percent and noncompensable ratings, respectively. That rating decision also denied the Veteran's claims for service connection for recurring rashes of her arms, legs, face, neck, and stomach, and follicular degeneration. Jurisdiction of the Veteran's case is currently with the VA RO in Nashville, Tennessee. The Veteran filed a notice of disagreement on March 2008. A statement of the case (SOC) was provided on October 2008. The Veteran perfected her appeal with the timely submission of a VA Form 9 in December 2008. Although the Veteran indicated that she desired a video hearing before a member of the Board in her December 2008 VA Form 9, a review of the record reveals that she was subsequently scheduled for such a hearing on February 2010, but failed to appear. As the Veteran has not provided any explanation as to her failure to attend and has not requested a new hearing, the request for a hearing is hereby deemed withdrawn. 38 C.F.R. § 20.704. In a February 2011 decision, the Board denied the Veteran's claim of entitlement to an initial compensable evaluation for IBS. At that time, the Board remanded her claims for service connection for a skin disorder and follicular degeneration, and increased initial ratings for Sjogren's syndrome with bilateral dry eye syndrome, Hashimoto's thryoiditis, and sinusitis, to the RO via the Appeals Management Center (AMC) in Washington, D.C., for further development. In a May 2012 rating decision, the AMC granted service connection for eczematous dermatitis and centripetal cicatricial alopecia. The AMC's action represents a full grant of the benefits sought as to the Veteran's claims for service connection for skin and follicular degeneration disorders. In June 2013 and February 2014, the Board remanded the Veteran's case to the RO via the AMC for further development. That development having been completed, this claim is once again before the Board. The United States Court of Appeals for Veterans Claims (Court) determined that where a claimant or the record raises the question of unemployability due to the disability for which an increased rating is sought, then part of the increased rating claim is an implied claim for TDIU. Rice v. Shinseki, 22 Vet. App. 447, 453-455 (2009). In this case, however, the Veteran has not alleged, and the record does not otherwise reveal, any such claim that needs to be resolved as part of this appeal. As such, there shall be no further discussion regarding entitlement to a TDIU. This appeal was processed using the Virtual VA/VBMS paperless claims processing system. Accordingly, any future consideration of this appellant's case should take into consideration the existence of this electronic record. FINDINGS OF FACT 1. The Veteran's Sjogren's syndrome symptoms, which include dry, itchy, painful eyes that are sensitive to light, are caused by a lack of tear production by the lacrimal apparatus in the bilateral eyes. 2. The Veteran's Hashimoto's thyroiditis is manifested by symptoms that include fatigability, constipation, muscular weakness, mental disturbance as shown by memory problems, weight gain, and cold intolerance. 3. The Veteran's sinusitis is manifested by symptoms of three to four non-incapacitating and acute episodes per year. CONCLUSIONS OF LAW 1. The criteria for an initial evaluation of 20 percent, but no higher, for service-connected Sjogren's syndrome have been met. 38 U.S.C.A. §§ 1155, 5103A, 5107 (West 2002 & Supp. 2013); 38 C.F.R. § 4.79, DC 6025 (2008). 2. The criteria for an initial evaluation of 60 percent, but no higher, for service-connected Hashimoto's thyroiditis have been met. 38 U.S.C.A. §§ 1155, 5103A, 5107 (West 2002 & Supp. 2013); 38 C.F.R. § 4.119, DC 7903 (2013). 3. The criteria for an initial compensable evaluation for service-connected sinusitis have not been met. 38 U.S.C.A. §§ 1155, 5103A, 5107 (West 2002 & Supp. 2013); 38 C.F.R. § 4.97, DC 6511 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS VCAA Under the VCAA, VA has a duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107 (West 2002 & Supp. 2013); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2013). Proper notice from VA must inform the claimant of any information and medical or lay evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. Quartuccio v. Principi, 16 Vet. App. 183, 186-87 (2002). This notice must be provided prior to an initial RO decision on a claim. Mayfield v. Nicholson, 444 F.3d 1328, 1333 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112, 119 (2004). VCAA notice requirements apply to all five elements of a service connection claim, including: (1) veteran status; (2) existence of a disability; (3) a connection between the veteran's service and the disability; (4) degree of disability; and (5) effective date of the disability. Dingess/Hartman v. Nicholson, 19 Vet. App. 473, 486 (2006). In a claim for an increased evaluation, the VCAA requirement is generic notice: the type of evidence needed to substantiate the claim, which consists of evidence demonstrating a worsening or increase in severity of the disability and the effect that worsening has on employment, as well as general notice regarding how disability ratings and effective dates are assigned. Vazquez-Flores v. Shinseki, 580 F.3d 1270 (Fed. Cir. 2009). Defective timing or content of VCAA notice is not prejudicial to a claimant if the error does not affect the essential fairness of the adjudication, such as where (1) the claimant demonstrates actual knowledge of the content of the required notice; (2) a reasonable person could be expected to understand from the notice what was needed; or (3) a benefit could not have been awarded as a matter of law. Sanders v. Nicholson, 487 F.3d 881, 889 (Fed. Cir. 2007), rev'd on other grounds, Shinseki v. Sanders/Simmons, 556 U.S. (2009). Defective timing may be cured by a fully compliant notice letter followed by a readjudication of the claim. Prickett v. Nicholson, 20 Vet. App. 370, 376 (2006). However, "[i]n cases where service connection has been granted and an initial disability rating and effective date have been assigned, such as in the case of the Veteran's TBI claim, the typical service-connection claim has been more than substantiated-it has been proven, thereby rendering section 5103(a) notice no longer required because the purpose that the notice is intended to serve has been fulfilled." Dingess/Hartman, 19 Vet. App. at 490; Dunlap v. Nicholson, 21 Vet. App. 112, 116-17 (2007) (noting that once an initial VA decision awarding service connection and assigning a disability evaluation and effective date has been made, section 5103(a) notice is no longer required). Additionally, where service connection has been granted, the claimant bears the burden of demonstrating prejudice from defective notice with respect to downstream elements such as effective dates or disability ratings. Goodwin v. Peake, 22 Vet. App. 128, 137 (2008). The Veteran has made no such assertions here. Accordingly, regarding the initial evaluations for the Veteran's Sjogren's syndrome, Hashimoto's thyroiditis, and sinusitis, VA's duty to notify has been satisfied. VA's duty to assist the Veteran has also been satisfied. 38 U.S.C.A. § 5103A(b), (c); 38 C.F.R. § 3.159(c)(1)-(3). The Veteran's service treatment records, available private treatment records, and VA outpatient treatment records have been obtained and associated with the claims file. The Board notes that in February 2011, it directed the RO/AMC to contact the Veteran and request that she identify all private physicians who treated her for disorders including Sjogren's syndrome, Hashimoto's thyroiditis, and sinusitis, since 2007. She was requested to provide authorization of release for VA to obtain them or submit the records. The Board further directed that "[a]ll attempts to secure these records, and any response received, must be documented in the claims file. If no records are available, a response to that effect is required and should be documented in the file." (Emphasis in the original.) In particular, the Board requested all medical records regarding the Veteran's treatment by each private physician identified in her June 5, 2008, March 7 2011 and May 2011 signed VA Form 21-4142s, including: Dr. Blevins , and Denise Verity, F.N.P., 2501 The Vanderbilt Clinic, Nashville, TN; Drs. Joseph Huston, Vipul Lakhani (and Denise Verity), Vanderbilt Hospital, 1210 Medical Center Drive, Nashville, TN; Dr. Vincent, Nashville Dermatology; and Drs. Adriane Schmidt, Sreedhar (Steve) Samudrala, and Thomas Wohl. The claim was remanded on February 2011, June 2013, and February 2014 in order to obtain the aforementioned records. Although, the RO/AMC obtained the authorizations in February 2011, it apparently did not attempt to obtain the associated records, a deficiency for which the claim was again remanded in June 2013. In July 2013, the RO/AMC sent a letter to the Veteran requesting new authorizations, due to the staleness of the ones executed in 2011. However, the Veteran did not respond and the RO/AMC readjudicated the claim in a Supplemental Statement of the Case (SSOC) on August 2013 without any additional private treatment records. The claim was again remanded in February 2014 to afford the Veteran another opportunity to execute new authorizations or provide additional records. Although the Board requested a formal finding if records could not be obtained, it is noted that, with regard to private medical records, no such finding is actually required. As such, the RO/AMC sent the Veteran a new letter in March 2014 requesting new signed authorizations. However, the Veteran again did not respond and the RO/AMC readjudicated the claim in a SSOC on September 2014 without any additional private treatment records. The Board finds that, with regard to the identified, but un-obtained, private treatment records, the duty to assist has been fulfilled. The duty to assist is not a one-way street, and the Veteran, despite be granted two more opportunities to do so, has not provided the updated authorizations needed to attempt to obtain the identified private treatment records. Wood v. Derwinski, 1 Vet. App. 190, 193 (1991). As such the Board will proceed to adjudicate the appeal based upon the evidence currently of record. VA provided the Veteran with adequate medical examinations. The examinations were adequate because they contained a history obtained from the Veteran and thorough examinations relevant to the applicable rating criteria. They also addressed the functional effects caused by the Veteran's disability, to include the effects on his occupation. The information of record does not indicate that there is additional evidence relevant to the issue decided herein which has not been associated with the claims file. See Pelegrini, 18 Vet. App. at 121-22. The Board finds that the duty to assist has been met. In summary, the facts relevant to this appeal have been properly developed and there is no further action to be undertaken to comply with the provisions of 38 U.S.C.A. §§ 5103(a), 5103A or 38 C.F.R. § 3.159 . Therefore, the Veteran will not be prejudiced as a result of the Board proceeding to the merits of the appeal. See Bernard v. Brown, 4 Vet. App. 384, 392-94 (1993). The Board concludes that that the Board's remand orders have been substantially complied with, and it may proceed with a decision at this time. See Dyment v. West, 13 Vet. App. 141, 146-47 (1999) (remand not required under Stegall v. West, 11 Vet. App. 268 (1998), where the Board's remand instructions were substantially complied with), aff'd, Dyment v. Principi, 287 F.3d 1377 (Fed. Cir. 2002). In adjudicating the claim below, the Board has reviewed all of the evidence in the Veteran's claims file including those found in Virtual VA and the Veteran's Benefits Management System (VBMS). Although the Board has an obligation to provide adequate reasons and bases supporting this decision, there is no requirement that all the evidence submitted by the Veteran or obtained on his behalf be discussed in detail. Rather, the Board's analysis below will focus specifically on what evidence is needed to substantiate the claim and what the evidence in the claims files shows, or fails to show, with respect to the claim. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000); Timberlake v. Gober, 14 Vet. App. 122, 128-30 (2000). Legal Criteria Disability ratings are determined by applying the criteria set forth in the VA's Schedule for Rating Disabilities, which is based on the average impairment of earning capacity resulting from disability. Separate diagnostic codes identify the various disabilities. See 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. § 4.1 (2013). If two evaluations are potentially applicable, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for the higher evaluation; otherwise, the lower evaluation will be assigned. See 38 C.F.R. § 4.7 (2013). Any reasonable doubt regarding the degree of disability will be resolved in favor of the Veteran. 38 C.F.R. § 4.3 (2013). 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). When, as here, the Veteran is requesting an increased rating for an established service-connected disability, the present disability level is the primary concern and past medical reports do not take precedence over current findings. See Francisco v. Brown, 7 Vet. App. 55 (1994). However, the most recent examination is not necessarily and always controlling; rather, consideration is given not only to the evidence as a whole but to both the recency and adequacy of examinations. See Powell v. West, 13 Vet. App. 31, 35 (1999). Nevertheless, the Board acknowledges that a claimant may experience multiple distinct degrees of disability that might result in different levels of compensation from the time the increased rating claim was filed until a final decision is made. See Hart v. Mansfield, 21 Vet. App. 505 (2007). The analysis in the following decision is therefore undertaken with consideration of the possibility that different "staged" ratings may be warranted for different time periods. Where, as in this case, the current appeal is based on the assignment of an initial rating for a disability following a grant of service connection, the evidence contemporaneous with the claim and the initial rating decision are most probative of the degree of disability existing when the initial rating was assigned and should be the evidence used to decide whether an original rating on appeal was erroneous. See Fenderson v. West, 12 Vet. App. 119, 126 (1999). If later evidence indicates that the degree of disability increased or decreased following the assignment of the initial rating, "staged" ratings may be assigned for separate periods of time. Id. When adjudicating a claim for an increased-initial evaluation, the relevant time period is from the date of the claim. Moore v. Nicholson, 21 Vet. App. 211, 215 (2007), rev'd in irrelevant part, Moore v. Shinseki, 555 F.3d 1369 (2009). Sjogren's syndrome The Board notes that while the Veteran's appeal was pending, the Rating Schedule for evaluating disabilities of the eyes was revised and amended. See 73 Fed. Reg. 66543 -54 (Nov. 10, 2008). The effective date of the revisions is December 10, 2008, and the revised criteria apply to all applications for benefits received by VA on or after that date. The Board notes that the Veteran filed her claim in 2006 prior to her discharge from service; thus, the post-2008 regulation does not apply to her claim. The Veteran's service-connected Sjogren's syndrome is rated as 0 percent disabling in accordance with the General Rating Formula for Diseases of the Eye. 38 C.F.R. § 4.79, DC 6018 (in effect prior to December 10, 2008). A healed condition is rated based upon residuals or given a 0 percent evaluation if there are no residuals. Id. An active condition with objective symptoms is given a 10 percent evaluation. Id. The severity of visual acuity loss is determined by applying the criteria set forth at 38 C.F.R. § 4.84a . Under these criteria, impairment of central visual acuity is evaluated from noncompensable to 100 percent based on the degree of the resulting impairment of visual acuity. 38 C.F.R. § 4.84a, Diagnostic Codes 6061-79 (in effect prior to December 10, 2008). A disability rating for visual impairment is based on the best distant vision obtainable after the best correction by glasses. 38 C.F.R. § 4.75. The percentage evaluation will be found from Table V by intersecting the horizontal row appropriate for the Snellen index for one eye and the vertical column appropriate to the Snellen index of the other eye. 38 C.F.R. § 4.83a. Impairment of field of vision is evaluated pursuant to the criteria found in Diagnostic Code 6080. 38 C.F.R. § 38 C .F.R. § 4.84a, Diagnostic Code 6080 (in effect prior to December 10, 2008). An interference with the lacrimal duct from any cause is evaluated pursuant to the criteria found in Diagnostic Code 6025. 38 C .F.R. § 4.84a, Diagnostic Code 6025 (in effect prior to December 10, 2008). A 10 percent evaluation is warranted for unilateral involvement. Id. A 20 percent evaluation is warranted for bilateral involvement. Id. Hashimoto's thyroiditis The Veteran's Hashimoto's thyroiditis is evaluated as 10 percent disabling in accordance with the General Rating Formula for the Endocrine System and is rated as hypothyroidism, which is considered under the disability criteria set forth at 38 C.F.R. § 4.119, Diagnostic Code 7903. Under those criteria, a 10 percent evaluation is assigned when symptoms are manifested by fatigability, or; continuous medication required for control. Id. A 30 percent disability rating is assigned when hypothyroidism is manifested by fatigability, constipation, and mental sluggishness. Id. A 60 percent disability rating is warranted where hypothyroidism is manifested by muscular weakness, mental disturbance, and weight gain. Id. A 100 percent disability rating is warranted where the disability is manifested by cold intolerance, muscular weakness, cardiovascular involvement, mental disturbance (dementia, slowing of thought, depression), bradycardia (less than 60 beats per minute), and sleepiness. See also Tatum v. Shinseki, 23 Vet. App. 152, 155 (2009) (holding that the rating criteria for Diagnostic Code 7903 are not successive, i.e. all of the symptoms listed for a particular disability rating are not required in order to establish entitlement to the next higher disability rating for hypothyroidism). Sinusitis The Veteran's service-connected sinusitis is currently evaluated as noncompensable under 38 C.F.R. § 4.97, Diagnostic Code 6511. Under Diagnostic Code 6511, a noncompensable evaluation is assigned for sinusitis detected by X-ray only. Id. A 10 percent rating is assigned 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. Id. A 30 percent rating is assigned 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. Id. A maximum 50 percent rating is assigned for sinusitis 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. Id. An incapacitating episode of sinusitis is defined as one that requires bed rest and treatment by a physician. 38 C.F.R. § 4.97, Diagnostic Code 6511, at Note. Background Sjogren's syndrome The Veteran claims that her Sjogren's syndrome is worse than currently reflected by her initial noncompensable evaluation. To this effect, the Veteran has stated that she suffers from bilateral eye pain that results from dryness and inflammation as well as sensitivity to light. The Veteran was provided with a VA examination in August 2006. The Veteran was noted to have been suffering from Sjogren's syndrome since 2002. The current symptoms were noted as irits, dry mouth, dry skin, thinning hair, chronic fatigue, and swelling of the hands and joints. She report that her condition was currently active and had been for four years. She was being treated with medication. Functional impairment was noted as visual impairment due to blurred vision and sore eyes. Sensitivity to sunlight limited outdoor activities. Objective examination revealed no icterus. Extraocular muscle movements were intact. Pupils were round and reacted to light. There were no ocular signs of hyperthyroidism. A review of the Veteran's private treatment records reflects continued treatment for her Sjogren's syndrome. In April 2009 the Veteran was seen for complaints of dry eyes related to her condition and provided with medication. In November 2011, the Veteran was seen again by the same physician that noted her condition had not changed and continued medication treatment. VA outpatient treatment records also reflect that the Veteran has received ongoing treatment for this condition. A February 2010 note indicated that the Veteran's condition was found to be moderate. The Veteran was provided with an additional VA examination in April 2011. At that examination is was noted that the Veteran had been diagnosed with Sjogren's syndrome in 2000. Associated symptoms included iritis and dry eyes. Objective testing revealed a normal eye examination. It was noted that the Veteran used medication to treat this condition. The occupational effects of this condition were noted as eye pain and the effects on activities of daily living included pain when reading. Hashimoto's thyroiditis The Veteran contends that her Hashimoto's thyroiditis is worse than currently reflected by her 10 percent evaluation. To this effect, the Veteran has complained of worsening symptoms, to include fatigue, low energy, memory problems, weight fluctuations, heat and cold intolerance, dry skin, and constipation. The Veteran was provided with a VA examination in August 2006. It was noted that the Veteran had been suffering from Hashimoto's thyroiditis since 2001. She reported that the condition had been active since 2004. Reported symptoms included fatigability, sleeplessness, poor memory, cold intolerance, weight fluctuations, and goiter. There were no heart or gastrointestinal conditions found to be related to her condition. It was noted that the Veteran required medication for the treatment of her condition. There were no functional impacts noted. A review of the Veteran's private treatment records and VA outpatient treatment records reveals that she has been followed for this condition. In June 2009, it was noted that the Veteran had active thyroiditis. In December 2009, the Veteran was seen for complaints of fatigue, decreased energy, cold intolerance, dry skin, and weight gain. Based upon these symptoms, the doctor decided to increase her medication. In February 2010, the Veteran was seen for complaints of cold intolerance, constipation, weight changes, dry skin, and memory problems. The Veteran's medication increase was continued. In December 2010, the Veteran's medication was again increased. Lay statements from the Veteran's child and co-worker have also provided that they have observed the Veteran's memory problems and cold intolerance. The Veteran was provided with an additional VA examination in April 2011. At this examination, it was noted that the Veteran had been diagnosed with thyroidism since 2000. The examiner noted that the Veteran's thyroid was currently within normal limits and had improved since onset with the use of medication to treat. Symptoms included fatigability, general weakness, hot and cold intolerance, and insomnia. There were no functional effects noted. Sinusitis The Veteran contends that her sinusitis is currently worse than reflected by her noncompensable evaluation. To this effect, the Veteran has testified that she experiences several incapacitating episodes per year. The Veteran was provided with a VA examination in August 2006. The Veteran reported having recurring headaches since 2002, that are of a sharp, throbbing nature with pain behind the eyes. When the attacks occur, she is able to go to work, but has to use medication. The headaches occur twice per week and last about one hour. There was no functional impairment noted with this condition. X-rays revealed evidence of sinusitis. A review of the Veteran's private treatment records and VA outpatient treatment records reveals treatment for sinusitis with medication. However, there were no noted instances of incapacitating episodes, to include doctor-ordered bed rest. The Veteran was provided with an additional VA examination in April 2011. At this examination, the examiner noted that the Veteran had sinusitis with onset in the 1990s. It was noted that the Veteran had approximately three to four acute non-incapacitating episodes per year. Treatment included the use of antibiotics. X-rays were negative for any signs of sinusitis. There were no functional effects noted. Analysis Sjogren's syndrome The Board finds that the Veteran warrants an evaluation of 20 percent for her Sjogren's syndrome. This is because the medical evidence of record, to include treatment records and the VA examinations, shows that the Veteran's Sjogren's syndrome has been manifested by symptoms, which include dry, itchy, painful eyes that are sensitive to light, and are caused by a lack of tear production by the lacrimal apparatus in the bilateral eyes, throughout the appeals period. The Veteran is currently evaluated for Sjogren's syndrome under an analogous diagnostic code 6018 for chronic conjunctivitis, as there is no specific diagnostic code for that condition. When an unlisted condition is encountered it is permissible to rate under a closely related disease or injury in which not only the functions affected, but also the anatomical localization and symptomatology are closely analogous. Conjectural analogies will be avoided, as will the use of analogous ratings for conditions of doubtful diagnosis, or for those not fully supported by clinical and laboratory findings, nor will ratings assigned to organic disease and injuries be assigned by analogy to conditions of functional origin. See 38 C.F.R. § 4.20. However, the Board notes that Sjogren's syndrome includes the condition of keratoconjunctivitis sicca, which is further explained to involve a lacrimal deficiency, causing dryness that results in itching and burning eyes, often with reduced visual acuity. See Dorland's Illustrated Medical Dictionary 348 (32nd ed. 2012). As such, the Board finds that the Veteran's Sjogren's syndrome can properly be considered as an interference with the lacrimal duct, since the Veteran's condition causes a deficiency in that duct so that tears may not be produced resulting in her current symptoms. Therefore, in light of the symptoms of Sjogren's syndrome shown by the medical evidence of record, the Board will evaluate the Veteran's disability under 38 C.F.R. § 4.79, Diagnostic Code 6025 (2008) for Epiphora (interference with lacrimal duct from any cause), as her condition is more accurately described as lacrimal duct interference as opposed to swelling and irritation of the conjunctive tissue. See Read v. Shinseki, 651 F.3d 1296 (Fed. Cir. 2011) (The changing of the diagnostic code to a more appropriate diagnostic code was warranted in light of new manifestations and did not result in a de facto reduction of disability rating); see also Butts v. Brown, 5 Vet.App. 532, 539 (1993) (holding that the Board's selection of a diagnostic code may not be set aside as "arbitrary, capricious, an abuse of discretion, or otherwise not in accordance with law," if relevant data is examined and a reasonable basis exit for its selection) (citations omitted). Using the 2008 version of Diagnostic Code 6025, as the Veteran's claim is subject to that version of the Schedule prior to the change of law as described above, the Board finds that the Veteran is entitled to a 20 percent evaluation because her lacrimal interference, caused by Sjogren's syndrome, affects the eyes bilaterally. The Board notes that the 20 percent evaluation under Diagnostic Code 6025 is the highest evaluation for that particular code. The Board further finds that the symptoms of the Veteran's Sjogren's syndrome are not reflected by any other diagnostic codes relating to visual acuity or visual field disabilities, as the Veteran's eye examinations provided by VA and private doctors have been medically determined to be within normal limits. The Veteran's symptoms of pain, burning, itching, and sensitivity to light are best reflected by the 20 percent evaluation under Diagnostic Code 6025. Therefore, entitlement to a higher evaluation is not warranted based upon symptoms manifested during the current appeal period. Consideration has also been given regarding whether the schedular evaluations are inadequate, thus requiring that the RO refer a claim to the Chief Benefits Director or the Director, Compensation and Pension Service, for consideration of 'an extra-schedular evaluation commensurate with the average earning capacity impairment due exclusively to the service-connected disability or disabilities. 38 C.F.R. § 3.321(b)(1) (2013); Thun v. Peake, 22 Vet. App. 111 (2008). In this regard, the schedular evaluations in this case are not inadequate. Ratings in excess of those assigned are provided for certain manifestations of the service-connected Sjogren's syndrome, but the evidence reflects that those manifestations, namely the presence of visual acuity or field problems, are not present. The diagnostic criteria adequately describe the severity and symptomatology of the Veteran's Sjogren's syndrome. The Veteran has not described any exceptional or unusual features associated with her disability or described how her Sjogren's syndrome affects her functioning in an exceptional or unusual manner. Rather, VA examiners have noted that the Veteran's condition only results in light sensitivity and pain with reading, but otherwise no significant functional effects. Therefore, the Veteran's current rating appropriately contemplates the scope of her complaints. Accordingly, referral is not required. The Board has considered the doctrine of reasonable doubt. However, as the most probative evidence of record is against the Veteran's claim, the Board finds that this doctrine is not for application with re. 38 U.S.C.A. § 5107(b); see also, e.g., Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Hashimoto's thyroiditis The Board finds that the Veteran warrants an evaluation of 60 percent for her Hashimoto's thyroiditis. This is because the medical evidence of record, to include treatment records and the VA examinations, as well as lay statements of objective observations of the Veteran, shows that the Veteran's Hashimoto's thyroiditis showed symptoms of fatigability, constipation, muscular weakness, mental disturbance as shown by memory problems, weight gain, and cold intolerance throughout the appeals period. The Board, however, finds that a 100 percent evaluation is not warranted at any time during the relevant appeal period. Although the Veteran does meet the elements of cold intolerance, muscular weakness, and mental disturbance (the latter two forming the basis for the 60 percent evaluation), there is no indication of cardiovascular involvement, bradycardia (less than 60 beats per minute), and sleepiness. The presence of these additional symptoms would indicate that the Veteran's condition had spread to more vital body symptoms and create more substantial functional impairment. However, here, the Veteran's symptom of cold intolerance is the only present symptom that seems to indicate a shift into consideration for the higher evaluation, as the muscular weakness and mental disturbance are already considered for the 60 percent evaluation. As cold intolerance is but one of four additional symptoms considered in the 100 percent evaluation, the Board finds that it does not yet rise to the level of such impairment. As such, the overall disability picture more closely approximates the 60 percent evaluation criteria. Consideration has also been given regarding whether the schedular evaluations are inadequate, thus requiring that the RO refer a claim to the Chief Benefits Director or the Director, Compensation and Pension Service, for consideration of 'an extra-schedular evaluation commensurate with the average earning capacity impairment due exclusively to the service-connected disability or disabilities. 38 C.F.R. § 3.321(b)(1) (2013); Thun, 22 Vet. App. at 111. In this regard, the schedular evaluations in this case are not inadequate. Ratings in excess of those assigned are provided for certain manifestations of the service-connected Hashimoto's thyroiditis, but the evidence reflects that those manifestations, namely the presence of cardiovascular involvement, bradycardia (less than 60 beats per minute), and sleepiness, are not present. The diagnostic criteria adequately describe the severity and symptomatology of the Veteran's Hashimoto's thyroiditis. The Veteran has not described any exceptional or unusual features associated with her disability or described how her Hashimoto's thyroiditis affects her functioning in an exceptional or unusual manner. Rather, VA examiners have noted that the Veteran's condition is stabilized with the use of medication and there are no functional effects. Therefore, the Veteran's current rating appropriately contemplates the scope of her complaints. Accordingly, referral is not required. The Board has considered the doctrine of reasonable doubt. However, as the most probative evidence of record is against the Veteran's claim, the Board finds that this doctrine is not for application. 38 U.S.C.A. § 5107(b); see also, e.g., Gilbert, 1 Vet. App. at 49. Sinusitis The medical evidence of record revealed x-ray evidence of sinusitis in August 2006. However, the record does not show any resulting incapacitation episodes or doctor-ordered bed rest at any time during the pendency of the appeal. Rather, the evidence shows that the Veteran's condition does not result in any significant functional impact during intermittent acute episodes of sinusitis. Therefore, the Board finds that the most probative evidence of record does not show that the Veteran met the criteria for compensable evaluation for her sinusitis under 38 C.F.R. § 4.97, DC 6511. This is true throughout the period of time during which his claim has been pending and therefore consideration of staged ratings are not warranted. Consideration has also been given regarding whether the schedular evaluations are inadequate, thus requiring that the RO refer a claim to the Chief Benefits Director or the Director, Compensation and Pension Service, for consideration of 'an extra-schedular evaluation commensurate with the average earning capacity impairment due exclusively to the service-connected disability or disabilities. 38 C.F.R. § 3.321(b)(1); Thun, 22 Vet. App. at 111. In this regard, the schedular evaluations in this case are not inadequate. Ratings in excess of those assigned are provided for certain manifestations of the service-connected sinusitis, but the evidence reflects that those manifestations, namely the presence of incapacitating episodes, are not present. The diagnostic criteria adequately describe the severity and symptomatology of the Veteran's sinusitis. The Veteran has not described any exceptional or unusual features associated with her disability or described how her sinusitis affects her functioning in an exceptional or unusual manner. Rather, she told the VA examiner that she was still able to work during periods where her sinusitis flares up after she takes medication. Therefore, the Veteran's current rating appropriately contemplates the scope of her complaints. Accordingly, referral is not required. The Board has considered the doctrine of reasonable doubt. However, as the most probative evidence of record is against the Veteran's claim, the Board finds that this doctrine is not for application. 38 U.S.C.A. § 5107(b); see also, e.g., Gilbert v.,1 Vet. App. at 49. ORDER Entitlement to a 20 percent initial rating, but no higher, for Sjogren's syndrome with bilateral dry eye syndrome is granted, subject to the law and regulations governing the award of monetary benefits. Entitlement to a 60 percent initial rating, but no higher, for Hashimoto's thyroiditis is granted, subject to the law and regulations governing the award of monetary benefits. Entitlement to an initial compensable rating for sinusitis, claimed as headaches, is denied. ____________________________________________ DEBORAH W. SINGLETON Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs