Citation Nr: 9928216 Decision Date: 09/29/99 Archive Date: 10/12/99 DOCKET NO. 97-30 214 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Jackson, Mississippi THE ISSUES 1. Entitlement to service connection for bursitis of the left shoulder. 2. Entitlement to an evaluation in excess of 30 percent for hypertensive heart disease. ATTORNEY FOR THE BOARD L. McCain Parson, Associate Counsel INTRODUCTION The veteran had active duty from October 1978 to November 1995. These matters come before the Board of Veterans' Appeals (Board) on appeal from a November 1996 rating decision issued by the Department of Veterans Affairs (VA), Regional Office (RO) in Jackson, Mississippi, which granted, inter alia, entitlement to service connection for hypertension, and a 10 percent evaluation was assigned (effective from December 1, 1995). By that same rating action, service connection for bursitis of the left shoulder was denied. In April 1997, the veteran filed a notice of disagreement, which specifically challenged the assignment of the 10 percent rating for his service-connected hypertension, and the denial of service connection for bursitis of the left shoulder. The RO furnished a Statement of the Case relative to both of these claims in April 1997. The RO received the veteran's substantive appeal in September 1997. In June 1998, the Board entered a decision which granted a 20 percent evaluation for the veteran's service-connected tendinitis of the right shoulder. The Board also remanded the appeal to the RO for further development of the record with respect to the issues of entitlement to service connection for bursitis of the left shoulder, and entitlement to an evaluation in excess of 10 percent for hypertension. By a rating decision in January 1999, the RO continued the denial of service connection for bursitis of the left shoulder. The RO also recharacterized the veteran's service- connected disability as hypertensive heart disease, and granted a 30 percent evaluation for that disability (effective from December 1, 1995). Inasmuch as the grant of 30 percent evaluation is not the maximum benefit under the rating schedule, the issue concerning the disability evaluation assigned for the service-connected hypertensive heart disease remains in controversy and; hence, it is a viable issue for appellate consideration by the Board. See AB v. Brown, 6 Vet. App. 35, 38 (1993). The Board's appellate review will, therefore, be limited to the issues listed on the cover page of this decision. The Board notes that effective March 1, 1999, the United States Court of Veterans Appeals changed its name to the United States Court of Appeals for Veterans Claims (hereinafter, "the Court"). FINDINGS OF FACT 1. All relevant evidence necessary for an equitable disposition of these claims has been obtained by the RO, to the extent possible. 2. Competent medical evidence fails to establish that the left shoulder bursitis is related to military service. 3. The veteran's service-connected hypertensive heart disease is characterized by an ejection fraction of 60 percent, tricuspid regurgitation, a workload of 6 METs on the treadmill stress test that resulted in dyspnea and fatigue, and cardiac enlargement as suggested by electrocardiogram. CONCLUSIONS OF LAW 1. Competent medical evidence fails to demonstrate that the current left shoulder bursitis is related to an incident of military service. 38 U.S.C.A. § 5107 (West 1991). 2. The criteria for an evaluation in excess of 30 percent for hypertensive heart disease have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 1991); 38 C.F.R. §§ 3.321(b)(1), 4.1, 4.3, 4.104, Diagnostic Code (DC) 7007 (effective through January 11, 1998), and as amended by 38 C.F.R. § 4.104, DC 7007 (1998) (effective from January 12, 1998). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS At the outset, the Board acknowledges that the service medical records are incomplete. In June 1998, pursuant to the Board's remand, the RO sought to secure through official channels the veteran's service medical records for the period of October 1978 to November 1995. In July 1998, the RO also contacted the veteran and requested that he submit any treatment records that he may have. In July 1998, the veteran submitted his Certification of Military Service for the period October 1974 to October 1978. The claims folder contains Request for Information forms submitted in July and August 1998 to the National Personnel Records Center requesting a copy of induction physical examination and separation physical examination. A routing and transmittal slip dated in August 1998 reflects "BIRLS indicates the following: SMRC 323". A subsequent response received by the RO in January 1999 reflects that "meds are located at VARO #323". The Board notes that VARO #323 is the number of the requesting RO. Based on the foregoing search efforts, the Board finds that the RO has expended sufficient efforts to obtain the service medical records. See Jolley v. Derwinski, 1 Vet. App. 37, 39-40 (1990). I. Service connection for the left shoulder Service connection may be granted for disability due to disease or injury incurred in or aggravated by service. 38 U.S.C.A. §§ 1110, 1131 (West 1991); 38 C.F.R. § 3.303(a) (1998). The threshold question to be answered is whether the veteran has presented evidence sufficient to justify a belief by a fair and impartial individual that his claim for service connection for bursitis of the left shoulder is well- grounded; that is, a claim which is plausible and capable of substantiation. See 38 U.S.C.A. § 5107(a); Chelte v. Brown, 10 Vet. App. 268, 270 (1997) (citing Murphy v. Derwinski, 1 Vet.App. 78, 81 (1990)). If the claim is not well-grounded claim, the appeal must fail and there is no duty to assist in developing the facts pertinent to this claim. See Epps v. Gober, 126 F.3d 1464, 1469 (Fed.Cir. 1997); Morton v. West, 12 Vet. App. 477 (1999) (per curiam). Generally, a well-grounded claim for service connection requires (1) medical evidence of a current disability; (2) medical or, in certain circumstances, lay evidence of in- service incurrence or aggravation of a disease or injury; and (3) medical evidence of a nexus between the claimed in- service disease or injury and the present disease or injury. See Caluza v. Brown, 7 Vet. App. 489, 504, 506 (1995); see also Epps v. Gober 126 F.3d at 1468 (expressly adopting definition of well-grounded claim set forth in Caluza, supra). The second and third Caluza elements can be satisfied under 38 C.F.R. 3.303(b) by (a) evidence that the condition was "noted" during service or during an applicable presumptive period; (b) evidence showing post- service continuity of symptomatology; and (c) medical or, in certain circumstances, lay evidence of a nexus between the present disability and the post-service symptomatology. 38 C.F.R. 3.303(b); Savage v. Gober, 10 Vet. App. 488, 495-97 (1997). For the purpose of determining whether a claim is well-grounded, the credibility of the evidence in support of the claim must be presumed. See Robinette v. Brown, 8 Vet. App. 69, 75 (1995). Where the determinant issue involves a question of medical diagnosis or medical causation, competent medical evidence to the effect that the claim is plausible or possible is required to establish a well-grounded claim. Lay assertions of medical causation cannot constitute evidence to render a claim well-grounded; if no cognizable evidence is submitted to support a claim, the claim cannot be well-grounded. See Grottveit v. Brown, 5 Vet. App. 91, 93 (1993). The available service medical records in evidence reflect that the veteran complained of right shoulder pain as early as October 1994, there is no mention of left shoulder complaints. The remainder of the service medical records are silent for a chronic left shoulder disability or left shoulder injury. A separate physical profile dated in June 1990 or 1995 "illegible year" reflects that the P-U-H-L-E-S for the upper extremities was "1". The claims folder does contain a copy of the medical history completed for retirement conducted in May 1995. The veteran reported on the report of medical history that he had a painful right shoulder. An examining physician reviewed the report of medical history; and his comments were limited to the right shoulder. The veteran reported at that time, he injured his right shoulder picking up a tire. The retirement examination report reflects chronic shoulder pain without distinguishing the right or left. The physical profile reflects a "1" for the upper extremities. An August 1996 x-ray report from Singing River Radiology Group reflects no bony abnormalities are demonstrated of the left shoulder. The August 1996 VA joints examination reflects that the veteran is right hand dominant. The veteran reported that he had no recollection of any injury to account for the onset of the shoulder pain. Reaching or working overhead worsens the pain in the shoulders. He was taking no medications for his shoulders. Discomfort was elicited on extremes of movement of the left shoulder. The assessment was chronic tendinitis versus bursitis of both shoulders, right more symptomatic. Notwithstanding the reference to chronic shoulder pain in the retirement examination, associated with the right shoulder, the available service medical records are negative for complaints, treatment, or a diagnosis of a left shoulder condition. The medical and clinical evidence post service is also negative for reference to a chronic left shoulder disability that is related to military service. During the August 1996 VA examination, the veteran complained of chronic pain in both shoulders. On examination, the shoulder had slight limitation of motion with complaints of increased pain on extremes of motion. The examiner did not relate the current findings to the veteran's military service. Essentially, the only evidence of record that relates the veteran's complaints to military service are the veteran's statements. See Espiritu v. Derwinski, 2 Vet. App. 492, 494 (1992) (lay statements as to medical diagnosis or causation are not competent); see Brewer v. West, 11 Vet. App. 228, 234 (1998). Without competent medical evidence of a current disability and nexus to service, the Board determines that the claim for entitlement to service connection for bursitis of the left shoulder is not well-grounded. See Caluza, supra. Accordingly, the claim is denied. Further, the Board views its discussion as sufficient to inform the veteran of the elements necessary to complete his application for service connection for left shoulder bursitis. See Robinette v. Brown, supra. II. A disability evaluation in excess of 30 percent for hypertensive heart disease As a preliminary matter, the Board finds that the veteran's claim is plausible and capable of substantiation and is thus well-grounded within the meaning of 38 U.S.C.A. § 5107(a). The Board is satisfied that all relevant facts have been properly developed. No further assistance to the veteran is required in order to comply with the duty to assist as mandated by 38 U.S.C.A. § 5107(a). Initially, the Board points out that disability ratings are based, as far as practicable, upon the average impairment of earning capacity attributable to specific disabilities, according to the VA Schedule of Rating Disabilities. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4, § 4.1. Different diagnostic codes identify various disabilities. 38 C.F.R. Part 4. Generally, the degrees of disability specified 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, 4.10 (1998). 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. 38 C.F.R. § 4.7 (1998). Otherwise, the lower rating will be assigned. Id. By a November 1996 rating decision, the RO granted service connection for hypertension and assigned a 10 percent disability rating under Diagnostic Code 7101, effective December 1, 1995, the day following the veteran's separation from service. The veteran perfected a timely appeal as to the rating. During the pendency of the appeal, in January 1999, the RO granted a 30 percent disability rating under Diagnostic Code 7005, effective from December 1, 1995. The current disability rating was based on the amended diagnostic criteria for the cardiovascular system, which became effective on January 12, 1998. In light of the foregoing, the Board notes that this case involves an appeal as to the initial rating of the veteran's hypertension, rather than an increased rating claim where entitlement to compensation had previously been established. Fenderson v. West, 12 Vet. App. 119, 126 (1999). In initial rating cases, separate ratings can be assigned for separate periods of time based on the facts found, a practice known as "staged" ratings. Accordingly, the Board should consider the applicability of a higher rating for the entire period in which the appeal has been pending. Id. Before proceeding, the Board observes that on remand in January 1999, the RO changed the applicable Diagnostic Code from 7505 - arteriosclerotic heart disease to Diagnostic Code 7007 - hypertensive heart disease (amended criteria) based on the most recent VA examination findings. As briefly mentioned, the veteran's hypertension is currently rated under Diagnostic Code 7007. The Board points out that the VA Schedule for Rating Disabilities has been revised with respect to the regulations applicable to rating diseases of the heart. See 62 Fed. Reg. 65,207 (1997). Those provisions, which became effective January 12, 1998, replaced the rating criteria of 38 C.F.R. § 4.104, Diagnostic Code 7000-7123 (as in effect through January 11, 1998). The amended rating criteria are sufficiently different from those in effect through January 11, 1998. The Court has held that where a law or regulation changes after a claim has been filed or reopened, but before the administrative or judicial appeal process has been concluded, the version most favorable to a veteran applies unless Congress provided otherwise or permitted the Secretary to do otherwise and the Secretary does so. Marcoux v. Brown, 9 Vet. App. 289 (1996); Karnas v. Derwinski, 1 Vet. App. 308 (1991); see also VAOGCPREC 69-90 (55 Fed. Reg. 43254 (1990)). Thus, the veteran's claim for an initial higher rating for hypertension should be evaluated under both the old and the amended rating criteria to determine which version is most favorable to the veteran. To warrant a 60 percent disability evaluation under Diagnostic Code 7007 of the old criteria for hypertensive heart disease, there must be marked enlargement of the heart, confirmed by roentgenogram, or the apex beat is beyond the midclavicular line, there is sustained diastolic hypertension, a diastolic pressure of 120 or more, which may later have been reduced, dyspnea on exertion, and more than light manual labor is precluded. To warrant a 30 percent evaluation, there must be definite enlargement of the heart, sustained diastolic hypertension of 100 or more, and moderate dyspnea on exertion. 38 C.F.R. § 4.104, DC 7007 (1996) (Effective through January 11, 1998). To warrant a 60 percent disability rating under the amended criteria, there must be more than one episode of acute congestive heart failure in the past year, or; a workload of greater than 3 METs but not greater than 5 METs results in dyspnea, fatigue, angina, dizziness, or syncope, or; left ventricular dysfunction with an ejection fraction of 30 to 50 percent. The current 30 percent disability rating is warranted where a workload of greater than 5 METs but not greater than 7 METs results in dyspnea, fatigue, angina, dizziness, or syncope, or; evidence of cardiac hypertrophy or dilatation on electrocardiogram, echocardiogram, or X-ray. 38 C.F.R. § 4.104, Diagnostic Code 7007 (Effective on January 12, 1998). In pertinent part, the service medical records in evidence reflect that in October and November 1990, the veteran manifest blood pressure readings of 142/109 and 154/112. The veteran was referred for a consult. A consult report is not associated with the claims folder. Thereafter, the records reflect random blood pressure readings that fluctuated from 138/85, 152/106, to 160/100. The March 1995 chest x-ray conducted for retirement reflects that the pulmonary vessels were normal. The cardiac size was within normal limits. There was no acute or focal cardiopulmonary disease seen. An April 1995 emergency room entry reflects serial blood pressure readings of 150/110, 155/101, 170/116. A chest x- ray dated in April 1995 reflects rule out pneumonia, that the pulmonary vessels were normal, that the cardiac size was within normal limits, and there was no acute or focal cardiopulmonary disease that could be seen. The retirement physical dated in May 1995 reflects by electrocardiogram a normal sinus rhythm with left axial deviation. The retirement examination report reflects hypertension, that the blood pressure was 160/100 during an upper respiratory infection, and 110/85-post illness. Internal medicine entries dated in June 1995 reflect blood pressure readings of 180/113, 138/100, 132/96, and 129/94. The veteran reportedly was on no medications in June 1995. Thereafter, a physician relates probable hypertension (but superimposed normal readings cannot exclude white coat hypertension). The veteran retired from military service in November 1995. In relevant part, the first post service records dated in July 1996 include an emergency room report. The veteran complained of feet swelling for 1 week with a history of hypertension for 1 year. The blood pressure on admission was 191/119. He presented with periorbital swelling, his bilateral breath sounds were clear, and he had no shortness of breath. The veteran was begun on Normandy 20 milligrams slow intravenous push. The blood pressure decreased to 135/95 and 129/86. He was discharged home on Normandy. The problem list reflects hypertensive vascular disease and pseudo gout. The July 1996 chest x-ray reflects that the lungs and cardiomediastinal silhouette were normal for the patient's age. The electrocardiogram reflects normal sinus rhythm, left axis deviation, voltage criteria for left ventricular hypertrophy, ST elevation, and consider early repolarization, pericarditis, or injury. The final assessment was abnormal electrocardiogram. The August 1996 VA hypertension examination reflects that the veteran was first diagnosed as hypertensive approximately 12 years earlier. He was initially treated with salt restriction and weight reduction. Medication was started in August 1994. The veteran complained of non-productive cough and occasionally had the sensation that he could not get his breath. The sitting blood pressure was 157/96. On physical examination, the lungs were clear to percussion and auscultation. The heart was not clinically enlarged. The heart tones were of good quality and of normal intensity. There were no murmurs. There was no pitting edema of the lower extremities and the pulses were present and symmetrical. The serial blood pressures were as follows: sitting 157/96; lying 160/100; and standing 158/98. He medicated with Fosinopril. The apex beat was not beyond the midclavicular line. The electrocardiogram showed an incomplete right bundle branch block and voltage criteria for left ventricular hypertrophy. The diagnosis was hypertensive vascular disease, benign, treated, poorly controlled. The examiner added that the veteran was advised that his symptoms of cough and difficulty breathing could be a side-effect of his medication and was advised to see his attending physician. A September 1996 emergency room entry reflects serial blood pressure readings of 170/95, 127/82, 130/82. His oxygen saturation was 97 percent. The lungs were clear to auscultation. The veteran was tachycardic without murmur. The veteran complained of increased pain and swelling of his feet. The assessment was probable gout. Treatment records dated in August 1997 reflect blood pressure readings of 146/110 in the left arm and 134/102 in the right arm. On examination in August 1997, there was no jugular vein distention, the breath sounds were clear, and the heart had a regular rate without murmur or ectopy. The assessment inter alia included hypertensive. Medications were added to his treatment plan. An October 1997 medical record reflects that the veteran was admitted for diabetes mellitus type II and hypertension. On admission, his blood pressure was 117/85 and his lungs were clear to auscultation bilaterally. The heart rate and rhythm was regular without murmur. There was trace edema. A November 1997 internal medicine entry reflects that the blood pressure was 118/75 and that the veteran worked for the post office. A November 1997 chest x- ray reflects that the heart size was normal and that the pulmonary vasculature was evenly distributed with no infiltrate, soft tissue nodule, or pleural effusion present. The impression was no acute disease. A subsequent blood pressure reading was 111/77. Briefly, medical records dated in August 1998 and September 1998 reflect that the veteran complained his blood pressure was up; the blood pressure reading was 141/56. Blood pressure earlier that August morning was approximately 160/100. There was no shortness of breath, dyspnea on exertion, chest pain, orthopnea, abdominal pain, diaphoresis or pedal edema. He complained of headache and blurred vision after the second Nifedipine. The diagnosis was cephalalgia and probable viral syndrome. The August 1998 chest x-ray revealed no acute infiltrate. The heart, mediastinum, and diaphragm appeared normal. The report reflects that there were no changes since 1996. The electrocardiogram reflects normal sinus rhythm, left anterior fascicular block, high QRS voltage, probable early repolarization pattern, and abnormal electrocardiogram. Thereafter, the veteran was admitted for febrile illness and renal failure. The blood pressure on admission was 147/84 and thereafter, 152/102. A September 1998 electrocardiogram reflects sinus tachycardia, left anterior fascicular block, abnormal electrocardiogram, and late transition. The December 1998 VA examination reflects complaints of dyspnea, especially on exertion and with climbing up stairs. On level ground, he can only walk one block before he gets dyspneic. He complained of sharp chest pains located on the right chest with nausea, lasting from minutes to an hour. He medicated with Glucotrol, Adalat, Allopurinol, Colchicine, and Probenecid. He claimed fluctuating blood pressure despite the Adalat. On physical examination, the blood pressure was 160/105. There was no jugular vein distention and no bruits. The chest was clear to auscultation. The cardiovascular examination revealed a normal S1, S2, and S4 heard on the apex. There were no murmurs or rubs. The point of maximal impulse was difficult to evaluate because of the obesity. The abdomen was non-tender and non-distended. The extremities revealed normal pulses and no edema. The veteran underwent a treadmill stress test, on which he did 6 METs, the equivalent of 4-4 1/2 minutes of exercise. The stress level was adequate and the stress was negative for ischemia by electrocardiogram. The function capacity was limited, however. He had no chest pain but fatigue and shortness of breath during the stress test. The echocardiogram revealed a normal AV size with LDH and an ejection fraction of 60%. The left atrium, right atrium, and RV size were normal. There was no pericardial effusion. There was trivial tricuspid regurgitation with an estimated P/A systolic pressure of 32- mm mercury. There was nonspecific thickening of the mitral valve leaflets. By chest x-ray, the heart, mediastinum, and diaphragm appeared normal. An electrocardiogram revealed evidence of left fascicular block and moderate voltage criteria for left ventricular hypertrophy. The examiner reported that the results support the diagnosis of hypertensive heart disease. A March 1999 VA medical record entry for an unrelated condition reflects blood pressure of 151/71. The record clearly supports a finding of fluctuating blood pressures during and since military service, evidencing diastolic readings of 100 or more. Based on the evidence of record, at most, the record shows that the veteran has symptoms that characterize a 30 percent evaluation under both the old and amended criteria of Diagnostic Code 7007. The Board observes that the medical data indicate that the veteran experiences dyspnea and fatigue after 4-4 1/2 minutes of the treadmill stress test or 6 METs. The Board emphasizes that evidence of record, including the December 1998 VA examination report, reflects that the veteran has a blood pressure of 160/105, no ischemia by stress test, an ejection fraction of 60 percent per echocardiogram, tricuspid regurgitation, non-specific thickening of the mitral valve leaflets, normal heart, mediastinum, and diaphragm, and fluctuating blood pressures despite Adalat. The recent echocardiogram revealed again voltage criteria suggestive of left ventricular hypertrophy that was originally noted in 1996. Moreover, the Board notes that these same findings are also suggestive of an enlargement of the heart, diastolic hypertension of 100 or more, and dyspnea on exertion, which more nearly approximates a disability picture for a 30 percent evaluation under the old criteria. 38 C.F.R. § 4.7. Therefore, the Board determines that a 30 percent evaluation for the veteran's hypertensive heart disease is warranted under the old and amended schedular criteria of Diagnostic Code 7007. Based on the findings as described above, the veteran's hypertension heart disease is not clinically characteristic of diastolic pressures predominantly 120 or more and moderately severe symptoms to warrant a 40 percent evaluation under the old or amended criteria of Diagnostic Code 7101. The Board notes that the old and amended criteria of Diagnostic Code 7005 is not applicable in this case, as the evidence of record reflects a current diagnosis of hypertensive heart disease and not arteriosclerotic heart disease. Furthermore, the evidence of record does not reflect that a 60 percent disability evaluation is not warranted under the new criteria of Diagnostic Code 7007, as the veteran has not presented with congestive heart failure, a workload of greater than 3 METs but not greater than 5 METs that results in dyspnea, fatigue, angina, dizziness, or syncope, or left ventricular dysfunction with an ejection fraction of 30 to 50 percent. Moreover, the medical evidence of record is not reflective of marked enlargement of the heart, which has been confirmed by roentgenogram, or other symptomatology, which precludes more than light manual labor, as required for a rating in excess of 30 percent under old criteria of Diagnostic Code 7007. In the October 1997 and May 1999 supplemental statements of the case, the RO noted that consideration of 38 C.F.R. §§ 3.321(b)(1) and 4.16(b) had been given, but that the case was not considered so unusual as to warrant referral to the Director, Compensation and Pension, for a higher rating on an extraschedular basis because the evidence did not show marked interference with employment or frequent medical care due to the service connected condition. Moreover, it is the established policy of the VA that all veterans who are unable to secure and follow a substantially gainful occupation by reason of service-connected disabilities shall be rated totally disabled. 38 C.F.R. § 4.16(b). However, as regards the criteria for a total rating based unemployability, the record reflects that the veteran is currently employed as a mail carrier. As a result, the provisions of section 4.16(b) are not for application in this case. As to the disability picture presented in this case, the Board determines that the disability picture is not so unusual or exceptional, with such related factors as frequent periods of hospitalization or marked interference with employment, as to prevent the use of the regular rating criteria. The Board observes that the information of record indicates that the veteran's current occupation is that of a mail carrier, and he contends that his service-connected hypertensive heart disease affects his employment status. Clearly, due to the nature and severity of the veteran's service connected heart disability, interference with the veteran's employment status is foreseeable. However, the Board finds that the record does not reflect frequent periods of inpatient care for the service-connected disability at issue, nor interference with his employment to a degree greater than that contemplated by the regular schedular standards, which are based on the average impairment of employment. 38 C.F.R. §§ 4.1, 4.10. Thus, the record does not present an exceptional case where the 30 percent rating assigned for the veteran's heart disability is found to be inadequate. See Van Hoose v. Brown, 4 Vet. App. 361, 363 (1993) (noting that the disability evaluation itself is recognition that industrial capabilities are impaired); Moyer v. Derwinski, 2 Vet. App. 289, 293 (1992). Therefore, in the absence of such factors, the Board finds that the criteria for submission for assignment of an extra-schedular rating pursuant to 38 C.F.R. § 3.321(b)(1) are not met. Accordingly, an evaluation in excess of the 30 percent for the service-connected hypertensive heart disease is not warranted. In any event, the VA has an obligation under the 38 U.S.C.A. § 5103(a) (West 1991) to advise a veteran of the evidence necessary to complete his or her application for VA benefits. In this case, the veteran is hereby notified that preliminary review indicates that the evidence necessary for consideration of his claim on an extra-schedular rating under 38 C.F.R. § 3.321(b)(1), is documentary and/ or lay evidence which relates to such factors as interference with his employment status (i.e., employment, personnel, and medical data, etc.), as well as competent medical evidence of frequent periods of inpatient care, due solely to the service-connected disability at issue. See Spurgeon v. Brown, 10 Vet. App. 194, 197-98 (1997). Accordingly, the Board views its discussion as sufficient to inform the veteran of the elements necessary to complete his application for a claim for increased VA benefits on an extra-schedular basis. See Robinette v. Brown, 8 Vet. App. 69, 80 (1995). ORDER Service connection for bursitis of the left shoulder is denied. An evaluation in excess of 30 percent for hypertensive heart disease is denied. Deborah W. Singleton Member, Board of Veterans' Appeals