Citation Nr: 0813372 Decision Date: 04/23/08 Archive Date: 05/01/08 DOCKET NO. 07-25 559 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Boston, Massachusetts THE ISSUES 1. Entitlement to an increased rating for status post second and third degree burns with residual symptomatology right hand and forearm, currently rated 30 percent disabling. 2. Entitlement to an increased rating for status post second and third degree burns of the left hand, currently rated 10 percent disabling. 3. Entitlement to an increased rating for right carpal tunnel syndrome, currently rated 10 percent disabling. REPRESENTATION Appellant represented by: Massachusetts Department of Veterans Services WITNESS AT HEARING ON APPEAL The veteran ATTORNEY FOR THE BOARD James A. DeFrank, Associate Counsel INTRODUCTION The veteran served on active duty for training in the Massachusetts National Guard from January 1978 to April 1978. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a January 2007 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Boston, Massachusetts which continued a 30 percent rating for status post second and third degree burns with residual symptomatology right hand and forearm, continued a 10 percent rating for status post second and third degree burns of the left hand and continued a 10 percent rating for right carpal tunnel syndrome. In December 2007, the veteran attended a hearing at the RO before the undersigned. The transcript of the hearing is associated with the claims file. Where a veteran: (1) submits evidence of a medical disability; (2) makes a claim for the highest rating possible; and (3) submits evidence of unemployability, the requirement in 38 C.F.R. § 3.155(a) (2001) that an informal claim "identify the benefit sought" has been satisfied and VA must consider whether the veteran is entitled to a total rating for compensation purposes based on individual unemployability (TDIU). Roberson v. Principi, 251 F.3d 1378 (Fed. Cir. 2001). In this case the veteran has testified that he is unable to work due to service-connected disabilities of his hands. His inferred claim for a total rating based on individual unemployability is referred to the RO for initial adjudication. The questions of entitlement to increased extraschedular ratings for status post second and third degree burns with residual symptomatology right hand and forearm, status post second and third degree burns of the left hand and right carpal tunnel syndrome are REMANDED to the RO via the Appeals Management Center, and are discussed in the REMAND section of this decision. FINDINGS OF FACT 1. Residuals of the veteran's third degree burns consist of slight thickening of the skin of the dorsum of the forearm and moderate incomplete paralysis of the lower radicular group without evident scars. 2. Residuals of the veteran's second and third degree burns of the left hand are manifested by moderate incomplete paralysis of the lower radicular group without evident scars. 3. The veteran's right carpal tunnel syndrome is manifested by mild incomplete paralysis of the median nerve. CONCLUSIONS OF LAW 1. The criteria for a 40 percent rating for status post second and third degree burns with residual symptomatology right hand and forearm have not been met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 3.321(b)(1), 4.1-4.14, 4.118, Diagnostic Codes 7801, 7802, 7803, 7804, 7805, 8512 (2007). 2. The criteria for a 30 percent rating for status post second and third degree burns of the left hand have been met. 38 U.S.C.A. § 1155; 38 C.F.R. §§ 3.321(b)(1), 4.1-4.14, 4.118, Diagnostic Codes 7801, 7802, 7803, 7804, 7805, 8512. 3. The schedular criteria for an evaluation in excess of 10 percent for right carpal tunnel syndrome have not been met. 38 U.S.C.A. § 1155; 38 C.F.R. §§ 4.71a, 4.124a, Diagnostic Codes 5215, 8515 (2007). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Veterans Claims Assistance Act of 2000 The Veterans Claims Assistance Act of 2000 (VCAA) and implementing regulations impose obligations on VA to provide claimants with notice and assistance. 38 U.S.C.A. §§ 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2007); 38 C.F.R §§ 3.102, 3.156(a), 3.159, 3.326(a) (2007). Proper VCAA notice must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; (3) that the claimant is expected to provide; and (4) must ask the claimant to provide any evidence in her or his possession that pertains to the claim. 38 U.S.C.A. § 5103(a) (West 2002); C.F.R. § 3.159(b)(1) (2007). VCAA notice should be provided to a claimant before the initial unfavorable agency of original jurisdiction (AOJ) decision on a claim. Pelegrini v. Principi, 18 Vet. App. 112 (2004). In a letter dated December 2006, the agency of original jurisdiction (AOJ) informed the veteran of the evidence needed to substantiate the claims, what medical or other evidence he was responsible for obtaining, and what evidence VA would undertake to obtain. The letter told the veteran that he could send VA information that pertained to his claims. This notice served to inform him of the need to submit relevant evidence in his possession. The Court has also held that that the VCAA notice requirements of 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) apply to all five elements of a service connection claim. Those five elements include: (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 (2006). The veteran has substantiated his veteran's status, and his entitlement to service connection. Hence notice on the first three Dingess elements is not necessary. The December 2006 letter contained notice as to the effective date and rating elements as required by Dingess. The Court has held that, at a minimum, adequate VCAA notice in an increased rating claim requires that VA notify the claimant that, to substantiate such a claim: (1) the claimant must provide, or ask VA to obtain, medical or lay evidence demonstrating a worsening or increase in severity of the disability and the effect that worsening has on the claimant's employment and daily life; (2) if the diagnostic code under which the claimant is rated contains criteria necessary for entitlement to a higher disability rating that would not be satisfied by the claimant demonstrating a noticeable worsening or increase in severity of the disability and the effect of that worsening has on the claimant's employment and daily life (such as a specific measurement or test result), the Secretary must provide at least general notice of that requirement to the claimant; (3) the claimant must be notified that, should an increase in disability be found, a disability rating will be determined by applying relevant diagnostic codes; and (4) the notice must also provide examples of the types of medical and lay evidence that the claimant may submit (or ask VA to obtain) that are relevant to establishing entitlement to increased compensation. Vazquez-Flores v. Peake, 22 Vet. App. 37. (2008). The December 2006 letter told the veteran that to substantiate entitlement to an increased rating the evidence must show that the disability had worsened. The letter told him that in assigning a rating, VA considered evidence of the impact of the disability on employment. The letter did not explicitly tell him that a rating would be based on the impact of the disability on his daily activities. Any notice error will be presumed prejudicial unless VA can show that the error did not affect the essential fairness of the adjudication and persuade the Court that the purpose of the notice was not frustrated, for example by demonstrating "(1) that any defect was cured by actual knowledge on the part of the claimant, (2) that a reasonable person could be expected to understand from the notice what was needed, or (3) that a benefit could not have been awarded as a matter of law." Sanders v. Nicholson, 487 F.3d 881, 888-9 (Fed. Cir. 2007), George-Harvey v. Nicholson, 21 Vet. App. 334, 339 (2007). The veteran demonstrated actual knowledge that evidence of the impact of the disability on daily activities could substantiate his claim. In this regard he testified as to the effects of the disability on his daily activities. Arguably some of the rating criteria contemplate specific test results. The December 2006 letter told the veteran to submit any laboratory or test results. The veteran received notice of the rating criteria in the August 2007, statement of the case (SOC). VCAA notice cannot be provided in a SOC, but the SOC did provide actual notice to the veteran. He has had the opportunity to submit argument and evidence and to have a hearing in the since the SOC provided actual knowledge. Hence, he has had a meaningful opportunity to participate in the adjudication of his claim, despite the deficient notice on this element and there is no prejudice from the deficiency. The December 2006 letter provided notice on the third and fourth Vazquez elements. It told him that percentage ratings were provided in accordance with criteria contained in the rating schedule. The letter provided examples of evidence that could be used to substantiate the claim. The letter told him that he could submit this evidence, and offered VA assistance in obtaining evidence. There was a timing deficiency with the December 2006 letter, because it was provided after the initial evaluation. Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). The timing deficiency was cured by the re-adjudication of the claim after the notice was provided. Id. VA has thereby met its VCAA notice obligations. Charles v. Principi, 16 Vet. App. 370 (2002); Quartuccio v. Principi, 16 Vet. App. 183 (2002). The duty to assist Under 38 U.S.C.A. § 5103A, VA must make reasonable efforts to assist the claimant in obtaining evidence necessary to substantiate the claim. The RO has obtained all the evidence reported by the veteran or suggested by the record. The veteran underwent necessary VA examinations in July 2005, December 2006 and December 2007. The veteran has not reported any missing VA or private medical records that need to be obtained. The Board is not aware of any such records, nor is the Board aware of any additional evidence that could assist the veteran in substantiating his claim. Therefore, the facts relevant to the veteran's claim have been properly developed, and there is no further action to be undertaken to comply with the provisions of the VCAA and the implementing regulations. See Wensch v. Principi, 15 Vet App 362 (2001); see also 38 U.S.C.A. §5103A(a)(2) (Secretary not required to provide assistance "if no reasonable possibility exists that such assistance would aid in substantiating the claim"). Applicable law and regulations Disability evaluations are determined by the application of rating criteria set forth in the VA Schedule for Rating Disabilities (38 C.F.R. Part 4) based on the average impairment of earning capacity. Separate diagnostic codes identify the various disabilities. 38 U.S.C.A. § 1155. Where entitlement to compensation has already been established and an increase in the disability rating is at issue, the present level of disability is of primary concern. Although a rating specialist is directed to review the recorded history of a disability in order to make a more accurate evaluation, see 38 C.F.R. § 4.2, the regulations do not give past medical reports precedence over current findings. Francisco v. Brown, 7 Vet. App. 55 (1994). Staged ratings are, however, appropriate for an increased rating claim when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. The relevant focus for adjudicating an increased rating claim is on the evidence concerning the state of the disability from the time period one year before the claim was filed until VA makes a final decision on the claim. Hart v. Mansfield, 21 Vet. App. 506 (2007). Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. See 38 C.F.R. § 4.7. In view of the number of atypical instances it is not expected, especially with the more fully described grades of disabilities, that all cases will show all the findings specified. Findings sufficiently characteristic to identify the disease and the disability therefrom, and above all, coordination of rating with impairment of function will, however, be expected in all instances. 38 C.F.R. § 4.21 (2007). The medical as well as industrial history is to be considered, and a full description of the effects of the disability upon ordinary activity is also required. 38 C.F.R. §§ 4.1, 4.2, 4.10. Factual Background In July 1987, the veteran sustained second and third degree burns of the left and right forearm and hand when a burner ignited. In an August 1998 rating decision, the RO granted service connection for residuals, second and third degree burns both hands and right arm, and assigned the disabilities a noncompensable rating under 38 C.F.R. § 4.118, Diagnostic Code 7801-7802, effective April 27, 1998. A December 1998 rating decision increased the disability evaluations to a 10 percent rating, effective April 27, 1998. In a July 1999 decision the RO granted entitlement to an earlier effective date for residuals, second and third degree burns both hands and right arm, effective October 29, 1991. In a March 2001 rating decision, the RO increased the rating for status post second and third degree burns with residual symptomatology right hand and forearm to a 30 percent rating, effective January 1, 2000. The RO also granted service connection for status post second and third degree burns of the left hand to 10 percent effective January 13, 2000. In July 2003 the veteran underwent a VA examination. The examiner noted that there were visible burn marks over the veteran's right forearm. However, there was no contracture. The movement of his elbow and wrist joints was normal. Deep tendon reflexes were symmetrical and the sensory examination as such was intact. His EMG study was indicative of mild carpal tunnel syndrome. The examiner noted that the March 2000 VA examination showed no atrophy or fasciculation. However, the veteran reported mild weakness with a degree of 4+/5 in the grip strength, adductor extension. Sensory examination had shown diminished light touch and pinprick in the right upper extremity in the lateral forearm and lateral three fingers. The examiner concluded that the veteran had mild carpal tunnel syndrome. This would not interfere with the nature of the work he was required to perform but it was suggested that he avoided repetitive use of the right hand. In an addendum, the VA examiner stated that the veteran's carpal tunnel syndrome was not a symptom of, or related to his right hand and forearm third degree burn condition. In a March 2004 decision, the Board granted service connection for right carpal tunnel syndrome. The RO assigned a 10 percent disability evaluation, effective June 10, 2002. In July 2005 the veteran underwent a VA examination. The veteran reported that since returning from the Army he had been employed as a chef. He had some problems with his burn sites. He complained of sensitivity to cold and had also developed some burning pains in the right forearm and left hand. He also had complaints of occasional numbness in his right hand. On examination, his right forearm had mild thickening of the skin of the dorsum of his right forearm which was completely healed and covered with normal hair growth. There were no obvious scars at this site and the veteran had no limitation of motion of his right wrist or his fingers. He had a negative Tinel sign of his right hand, signifying absence of a severe carpal tunnel syndrome. Examination of the left hand revealed no abnormalities. The skin of the dorsum of the veteran's left hand was completely normal with normal hair growth. There was no scarring of any degree. The range and motion of his wrist and fingers were normal. The grasps of both hands were normal. The diagnosis was second degree thermal burns which resulted in a long hospitalization with complete healing of the burn sites without necessity for grafting. He had complete healing of the burns on his left hand and had no restriction of range of motion on his left hand with normal range of motion and grasp. The results of his burns had healed without serious event. In February 2006 the veteran underwent an EMG consultation at a VA Medical Center (VAMC). The veteran was referred as a result of numbness and weakness in his hands, right worse than left. The EMG and nerve conduction study of the upper extremities demonstrated evidence of mild right carpal tunnel syndrome without evidence of axonal loss. These findings were mildly worsened compared to a previous study in 2002. There were no definite signs of a cervical radiculopathy on the study. There was no evidence of ulnar neuropathy at the cubital tunnel. There was mild underlying predominantly demyelinating peripheral neuropathy. In December 2006 the veteran underwent a VA examination for his skin. The veteran reported being employed as a chef. He stated that he had some problems with the burn sites of his right arm because they were sensitive to cold. He also still had occasional difficulty with movements of his left hand. He had slight sensory loss in his left hand which had not affected his work and apparently had been of no great consequence. There had been no problems with the muscular strength of either hand or arm. On examination, he had a slight thickening of the skin of the dorsum of his right forearm which was completely healed. There was normal hair growth. There were no obvious scars on the site of the right arm. There was no limitation of motion on the right wrist or fingers. He had a negative Tinel's sign. Examination of his left arm revealed no abnormalities. His skin was completely healed and there was no residual from the previous burns. Range of motion of the wrist and fingers were normal and the grasp of both hands was 5/5. In January 2007 the veteran underwent a VA peripheral nerves examination. The veteran reported intermittent pains and numbness in both hands that radiate from the hands into the forearms, into both elbows and are more prominent in the skin areas that have been burned. Of particular concern was the decreased strength of the hand grip, more so on the right than the left and decreased sensation in both hands. He also occasionally got cold feelings in the hands and cramping in the arms. Not infrequently, he had to shake his hands for the limb sensation to come back to normal. In the past 8 months he developed some mild numbness in both feet. On examination, the cranial nerves showed intact extraocular movements in all directions with no evidence of nystagmus. Motor examination showed a mild increase of muscle bulk distally in the forearm of the type seen in distal axonal peripheral neuropathies. The muscle tone however was normal in all muscle groups in both upper and lower extremities. There was mildly decreased wrist extension and hand grip flexion in both hands, more so on the right than the left with normal strength in all leg muscle groups. There was also mild weakness of the inerosseous muscles of the both hands on both sides. There was mildly decreased sensation to touch and pinprick in both hands and forearm in somewhat patchy distribution. This seemed to correspond with the old burn injuries which had been marked by patchy hyperpigmented areas of both forearms, more so on the right than the left. The deep tendon reflexes were absent on the examination throughout. The examiner stated that the veteran had been having moderate neuorpathic symptoms since the burn injuries in 1987. The veteran also had developing superimposed mild distal neuropathy in the upper and lower extremities which might be related to the onset of his diabetes mellitus. The diagnosis was history of burn injuries to both hands and forearms, mild diffuse peripheral nerve dysfunction in the upper forearms and hands probably secondary to the burn skin injury and right sided carpal tunnel syndrome by EMG. At his December 2007 hearing, the veteran testified that he experienced stiffness in his hands on a daily basis. He also stated that he was not currently working as his difficulties with picking up pots made his applications for chef positions difficult. I. Right hand and forearm. Analysis The veteran's is currently evaluated as 30 percent disabling under Diagnostic Code 7801. The March 2001 rating decision assigned that evaluation under the old version of the diagnostic code, which provided a 30 percent rating for third degree burn scars exceeding one half square foot in area. 38 C.F.R. § 4.118 (2002), Diagnostic Code 7801. Diagnostic Code 7801, effective August 30, 2002, provides criteria for rating scars other than of the head, face, or neck, that are deep or that cause limited motion. When such scars exceed 144 square inches (929 sq. cm.), a 40 percent disability evaluation is warranted. Scars in an area or areas exceeding 72 square inches (465 sq. cm.) warrant a 30 percent disability evaluation. Scars in an area or areas exceeding 12 square inches (77 sq. cm.) warrant a 20 percent disability evaluation. Scars in an area or areas exceeding 6 square inches (39 sq. cm.) warrant a 10 percent disability evaluation. Note (1): Scars in widely separated areas, as on two or more extremities or on anterior and posterior surfaces of extremities or trunk, will be separately rated and combined in accordance with § 4.25 of this part. Note (2): A deep scar is one associated with underlying soft tissue damage. Under Diagnostic Code 7802, scars, other than head, face, or neck, that are superficial and that do not cause limited motion with an area or areas of 144 square inches (929 sq. cm.) or greater warrant a 10 percent disability evaluation. Note (1): Scars in widely separated areas, as on two or more extremities or on anterior and posterior surfaces of extremities or trunk, will be separately rated and combined in accordance with § 4.25 of this part. Note (2): A superficial scar is one not associated with underlying soft tissue damage. Under Diagnostic Code 7803, scars, superficial, unstable, warrant a 10 percent disability evaluation. Note (1): An unstable scar is one where, for any reason, there is frequent loss of covering of skin over the scar. Note (2): A superficial scar is one not associated with underlying soft tissue damage. Under Diagnostic Code 7804, scars, superficial, painful on examination, warrant a 10 percent disability evaluation. Under diagnostic code 7805, scars, other; are rated on limitation of function of affected part. A higher evaluation is available under Diagnostic Code 7805 for limitation of function of the affected part. However, there has been no limitation associated with the scar. Specifically, the December 2006 VA examiner stated that there had been no limitation of motion on the right wrist or fingers. Therefore a higher evaluation under Diagnostic Code 7805 is not warranted. Examinations conducted during the course of this appeal have shown that there are no apparent remaining scars at the site of the burns in the right arm. As such, an increased rating is not warranted under the diagnostic codes pertaining to scars. At the January 2007 VA examination, the examiner commented that the veteran had been having moderate neuropathic symptoms and found deep tendon reflexes to be absent. At other points the examiner described the neurologic disability as mild, and the EMG studies were also interpreted as showing mild impairment. In any event, the examiner associated the neurologic impairment with the service connected burns. The Board must, therefore consider rating the disability on the basis of its neurologic manifestations. Neurologic disabilities are rated on a scale from mild incomplete paralysis to complete paralysis for the nerve or nerve group involved. 38 C.F.R. § 4.124a (2007). The rating schedule provides the following guidance in rating neurologic disabilities: The term "incomplete paralysis," with peripheral nerve injuries, indicates a degree of lost or impaired function substantially less than that which occurs for a complete paralysis given with each nerve, whether due to varied level of the nerve lesion or to partial regeneration. 38 C.F.R. § 4.124a. Neuritis, cranial or peripheral, characterized by loss of reflexes, muscle atrophy, sensory disturbances, and constant pain, at times excruciating, is to be rated on the scale provided for injury of the nerve involved, with a maximum equal to severe, incomplete, paralysis. See nerve involved for diagnostic code number and rating. The maximum rating which may be assigned for neuritis not characterized by organic changes referred to in this section will be that for moderate, or with sciatic nerve involvement, for moderately severe, incomplete paralysis.38 C.F.R. § 4.123 (2007). Neuralgia, cranial or peripheral, characterized usually by a dull and intermittent pain, of typical distribution so as to identify the nerve, is to be rated on the same scale, with a maximum equal to moderate incomplete paralysis. See nerve involved for diagnostic code number and rating. Tic douloureux, or trifacial neuralgia, may be rated up to complete paralysis of the affected nerve.38 C.F.R. § 4.124 (2007). While there is some evidence that the veteran's disability is mild, there is also evidence of absent reflexes and opinion that there is moderate neuropathy. Resolving reasonable doubt in the veteran's favor, the Board concludes that the disability approximates moderate incomplete paralysis. The rating schedule provides a 40 percent evaluation for moderate incomplete paralysis of the major lower radicular group. 38 C.F.R. § 4.118, Diagnostic Code 8512. The finding of absent reflexes could arguably support a finding of moderately severe incomplete paralysis, but medical professionals have found no more than moderate disability, and atrophy or constant excruciating pain have not been demonstrated. The weight of the evidence is therefore against a finding of more than moderate incomplete paralysis. Because the veteran has no current scars, a separate rating on that basis is not warranted. The veteran's disability is neurologic. For this reason, it is more appropriate to rate his disability on the basis of diagnostic codes that contemplate neurologic impairment. See Butts v. Brown, 5 Vet. App. 532, 539 (1993) (Board may choose a diagnostic code that differs from that chosen by the RO, if adequate reasons and bases are provided). Resolving reasonable doubt in the veteran's favor, a 40 percent rating is warranted for that disability. 38 U.S.C.A. § 5107(b); 38 C.F.R. §§ 4.7, 4.21. II. Left hand. Analysis The veteran's status post second and third degree burns of the left hand are also evaluated under Diagnostic Code 7801. The evidence is to the effect that the veteran no longer has scars of the left hand. A higher rating is therefore not warranted on the basis of scars. Again, at the January 2007 VA examination, the examiner noted that the veteran had mildly decreased sensation to touch and pinprick in both hands and forearm in somewhat patchy distribution that seemed to correspond with the old burn injuries which were marked by patchy hyperpigmented areas of both forearms. The diagnosis was history of burn injuries to both hands and forearms, mild diffuse peripheral nerve dysfunction in the upper forearms and hands probably secondary to the burn skin injury. Much of what has just been said with regard to the neurologic impairment related to the burn injury on the right, could also be said of the injury on the left. For the same reasons, it is most appropriate to rate the burn residuals on the left on the basis of neurologic impairment. Given the lack of current scars, a separate evaluation is not warranted on that basis. The neurologic findings on the left are the same as those on the right. Accordingly a rating based on moderate incomplete paralysis of the lower radicular group is warranted. Diagnostic Code 8512 provides a 30 percent rating for moderate incomplete paralysis of the lower radicular group on the minor side. For the same reasons discussed with regard to the burns on the right, the evidence is against a finding of more than moderate incomplete paralysis on the left. III. Right carpal tunnel syndrome. Analysis Under 38 C.F.R. § 4.124a, Code 8515, where there is complete paralysis of the median nerve with the dominant hand inclined to the ulnar side; the index and middle fingers more extended than normal; considerable atrophy of the muscles of the thenar eminence; the thumb in the plane of the hand (ape hand); pronation incomplete and defective; absence of flexion of index finger and feeble flexion of middle finger; an inability to make a fist; the index and middle fingers remain extended; an inability to flex the distal phalanx of thumb; defective opposition and abduction of the thumb, at right angles to palm; weakened wrist flexion; and pain with trophic disturbances; a 70 percent rating is warranted. Incomplete, severe paralysis warrants assignment of a 50 percent rating; incomplete, moderate paralysis warrants a 30 percent rating, and incomplete mild paralysis warrants a 10 percent rating. Diagnostic Code 8615 pertains to neuritis and Code 8715 to neuralgia. VA examiners have at worst, found the carpal tunnel syndrome to be mild and have reported no more than mild symptoms. The recent EMG also yielded a finding of mild carpal tunnel syndrome. The veteran has not testified to, or otherwise reported, more severe symptomatology. There is essentially no evidence of more than mild incomplete paralysis of the right median nerve during the appeal period. Therefore, a rating in excess of 10 percent for right carpal tunnel syndrome is not warranted. 38 U.S.C.A. § 5107(b); 38 C.F.R. §§ 4.7, .4.21 (2007). ORDER Entitlement to an increased schedular rating of 40 percent for status post second and third degree burns with residual symptomatology right hand and forearm is granted. Entitlement to an increased schedular rating of 30 percent for status post second and third degree burns of the left hand is granted. Entitlement to an increased schedular rating in excess of 10 percent for carpal tunnel syndrome is denied. REMAND In exceptional cases where the schedular evaluation is found to be inadequate, pursuant to 38 C.F.R. § 3.321(b)(1) (2007), the Under Secretary for Benefits or the Director of VA's Compensation and Pension Service may approve an extra- schedular evaluation commensurate with the average earning capacity impairment due exclusively to the service-connected disability or disabilities. The governing norm in these exceptional cases is: A finding that the case presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization as to render impractical the application of the regular schedular standards. In this case, the veteran has provided evidence of marked interference with employment by testifying that he is unable to work due to the service connected disabilities of both hands. The Court has cast doubt on whether the Board can on the one hand refer a claim for TDIU for initial adjudication, while at the same time failing to refer increased rating claims for consideration of an extraschedular rating. Cox v. Nicholson, 20 Vet. App. 563 (2007). On the other hand, the Board is precluded from granting an extraschedular rating in the first instance. Floyd v. Brown, 9 Vet. App. 88, 95 (1996). Accordingly, this case must be remanded for the following: 1. Refer the veteran's claims for increased ratings for residuals of burns of second and third degree burns of the right hand and forearm and left hand; and for right carpal tunnel syndrome to the Director of VA's Compensation and Pension Service or Under Secretary for Benefits for consideration of entitlement to extraschedular ratings in accordance with 38 C.F.R. § 3.321(b). 2. If any benefit sought on appeal remains denied, issue a supplemental statement of the case before returning the case to the Board, if otherwise in order. The veteran has the right to submit additional evidence and argument on the matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2007). ___________________________________________ Mark D. Hindin Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs