Citation Nr: 0814732 Decision Date: 05/02/08 Archive Date: 05/12/08 DOCKET NO. 05-02 657 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Louis, Missouri THE ISSUES 1. Entitlement to a rating in excess of 70 percent for service-connected pigmented villonodular synovitis with right total hip replacement. 2. Entitlement to service connection for hypertension. REPRESENTATION Veteran represented by: Missouri Veterans Commission WITNESS AT HEARING ON APPEAL The veteran ATTORNEY FOR THE BOARD K. M. Schaefer, Associate Counsel INTRODUCTION The veteran served on active duty from October 1975 to October 1977, January 1981 to August 1989, and December 1990 to April 1991. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a rating decision issued in September 2003 by the Department of Veterans Affairs (VA) Regional Office (RO) in St. Louis, Missouri, which denied service connection for hypertension and granted service connection for service-connected pigmented villonodular synovitis with right total hip replacement and assigned a rating of 30 percent, effective February 11, 2003. Thereafter, the veteran appealed the issues of service connection for hypertension and the initially assigned rating for her hip disability. While her appeal was pending, a November 2007 Decision Review Officer (DRO) decision assigned a 70 percent evaluation, also effective February 11, 2003. However, although the veteran has been assigned a higher rating, it is still less than the maximum benefit available; therefore, her appeal for an increased rating is still before the Board. AB v. Brown, 6 Vet. App. 35, 38 (1993). The veteran testified at a personal hearing before a DRO, sitting at the RO in February 2005. A transcript of the hearing is associated with the claims file. In July 2007, the Board remanded the case to the agency of original jurisdiction (AOJ) for additional development, and it now returns to the Board for appellate review. The Board observes that the veteran also filed a timely notice of disagreement with regard to the denial of service connection for hypercholesterolemia and the initial rating for a service-connected back disability, arguing that a 20 percent rating evaluation was warranted. In a December 2004 DRO decision, the veteran's initial rating for this disorder was increased to 20 percent. As this decision was a complete grant of the benefit sought on appeal, this issue is not before the Board at this time. See id. Then, in January 2005, the veteran perfected her appeal only as to service connection for hypertension and the initial rating for her right hip disability. Thus, the Board determines that she has withdrawn her appeal with regard to service connection for hypercholesterolemia. However, the Board observes that, in February 2005, the veteran submitted a claim for an increased rating for her back disorder due to the findings of a recent examination. Thus, this claim for an increased rating is referred to the RO for appropriate action. FINDINGS OF FACT 1. VA notified the veteran of the evidence needed to substantiate the claims decided herein, explained to her who was responsible for submitting such evidence, and developed all available evidence necessary for an equitable disposition of the claims. 2. Service-connected pigmented villonodular synovitis with right total hip replacement is manifested by weakness with active range of motion of the hip, pain that prohibits passive range of motion testing, flexion of the hip to 80 degrees when sitting, antalgic gait favoring the right leg, and from August 15, 2007, the occasional use of a walker due to pain. 3. Hypertension was not present in service, manifested within one year of the veteran's discharge from service, or shown to be causally or etiologically related to any disease, injury, or incident in service. CONCLUSIONS OF LAW 1. The criteria for a rating in excess of 70 percent for service-connected pigmented villonodular synovitis with right total hip replacement have not been met for the period from February 11, 2003 to August 14, 2007. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. § 4.71a, Diagnostic Code 5054. 2. The criteria for a rating of 90 percent, but no greater, for service-connected pigmented villonodular synovitis with right total hip replacement have been met for the period from August 15, 2007 onward. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. § 4.71a, Diagnostic Code 5054. 3. Hypertension was not incurred in or aggravated by the veteran's active duty military service, nor may it be presumed to have been incurred in or aggravated by such service. 38 U.S.C.A. §§ 1101, 1110, 1112, 1131 (West 2002); 38 C.F.R. §§ 3.303, 3.307, 3.309 (2007). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. VA's Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA), Pub. L. No. 106-475, 114 Stat. 2096 (2000), enacted November 9, 2000 (codified at 38 U.S.C.A. §§ 5102, 5103, 5103A, 5107 (West 2002 & Supp. 2007)), eliminated the concept of a well- grounded claim and redefined VA's obligations with respect to its duties to notify and assist a claimant. In August 2001, VA issued regulations to implement the VCAA. 66 Fed. Reg. 45,620 (August 29, 2001) (codified at 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2007)). The Court of Appeals for Veterans Claims' (Court) decision in Pelegrini v. Principi, 18 Vet. App. 112 (2004), held, in part, that a VCAA notice, as required by 38 U.S.C.A. § 5103(a), must be provided to a claimant before the initial unfavorable agency of original jurisdiction (AOJ) decision on the claims for VA benefits. In this case, the veteran filed her claims of entitlement to service connection for hypertension and a hip disability in February 2003. The decision issued in September 2003 denied service connection for hypertension and granted service connection for pigmented villonodular synovitis with right total hip replacement and assigned an initial 30 percent disability rating, effective February 11, 2003. The veteran thereafter appealed with respect to the initially assigned disability rating. The Board notes that initial rating claims are generally considered to be "downstream" issues from the original grant of benefits. VA's General Counsel issued an advisory opinion holding that separate notice of VA's duty to assist the veteran and of her concomitant responsibilities in the development of her claim involving such downstream issues is not required when the veteran was provided adequate VCAA notice following receipt of the original claim. See VAOPGCPREC 8-2003. However, the Court of Appeals for Veterans Claims (Court) held in Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006), 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. In this case, the veteran was provided with a VCAA notification letter in June 2003, prior to the initial unfavorable AOJ decision issued in September 2003. Additional VCAA letters were sent in May 2005, July 2005, December 2005, April 2006, and August 2007. Further, under Pelegrini, for a VCAA notice to be consistent with 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b), the notice must: (1) inform a claimant about the information and evidence not of record that is necessary to substantiate the claims; (2) inform the claimant about the information and evidence that VA will seek to provide; (3) inform the claimant about the information and evidence that the claimant is expected to provide; and (4) request or tell the claimant to provide any evidence in the claimant's possession that pertains to the claims. Pelegrini, 18 Vet. App. at 120-121. The Board observes that the VCAA notices issued in June 2003 and August 2007 informed the veteran of the type of evidence necessary to establish service connection, how VA would assist her in developing her claims, and her and VA's obligations in providing such evidence for consideration. The August 2007 letter also informed her that in order to substantiate an increased rating, she must demonstrate that her service-connected hip disability had gotten worse, and requested that she send any evidence in her possession to VA. The letters sent in May 2005, July 2005, December 2005, and April 2006 were specific to requests for records made by VA on behalf of the veteran. Failure to provide pre-adjudicative notice of any of required elements of VCAA notice is presumed to create prejudicial error. See Sanders v. Nicholson, 487 F.3d 881 (Fed. Cir. 2007); Simmons v. Nicholson, 487 F.3d 892 (Fed. Cir. 2007). The Secretary has the burden to show that this error was not prejudicial to the veteran. Lack of prejudicial harm may be shown in three ways: (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; see also Mayfield v. Nicholson, 19 Vet. App. 103, (2005), rev'd on other grounds, Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). Additionally, the United States Court of Appeals for the Federal Circuit recently held that a statement of the case (SOC) or supplemental statement of the case (SSOC) can constitute a "readjudication decision" that complies with all applicable due process and notification requirements if adequate VCAA notice is provided prior to the SOC or SSOC. See Mayfield v. Nicholson, 499 F.3d 1317 (Fed. Cir. 2007) [hereinafter Mayfield III]. As a matter of law, the provision of adequate VCAA notice prior to a readjudication "cures" any timing problem associated with inadequate notice or the lack of notice prior to an initial adjudication. See Mayfield III, (citing Mayfield v. Nicholson, 444 F.3d at 1328). In the present case, subsequent to the August 2007 VCAA notice, the veteran was issued SSOCs, thereby providing her with the opportunity to respond to the remedial notice and submit additional evidence. Therefore, despite the inadequate timing of the notice provided to the veteran, the Board finds no prejudice to her in proceeding with the issuance of a final decision. See Bernard v. Brown, 4 Vet. App. 384, 394 (1993) (where the Board addresses a question that has not been addressed by the agency of original jurisdiction, the Board must consider whether the veteran has been prejudiced thereby). Additionally, the Board notes that March 2006 and August 2007 letters informed the veteran of the evidence required to establish disability ratings and effective dates for the disabilities on appeal, as required by Dingess/Hartman. Again, the Board finds the untimeliness of this notice to be nonprejudicial. As the Board concludes herein that the preponderance of the evidence is against the veteran's service connection claim, any questions as to a disability rating or effective date for the veteran's hypertension are rendered moot. As for her increased rating claim, the Board herein assigns a higher rating for the veteran's service- connected hip disability for part of the appeal period, but any further notice necessary as to the assignment of an effective date will be addressed by the RO. The Board acknowledges that a recent Court decision held that there are specific requirements for VCAA notices in increased rating claims. Vazquez-Flores v. Peake, 22 Vet. App. 37 (2008). However, the Board determines that these requirements do not apply to initial rating claims, such as the one now before the Board. Initially, the Board notes that Vazquez-Flores was an appeal of an increased rating claim, not an initial rating claim. More importantly, the Court's decision distinguishes the notice requirements therein defined from the notice required for initial rating claims. Specifically, the Court, after outlining the notice requirements for increased rating claims, states that the notice in an increased rating claim must also provide examples of the medical and lay evidence that are relevant to establishing entitlement to increased compensation, "[a]s with proper notice for an initial disability rating." Id. at 43. Thus, the Board concludes that the Court intended the requirements outlined in its decision to apply only to increased rating claims, and therefore, these requirements are not applicable to the instant claim. Based on the above analysis, the notice requirements for an initial rating claim have been met. VA has also fulfilled its duty to assist the veteran in making reasonable efforts to identify and obtain relevant records in support of the veteran's claims and providing her with a VA examination. The veteran's service medical records to the extent available, and her private treatment records, VA treatment records, and reports from April 2003, December 2004, August 2007, and October 2007 VA examinations were reviewed by both the AOJ and the Board in connection with adjudication of her claims. At her October 2007 VA orthopedic examination, the veteran reportedly brought a copy of statement by Dr. L. W., based on an August 2007 examination. However, this statement does not appear to be in the claims file. The veteran was informed that she should submit any relevant evidence in her possession, and that she could request that VA obtain records from private physicians, such as Dr. L. W. She has not submitted this letter, nor requested that VA obtain any additional records from Dr. L. W. As the Court stated in Wood v. Derwinski, "[t]he duty to assist is not always a one-way street. If a veteran wishes help, [s]he cannot passively wait for it in those circumstances where [s]he may or should have information that is essential in obtaining the putative evidence." 1 Vet. App. 190, 193, reconsidered, 1 Vet. App. 406 (1991); see also Wamhoff v. Brown, 8 Vet. App. 517 (1996). Therefore, in the present case, the Board determines that VA is not obligated to make efforts to obtain these records identified by the veteran. The Board observes that the majority of the veteran's service medical records appear to be unavailable. Specifically, the Board notes that the veteran's service medical records for her first period of service are not in the claims file and that records for her second and third periods of service appear to be incomplete. In addition to requests to the National Personnel Records Center (NPRC), the AOJ asked the veteran if she had any service medical records in her possession. At her April 2005 DRO hearing, she indicated that she had a copy of a record from her Gulf War service that showed she was treated for hypertension. She was requested to provide VA with a copy, but has not done so. The Board also notes that the veteran reportedly had copies of relevant service medical records, some of which were dated during her second period of service, at her April 2003 VA orthopedic examination, but that at her April 2003 VA examination for hypertension, she stated that she had submitted the service medical records that she possessed to the Fort Leonard Wood VA facility. Regardless, in August 2003 and December 2006, she indicated that she had no service medical records dated after 1980 to submit to VA. Thus, the Board concludes that the service medical records in the claims folder are all that are available. The Board acknowledges that, in cases where some or all of the veteran's service medical records are unavailable, VA has a heightened duty to explain its findings and conclusions and to consider carefully the benefit of the doubt rule. O'Hare v. Derwinski, 1 Vet. App. 365, 367 (1991). The Board's analysis of the veteran's claim has been undertaken with this duty in mind. The case law does not, however, lower the legal standard for proving a claim for service connection but rather increases the Board's obligation to evaluate and discuss in its decision all the evidence that may be favorable to the veteran. Russo v. Brown, 9 Vet. App. 46 (1996). The veteran has not identified any additional, relevant records that VA needs to obtain for an equitable disposition of her claim. Based on these facts, the Board concludes that the medical evidence of record is sufficient to adjudicate the veteran's claims without further development, and that further efforts to assist the veteran in accordance with VCAA would serve no useful purpose. See Soyini v. Derwinski, 1 Vet. App. 540, 546 (1991) (strict adherence to requirements of the law does not dictate an unquestioning, blind adherence in the face of overwhelming evidence in support of the result in a particular case; such adherence would result in unnecessarily imposing additional burdens on VA with no benefit flowing to the veteran); Sabonis v. Brown, 6 Vet. App. 426, 430 (1994) (remands which would only result in unnecessarily imposing additional burdens on VA with no benefit flowing to the veteran are to be avoided). VA has satisfied its duty to inform and assist the veteran at every stage in this case. Therefore, she will not be prejudiced by the Board proceeding to the merits of the claim. II. Analysis A. Relevant law Disability evaluations are determined by the application of VA's Schedule for Rating Disabilities (Rating Schedule), 38 C.F.R. Part 4 (2007). The percentage ratings contained in the Rating Schedule represent, as far as can be practicably determined, the average impairment in earning capacity resulting from diseases and injuries incurred or aggravated during military service and their residual conditions in civil occupations. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. The basis of disability evaluation is the ability of the body as a whole, or of the psyche, or of a system or organ of the body to function under the ordinary conditions of daily life including employment. 38 C.F.R. § 4.10. 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 for that rating. Otherwise the lower rating will be assigned. 38 C.F.R. § 4.7. All benefit of the doubt will be resolved in the veteran's favor. 38 C.F.R. § 4.3. In general, all disabilities, including those arising from a single disease entity, are rated separately, and all disability ratings are then combined in accordance with 38 C.F.R. § 4.25. Pyramiding, the evaluation of the same disability, or the same manifestation of a disability, under different diagnostic codes, is to be avoided when rating a veteran's service-connected disabilities. 38 C.F.R. § 4.14. In Fenderson v. West, 12 Vet. App. 119 (1999), the Court held that evidence to be considered in the appeal of an initial assignment of a disability rating was not limited to that reflecting the then current severity of the disorder. As such, the Board has considered all evidence of record in evaluating the veteran's hip disability. Also, in Fenderson, the Court discussed the concept of the "staging" of ratings, finding that in cases where an initially assigned disability evaluation has been disagreed with, it was possible for a veteran to be awarded separate percentage evaluations for separate periods based on the facts found during the appeal period. Fenderson at 126-28. As such, in accordance with Fenderson, the Board has considered the propriety of staged ratings in evaluating the veteran's service-connected hip disability. In rating musculoskeletal disabilities, the provisions of 38 C.F.R. §§ 4.10, 4.40, and 4.45 are for consideration. See DeLuca v. Brown, 8 Vet. App. 202 (1995). Disability of the musculoskeletal system is primarily the inability, due to damage or infection in parts of the system, to perform the normal working movements of the body with normal excursion, strength, speed, coordination and endurance. Functional loss may be due to the absence or deformity of structures or other pathology, or it may be due to pain, supported by adequate pathology and evidenced by the visible behavior in undertaking the motion. Weakness is as important as limitation of motion, and a part that becomes painful on use must be regarded as seriously disabled. 38 C.F.R. § 4.40. With respect to joints, in particular, the factors of disability reside in reductions of normal excursion of movements in different planes. Inquiry will be directed to more or less than normal movement, weakened movement, excess fatigability, incoordination, pain on movement, swelling, deformity or atrophy of disuse. 38 C.F.R. § 4.45. The intent of the Rating Schedule is to recognize actually painful, unstable or malaligned joints, due to healed injury, as entitled to at least the minimum compensable rating for the joint. 38 C.F.R. § 4.59. Service connection may be granted for disability arising from disease or injury incurred in or aggravated by service. 38 U.S.C.A. § 1110, 1131 (West 2002); 38 C.F.R. § 3.303(a). Connecting the disability to service may be accomplished through statutory presumption or through affirmative evidence that shows inception or aggravation during service or that otherwise indicates a direct relationship between service and the current disability. 38 C.F.R. §§ 3.303(a), (d). The statutory presumptions and VA regulations implementing them are intended to allow service connection for certain diseases when the evidence might otherwise not indicate service connection is warranted. See 38 C.F.R. § 3.303(d). Where a veteran served for at least 90 days during a period of war or after December 31, 1946, and manifests certain chronic diseases, including hypertension, to a degree of 10 percent within one year from the date of termination of such service, such disease shall be presumed to have been incurred or aggravated in service, even though there is no evidence of such disease during the period of service. 38 U.S.C.A. §§ 1101, 1112; 38 C.F.R. §§ 3.307, 3.309. However, presumptive periods are not intended to limit service connection to diseases so diagnosed when the evidence warrants direct service connection. 38 C.F.R. § 3.303(d). Direct service connection may be granted for disease or disability diagnosed in service; or, if diagnosed after service, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. Id. A finding of direct service connection requires medical evidence of a current disability; medical or, in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and medical evidence of a nexus between the claimed in-service disease or injury and the present disease or injury. 38 U.S.C.A. § 1112; 38 C.F.R. § 3.304. See also Caluza v. Brown, 7 Vet. App. 498, 506 (1995) aff'd, 78 F.3d 604 (Fed. Cir. 1996) (table)]. Alternatively, service connection may be established under 38 C.F.R. § 3.303(b) by (a) evidence of (i) the existence of a chronic disease in service or during an applicable presumption period under 38 C.F.R. § 3.307 and (ii) present manifestations of the same chronic disease, or (b) when a chronic disease is not present during service, evidence of continuity of symptomatology. B. Increased rating The veteran's service-connected disability of service- connected pigmented villonodular synovitis with right total hip replacement is currently evaluated as 70 percent disabling pursuant to 38 C.F.R. § 4.71a, Diagnostic Code 5054. She contends that her service-connected hip disability is more severe than contemplated under the current rating evaluation. Therefore, she argues that a higher rating should be assigned. Under Diagnostic Code 5054, a 100 percent rating evaluation may be assigned for hip replacement (prosthesis) with prosthetic replacement of the head of the femur or of the acetabulum for 1 year following implantation of prosthesis. A 90 percent rating evaluation may be assigned following implantation of prosthesis, with painful motion or weakness such as to require the use of crutches. A 70 percent rating evaluation is assignable for markedly severe residual weakness, pain, or limitation of motion following implantation of prosthesis. 38 C.F.R. § 4.71a, Diagnostic Code 5054. Based on the following analysis, the Board determines that a rating in excess of 70 percent for the veteran's service- connected hip disability for the period from February 11, 2003 to August 14, 2007 is not warranted, but that her symptoms more closely approximate a 90 percent rating from August 15, 2007 onward. Specifically, the Board finds that the veteran's service-connected pigmented villonodular synovitis with right total hip replacement is manifested by weakness with active range of motion of the hip, pain that prohibits passive range of motion testing, flexion of the hip when sitting, an antalgic gait favoring the right leg, and from August 15, 2007, the occasional use of a walker due to pain. The Board observes that the veteran was diagnosed with pigmented villonodular synovitis in her right hip upon her return from the Gulf War in 1991. A right hip total replacement was performed in January 1997. At her April 2003 VA examination, the veteran was observed to walk briskly without a limp. Use of a cane was denied. Trendelenburg sign was negative and strength of her hip abductor and extensor muscles was good. Range of motion of the right hip was flexion to 90 degrees, extension to 0 degrees, adduction of both hips to 25 degrees, abduction to 40 degrees, external rotation to 45 degrees, and internal rotation to 10 degrees. No pain was demonstrated during range of motion testing. A 30 cm lateral right hip scar was noted with slight depression, but no localized tenderness. Similar findings were reported at the December 2004 VA examination, with the exception of adduction being reported as to 30 degrees. The veteran presented with subjective complaints of increased pain in the right hip and that she had had to decrease her treadmill use from 3 miles per day to one-half mile per day. The examiner stated that there were no true episodes of flare-up, nor any suggestion of changes in range of motion. The veteran did not complain of pain during passive range of motion testing. She also denied use of a cane. Complaints of increased pain the right hip and difficulty walking and climbing stairs were noted in a 2005 private treatment report. Osteolysis was found by X-ray. However, findings at the October 2007 VA examination represent the greatest severity of symptomology of the veteran's service- connected hip disability. The veteran reported daily hip pain that was significantly increased with standing or walking for longer than 40 minutes. She denied use of a cane, but stated that she used a walker from time to time when pain was increased. Specifically, the examiner observed antalgic gait, favoring the right side and a positive Trendelenburg sign. Weakness of the right hip was found with active hip flexion, adduction, and abduction while sitting. Passive range of motion testing could not be done when the veteran was in a supine position due to pain, although flexion of the hip was observed while the veteran was sitting. X-rays showed osteolysis about the acetabulum and prosthetic components. The examiner also reviewed the aforementioned letter from Dr. L. W., which pertained to an examination done on August 15, 2007. Dr. L. W. noted the presence of osteolysis and indicated that a right total hip revision would be needed in the future. Further, the October 2007 VA examiner noted that the veteran was apparently experiencing pain at the August 2007 examination, which required she use a walker. The VA examiner opined that the veteran's hip would likely require total revision and that her condition was worse than when he had examined her in December 2004. The veteran has been assigned a 70 percent evaluation under Diagnostic Code 5054 in contemplation of the symptoms of her service-connected pigmented villonodular synovitis with right total hip replacement. Current manifestations of this disability include complaints of increased pain, aggravated by standing or walking for longer than 40 minutes; and objective evidence of weakness of the right hip with active hip flexion, adduction, and abduction while sitting, passive range motion testing prevented by pain, flexion of the hip in sitting position and X-rays showing osteolysis about the acetabulum and prosthetic components. The use of crutches was not required, but the occasional use of a walker due to pain was reported as of August 15, 2007. The Board, therefore, determines that the veteran's symptomology does not support a rating in excess of 70 percent for the period from February 11, 2003 to August 14, 2007, but that it does more closely approximate the criteria for a 90 percent disability evaluation from August 15, 2007 onward. Consideration has been given to the potential application of the various provisions of 38 C.F.R. Parts 3 and 4 (2007), as required by Schafrath v. Derwinski, 1 Vet. App. 589 (1991). The Board notes that the veteran has a scar from her hip replacement. However the scar is reported as slightly depressed with no localized tenderness. Therefore a separate evaluation for the scar is not supported by the evidence. 38 C.F.R. Part 4, Diagnostic Codes 7803, 7804, 7805. The Board also notes that functional limitation due to pain, weakness, and fatigue experienced by the veteran is contemplated in both the 70 percent assigned by the RO and the 90 percent herein assigned, beginning August 15, 2007. See Deluca. Accordingly, no additional compensation in consideration of these factors is warranted. Thus, the Board determines that a preponderance of the evidence is against a rating in excess of 70 percent from February 11, 2003 to August 14, 2007, but that, giving the benefit of the doubt to the veteran, a rating of 90 percent, but no greater, is warranted for the veteran's service-connected hip disability from August 15, 2007 onward. C. Service connection VA regulations require that hypertension must be confirmed by blood pressure (BP) readings taken two or more times on at least three different days of diastolic pressure of predominately 90 or more or of systolic pressure of predominantly 160 or more with a diastolic pressure of less than 90. 38 C.F.R. § 4.104, Diagnostic Code 7101, Note 1 (2007). The veteran contends that her claimed hypertension manifested during or shortly after her second period of service. Specifically, she has cited the years 1980, 1985, and 1989 as when she was first treated, and also reported that hypertension was first observed clinically in 1987. Thus, she claims that service connection is warranted for hypertension. Service medical records are silent as to complaint, treatment, or diagnosis for hypertension. Although only a few of the records from her second period of active service are of record, there are multiple blood pressure (BP) readings reported. The highest systolic reading reported was 136 and the highest diastolic reading reported was 90. At an October 1989 physical examination, her BP was 118/76, and at her March 1991 service separation examination, her BP reading was 128/80. No diagnosis or notation with regard to the veteran's BP is demonstrated by the service medical records. Post-service records demonstrate a diagnosis of hypertension. Specifically, hypertension was diagnosed at both April 2003 and August 2007 VA examinations. Additionally, private treatment records dated after November 1994 reflect diagnoses of hypertension. The Board observes that the veteran's post- service BP readings generally do not reflect hypertension to a compensable degree, with the highest systolic reading being 156, and the highest diastolic reading, 100. However, private treatment records report that her hypertension is well-controlled, so the Board finds no reason to question such diagnosis. The Board has considered all relevant evidence of record regarding the veteran's claims for service connection for hypertension. The Board first considered whether service connection is warranted for hypertension on a presumptive basis. However, the record fails to show that the veteran manifested hypertension to a degree of 10 percent within one year following discharge from active duty in October 1977, August 1989, or April 1991. The Board observes that the first reported post-service BP reading was in June 1992 and the reading was elevated at 156/100. However, no diagnosis of hypertension accompanies this reading, and even if hypertension were diagnosed at that time, June 1992 is more than one year after the veteran's April 1991 discharge from active service. Thus, the medical evidence does not support a finding of presumptive service connection for hypertension. 38 U.S.C.A. §§ 1101, 1112; 38 C.F.R. §§ 3.307, 3.309. The Board next considered whether service connection is warranted for hypertension on a direct basis. However, the Board notes that there is no diagnosis of hypertension in the veteran's service medical records, to include her final service discharge examination in March 1991. In a statement dated in October 2005, Dr. A. P. indicates that the veteran was under treatment for high blood pressure in 1985 and that he would just take her blood pressure and give her a Vasotec prescription. However, the Board notes that this statement appears to be a reiteration of the veteran's contentions as to why service medical records do not reflect treatment for hypertension. Dr. A. P. does not report any details surrounding his diagnosing the veteran with hypertension or follow-up treatment. Without such supporting information, the Board can afford the statement no probative weight. A June 2006 statement by Dr. J. M. indicates that the veteran has had a history of hypertension since 1985, but Dr. J. M. does not provide any basis for this statement, and the Board can only conclude that it was founded only on the veteran's self-reported history. As discussed below, the veteran's reported history of her hypertension is not credible. Additionally, the Board observes that Dr. J. M. does not provide any detail as to when his treatment of the veteran began. As Dr. J. M. does not provide a basis for this statement other than the veteran's history as provided to him, the Board also affords this statement no probative weight. Finally, the Board acknowledges the veteran's claim that her high BP was not recorded in her service medical records because she was concerned that such diagnosis would affect her active duty status. However, the Board does not find the veteran's accounts of the onset of her hypertension credible. In making this determination, the Board cannot rely merely on the lack of contemporaneous medical evidence, but must consider the credibility of the lay evidence in and of itself. Buchanan v. Nicholson, 451 F3d. 1331 (2006). In this regard, the Board observes that the veteran has claimed that she was first treated for hypertension in 1980, 1985, and 1989, as well as stated that hypertension was first noted at a health fair in 1987. Initially, the Board notes that 1980 is not within a period of active duty. She has submitted the statements by Dr. A. P. and Dr. J. M., which report onset in 1985, as well as testified that she was first prescribed medication for hypertension in 1989 by Dr. J. M. However, the earliest treatment record received from Dr. J. M. is dated in June 1992, and the first report of hypertension as a medical problem for the veteran is dated in November 1994. In fact, a February 1983 list of medical problems reports the veteran's hip disability, hemorrhoids, mitral valve prolapse, hypercholesterolemia, a history of recurrent sinusitis and endometriosis, and calcifications noted on a mammogram, but the record specifically indicates there was no hypertension. Further, the veteran testified that she ran out of her medication while serving in Italy during the Gulf War and that she had a copy of a service medical record reflecting that she was given a refill. However, although informed at her February 2005 hearing that the record would be helpful to her claim and that she should submit it to VA, she has not done so. Thus, considering the discrepancies in the veteran's own accounts of the onset of her hypertension, together with the lack of contemporaneous corroborating medical evidence that she was diagnosed and/or treated for hypertension in 1980, 1985, 1987, 1989, or at any other point during or immediately after service, the Board finds that the veteran's claims as to the onset of her hypertension lack credibility and have no probative weight. Additionally, the first claimed date during active duty for treatment of the veteran's hypertension is 1985. However, the Board notes that, in addition to 1985 BP readings showing normal blood pressure, prior to 1985, the veteran did not exhibit high BP readings. Specifically, the highest reading reported was 136/80, taken in June 1983, and in the last reading of record prior to 1985, in July 1984, her BP was 128/72. The lowest readings considered to qualify as high blood pressure are 140 systolic and 90 diastolic. DORLAND'S ILLUSTRATED MEDICAL DICTIONARY, p. 889 (30th ed. 2003). Thus, the readings prior to 1985 are not reflective of the inception of hypertension. Although this evidence does not conclusively disprove that hypertension could have developed by 1985, it weighs against such a finding. Moreover, there is no competent and probative medical evidence establishing a nexus between her current hypertension and any period of active duty military service. The only competent and probative nexus opinion of record is of the August 2007 VA examiner. He stated that it is less likely than not that the veteran's hypertension is related to her active duty, including a one year period thereafter. In forming this opinion, the examiner noted that the only documentation in her favor is a note from Dr. A. P. stating that he gave her prescriptions for Vasotec in 1985. Thus, he concluded that to establish connection of her high blood pressure to her active military duty would require some degree of speculation. The Board notes that, under VA regulations and Court decisions, service connection may not be based on pure speculation or remote possibility. See 38 C.F.R. § 3.102 (2007); see also Davis v. West, 13 Vet. App. 178, 185 (1999); Bostain v. West, 11 Vet. App. 124, 127-28 (1998); Beausoleil v. Brown, 8 Vet. App. 459, 463 (1996); Perman v. Brown, 5 Vet. App. 237, 241 (1993). Therefore, there is no competent and probative medical opinion attributing the onset of the veteran's hypertension to her service. The veteran's claims that the onset of her hypertension was during or shortly after her period of service from 1981 to 1988 are not supported by any competent or probative evidence. She, as a layperson, is competent to speak to symptomology when the symptoms are readily observable. Layno v. Brown, 6 Vet. App. 465, 469 (1994). However, only those with specialized medical knowledge, training, or experience are competent to provide evidence on the question of diagnosis and causation. See Jones v. Brown, 7 Vet. App. 134, 137 (1994); Espiritu v. Derwinski, 2 Vet App 492 (1992). In the absence of any competent and probative evidence demonstrating a diagnosis of hypertension during service, within one year of service, or connecting the veteran's hypertension to her time in service, the Board concludes that service connection for hypertension is not warranted. D. Other considerations When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C.A. § 5107 (West 2002); see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). As indicated, the Board has applied the benefit of the doubt in granting a 90 percent disability rating for the veteran's service-connected hip disability from August 15, 2007; however, the preponderance of the evidence is against the veteran's claim of entitlement service connection for hypertension and to a rating in excess of 70 percent from February 11, 2003 to August 14, 2007. Therefore, her service connection claim must be denied. The Board has contemplated whether the case should be referred for extra-schedular consideration. An extra- schedular disability rating is warranted if the case presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization that application of the regular schedular standards would be impracticable. 38 C.F.R. § 3.321(b)(1) (2007). The Board finds no evidence that the veteran's service-connected service-connected pigmented villonodular synovitis with right total hip replacement. presents such an unusual or exceptional disability picture at any time so as to require consideration of an extra-schedular evaluation pursuant to the provisions of 38 C.F.R. § 3.321(b)(1). The objective medical evidence of record shows that manifestations of the veteran's service- connected disability does not result in a marked functional impairment in a way or to a degree other than that addressed by VA's Rating Schedule. The schedular rating criteria are designed to compensate for average impairments in earning capacity resulting from service-connected disability in civil occupations. 38 U.S.C.A. § 1155 (West 2002). Generally, the degrees of disability specified in the rating schedule are considered adequate to compensate for considerable loss of working time from exacerbations or illnesses proportionate to the severity of the several grades of disability. 38 C.F.R. § 4.1. Consequently, the Board concludes that referral of this case for consideration of an extra-schedular rating is not warranted. Bagwell v. Brown, 9 Vet. App. 337, 338-39 (1996); Floyd v. Brown, 9 Vet. App. 88, 96 (1996). ORDER A rating in excess of 70 percent for service-connected pigmented villonodular synovitis with right total hip replacement for the period from February 11, 2003 to August 14, 2007 is denied. A rating of 90 percent but no greater, for service-connected pigmented villonodular synovitis with right total hip replacement is granted for the period from August 15, 2007 onward, subject to the law and regulations governing the payment of monetary benefits. . Service connection for hypertension is denied. ____________________________________________ MILO H. HAWLEY Veterans Law Judge, Board of Veterans' Appeals D0epartment of Veterans Affairs