Citation Nr: 0815184 Decision Date: 05/08/08 Archive Date: 05/14/08 DOCKET NO. 04-30 461 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Huntington, West Virginia THE ISSUES 1. Entitlement to compensation under the provisions of 38 U.S.C.A. § 1151 for loss of use of the left long finger. 2. Entitlement to a rating in excess of 30 percent for right carpal tunnel syndrome. 3. Entitlement to a rating in excess of 10 percent for the residuals of a right maxilla fracture with deviated septum. REPRESENTATION Appellant represented by: Veterans of Foreign Wars of the United States WITNESS AT HEARING ON APPEAL Appellant and Spouse ATTORNEY FOR THE BOARD T. Douglas, Counsel INTRODUCTION The appellant is a veteran who served on active duty from January 1962 to January 1965. This matter comes before the Board of Veterans' Appeals (Board) on appeal from rating decisions in December 2002, August 2003, and January 2004 by the Huntington, West Virginia, Regional Office (RO) of the Department of Veterans Affairs (VA). In March 2008, the veteran testified at a personal hearing before the undersigned Veterans Law Judge. A copy of the transcript of that hearing is of record. The issue of entitlement to compensation under the provisions of 38 U.S.C.A. § 1151 for loss of use of the left long finger is addressed in the REMAND portion of the decision below and is REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. FINDINGS OF FACT 1. All relevant evidence necessary for the equitable disposition of the issues addressed in this decision was obtained. 2. Right carpal tunnel syndrome is manifested by no more than a moderate impairment to the right median nerve of the major extremity. 3. There is limitation of motion of the right wrist and X- ray evidence of degenerative changes without dorsiflexion of less than 15 degrees or palmar flexion limited in line with the forearm, including as a result of pain or dysfunction. 4. Residuals of a right maxilla fracture with deviated septum are manifested by air flow of 40 percent through the right side of the nose. CONCLUSIONS OF LAW 1. The criteria for a rating in excess of 30 percent for right carpal tunnel syndrome have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002 & Supp. 2007); 38 C.F.R. § 4.124a, Diagnostic Code 8515 (2007). 2. The criteria for a separate 10 percent rating for right wrist arthritis have been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002 & Supp. 2007); 38 C.F.R. § 4.71a, Diagnostic Code 5215 (2007). 3. The criteria for a rating in excess of 10 percent for the residuals of a right maxilla fracture with deviated septum have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002 & Supp. 2007); 38 C.F.R. § 4.96, Diagnostic Code (2007). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The provisions of the Veterans Claims Assistance Act of 2000 (VCAA), codified at 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a), and as interpreted by the United States Court of Appeals for Veterans Claims (hereinafter "the Court") have been fulfilled by information provided to the veteran by correspondence dated in October 2002, November 2003, June 2007. Those letters notified the veteran of VA's responsibilities in obtaining information to assist in completing his claim, identified the veteran's duties in obtaining information and evidence to substantiate his claim, and requested that he send in any evidence in his possession that would support his claim. (See 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a)), Quartuccio v. Principi, 16 Vet. App. 183 (2002), Pelegrini v. Principi, 18 Vet. App. 112 (2004). See also Mayfield v. Nicholson, 19 Vet. App. 103, 110 (2005), reversed on other grounds, 444 F.3d 1328 (Fed. Cir. 2006), Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006); Mayfield v. Nicholson (Mayfield II), 20 Vet. App. 537 (2006). During the pendency of this appeal, the Court in Dingess/Hartman found that the VCAA notice requirements applied to all elements of a claim. An additional notice as to these matters was provided in the June 2007 correspondence to the veteran. The Board further finds that through his written statements and in his March 2008 hearing testimony, the veteran has demonstrated actual knowledge of all relevant VA laws and regulations concerning his increased rating claims. See Vazquez-Flores v. Peake, 22 Vet. App. 37 (2008). The applicable rating criteria were adequately reported in statements of the case issued in August 2004. In a July 2007 VA Form 646 the veteran's representative demonstrated full knowledge of the applicable law as shown by reference to various VA regulations in that document. The notice requirements pertinent to the issues addressed in this decision have been met and all identified and authorized records relevant to these matters have been requested or obtained. Further attempts to obtain additional evidence would be futile. The Board finds the available medical evidence is sufficient for adequate determinations. There has been substantial compliance with all pertinent VA law and regulations and to move forward with the claims would not cause any prejudice to the appellant. Increased Rating Claims - General Law and Regulations Disability evaluations are determined by the application of the VA's Schedule for Rating Disabilities (Rating Schedule), 38 C.F.R. Part 4. The percentage ratings 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(West 2002); 38 C.F.R. § 4.1 (2007). The Court has held that a claimant may experience multiple distinct degrees of disability that might result in different levels of compensation from the time the increased rating claim was filed until a final decision is made. Hart v. Mansfield, 21 Vet. App. 505 (2007). Upon award of service connection, separate compensable evaluations may be assigned for separate periods of time if such distinct periods are shown by the competent evidence of record during the appeal, a practice known as "staged" ratings. See Fenderson v. West, 12 Vet. App. 119, 126 (1999). It is the responsibility of the rating specialist to interpret reports of examination in the light of the whole recorded history, reconciling the various reports into a consistent picture so that the current rating may accurately reflect the elements of disability present. 38 C.F.R. § 4.2 (2007). Consideration of factors wholly outside the rating criteria constitutes error as a matter of law. Massey v. Brown, 7 Vet. App. 204, 207-08 (1994). Evaluation of disabilities based upon manifestations not resulting from service- connected disease or injury and the pyramiding of ratings for the same disability under various diagnoses is prohibited. 38 C.F.R. § 4.14 (2007). When there is a question as to which of two evaluations to apply, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating, otherwise the lower rating shall be assigned. 38 C.F.R. § 4.7 (2007). The Court has held that where the determinative issue involves medical causation or a medical diagnosis, competent medical evidence is required. Grottveit v. Brown, 5 Vet. App. 91 (1993); see also Espiritu v. Derwinski, 2 Vet. App. 492 (1992). The United States Court of Appeals for the Federal Circuit (Federal Circuit) has also recognized the Board's "authority to discount the weight and probity of evidence in light of its own inherent characteristics and its relationship to other items of evidence." Madden v. Gober, 125 F.3d 1477, 1481 (Fed. Cir. 1997). It is the policy of VA to administer the law under a broad interpretation, consistent with the facts in each case with all reasonable doubt to be resolved in favor of the claimant; however, the reasonable doubt rule is not a means for reconciling actual conflict or a contradiction in the evidence. 38 C.F.R. § 4.3 (2007). Right Wrist/Carpal Tunnel Syndrome - Specific Laws and Regulations 500 3 Arthritis, degenerative (hypertrophic or osteoarthritis): Degenerative arthritis established by X-ray findings will be rated on the basis of limitation of motion under the appropriate diagnostic codes for the specific joint or joints involved (DC 5200 etc.). When however, the limitation of motion of the specific joint or joints involved is noncompensable under the appropriate diagnostic codes, a rating of 10 pct is for application for each such major joint or group of minor joints affected by limitation of motion, to be combined, not added under diagnostic code 5003. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. In the absence of limitation of motion, rate as below: With X-ray evidence of involvement of 2 or more major joints or 2 or more minor joint groups, with occasional incapacitating exacerbations 20 With X-ray evidence of involvement of 2 or more major joints or 2 or more minor joint groups 10 Note (1): The 20 pct and 10 pct ratings based on X-ray findings, above, will not be combined with ratings based on limitation of motion. Note (2): The 20 pct and 10 pct ratings based on X-ray findings, above, will not be utilized in rating conditions listed under diagnostic code 5013 to 5024, inclusive. 38 C.F.R. § 4.71a, Diagnostic Code 5003 (2007). 521 5 Wrist, limitation of motion of: Majo r Mino r Dorsiflexion less than 15º 10 10 Palmar flexion limited in line with forearm 10 10 38 C.F.R. § 4.71a (2007). 38 C.F.R. § 4.71, Plate I (2007) The intent of the schedule is to recognize painful motion with joint or periarticular pathology as productive of disability. It is the intention to recognize actually painful, unstable, or malaligned joints, due to healed injury, as entitled to at least the minimum compensable rating for the joint. Crepitation either in the soft tissues such as the tendons or ligaments, or crepitation within the joint structures should be noted carefully as points of contact which are diseased. 38 C.F.R. § 4.59 (2007). The Court has held that disabilities may be rated separately without violating the prohibition against pyramiding unless the disorder constitutes the same disability or symptom manifestations. See Esteban v. Brown, 6 Vet. App. 259, 261 (1994). A separate rating, however, must be based upon additional disability. If the veteran does not at least meet the criteria for a zero percent rating under either of those codes, there is no additional disability for which a rating may be assigned. See Degmetich v. Brown, 104 F.3d 1328, 1331 (Fed. Cir. 1997) (assignment of zero-percent ratings is consistent with requirement that service connection may be granted only in cases of currently existing disability). The Court has also held that diagnostic codes predicated on limitation of motion do not prohibit consideration of a higher rating based on functional loss due to pain on use or due to flare-ups under 38 C.F.R. §§ 4.40, 4.45, and 4.59. See Johnson v. Brown, 9 Vet. App. 7 (1996); DeLuca v. Brown, 8 Vet. App. 202, 206 (1995). VA regulations require that a finding of dysfunction due to pain must be supported by, among other things, adequate pathology. 38 C.F.R. § 4.40 (2007). "[F]unctional loss due to pain is to be rated at the same level as the functional loss when flexion is impeded." Schafrath v. Derwinski, 1 Vet. App. 589, 592 (1993). The Median Nerve 851 5 Paralysis of: Majo r Mino r Complete; the hand inclined to the ulnar side, the index and middle fingers more extended than normally, 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, cannot make a fist, index and middle fingers remain extended; cannot flex distal phalanx of thumb, defective opposition and abduction of the thumb at right angles to palm; flexion of wrist weakened; pain with trophic disturbances 70 60 Incomplete: Severe 50 40 Moderate 30 20 Mild 10 10 861 5 Neuritis 871 5 Neuralgia 38 C.F.R. § 4.124a, Diagnostic Codes 8515, 8615, 8715 (2007). The term "incomplete paralysis" indicates a degree of lost or impaired function substantially less than the type picture for complete paralysis given with each nerve, whether due to varied level of the nerve lesion or to partial regeneration. When the involvement is wholly sensory, the rating should be for the mild, or at most, the moderate degree. The ratings for the peripheral nerves are for unilateral involvement; when bilateral the rating should include the application of the bilateral factor. 38 C.F.R. § 4.124a (2007). Factual Background Service medical records show the veteran developed arthritis to the right wrist due to aseptic necrosis of the lunate. A November 1964 separation examination report noted the wrist should remain in a plaster cast for four to six months until the lesion healed or was stable. VA examination in July 1965 revealed pain on the extremes of all wrist motion. The diagnosis was old right lunate fracture with aseptic necrosis. A July 1970 VA orthopedic examination report noted traumatic arthritis to the right wrist. X-rays revealed the veteran's aseptic necrosis was not as marked as it was four years earlier. Private medical records dated in June 1982 show the veteran sustained a spiral fracture to the right distal ulna while playing volleyball. VA examination in September 1997 included a diagnosis of status post fracture of the right wrist with development of traumatic arthritis and some loss of motion, mildly diminished grip, and probable right carpal tunnel syndrome. VA medical records dated in August 1999 noted a positive Tinel's sign to the median nerve of the right wrist. Records show the veteran underwent a right carpal tunnel release in October 1999. VA treatment records dated in November 2001 included a diagnosis of traumatic arthritis to the right wrist. It was noted the veteran complained of a loss of right wrist motion and pain on activity and that X-rays in January 2000 revealed degenerative changes. The examiner noted the veteran only had about 25 percent of normal motion in all directions of the wrist. Simple tasks such as using a computer mouse were very painful and splitting wood caused extreme aggravation of pain. On VA examination in October 2002 the veteran complained of pain, weakness, stiffness, giving way, locking, and loss of grip strength in his right hand. He complained of flare-ups every time he used his right hand. He used a brace as a corrective device. It was noted that he stated the disorder was an impairment in his employment as a mine safety inspector in using computers, writing, or crawling. However, the disorder did not affect his daily activities of living. The examiner noted the veteran was right hand dominant. An examination revealed right wrist dorsiflexion from 0 to 50 degree, palmar flexion from 0 to 50 degrees, ulnar deviation from 0 to 25 degrees, and radial deviation from 0 to 30 degrees. There was pain at the ends of motion and an impediment to motion secondary to stiffness. X-rays revealed probable remote traumatic deformity involving the lunate and old un-united avulsed fracture fragments at the level of the ulnar styloid process. The examiner noted that there was no X-ray evidence of bone degenerative disease, but that a carpal tunnel release in October 1999 may have destroyed the evidence of arthritis. It was also noted that it was most likely the veteran's wrist problems were secondary to his wrist injury during service. The December 2002 rating decision revised the veteran's service-connected disability from limitation of motion of the right wrist as a residual of an old fracture with aseptic necrosis assigned a 10 percent rating to carpal tunnel syndrome of the right wrist with history of traumatic arthritis, status post carpal tunnel surgery, and old fracture and aseptic necrosis. A 30 percent disability rating was assigned effective from December 1, 1999. In his notice of disagreement the veteran asserted higher ratings were warranted for incomplete paralysis and for arthritis. In his substantive appeal he noted he had limited motion in his right wrist, constant pain, and very little use of his hand. He stated he was unable to touch his thumb to his pointer and pinky fingers and that he had problems holding a pen or driving a car. On VA examination in December 2004 the veteran complained of right wrist pain at two on a ten point scale at the lowest level and at seven at its worst. He stated he had weakness and swelling and that he had stiffness all the time. He complained of heat and soreness when he used his wrist a lot. There was no instability or locking, but he could not play or shuffle cards because of fatigability. He described flare- ups lasting approximately 40 minutes five times per week which were precipitated by operating a vacuum sweeper, helping to clean house, working with a hammer, or playing cards. His primary problem on flare-ups was functional loss and secondarily was pain. He noted he wore wrist splints at night. He also stated he was unable to use his right wrist while working in the yard or around the house. The examiner noted there was tenderness over the area of the lunate bone with no instability. There was demonstrated weakness and associated carpal tunnel syndrome. There was no edema, effusion, redness, heat, abnormal movement, guarding, or ankylosis. Range of motion studies revealed dorsiflexion to 25 degrees with an additional 5 degrees possible with discomfort (normal was noted as from 0 to 70 degrees). Palmar flexion was from 0 to 50 degrees with discomfort at that level (normal was noted as from 0 to 80 degrees). Radial deviation was from 0 to 10 degrees with discomfort (normal was noted as from 0 to 20 degrees). Ulnar deviation was from 0 to 20 degrees with discomfort (normal was noted as from 0 to 45 degrees). After squeezing a flashlight ten times dorsiflexion was to 10 degrees with pain on addition motion from 15 to 25 degrees. It was noted there were complaints of pain, discomfort, and generalized tenderness in the wrist after this exercise. Palmer flexion was from 0 to 30 degrees with addition motion of 10 with discomfort. Radial deviation was from 0 to 10 degrees with discomfort at that point and ulnar deviation was from 0 to 20 degrees with discomfort at that point. X-rays revealed a persistent deformity to the right lunate and to a lesser degree the right navicular bone apparently related to an old injury. The diagnoses included fracture and deformity of the lunate and old un-united evulsed fracture fragment involving the level of the ulnar styloid process. There was degenerative joint disease of the right wrist with un-united fracture fragments of the ulnar styloid process and traumatic deformity of the lunate. VA peripheral nerve examination in December 2004 noted the veteran complained that his finger went to sleep, that he could not grip, that both hands would swell, and that the third and fourth metacarpal phalangeal joints locked up. He described pain as the primary problem with his right carpal tunnel syndrome and a secondary problem of numbness waking him up at night with paresthesia. He noted the problems were precipitated by lifting over 10 to 15 pounds. He described flare-ups as occurring five days a week and lasting 30 to 40 minutes usually with functional loss and secondarily with weakness and fatigue. He estimated the pain to his right wrist at two on a ten point scale going up to five if he split logs or lifted. He stated the disorder interfered with his activities in that he could not split logs, pound nails, or open jars without an aid. He stated he had dropped dishes while helping around the house. An examination revealed normal vibratory and heat/cold sensation. There was a decreased ability to perceive sharp to the fingers and thumb. The examiner noted decreased 2.5/5 handgrip strength that was equal, bilaterally. There was decreased muscle mass at the base of the thenar eminence. The diagnoses included status post right carpal tunnel release with recurrent symptoms associated with a wrist fracture. At his personal hearing in March 2008 the veteran testified that if he did not use his right wrist his pain was only about five on a ten point scale, but if he bumped it or worked with it his hand would swell. He stated his doctor had recommended surgery for his right carpal tunnel syndrome, but that he did not want that doctor to perform the surgery because of a prior experience. Analysis Based upon the evidence of record, the Board finds the veteran's right carpal tunnel syndrome is manifested by no more than a moderate impairment to the right median nerve of the major extremity. The degree of lost or impaired function is substantially less than complete paralysis of the median nerve. The veteran's hand is not inclined to the ulnar side, the index and middle fingers are not shown to be more extended than normal, the thumb is not in the plane of the hand. Although decreased muscle mass at the base of the thenar eminence was noted upon examination in December 2004, there is no indication of considerable atrophy of the muscles. There is also no evidence demonstrating incomplete and defective pronation as a result of the median nerve disorder nor of an absence of flexion to the index finger with feeble flexion of the middle finger. The Board finds that the veteran's report of increased problems after working with a hammer indicate he is able to make a fist and that his index and middle fingers do not remain extended. He complains of defective opposition and abduction of the thumb to the palm and examination has shown weakened wrist flexion and pain, but the overall evidence is not indicative of severe incomplete paralysis. Therefore, higher or "staged" ratings in excess of 30 percent for right carpal tunnel syndrome are not warranted. The Board finds, however, that there is an additional disability manifested by limitation of motion of the right wrist with X-ray evidence of degenerative changes. There is no evidence of dorsiflexion less than 15 degrees or palmar flexion limited in line with the forearm, including as a result of pain or dysfunction for a compensable rating under Diagnostic Code 5215, but the wrist is a major joint under applicable VA regulations and the overall evidence of record demonstrates the presence of arthritis at least since January 2000. Therefore, a separate 10 percent rating is warranted for right wrist arthritis under Diagnostic Code 5003. Residuals of a Right Maxilla Fracture with Deviated Septum Additional Laws and Regulations Diseases of the Nose and Throat 650 2 Septum, nasal, deviation of: Ratin g Traumatic only, 10 With 50-percent obstruction of the nasal passage on both sides or complete obstruction on one side 38 C.F.R. § 4.97, Diagnostic code 6502 (2007). 6513 Sinusitis, maxillary, chronic. General Rating Formula for Sinusitis (DC's 6510 through 6514): Following radical surgery with chronic osteomyelitis, or; near constant sinusitis characterized by headaches, pain and tenderness of affected sinus, and purulent discharge or crusting after repeated surgeries 5 0 Three or more incapacitating episodes per year of sinusitis requiring prolonged (lasting four to six weeks) antibiotic treatment, or; more than six non-incapacitating episodes per year of sinusitis characterized by headaches, pain, and purulent discharge or crusting 3 0 One or two incapacitating episodes per year of sinusitis requiring prolonged (lasting four to six weeks) antibiotic treatment, or; three to six non-incapacitating episodes per year of sinusitis characterized by headaches, pain, and purulent discharge or crusting 1 0 Detected by X-ray only 0 Note: An incapacitating episode of sinusitis means one that requires bed rest and treatment by a physician. 38 C.F.R. § 4.97, Diagnostic code 6513 (2007). Factual Background Service medical records show the veteran was treated for an injury to the right maxillary area after a fight in December 1964. The final diagnosis was compound fracture to the right maxilla or maxillary antrum. VA examination in April 1967 revealed an asymptomatic old fracture to the right maxilla. VA treatment records dated in February 2002 noted the veteran's nose was clear. In correspondence dated in May 2003 the veteran requested entitlement to an increased rating. He stated the site of his maxilla fracture was tender to the touch and that he experienced a lot of drainage from the sinus cavity with bloody discharge when he blew his nose. In subsequent statements he complained of headaches with tenderness and greenish drainage from the right maxilla. On VA examination in June 2003 the veteran reported that he had experienced difficulty breathing through his nose since the injury during active service. He stated that he had been on allergy medication and that the disorder had gotten progressively worse over the years. He also stated that he had difficulty breathing out of the right side of his nose and that he had to mouth breathe about 90 percent of the time. He reported he blew blood out of his nose approximately 12 to 15 times per month and that he had green to yellow drainage almost every night. He stated he had chronic sinusitis and that the weather affected his symptoms, but that he had no allergy attacks and no periods of incapacitation or loss of work. He stated he had worked when he was uncomfortable. The examiner noted the flow through the veteran's right nostril was estimated at 10 to 20 percent and 80 to 90 percent on the left. The nose was deviated to the left. There was tenderness over the left maxillary sinus. There was no visible drainage or crusting. The diagnosis was status post maxillary sinus fracture on the right with nasal deviation to the left from the right. X-rays revealed no gross evidence of acute fracture of the nasal or facial bones. There was no gross evidence of definite fluid levels in the sinuses. There was mild clouding around the nasal turbinates possibly representative of sinus disease. VA treatment records dated in November 2003 noted a significant septal deviation with lateral airway obstruction. The possibility of a nasal septoplasty was discussed. A computerized tomography (CT) scan revealed very little chronic sinusitis to the right maxillary sinus. There was some nasal septal deviation to the left with possible slight nasal cavity narrowing, but intact osteomeatal units. VA examination in December 2004 revealed mucosal edema likely secondary to allergies, bilaterally, with a deviated septum. The air flow was 40 percent through the right side of the nose. There was tenderness to the anterior cheek adjacent to the chin. It was noted the veteran described headaches to the bilateral frontal area, but not to the maxillary or the left side of the nose. He also complained of severe nasal drainage at night and coughing up brownish-colored material. The drainage was "described as serous, but a slightly yellow color." The examiner noted there was no purulent drainage, no specific allergy attacks, and no periods of incapacitation. X-rays revealed no sinus disease. The diagnoses included deviated nasal septum, allergic rhinitis, and past history of right maxillary sinus fracture with no present evidence of sinusitis. At his personal hearing in March 2008 the veteran testified that he had a severe breathing problem and a lung disability from working in the mines for 30 years, but that his deviated septum was affecting his ability to breathe. His spouse noted that doctors wanted to perform surgery on his nose. The veteran stated that he had more problems breathing in the winter when his allergies were more severe. Analysis Based upon the evidence of record, the Board finds the veteran's residuals of a right maxilla fracture with deviated septum are manifested by air flow of 40 percent through the right side of the nose. The presently assigned 10 percent disability rating is the maximum schedular rating available under Diagnostic Code 6502. Therefore, a entitlement to a higher or "staged" schedular rating is not possible. The veteran also contends that he has chronic sinusitis manifested by headaches, tenderness, and drainage. The evidence of record demonstrates that he has allergic rhinitis for which he has been taking medication of many years without any competent evidence indicating that this disorder was caused or aggravated as a result of the veteran's maxilla fracture in service. Although a June 2003 X-ray noted mild cloudiness possibly representing a sinus disease and a November 2003 CT scan revealed a very little chronic sinusitis to the right maxillary sinus, the December 2004 VA X-ray examination found no evidence of maxillary sinusitis. It was the opinion of the December 2004 VA examiner that there was no present evidence of sinusitis. The Board notes that there is no competent medical evidence addressing the issue of whether the veteran has chronic right maxillary sinusitis as a result of service, but that no further development is required at this time because the criteria for a separate rating under Diagnostic Code 6513 have not been met. There is no present evidence of sinusitis detected by X-ray and no evidence of one or two incapacitating episodes per year of sinusitis requiring prolonged antibiotic treatment. There is also no probative evidence of three to six non-incapacitating episodes per year of sinusitis characterized by headaches, pain, and purulent discharge or crusting. In fact, the December 2004 VA examiner noted the veteran described headaches to the bilateral frontal area and not to the maxillary area. Sinus pain and purulent discharge or crusting due to sinusitis are not shown to have been observed upon medical examination. While the veteran may sincerely believe that his headaches, tenderness, and nasal discharge are due to chronic maxillary sinusitis, he is not a licensed medical practitioner and is not competent to offer opinions on questions of medical causation or diagnosis. Grottveit, 5 Vet. App. 91; Espiritu, 2 Vet. App. 492. Therefore, entitlement to a higher, "staged," or separate rating is not warranted. When all the evidence is assembled VA is then responsible for determining whether the evidence supports the claim or is in relative equipoise, with the claimant prevailing in either event, or whether a preponderance of the evidence is against the claim in which case the claim is denied. Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990); Ortiz v. Principi, 274 F. 3d 1361 (Fed. Cir. 2001). The preponderance of the evidence in this case is against the veteran's claim for an increased rating. The Board further finds there is no evidence of any unusual or exceptional circumstances, such as marked interference with employment or frequent periods of hospitalization, related to these service-connected disorders that would take the veteran's case outside the norm so as to warrant an extraschedular rating. The veteran's service-connected disorders are adequately rated under the available schedular criteria. The objective findings of physical impairment are well documented. The Board finds the overall evidence of record is not indicative of a marked interference with employment. Therefore, referral by the RO to the Chief Benefits Director of VA's Compensation and Pension Service, under 38 C.F.R. § 3.321, is not warranted. See Bagwell v. Brown, 9 Vet. App. 337 (1996). ORDER Entitlement to a rating in excess of 30 percent for a medial nerve impairment as a residual of right carpal tunnel syndrome is denied. A separate 10 percent rating for right wrist limitation of motion with X-ray evidence of arthritis is granted, subject to the regulations governing the payment of monetary awards. Entitlement to a rating in excess of 10 percent for the residuals of a right maxilla fracture with deviated septum is denied. REMAND A review of the record shows the veteran was notified of the VCAA duties to assist and of the information and evidence necessary to substantiate his 1151 claim by correspondence dated in November 2003 and June 2007. He was also notified by the June 2007 correspondence of the VCAA notice requirements for all elements of his claim. The revised VCAA duty to assist requires that VA make reasonable efforts to assist the claimant in obtaining evidence necessary to substantiate a claim and in claims for disability compensation requires that VA provide medical examinations or obtain medical opinions when necessary for an adequate decision. See 38 C.F.R. § 3.159. In this case, the veteran contends that he has loss of use of his left long finger as a result of VA medical treatment. VA hospital records show the veteran underwent tenosynovectomy and tenolysis to the flexor tendon of the left middle finger in September 2002. Postoperative records note treatment for an infection. An October 2002 report noted a ruptured flexor tendon to the left middle finger, postoperative trigger finger release on September 18, 2002, and stitch abscess on September 27, 2002. Records indicate he underwent a silastic rod insertion to the left middle finger in May 2003. An April 2007 VA orthopedic surgery note reported he presented with a non-functional left long finger with a history a trigger finger release at the base that became infected with scarring of the tendons. The veteran was referred for possible reconstructive surgery. No opinion, however, has been provided as to whether the veteran has an additional disability caused by VA hospital care or medical or surgical treatment. In light of the evidence of record, the Board finds further development is required prior to appellate review. Regulations provide that benefits under 38 U.S.C. 1151(a), for claims received by VA on or after October 1, 1997, for additional disability or death due to hospital care, medical or surgical treatment, examination, training and rehabilitation services, or compensated work therapy program, require actual causation not the result of continuance or natural progress of a disease or injury for which the care, treatment, or examination was furnished, unless VA's failure to timely diagnose and properly treat the disease or injury proximately caused the continuance or natural progress. The additional disability or death must not have been due to the veteran's failure to follow medical instructions. 38 C.F.R. § 3.361 (2007). To establish causation the evidence must show that the hospital care, medical or surgical treatment, or examination resulted in the veteran's additional disability or death. Merely showing that a veteran received care, treatment, or examination and that the veteran has an additional disability or died does not establish cause. Hospital care, medical or surgical treatment, or examination cannot cause the continuance or natural progress of a disease or injury for which the care, treatment, or examination was furnished unless VA's failure to timely diagnose or properly treat the disease proximately caused the continuance or natural progress. 38 C.F.R. § 3.361(c). It must be shown that the hospital care, medical or surgical treatment, or examination caused the veteran's additional disability or death and that (i) VA failed to exercise the degree of care that would be expected of a reasonable health care provider or that (ii) VA furnished the hospital care, medical or surgical treatment, or examination without the veteran's or, in appropriate cases, the veteran's representative's informed consent. To establish the proximate cause of an additional disability or death it must be shown that there was carelessness, negligence, lack of proper skill, error in judgment, or similar instance of fault on VA's part in furnishing hospital care, medical or surgical treatment, or examination. Whether the proximate cause of a veteran's additional disability or death was an event not reasonably foreseeable is in each claim to be determined based on what a reasonable health care provider would have foreseen. The event need not be completely unforeseeable or unimaginable but must be one that a reasonable health care provider would not have considered to be an ordinary risk of the treatment provided. In determining whether an event was reasonably foreseeable, VA will consider whether the risk of that event was the type of risk that a reasonable health care provider would have disclosed in connection with the informed consent procedures of 38 C.F.R. § 17.32. 38 C.F.R. § 3.361(d). Accordingly, the case is REMANDED for the following action: 1. Copies of the veteran's complete VA medical records, including all handwritten reports and signed consent documents for any procedures performed, should be obtained and associated with the appellate record. 2. Thereafter, the veteran should be scheduled for VA examination, by an orthopedic surgeon, for an opinion as to whether there is at least a 50 percent probability or greater (at least as likely as not) that he has any additional left long finger disability as a result of VA treatment. If any additional disability was incurred during VA hospitalization, the examiner should address whether the proximate cause of the additional disability was due to carelessness, negligence, lack of proper skill, error in judgment, or similar instance of fault on VA's part in furnishing hospital care. Whether the proximate cause of an additional disability was an event not reasonably foreseeable is to be determined based on what a reasonable health care provider would have foreseen. All indicated tests and studies are to be performed. Prior to the examination, the claims folder and a copy of this remand must be made available to the physician for review of the case. A notation to the effect that this record review took place should be included in the report. Opinions should be provided based on the results of any examination, a review of the medical evidence of record, and sound medical principles. All examination findings, along with the complete rationale for all opinions expressed, should be set forth in the examination report. 3. The veteran must be given adequate notice of the date and place of any requested examination. A copy of all notifications, including the address where the notice was sent, must be associated with the claims folder. The veteran is to be advised that failure to report for a scheduled VA examination without good cause shown may have adverse effects on his claim. 4. After completion of the above and any additional development deemed necessary, the issue remaining on appeal should be reviewed with consideration of all applicable laws and regulations. If any benefit sought remains denied, the veteran and his representative should be furnished a supplemental statement of the case and be afforded the opportunity to respond. Thereafter, the case should be returned to the Board for appellate review. The appellant has the right to submit additional evidence and argument on the matter or 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). ______________________________________________ RENÉE M. PELLETIER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs