Citation Nr: 1300843 Decision Date: 01/09/13 Archive Date: 01/16/13 DOCKET NO. 07-26 046 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUE Entitlement to an increased rating for status post right internal carotid artery ligation, hypertension, and history of seizures, assigned a 40 percent evaluation from March 4, 2005, and an 80 percent rating effective from March 24, 2011. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD K. Hudson, Counsel INTRODUCTION The Veteran had active service from January 1960 to March 1990. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a regional office (RO) rating decision of July 2006, which denied a rating in excess of 40 percent for postoperative residuals of right internal carotid artery ligation. In February 2011, the appeal was remanded for additional development. While in remand status, the RO granted an 80 percent rating for the postoperative residuals of right internal carotid artery ligation, effective March 29, 2011. The staged rating issue, as set forth on the title page, remains on appeal, as a grant of less than the maximum available rating does not terminate the appeal, unless the veteran expressly states he is satisfied with the assigned rating. See AB v. Brown, 6 Vet.App. 35, 38 (1993). In certain circumstances, a claim for TDIU can be inferred as part of a claim for increased compensation. See Rice v. Shinseki, 22 Vet. App. 447 (2009). This case differs, however, because a formal claim for TDIU, as a separate issue, was considered and denied by the RO in the July 2006 rating decision on appeal. Although he submitted a notice of disagreement, and a statement of the case was furnished addressing that issue, in his June 2007 substantive appeal, he said he was appealing only the issue of an increased rating for postoperative residuals of right internal carotid artery ligation. Therefore, in these circumstances of this case, the Board finds that a TDIU claim is not on appeal. FINDINGS OF FACT 1. For the period from March 4, 2005, to March 23, 2011, the Veteran did not have 2 major seizure-like episodes per year; or average of more than 8 minor seizure-like episodes per week. 2. For the period from March 24, 2011, the Veteran has not manifested 1 major seizure per month over the past year. 3. The Veteran's service-connected hypertension requires the continuous use of medication for control; diastolic readings have not been shown to be predominantly 110 or more, and systolic readings have not been shown to be predominantly 200 or more. CONCLUSIONS OF LAW 1. From March 4, 2005, to March 23, 2011, the criteria for a rating in excess of 40 percent for postoperative residuals of right internal carotid artery ligation were not met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 3.321, 4.124a, Diagnostic Code 8008-8911 (2012). 2. Beginning March 24, 2011, the criteria for a rating in excess of 80 percent for postoperative residuals of right internal carotid artery ligation have not been not met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 3.321, 4.124a, Diagnostic Code 8008-8911 (2012). 3. The criteria for an evaluation of 10 percent, but no higher, for hypertension have been met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 3.321, 4.1, 4.2, 4.7, 4.104, Diagnostic Code 7101 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Veterans Claims Assistance Act (VCAA) Compliance Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant and his representative of any information, and any medical or lay evidence, that is necessary to substantiate the claim. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b). In a letter dated in April 2006, the RO advised the claimant of the information necessary to substantiate the claim for an increased rating, service connection, and of his and VA's respective obligations for obtaining specified different types of evidence. See Quartuccio v. Principi, 16 Vet. App. 183 (2002). He was informed of the types of medical and lay evidence that the claimant may submit (or ask the Secretary to obtain) that are relevant to establishing entitlement to increased compensation-e.g., treatment records, or statements of personal observations from other individuals. He was informed that a disability rating will be determined by applying relevant Diagnostic Codes, which typically provide for a range in severity of a particular disability from noncompensable to as much as 100 percent (depending on the disability involved), based on the nature of the symptoms of the condition for which disability compensation is being sought, their severity and duration, and their impact upon employment. He was also provided with information regarding ratings and effective dates. See Vazquez-Flores v. Shinseki, 580 F.3d 1270 (Fed. Cir. 2009); Dingess v. Nicholson, 19 Vet. App. 473 (2006). Thus, the duty to notify has been satisfied. Under the VCAA, the VA also has a duty to assist the Veteran by making all reasonable efforts to help a claimant obtain evidence necessary to substantiate a claim. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159(c). The Veteran's service treatment records have been obtained, as have identified VA treatment records and private treatment records. VA examinations were provided in April 2005, May 2006, and March 2011. Those examinations, when considered in conjunction with the other evidence of record, describe the disability in sufficient detail for the Board to make an informed decision. See Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). In this regard, as discussed in more detail below, although further studies were recommended in the March 2011 examination to determine the cause of the Veteran's claimed seizures, for rating purposes, it is the severity and frequency of the seizure-like episodes which are relevant, and not the cause of the episodes. In this regard, they have been found by the RO to be service-connected, and there is no indication that further diagnostic testing, such as an electroencephalogram, would elicit additional symptoms. There is no evidence indicating that there has been a material change in the service-connected disorder since the last evaluation. 38 C.F.R. § 3.327(a). Thus, the Board finds that all necessary notification and development has been accomplished, and therefore appellate review may proceed. Significantly, neither the appellant nor his representative has identified, and the record does not otherwise indicate, any additional existing evidence that is necessary for a fair adjudication of the claim that has not been obtained. Hence, no further notice or assistance to the appellant is required to fulfill VA's duty to assist the appellant in the development of the claim. Smith v. Gober, 14 Vet. App. 227 (2000), aff'd 281 F.3d 1384 (Fed. Cir. 2002); Dela Cruz v. Principi, 15 Vet. App. 143 (2001); see also Quartuccio v. Principi, 16 Vet. App. 183 (2002). II. Background Service treatment records show that in June 1975, the Veteran experienced visual changes in his right eye characterized by scintillating scotomata. This lasted 4 to 5 minutes, then resolved. Two days later, he again experienced amaurosis in the right eye, characterized by loss of the superior visual filed, progression to blurred vision, and then finally to tunnel vision. This lasted about 45 minutes and prompted his evaluation. He was thought to have suffered an embolic process from his carotid artery, and was therefore transferred to another hospital for definitive evaluation and treatment. Ultimately, he was found on angiogram to have a pseudoaneurysm of the right internal carotid artery located at the entrance of the artery to the cranial vault, which was the etiology of his emboli. It was considered a risky aneurysm which demanded definitive treatment. He underwent right internal carotid artery ligation. On the second postoperative day he suffered weakness in the left arm and leg, thought to be due to a hypotensive episode which occurred during his recovery period. This weakness completely resolved within 7 days so that only a finely discernible neurological deficit was apparent. He was discharged to 6 months of limited duty. However, up on his return from convalescent leave in August 1975, he was not yet ready to return to limited duty and was transferred to a medical center for further convalescence. In September 1976, it was noted that during the six months following his initial medical board, he sustained intermittent episodes of left sided weakness as well as marked anxiety and depression which required psychiatric treatment. Both his mental and physical disabilities resolved so that by January 1976 he was considered nearly fully recovered. An additional six months of limited duty had been provided to allow complete recovery. On current examination, he was in general an "exceedingly" healthy male. Examination of the neurologic system revealed no abnormalities. There was no evidence of left-sided deficit, as determined by neurologic consultation, and evaluation of his mental status revealed him to be free of mental illness. During his last 6 months of limited duty, he had essentially functioned in a full active duty capacity. He suffered no difficulties with his work, and his postoperative mental and physical disabilities were "fully resolved." Although no stroke or cerebrovascular accident (CVA) was noted in the available records of treatment for the pseudoaneurysm during service, a history of a stroke was obtained during a 1978 hospitalization. After his discharge from service in March 1990, service connection was granted for residuals of a right CVA with postoperative residuals of right internal carotid artery ligation, hypertension, assigned a 10 percent evaluation under Diagnostic Code 8008. In March 2005, the Veteran claimed an increased rating for pseudoaneurysm, right internal carotid artery - occlusion, right internal carotid. He was treated for these conditions including surgery while on active duty. These conditions had worsened, and he was now having stroke-like symptoms including slurred speech, altered sensation in the left face, and left side weakness. Evidence obtained in connection with this claim includes records of the Veteran's evaluations by a private neurologist, R. F., M.D., who first evaluated the Veteran in December 2004. A history of right hemispheric cerebral infarction as a complication of the right internal carotid artery ligation was given by the Veteran. He said that physical therapy was required for 2 years, but that he made a good recovery. Two weeks ago, he had experienced a two-day episode in which he had difficulties with slurred speech, altered sensation in this left face, and mild left sided weakness. He had not had recurrent difficulties. On examination, there was no evidence of facial weakness, and his speech was clear. There was no drift or focal weakness observed. His reflexes in general were hypoactive but they were symmetric. In February 2005, Dr. R. F. noted that there were no acute findings shown on magnetic resonance angiogram (MRA) or magnetic resonance imaging (MRI) to account for his most recent symptoms. He did not have flow in his right internal carotid artery. There was collateral circulation with slowed flow and less dynamic flow to the right than left, which would be expected. Dr. Frank indicated concern that the episode may have related to the Veteran's blood pressure. He noted that pressures in the 140/90 range may be needed to ensure adequate circulation to his right cerebral hemisphere, to avoid "watershed" distribution transient ischemic attacks (TIAs). On a VA examination in April 2005, the Veteran said that after his surgery in service, he had a stroke during which he lost the use of the left side of his body, and his speech was affected. He was placed on limited duty for the next 2 years. He said that he never completely returned to normal. This history is inconsistent with the service treatment records, which, as noted above, show mild weakness in the left side, symptoms largely resolving within 6 months, and completely resolved within a year. He said he had now developed episodes where his left sided weakness increased and both his speech and cognition appeared to become somewhat impaired. He had never clearly seen any precipitating factors, and said that the duration of these symptoms was several days. On examination, he had a left carotid bruit. Motor examination revealed some increased tone and spasticity on the left as compared with the right. The deep tendon reflexes were brisker on the left than the right. Sensory examination revealed some decrease in pinprick, position sense, and vibratory sense on the left as compared with the right. He was somewhat clumsy with fine rapid motion on the left. Gait was normal. An electroencephalogram was recommended. In June 2005, the Veteran was seen by his family doctor, D. F., M.D., with the chief complaint of "discuss letter for VA." A history of nearly monthly events that had not been clearly defined as a TIAs or seizures, since a CVA in service, was noted. He essentially had acute onset of confusion and disorientation, often with a fugue state, lasting from minutes to days, but which seemed to clear without sequelae. Since they were occurring more often, their duration was unpredictable, had no therapeutic options, and were so devastating int their effects, he was unemployable. On examination, HEENT was normal, cranial nerves II - XII were intact, motor was 5/5, gait and station were normal, and central nervous system was nonfocal. In July 2005, Dr. R. F. noted that the Veteran had returned that day, stating that he had a spell in March which lasted for several days by his history. He asked the Veteran if he had one that lasted several days to try to get in touch so it could be seen what his appearance might be at the time. He indicated that he discussed with a VA physician who suggested that he might have an EEG if such an event occurred. Dr. R. F. did not think that his symptoms were compatible with seizure, but may do an EEG just for that purpose. On a VA examination in May 2006, the Veteran said he still got episodes as described in the earlier VA examination, when the left side felt like it was sliding off the body and slurred speech. It happened periodically but he could not give the frequency. In December 2004 he had a bad episode and reported has had had MRI/MRA. The episode lasted anywhere from a minute to days. He also got dizzy spells since August 2005. He was, however, able to walk 3 miles 3 times per week. On examination, speech was fluent and gait was normal. He was able to tandem walk with no sign of ataxia. He had mild unsustained nystagmus, right lateral gaze. He did not have any facial weakness. On motor examination, there was no muscle atrophy. Power was 4+/5 in the upper and lower extremities. Deep tendon reflexes in the upper extremities were 1-2, ad in the lower extremities, knee jerks were 1 and ankle jerks 0-1 on the right side, and 2 on the left side. Tone was normal. He reported vibration and pinprick, but said it felt different on the left side. It was noted that he experienced episodes of loose feeling on the left side of the body, slurred speech, etiology uncertain. The Veteran submitted a copy of a calendar in which he had reportedly logged his seizures for the period from August 2006 through March 2007. These totaled 101 seizures, averaging between 12 and 13 per month, including two that lasted 3 days. In August 2006, the Veteran reported ongoing intermittent TIAs to Dr. D. F. He denied symptoms including syncope or near-syncope. Neurological examination was normal, and deep tendon reflexes were 2+ bilaterally. Significantly, although in his log he reported a seizure the previous day, he did not mention this event. Dr. D. F. noted in January 2007 that the Veteran had a medical history of recurrent TIAs due to carotid ligation. His blood pressure was 122/80. On examination, strength was normal in both lower extremities. Motor function was normal with normal tone, no atrophy and no abnormal movements noted. Reflexes were 2+ bilaterally. Sensation was intact to light touch in the extremities. He had normal gait and station. Overall he was doing very well with few minor aches and pains. Again, he did not mention a seizure, although his seizure log reported a seizure two days earlier, and 15 seizures during the month. J. T., M.D., wrote in February 2007 that the Veteran had undergone a carotid ligation for a very large cerebral aneurysm back in 1975 for which he experienced a mild cerebrovascular accident but totally recovered with completely normal neurological function since that point. He was having TIAs which were described as vague left facial events. He really did not have big motor events. He had a very active lifestyle. Neurologically he was completely intact. He had been asked by neurology to keep his blood pressure from becoming too low. A carotid ultrasound showed the previous ligation of the right internal carotid artery. This artery was not contributing significantly to intracranial circulation. The left carotid showed no changes from the June 2002 study. In March 2007, he reported that he had left sided hemiparesis almost weekly; recently, he had experienced a 3-day bout of left-sided arm and leg weakness. Examination was normal, as it had been in January 2007. On a VA examination in March 2011, the examiner noted that differential diagnosis of the Veteran's spells had been TIAs versus seizures. Although the Veteran spoke of them as seizures, there was little to suggest seizures. Nonetheless, electroencephalogram was warranted to complete this evaluation. The examiner reported the history of light duty and physical therapy for about 2 years after the inservice surgery before reaching maximal recovery, followed by episodes of "left side weakness, slurred speech, loss of dexterity, depression and confusion" beginning shortly after the stroke and occurred at a rate of about one spell per month initially. Subsequently, the frequency and severity reportedly increased. Currently, he reported that he was having these episodes 25-30 times per month. They were variable in duration from minutes to 1 week. His wife had noticed a personality change before spells. He became angry and could not speak his mind. Onset was sudden with no aura suggestive of epileptic events. There was no loss of consciousness, no limb posturing or jerking, no incontinence, no progressive march of symptoms up or down one side of the body. He denied the equivalent of a postictal state unless one considered the longest spells to be postictal weakness and speech difficulty. He had never been treated with antiepileptic medication. These features suggested TIAs were more likely the explanation for the spells than seizures. He also reported ataxia on rising in the morning. On examination, there was an easily audible left carotid bruit. His speech was mostly fluent with occasional slow responses as if due to word finding difficulty; occasional paraphasic errors. Cranial nerves were normal except mild narrowing of the retinal arteries (hypertension). Strength was symmetrically 5/5 except 4/5 in the left hip flexors. Movements and tone were normal. Sensory examination was normal throughout, light touch, kinesthesia, and vibration, but he complained that the left side felt abnormal, like "sliding off my body." Reflexes showed deep tendon reflexes to be low volume symmetrically throughout. Gait was normal; he complained of transient dizziness without tendency to fall. Tandem gait was with mild difficulty. The diagnosis was uncertain. TIAs seemed more likely than seizures. Investigations, including EEG, had been ordered to clarify the diagnosis, after which a supplemental report would be provided. The problems were spells which were unpredictable but frequent (25-30 times per month). He became weak and had difficulty expressing himself, and any and all daily activities could be affected if not prevented during spells that lasted minutes to days. Additional evaluations to arrive at a definitive diagnosis were warranted because of the increasing frequency of spells. In March 2011, the Veteran submitted a statement, with reference to a number of enclosed records. He stated that his current doctor, ordered a CTA of the head and neck, and then told him that it was his medical opinion that the problem was too dangerous to correct. Although he is competent to report what a doctor told him, the fact that the CTA report was not even from the doctor he identified lessens the probative value. Moreover, he said that a VA physician had the same opinion, referring to enclosure (2). However, that enclosure shows that the doctor actually said, in July 2010, that considering the 35-year history and lack of any serious outcomes from these spells, an aggressive procedure such as vascular reconstruction would not likely be beneficial versus the risks. The Veteran felt the same way. The doctor noted that the Veteran was currently asymptomatic, and had intermittent events of mild left sided weakness that the doctor suspected were flow phenomena; seizure seemed unlikely. This conclusion, noting that he had a history of intermittent events of "mild left-sided weakness," with no serious outcomes, suggests that the level of symptomatology "confusion and disorientation often with a fugue state" was a significant factor in the physician's decision. In other words, the symptoms were not severe enough to warrant the risks of the procedure, and not simply that the procedure was too dangerous. The Veteran also said that carotid studies indicate his right internal carotid artery was blocked, but this has been the case since the original surgery in 1975, as demonstrated by the medical history. He also said that his physical and mental conditions following a TIA episode rendered him unable to perform basic physical and mental tasks. III. Analysis Disability evaluations are determined by the application of a schedule of ratings which is based on average impairment of earning capacity. Separate diagnostic codes identify the various disabilities. 38 U.S.C.A § 1155; 38 C.F.R. Part 4. Although the disability must be considered in the context of the whole recorded history, including service medical records, the present level of disability is of primary concern in determining the current rating to be assigned. See 38 C.F.R. § 4.2 (2007); Francisco v. Brown, 7 Vet. App. 55 (1994); Schafrath v. Derwinski, 1 Vet. App. 589 (1991). If the disability has undergone varying and distinct levels of severity throughout the entire time period the increased rating claim has been pending, staged ratings may be assigned. Hart v. Mansfield, 21 Vet. App. 505 (2007); 38 C.F.R. § 4.2. Here, a staged rating was assigned when the RO granted an 80 percent rating, effective March 24, 2011. The Board observes that the Veteran's service-connected disability is currently evaluated as 40 percent disabling under the criteria set out in Diagnostic Code 8008. See 38 C.F.R. § 4.124a. Under this code, thrombosis and hemorrhage of the brain vessels are rated as 100 percent disabling for six months. Thereafter, the rating is based on residual deficits with a minimum rating of 10 percent. Although the cause of his claimed "spells" or "seizures" has not been found, and he does not have a definitive diagnosis, based on his complaints of recurrent seizure-like episodes, the condition has been rated analogously to epilepsy. See 38 C.F.R. § 4.20 (2012). Diagnostic Code 8911, which governs epilepsy, petit mal, was used by analogy to rate the Veteran's seizure disorder. Under Diagnostic Code 8911, a 10 percent evaluation is assigned for a confirmed diagnosis of epilepsy with a history of seizures. 38 C.F.R. § 4.124a, Diagnostic Code 8911. A 20 percent evaluation is assigned for 1 major seizure during the preceding 2 years or 2 minor seizures during the preceding 6 months. A 40 percent evaluation is warranted for at least 1 major seizure in the last 6 months or 2 in the year or averaging at least 5 to 8 minor seizures weekly. An 80 percent evaluation is warranted for averaging at least 1 major seizure in 3 months over the last year or more than 10 minor seizures weekly. A 100 percent evaluation is assigned for an average of at least 1 major seizure per month over the last year. The Board observes that the most recent examination recommended additional studies to ascertain the etiology of the Veteran's "spells." In addition, the Veteran stated in March 2011 that he was undergoing additional evaluation in April 2011. For purposes of this evaluation, however, it is not necessary to obtain those tests or records. The RO, in its evaluation, has accepted the spells as seizures, and rated them as such. It should be noted that none of the spells described by the Veteran have ever been clinically observed. Under 38 C.F.R. § 4.121, to warrant a rating for epilepsy, the seizures must be witnessed or verified at some time by a physician. When there is doubt as to the true nature of epileptiform attacks, neurological observation in a hospital adequate to make such a study is necessary. As to frequency, competent, consistent lay testimony emphasizing convulsive and immediate post-convulsive characteristics may be accepted. Id. Although verification by a physician is supposed to be obtained first, the RO did not obtain verification of the "seizures," but did accept the Veteran's lay statements concerning the frequency and character of the episodes. Given these factors, it is not necessary to further investigate the cause of the Veteran's seizures, for rating purposes. In this regard, because the current rating is based on severity and frequency of seizures, rather than the cause, there is no likelihood that finding a cause for the Veteran's seizures, TIAs, or "spells" would warrant a higher rating. Moreover, the rating is also considered as an appropriate analogous rating, since there is no Diagnostic Code pertaining to TIAs, the most commonly posited explanation for the Veteran's symptoms, or other causes of these seizure-like episodes, as described by the Veteran. The Veteran states that he has a type of seizure or spell from 25 to 30 times per month. He has variously described symptoms ranging from vague left facial events to "left side weakness, slurred speech, loss of dexterity, depression and confusion" or "confusion and disorientation often with a fugue state." None of these incidents have been clinically documented, despite the Veteran having been advised to report for medical evaluation during one of the episodes lasting multiple days. The Board finds that the episodes are more likely than not at the mild end of his reported histories. For one thing, it is not likely that if the episodes, including the reported post-episode symptoms, were as debilitating as he has sometimes described, he would have failed to take the important step of seeking an evaluation during an episode, both to attempt to discern a cause and to document the episodes, for compensation purposes. More importantly, if the episodes were actual seizures, including loss of consciousness, even if brief, or loss of control over motor functions, there would be legal consequences with respect to his ability to drive. There is no indication that the Veteran's driving privileges have been suspended or even questioned due to his "seizures." In this regard, both Florida and Tennessee regulations require that an individual's driving privileges be suspended after a seizure, and that the individual be seizure-free for, at a minimum, 6 months before privileges can be restored. See Rules of Tennessee. Department of Safety, Driver Control Division, 1340-1-4.04; FLA. ADMIN. CODE ANN. r. 15A-5.004(1), (2) (2011); see also Fla. State §§ 322.126, 322.221; FLA. ADMIN. CODE ANN. r. 15A-5.002 (2011). This includes, in Florida, syncopal episodes with no clear diagnosis established, and, in Tennessee, momentary lapses of consciousness due to any cause. Id. Although the Veteran has stated, on some occasions, that he does not have any loss of consciousness during his spells, under the rating schedule, even a minor seizure requires a brief interruption in consciousness or conscious control. See 38 C.F.R. § 4.124a, Diagnostic Code 8911. The fact that there is no indication in the record that the Veteran's ability to drive has been questioned or discussed is evidence that his physicians do not believe that the reported "spells" are, in fact, comparable to seizures. In this regard, an individual with 25 to 30 unpredictable seizure-like episodes per month, with symptoms such as "left side weakness, slurred speech, loss of dexterity, depression and confusion" or "confusion and disorientation often with a fugue state" would present a danger to himself and others if one of these unpredictable episodes occurred while he was driving, and it does not seem likely that all of his doctors would have failed to mention this danger. Further, in view of the minor nature of the episodes, the Board does not find it credible that he has disabling after-effects during which he is unable to perform basic physical and mental tasks, such as bathing. In sum, the evidence establishes that a rating in excess of 40 percent is not warranted from March 4, 2005 to March 23, 2011, and a rating in excess of 80 percent is not warranted effective March 24, 2011. In this regard, the Veteran stated that he has 25-30 episodes of seizures/TIAs/spells per month, which, on average, is less than 8 spells per week, and the rating schedule provides that minor seizures averaging at least 5-8 weekly warrant a 40 percent rating. For an average of 9 to 10 minor seizures a week, a 60 percent rating is warranted, and more than 10 seizures a week warrants an 80 percent rating. It is not clear how the RO arrived at more than 10 seizures a week, because the explanation provided in the rating decision was that he had 25 to 30 seizures a month. The Veteran has not claimed to have more frequent seizures than that. His "seizure log" covering the period from August 2006 through March 2007 showed a total of 101 episodes, which averages out to between 12 and 13 per month. He has not otherwise claimed to have the episodes more often than 25 to 30 time per month. Hypertension The service-connected disability of hypertension has been combined as a single disability together with the Veteran's postoperative residuals of right internal carotid artery ligation. However, as there is no overlapping or duplicative symptomatology, this condition should be rated separately. See 38 C.F.R. § 4.14 ; Esteban v. Brown, 6 Vet.App. 259, 262 (1994). In this regard, although there is evidence indicating that treatment for one condition may affect the other condition, the symptomatology itself differs entirely. Hypertension or isolated systolic hypertension with diastolic blood pressure of predominantly 100 or more, or systolic pressure predominately 160 or more, or a history of diastolic pressure predominately 100 or more which requires continuous medication for control, warrants a 10 percent evaluation. A 20 percent evaluation requires diastolic blood pressure of predominantly 110 or more, or systolic pressure predominantly 200 or more. A 40 percent evaluation is warranted for diastolic blood pressure of predominantly 120 or more, and a 60 percent evaluation is warranted for diastolic blood pressure of predominantly 130 or more. 38 C.F.R. § 4.104, Code 7101 (2012). The medical evidence establishes that the Veteran's hypertension requires continuous medication for control; thus, affording the Veteran all reasonable doubt, a separate 10 percent rating is warranted for hypertension. A higher rating is not warranted, however, because diastolic blood pressure of predominantly 110 or more, or systolic pressure predominantly 200 or more, has not been shown. Thus, a separate 10 percent rating, but no higher, for hypertension is warranted. Extraschedular Consideration The Veteran contends that he lost a part-time job due to his service-connected postoperative residuals of right internal carotid artery ligation. When the rating schedule is inadequate to evaluate a claimant's disability picture and that picture has related factors such as marked interference with employment or frequent periods of hospitalization, then the case must be referred to the Under Secretary for Benefits or the Director of the Compensation and Pension Service for a determination of whether, to accord justice, the claimant's disability picture requires the assignment of an extraschedular rating. See Thun v. Peake, 22 Vet. App. 111 (2008), aff'd sub nom. Thun v. Shinseki, 572 F.3d 1366 (Fed. Cir. Jul. 17, 2009). Under Thun, there is a three-step analysis in determining whether referral for extraschedular consideration is appropriate. The initial step is a comparison between the level of severity and symptomatology of the claimant's service-connected disability with the established criteria found in the rating schedule for that disability. Id. If the criteria reasonably describe the claimant's disability level and symptomatology, then the claimant's disability picture is contemplated by the rating schedule, the assigned schedular evaluation is, therefore, adequate, and no referral is required. In addressing the first step, the Board finds that the Veteran's symptoms are contemplated by the rating schedule, which provides for higher evaluations for the service-connected disability rated analogously to seizures. There is no symptomatology pertaining to the condition which the Board has not considered. Moreover, the Veteran's prior employer, while stating that the Veteran moved from an outside job to an inside job, did not indicate he had lost any time off work, or his job, due to disability. Therefore, the ratings are adequate, and referral for extraschedular consideration is not required. The Board finds that hypertension should be rated separately, and a 10 percent rating is warranted. Regarding the postoperative residuals of right internal carotid artery ligation, there are no discrete periods during which an evaluation higher than 40 percent prior to March 23, 2011, or higher than 80 percent on or after that date, is warranted. In reaching these determinations, the Board is mindful that all reasonable doubt is to be resolved in the Veteran's favor. However, except for the grant of a separate 10 percent rating for hypertension, the preponderance of the evidence is against the claim, and the claim must be denied. 38 U.S.C. § 5107(b); see Ortiz v. Principi, 274 F.3d 1361 (Fed. Cir. 2001); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). ORDER Entitlement to an evaluation in excess of 40 percent for postoperative residuals of right internal carotid artery ligation, from March 4, 2005 to March 23, 2011, is denied. Entitlement to an evaluation in excess of 80 percent for postoperative residuals of right internal carotid artery ligation, beginning March 24, 2011, is denied. Entitlement to separate rating of 10 percent for hypertension is granted, subject to the laws and regulations governing monetary awards. ____________________________________________ JONATHAN B. KRAMER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs