Citation Nr: 1302991 Decision Date: 01/28/13 Archive Date: 02/05/13 DOCKET NO. 09-32 343A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Atlanta, Georgia THE ISSUES 1. Entitlement to an initial rating for hypothyroidism in excess of 10 percent for the period prior to June 2, 2009. 2. Entitlement to an initial rating in excess of 30 percent for hypothyroidism for the period from June 2, 2009, forward. 3. Entitlement to an initial rating in excess of 30 percent for left paralytic hemidiaphragm with asthma. 4. Entitlement to an initial compensable rating for a residual scar of the left leg status post spider bite with methicillin resistant staphylococcus aureus (MRSA). 5. Entitlement to an initial compensable rating for an additional residual scar of the left leg status post spider bite with MRSA. REPRESENTATION Appellant represented by: Georgia Department of Veterans Services ATTORNEY FOR THE BOARD L. A. Rein, Counsel INTRODUCTION The Veteran served on active duty from February 1999 to September 2008. These matters come before the Board of Veterans' Appeals (Board) on appeal from a November 2008 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Winston-Salem, North Carolina. Jurisdiction of these matters is with the RO in Atlanta, Georgia. In a February 2011 rating decision, the RO granted a higher, 30 percent rating for hypothyroidism, effective June 2, 2009. While the RO has assigned a higher rating for the Veteran's service-connected hypothyroidism during the pendency of this appeal, as a higher rating is available before and after June 2, 2009, and the Veteran is presumed to seek the maximum available benefit, the claim for an initial higher rating remains viable on appeal. Fenderson v. West, 12 Vet. App. 119 (1999); AB v. Brown, 6 Vet. App. 35 (1993). In September 2011, the Board remanded these matters for additional development. The Board observes that a claim for a total disability rating based on individual unemployability (TDIU) is generally part of an increased rating claim when that claim is raised by the record. Rice v. Shinseki, 22 Vet. App. 447 (2009). However, the Veteran has not asserted, and the record does not otherwise show, that he is unemployable due to service-connected disabilities. On the contrary, the evidence of record shows that the Veteran has been gainfully employed at Fort Benning throughout the period on appeal. Therefore, the Board finds that entitlement to TDIU is not part of the increased rating claims currently on appeal. The claim for an initial rating in excess of 30 percent for hypothyroidism is addressed in the remand following the order; that matter is being remanded to the RO via the Appeals Management Center (AMC), in Washington, DC. FINDINGS OF FACT 1. Since the September 24, 2008, effective date of the grant of service connection, the Veteran's hypothyroidism has required continuous medication for control, and is manifested by fatigue and mental sluggishness. 2. Since the September 24, 2008 effective date of the grant of service connection, the Veteran's left paralytic hemidiaphragm with asthma is not productive of a FEV-1 of less than 55-percent predicted, FEV-1/FVC of less than 55 percent, DLCO (SB) less than 55 percent of predicted, or a maximum oxygen consumption of less than 20 ml/kg/min (with cardiorespiratory limit). The Veteran has not required outpatient oxygen therapy, monthly visits to a physician for required care of exacerbations or at least three courses of systemic corticosteroids per year nor has he demonstrated cor pulmonale (right heart failure), right ventricular hypertrophy, pulmonary hypertension (shown by echo or cardiac catheterization), or an episode of acute respiratory failure. 3. The Veteran's two service-connected residual scars of the left leg status post spider bite with MRSA each result in complaints of numbness that more nearly approximates the criteria for a compensable rating for scarring that is painful, but does not result in any limitation of function or motion or other disabling effect. CONCLUSIONS OF LAW 1. Since September 24, 2008, the effective date of the grant of service connection, the criteria for an initial 30 percent rating for hypothyroidism have been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1, 4.3, 4.7, 4.119, Diagnostic Code 7903 (2012). 2. The criteria for an initial rating higher than 30 percent for left paralytic hemidiaphragm with asthma have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.321, 4.1, 4.2, 4.3, 4.7, 4.97, Diagnostic Codes (DCs) 6600, 6602, 6840 (2012). 3. Resolving all reasonable doubt in favor of the Veteran, the criteria for an initial 10 percent rating, but no higher, for a residual scar of the left leg status post spider bite with MRSA have been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.321, 4.1, 4.2, 4.3, 4.7, 4.118, Diagnostic Code 7804 (as in effect prior to October 23, 2008). 4. Resolving all reasonable doubt in favor of the Veteran, the criteria for an initial 10 percent rating, but no higher, for an additional residual scar of the left leg status post spider bite with MRSA have been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.321, 4.1, 4.3, 4.2, 4.7, 4.118, Diagnostic Code 7804 (as in effect prior to October 23, 2008). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Duties to notify and assist The Board has given consideration to the VCAA, which includes an enhanced duty on the part of VA to notify a veteran as to the information and evidence necessary to substantiate claims for VA benefits. 38 U.S.C.A. §§ 5103, 5103A (West 2002 & Supp. 2012); 38 C.F.R. § 3.159 (2012). The VCAA also redefines the obligations of VA with respect to its duty to assist veterans in the development of their claims. See 38 U.S.C.A. §§ 5103, 5103A (West 2002 & Supp. 2012). Upon receipt of a substantially complete application for benefits, VA is required to notify the claimant and his representative, if any, of any information, and any medical or lay evidence, that is necessary to substantiate the claim. See 38 U.S.C.A. § 5103(a) (West 2002); 38 C.F.R. § 3.159(b) (2012); Quartuccio v. Principi, 16 Vet. App. 183 (2002). Proper notice from VA must inform the claimant of any information and evidence that (1) is necessary to substantiate the claim; (2) VA will seek to provide; and (3) the claimant is expected to provide. This notice must be provided prior to an initial unfavorable decision on a claim by the agency of original jurisdiction. See Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). The notice requirements of the VCAA apply to all five elements of a service-connection claim, including: (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. See Dingess v. Nicholson, 19 Vet. App. 473 (2006). The Board observes, however, that the issue of a higher disability rating is a "downstream" issue. Once a decision awarding service connection, a disability rating, and an effective date has been made, section 5103(a) notice has served its purpose, and its application is no longer required because the claim has already been substantiated. See Sutton v. Nicholson, 20 Vet. App. 419 (2006) (citing Dingess). Given that the issues on appeal relate to the assignment of a higher initial rating for service-connected conditions, the Board concludes that VCAA notice requirements have been satisfied with respect to the issues on appeal. The Board also finds that the duty to assist requirements have been fulfilled. All relevant, identified, and available evidence has been obtained, and VA has notified the appellant of any evidence that could not be obtained. The appellant has not referred to any additional, unobtained, relevant, available evidence. The Board notes that the issue of entitlement to a rating in excess of 30 percent for hypothyroidism is being Remanded for the purpose of obtaining outstanding VA treatment records. Notably, when he was examined in January 2012, the Veteran reported that he received VA treatment for his hypothyroidism every six weeks. He provided no such history when he was examined for his scars or respiratory disorder. He reported no acute exacerbations of these disorders or the need to receive ongoing care. Instead, with respect to his respiratory disorder, he said his care for the condition was resting whenever he experienced shortness of breath. Thus, while records generated by VA facilities are considered constructively in possession of VA, the Board finds that no useful purpose would be served in Remanding the issues of increased rating for scars and left paralytic hemidiaphragm. Dunn v. West, 11 Vet. App. 462, 466-67 (1998). Specific VA medical examinations were conducted to assess the severity of the Veteran's service-connected disabilities. To that end, when VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). The Board finds the above VA examination reports to be thorough and adequate upon which to base a decision with regard to the Veteran's claim. The VA examiner personally interviewed and examined the Veteran, including eliciting a history from the Veteran, and provided the information necessary to evaluate the Veteran's disability under the applicable rating criteria. See 38 C.F.R. § 3.327(a) (2012); Caffrey v. Brown, 6 Vet. App. 377 (1994). Therefore, the available records and medical evidence have been obtained in order to make an adequate determination as to this claim. VA has satisfied the duty to assist provisions of law. No further notice or assistance to the Veteran is required to fulfill VA's duty to assist him in development. Smith v. Gober, 14 Vet. App. 227 (2000); Dela Cruz v. Principi, 15 Vet. App. 143 (2001); Quartuccio v. Principi, 16 Vet. App. 183 (2002). II. Increased ratings Disability ratings are determined by application of the criteria set forth in VA's Schedule for Rating Disabilities, which is based on average impairment of earning capacity. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4. When a question arises as to which of two ratings applies under a particular Diagnostic Code (DC), the higher rating is assigned if the disability more closely approximates the criteria for the higher rating; otherwise, the lower rating applies. 38 C.F.R. § 4.7. After careful consideration of the evidence, any reasonable doubt remaining is resolved in favor of the Veteran. 38 C.F.R. § 4.3 (2012). The Veteran's entire history is to be considered when making disability evaluations. See generally 38 C.F.R. § 4.1; Schafrath v. Derwinski, 1 Vet. App. 589 (1995). Where, as here, the question for consideration is the propriety of the initial rating assigned, evaluation of the medical evidence since the effective date of the grant of service connection and consideration of the appropriateness of "staged rating" (assignment of different ratings for distinct periods of time, based on the facts found) is required. See Fenderson, 12 Vet. App. at 126; see also Hart v. Mansfield, 21 Vet. App. 505 (2007). A. Hypothyroidism The Veteran is currently assigned an initial 10 percent disability rating for hypothyroidism for the period prior to June 2, 2009 and 30 percent disabling beginning on June 2, 2009, pursuant to 38 C.F.R. § 4.119, Diagnostic Code 7903 (2012). Under Diagnostic Code 7903, a 10 percent rating is warranted for fatigability, or; continuous medication required for control. A 30 percent rating is warranted for fatigability, constipation, and mental sluggishness. A 60 percent rating is warranted for muscular weakness, mental disturbance, and weight gain. A 100 percent rating is warranted for cold intolerance, muscular weakness, cardiovascular involvement, mental disturbance (dementia, slowing of thought, depression), bradycardia (less than 60 beats per minute), and sleepiness. August 2007 service treatment records show that the Veteran was diagnosed with hypothyroidism due to his low energy level. A March 2008 service treatment record reflects that the Veteran complained of fatigue, anxiety and mind racing as well as memory impairment, concentration problems, irritability, and symptoms of depression. It was noted that the Veteran had a history of hypothyroidism and was prescribed Levothyroxine .15 miligrams, daily. A July 2008 VA examination report reflects that the Veteran reported an overall fair state of health. He weighed 160 pounds. He was currently taking Levothyroxine 0.15mg, every day. The Veteran stated he was first diagnosed in 2007 and that he feels better on medication, has more energy, less fatigue, and has no unwanted side effects from it. He has no other significant functional limitations from this condition at present. The diagnosis was hypothyroidism, thyroid nodule, solitary. In a June 2009 letter from the Department of the Army medical department, D. J. Black, M.D., F.A.A.F.P., stated that the Veteran has Hashimoto's Thyroiditis which is a chronic lifelong degenerative condition of the thyroid which causes the Veteran to have fatigue, tiredness, irritability, and mental sluggishness. In an August 2009 statement, the Veteran's wife reported that the Veteran used to be a very vibrant husband, father, and soldier who ran, biked, garden and spent hours doing activities with his children. She stated he is now always tired, in pain, has severe mood swings, and can no longer spend the same active time with his children like he used to. An April 2010 VA examination report reflects that the Veteran stated he gets monthly blood tests in addition to treatment with the highest doses of Levothyroxine they can put him on. His energy comes and goes. Weight changes according to medication doses. His weight on examination was 159.3 pounds. He denied significant skin or hair problems. His skin has always been dry. His short term memory is horrible. There is cold intolerance. He denied constipation. Hypothyroidism has caused him to suffer with decreased energy levels and memory loss in the work place and in daily activities. It was noted that the Veteran was on Levothyroxine .2 mcg, daily. A January 2012 VA examination report reflects that the Veteran was diagnosed with hypothyroidism and was followed at Fort Benning with endocrinology every 6 weeks. He currently takes Synthroid 125 mcg daily, noting that he changed from Levothryoxine .3 because it was not working. He also takes Vitamin D once a day. Symptoms attributed to his hypothyroid condition are fatigability and sleepiness. The examiner noted that prior ultrasounds were consistent with Hashimoto's thyroiditis and that the Veteran was found to have a 5 millimeter right thyroid hyperschoic solid nodule. It was noted that the Veteran's thyroid condition impacted his work as he reported missing at least 24 days due to doctor's appointments and fatigue related to hypothyroidism. However, this has not caused unemployability. In this case, resolving any reasonable doubt regarding the degree of disability in favor of the claimant, the Board finds that the Veteran's symptoms related to his service-connected hypothyroid disability have more nearly approximated the criteria for an initial 30 percent disability rating since the effective date of the grant of service connection. 38 C.F.R. §§ 4.3, 4.7. In this regard, the medical evidence of record shows that the Veteran is diagnosed with Hashimoto's thyroiditis, which is a progressive type of autoimmune thyroiditis with lymphocytic infiltration of the gland and circulating antithyroid antibodies. See Dorland's Illustrated Medical Dictionary 542 (28th ed. 1994). Further, since March 2008, while in service and continuing thereafter, the evidence reasonably shows that the Veteran has been prescribed continuous medication, with doses that have needed to be increased to manage symptoms with an eventual change to the non-generic form of the medication for treatment and the Veteran has reported experiencing fatigability and mental sluggishness as well as irritability and tiredness. The issue of an initial rating in excess of 30 percent for hypothyroidism will be address in the Remand below. B. Left paralytic hemidiaphragm with asthma. Respiratory disorders are rated under Diagnostic Codes 6600 through 6817 and 6822 through 6847. Pursuant to 38 C.F.R. § 4.96(a), ratings under those diagnostic codes will not be combined with each other. Rather, a single rating will be assigned under the diagnostic code which reflects the predominant disability with elevation to the next higher rating only where the severity of the overall disability warrants such elevation. 38 C.F.R. § 4.96(a) (2012). The Veteran has been assigned an initial 30 percent rating for his service-connected left paralytic hemidiaphragm with asthma disability under Diagnostic Code (DC) 6602, which pertains to bronchial asthma. In considering the applicability of other diagnostic codes, the Board finds that DCs 6600 (chronic bronchitis), 6601 (bronchiectasis), 6603 (pulmonary emphysema), and 6604 (chronic obstructive pulmonary disease) are not applicable in this instance, as the medical evidence does not show that the Veteran has been diagnosed with any of those conditions. However, as the Veteran is service connected for left paralytic hemidiaphragm, consideration has been give to DC 6840 (Diaphragm paralysis or paresis), which is rated as restrictive lung disease. The General Rating Formula for Restrictive Lung Disease for diseases, DCs 6840-6845, provide for a 30 percent rating where pulmonary function tests (PFTs) show any of the following: FEV-1 of 56 to 70 percent predicted, FEV-1/FVC of 56 to 70 percent; or DLCO (SB) 56 to 65 percent of predicted. A 60 percent is warranted where PFTs show any of the following: FEV-1 of 40 to 55 percent predicted, FEV-1/FVC of 40 to 55 percent; DLCO (SB) 40 to 55 percent of predicted; or maximum oxygen consumption of 15 to 20 ml/kg/min (with cardiorespiratory limit). A 100 percent rating is warranted where PFTs show any of the following: FEV-1 less than 40 percent predicted, FEV-/FVC less than 40 percent; DLCO (SB) less than 40 percent of predicted; or maximum exercise capacity less than 15 ml/kg/min oxygen consumption (with cardiac or respiratory limitation), or; cor pulmonale (right heart failure), or; right ventricular hypertrophy, or; pulmonary hypertension (shown by echo or cardiac catheterization), or; episode(s) of acute respiratory failure, or; requiring outpatient oxygen therapy. Diagnostic Code 6602 provides for a 30 percent rating where pulmonary function tests (PFTs) show any of the following: FEV-1 of 56 to 70 percent predicted, FEV-1/FVC of 56 to 70 percent; or daily inhalational or oral bronchodilator therapy, or inhalational anti-inflammatory medication. A 60 percent rating is warranted where PFTs show any of the following: FEV-1 of 40 to 55 percent predicted, FEV-1/FVC of 40 to 55 percent; or at least monthly visits to a physician for required care of exacerbations, or intermittent (at least three per year) courses of systemic (oral or parenteral) corticosteroids. A 100 percent rating is warranted where PFTs show any of the following: FEV-1 less than 40 percent predicted, FEV-/FVC less than 40 percent; or more than one attack per week with episodes of respiratory failure, or where the use of systemic high dose corticosteroids or immuno-suppressive medications are required on a daily basis. 38 C.F.R. § 4.97, Diagnostic Code 6602 (2012). An August 2007 service treatment record includes a chest fluoroscopy showing an impression of 50 percent decrease in the movement of the left hemidiaphragm in comparison the right hemidiaphragm. A November 2007 service treatment record noted that PFTs showed a mixed restrictive and obstructive pattern (with minimal reveral with bronchiodilators). The provisional diagnosis was restrictive lung disease. A December 2007 record from a private pulmonary physician reflects an opinion that the Veteran has a condition which prohibits physical activity and this condition will not improve. He should remain on a limited profile indefinitely. The diagnosis was paralyzed diaphragm. A December 2007 service treatment record reflects that the Veteran complained of difficulty breathing with running or any exertional activity. It was noted that the Veteran was seen and presented with documentation from a private pulmonologist. Per documentation, the Veteran was diagnosed with idiopathic, paralyzed left hemidiaphragm. The Veteran dates the onset of dyspnea with exertion that began after hospitalization for MRSA on lower extremities. Examination revealed that lungs were clear to auscultation. A July 2008 VA examination report reflects that the Veteran's chest was normal, lungs were clear to auscultation bilaterally and there was a symmetric rise and fall without respiratory distress. No adventitious sounds auscultated. The Veteran reported that his symptoms started in 2007 after he was hospitalized for a severe MRSA infection. The diagnosis was history of paralytic left hemidiaphragm; mild intermittent asthma diagnosed by methacholine challenge. As stated by the Veteran, he may require ongoing medical support. An April 2010 VA examination report reflects that the Veteran receives his primary care at Fort Benning. He gets lightheaded and dyspneic with exertion, but does not require emergency room visits or nebulizer treatments. Inhalers, Advair and pills were unsuccessful. He curtails activities so he does not have any current asthma attacks. There is occasional dry cough. Inhalers were discontinued. There is no hemoptysis and no use of oxygen. He cannot do any sports due to his lungs or back. He has to do chores in moderation and with rest. He cannot do any strenuous yard work. He is not on any asthma medications. This condition has no impact on his sedentary job. It has a moderate to severe impact on chores, mild shopping, prevents exercise and sports, moderate recreation, and mild travel. Pulmonary examination revealed dullness to percussion along the left base; there was left lower lobe diminished expansion. There were no overt rales, rhonchi, or wheezes or diminished breath sounds. He had good color, was in no respiratory distress and there was no cough. PFT testing revealed FEV1, 71 percent post-bronchodilator, FEV1/FVC 82 percent post-bronchodilator, DLCO 79 percent pre-bronchodilator. Interpretation was mild obstructive lung defect. Additional restrictive lung defect cannot be excluded by spirometry alone. Mild decrease in diffusing capacity. Good response to bronchodilator. A January 2012 VA examination report reflects that the Veteran does not require parenteral corticosteroid medications, inhaled medications, oral bronchodilators, antibiotics, or oxygen therapy. The Veteran has asthma without any attack with episodes of respiratory failure in the past twelve months. Chest x-ray revealed no acute abnormality, elevate left hemidiaphragm without eventration or rupture, and minimal anterior mediastinal soft tissue density that likely represents. Residual thymic tissue. PFT testing revealed FEV-1, 82 percent post-bronchodilator, FEV-1/FVC, 79 percent post-bronchodilator, and DLCO 85 pre-bronchodilator. The examiner noted that the Veteran's respiratory condition impacts his ability to work in that he has shortness of breath, but he sits and rest. He has not been missing any work. The Board concludes that the Veteran is not entitled to an initial rating in excess of 30 percent. The medical evidence fails to establish by pulmonary function testing that the Veteran's service-connected left paralytic hemidiaphragm with asthma disability is productive of an FEV-1 of 40 to 55 percent or less predicted, an FEV-1/FVC of 40 to 55 percent or less, or DLCO (SB) 40 to 55 percent of predicted. A maximum oxygen consumption of less than 20 ml/kg/min (with cardiorespiratory limit) is also not shown. Nor does the medical evidence establish that the Veteran's respiratory disability has required outpatient oxygen therapy, monthly visits to a physician for required care of exacerbations or at least three courses of systemic corticosteroids per year. Cor pulmonale (right heart failure), right ventricular hypertrophy, pulmonary hypertension (shown by echo or cardiac catheterization), or an episode of acute respiratory failure has also not been demonstrated. His respiratory disorder was described as being "mild" in 2010 and no significant shift was shown when comparing the test results from 2010 to those gather in 2012. Based on the foregoing, the Veteran has not been shown to have met the criteria for an evaluation in excess of 30 percent. The Veteran is not entitled to a higher initial rating. The Board recognizes the Veteran's contentions as to the severity of his respiratory disability. Lay statements are considered to be competent evidence when describing the features or symptoms of an injury or illness. Falzone v. Brown, 8 Vet. App. 398 (1995). However, as a layperson, the Veteran is not competent to provide an opinion requiring medical knowledge, such as whether the current symptoms satisfy diagnostic criteria. See King v. Shinseki, No. 2011-7159 (Fed. Cir. Dec. 5, 2012). The Board acknowledges that the Veteran is competent to give evidence about what he experiences. Layno v. Brown, 6 Vet. App. 465 (1994). Competency must be distinguished from weight and credibility, which are factual determinations going to the probative value of the evidence. Rucker v. Brown, 10 Vet. App. 67 (1997). As a result, his assertions do not constitute competent medical evidence in support of a rating in excess of 30 percent for his service-connected respiratory disability. C. Scars of the left leg The Veteran is service-connected for two separate residual scars of the left leg status post spider bite with MRSA. They are each assigned an initial noncompensable rating under Diagnostic Code 7804, which pertains to unstable or painful scars. 38 C.F.R. § 4.118, Diagnostic Code 7804. The Board finds that Diagnostic Codes 7800 (disfigurement of the head, face, or neck), 7801 (scars other than head, face, or neck, that are deep or that cause limited), 7802 (superficial scars other than head, face, or neck, that do not cause limited motion, and that cover an area of 144 square inches or greater), and 7803 (superficial, unstable scars) are not applicable in this instance, as the medical evidence does not show that the Veteran has any of those conditions. 38 C.F.R. § 4.118, Diagnostic Codes 7800-7803 (2008). In addition, as the scars are not shown to cause limitation of function, hence, Diagnostic Code 7805 is also not for application in this instance. Under Diagnostic Code 7804, a maximum 10 percent rating is warranted for scars that are painful on examination. 38 C.F.R. § 4.118 (2008). Effective October 23, 2008, VA amended the Schedule for Rating Disabilities by revising that portion of the schedule that addresses the skin. 38 C.F.R. § 4.118, Diagnostic Codes 7800-7805 (2012); 67 Fed. Reg. 49590 -49599 (July 31, 2002). VAOPGCPREC 3-00, 65 Fed. Reg. 33422 (2000); 38 U.S.C.A. § 5110(g) (West 2002). However, those amendments only apply to applications received by VA on or after October 23, 2008, or where the Veteran expressly requests consideration under the new criteria, which he has not done. In this case, the Veteran's claim was received in June 2008. Therefore, the Board has no authority to consider those revisions in deciding this claim. VAOPGCPREC 3-00, 65 Fed. Reg. 33422 (2000); 38 U.S.C.A. § 5110(g) (West 2002). Service treatment records show that in May 2007 the Veteran was hospitalized after receiving a bug bite on the upper portion of his left lower extremity. He developed increased swelling and pain in his extremity and erythema that spread on the dorsum of his foot and to the point of his left knee. Findings were consistent with cellulites. It was noted that the Veteran's original incision was expanded to provide better drainage. The Veteran's wound cultures showed MRSA. A July 2008 VA examination reflects that the Veteran had 1 and 2 centimeter scars, left anterior foreleg, linear in appearance, not tender on palpation, not keloid, restrictive, adherent to underlying tissue or disfiguring, the 2 centimeter scar was also slightly depressed, not keloid. No painful, tender, restrictive, or disfigured scares were noted. The skin was healthy in appearance and texture. The Veteran reported that he has no significant functional limitation from this condition at the present. The diagnosis was history of cellulites, left foreleg, MRSA, 2 small scars on left foreleg, not functionally significant. Objective evidence of significant functional limitation was not identified during examination. In a June 2009 letter, Dr. Black stated that the Veteran had numbness around a scar on his left leg and that the Veteran stated that the area of numbness was getting bigger and more bothersome. An April 2010 VA examination report reflects that the Veteran reported using Bactroban ointment frequently on his scars. The scar of the leg is touchy around the edges and somewhat disfiguring. It is sunken in. The actual scars have no impact on employment or on daily activities. Physical examination revealed that there was a 2 centimeter by 1 centimeter scar located at the proximal anterolateral calf just distal to the left knee. There is thinning of the scar tissue with hypopigmentation, underlying soft tissue loss, but no adherence or skin breakdown. A few centimeters distally, there is a 1 centimeter by 3 millimeter healed scar, also with thinning, but without color change, skin breakdown, adherence or underlying soft tissue loss. Neither scar is disfiguring. Skin and hair are normal in texture and appearance. A January 2012 VA examination report reflects that the Veteran complained of redness and swelling of the scar with cold weather. He reported flare-ups in November and December time frame. He stated that he was seen by a doctor but was told there was no infection, just irritation. The examiner noted that the scars were not painful or unstable. The first scar measured 2 by 1 centimeter and the second scar measured 1 by three centimeters. The first scar total area was 2 centimeters squared and the second scar total area was 3 centimeters squared. There was no findings of disfigurement, abnormal pigmentation, limitation of function, or any other pertinent physical findings. Considering the pertinent evidence in light of the above criteria, and resolving all reasonable doubt in favor of the Veteran, the Board finds that an initial 10 percent rating for each of the Veteran's service-connected residual scars of the left leg on appeal is granted. The Veteran has consistently reported that he experiences numbness in the area of his scars and such contentions are supported by his wife's written statement that based on her observations, it appeared that the Veteran had no feeling in the area of his scars. The bothersome nature of the numbness is akin to the functional loss created by a scar that is tender. Thus, as the Veteran's scars are symptomatic and the Veteran has credibly reported constant numbness, the Board finds that an initial 10 percent, but no higher, rating for each residual scar of the left leg post spider bite with MRSA on appeal is warranted. Other Considerations The Board has also considered whether staged ratings are appropriate in this case. See Fenderson v. West, 12 Vet. App. 119, 125-26 (1999). However, at no time during the relevant appeal period have the Veteran's service-connected left paralytic hemidiaphragm with asthma or either residual scar of the left leg status post spider bite with MRSA more nearly met or nearly approximated the next higher rating under the respective criteria. Each of the above disability determinations are based on application of pertinent provisions of VA's rating schedule. The Board finds that at no point since the effective date of the grants of service connection have any of the Veteran's service-connected disabilities on appeal been shown to be so exceptional or unusual as to warrant the assignment of any higher rating on an extra-schedular basis. See 38 C.F.R. § 3.321(b)(1) (2012). In this regard, there is no evidence of an exceptional or unusual disability picture with related factors, such as marked interference with employment or frequent periods of hospitalization, so as to warrant referral of the case to appropriate VA officials for consideration of an extra schedular rating for these issues. See Shipwash v. Brown, 8 Vet. App. 218 (1995). Here, the record does not reflect that the Veteran was hospitalized for his service-connected disabilities considered herein. There is no objective evidence revealing that these service-connected disabilities caused marked interference with employment, e.g., employers' statements or sick leave records, beyond that already contemplated by the schedular rating criteria. 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 (2012). In this case, the Board finds that schedular criteria are adequate to rate each of the Veteran's service-connected disabilities under consideration. The rating schedule fully contemplates the described symptomatology, and provides for ratings higher than that assigned based on more significant impairment. Thus, the threshold requirement for invoking the procedures set forth in 38 C.F.R. § 3.321(b)(1) is not met. See Thun v. Peake, 22 Vet. App. 111 (2008). ORDER An initial 30 percent rating for hypothyroidism for the period since September 24, 2008, is granted. An initial rating in excess of 30 percent for left paralytic hemidiaphragm with asthma is denied. An initial 10 percent rating, but no higher, for a residual scar of the left leg status post spider bite with MRSA is granted An initial 10 percent rating, but no higher, for an additional residual scar of the left leg status post spider bite with MRSA is granted. REMAND Although further delay is regrettable, the Board finds that additional development is necessary as to the issue of an initial rating in excess of 30 percent for hypothyroidism. During a January 2012 VA examination report, the Veteran reported that he was diagnosed with hypothyroidism and was followed at Fort Benning with endocrinology every 6 weeks. However, the most recent treatment records from Fort Benning that are associated with the claims file are dated in June 2009. VA's duty to assist includes obtaining records in the custody of a federal department or agency. 38 C.F.R. § 3.159(c) (2); see also Bell v. Derwinski, 2 Vet. App. 611, 613 (1992) (holding that where VA medical treatment records are material to the issue on appeal and are not included within the claims file, a remand is necessary to acquire such VA records, because VA is deemed to have constructive knowledge of certain documents which are generated by VA agents or employees). VA is on notice that more recent treatment records are potentially available and has a duty to seek to obtain these records. As such, the Board has no choice but to remand the issue of entitlement to an initial rating in excess of 30 percent for hypothyroidism. Accordingly, this matter is REMANDED for the following action: 1. Obtain treatment records from Fort Benning from June 2009 to the present. A negative response is requested if no records are available. 2. Then, readjudicate the claim. If the claim remains denied, issue a supplemental statement of the case and allow the appropriate time for response. Then, return the case to the Board. 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. 2012). ____________________________________________ MICHAEL A. HERMAN Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs