Citation Nr: 1303311 Decision Date: 01/31/13 Archive Date: 02/05/13 DOCKET NO. 09-22 020 ) DATE ) ) On appeal from the Department of Veterans Affairs Medical and Regional Office Center in Fargo, North Dakota THE ISSUES 1. Entitlement to n evaluation in excess of 10 percent for right carpal tunnel syndrome prior to September 10, 2010. 2. Entitlement to n evaluation in excess of 20 percent for right carpal tunnel syndrome on or after September 10, 2010. 3. Entitlement to an evaluation in excess of 10 percent for left carpal tunnel syndrome. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL The appellant ATTORNEY FOR THE BOARD M. Turner, Counsel INTRODUCTION The Veteran served on active duty from May 1984 to August 1984, from April 1987 to July 1991, and from January 1993 to June 2001. This matter initially came before the Board of Veterans' Appeals (Board) on an appeal from a December 2008 rating decision issued by the Regional Office (RO) in Fargo, North Dakota. The case was remanded by the Board for additional development in June 2010. At that time, the issues included the propriety of the reductions of the Veteran's ratings for his bilateral carpal tunnel from 10 percent to noncompensable effective from January 1, 2009. However, in a July 2011 rating decision, the RO granted restoration of the prior 10 percent ratings, and his rating for his right carpal tunnel syndrome was increased to 20 percent effective from September 10, 2010. The Veteran was also granted a separate rating for scars from his carpal tunnel release surgery. Therefore, the issues of the propriety of the reductions and whether a separate rating was warranted for surgical scars have been granted and are not currently before the Board for appellate review. The Veteran testified before the undersigned Veterans Law Judge at an April 2010 hearing. A transcript of that hearing is of record. FINDINGS OF FACT 1. Prior to August 10, 2010, the symptoms of Veteran's right carpal tunnel syndrome most closely approximated mild incomplete paralysis of the median nerve of the non-dominant extremity. 2. From August 10, 2010, to September 10, 2010, the symptoms of the Veteran's right carpal tunnel syndrome most closely approximated moderate paralysis of the median nerve of the non-dominant extremity. 3. Beginning September 10, 2010, the symptoms of the Veteran's right carpal tunnel syndrome most closely approximate moderate paralysis of the median nerve of the non-dominant extremity. His symptoms were no productive of severe paralysis. 4. The symptoms of the Veteran's left carpal tunnel syndrome most closely approximate mild paralysis of the dominant extremity. CONCLUSIONS OF LAW 1. Prior to August 10, 2010, the criteria for a rating in excess of 10 percent for right carpal tunnel syndrome were not met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1-4.14, 4.124a, Diagnostic Code 8515 (2012). 2. From August 10, 2010, to September 10, 2010 the criteria for a 20 percent rating for right carpal tunnel syndrome were met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1-4.14, 4.124a, Diagnostic Code 8515 (2012). 3. On or after September 10, 2010, the criteria for a rating in excess of 20 percent for right carpal tunnel syndrome were not met38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1-4.14, 4.124a, Diagnostic Code 8515 (2012). 4. The criteria for a rating in excess of 10 percent for left carpal tunnel syndrome were not met. REASONS AND BASES FOR FINDINGS AND CONCLUSION Duty to Notify and Assist The Veterans Claims and Assistance Act of 2000 (VCAA) describes VA's duties to notify and assist claimants with substantiating their claims for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126; 38 C.F.R. § 3.102, 3.156(a), 3.159. Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant of any information, and any medical or lay evidence, that is necessary to substantiate his or her claim. 38 U.S.C.A. § 5103(a), 38 C.F.R § 3.159(b); Quartuccio v. Principi, 16 Vet. App. 183, 186-187 (2002). In accordance with 38 C.F.R. § 3.159(b)(1), proper VCAA notice must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. In Dingess v. Nicholson, 19 Vet. App. 473 (2006), aff'd sum nom Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007), the United States Court of Appeals for Veterans Claims (Court) held that VCAA notice requirements are applicable to all five elements of a service connection claim. Thus, the Veteran must be notified that a disability rating and effective date for the award of benefits will be assigned if service connection for a claimed disability is awarded. Id at 486. With regard to claims for increased disability ratings for service-connected conditions, the law requires VA to notify the claimant that, to substantiate a claim, the claimant must provide, or ask VA to obtain, medical or lay evidence demonstrating a worsening or increase in severity of the disability. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b); Vazquez- Flores v. Peake, 22 Vet. App. 37 (2008), vacated and remanded sub nom. Vazquez-Flores v. Shinseki, 580 F.3d 1270 (Fed. Cir. 2009). The claimant must be notified that, should an increase in disability be found, 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. Finally, the notice must provide examples of the types of medical and lay evidence that the Veteran may submit (or ask the VA to obtain) that are relevant to establishing her or his entitlement to increased compensation. However, the notice required by section 5103(a) need not be specific to the particular Veteran's circumstances; that is, VA need not notify a Veteran of alternative diagnostic codes that may be considered or notify of any need for evidence demonstrating the effect that the worsening of the disability has on the particular Veteran's daily life. Vazquez-Flores v. Shinseki, 580 F.3d 1270 (Fed. Cir. 2009). The notice must be provided prior to an initial unfavorable decision by the agency of original jurisdiction (AOJ). Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004). VCAA notice should be provided to a claimant before the initial unfavorable decision on a claim by the agency of original jurisdiction (AOJ). Pelegrini v. Principi, 18 Vet. App. 112, 115 (2004). However, the VCAA notice requirements may be satisfied notwithstanding errors in the timing or content of the notice if such errors are not prejudicial to the claimant. Id at 121. Further, a defect in the timing of the notice may be cured by sending proper notice prior to a re-adjudication of the claim. Mayfield v. Nicholson, 444 F.3d 1328, 1333-1334 (Fed. Cir. 2006). VA's General Counsel issued a precedential opinion interpreting Pelegrini as requiring the Board to ensure that proper notice is provided unless it makes findings regarding the completeness of the record or other facts that would permit the conclusion that the notice error was harmless. See VAOGCPREC 7-2004. The United States Court of Appeals for the Federal Circuit reaffirmed the importance of proper VCAA notice in Mayfield v. Nicholson, 499 F.3d 1317 (Fed. Cir. 2007). Mayfield and its progeny instruct that a comprehensive VCAA letter, as opposed to a patchwork of other post-decisional documents, is required to meet the VCAA's notification requirements. Id at 1320. However, VCAA notification does not require a pre-adjudicatory analysis of the evidence already contained in the record. See, e.g. Mayfield v. Nicholson, 20 Vet. App. 537, 541 (2006). In this case, the Veteran was sent a letter in February 2009 that informed him of what evidence was necessary to substantiate his claims for increased evaluations and the division of responsibilities in obtaining such evidence. The February 2009 letter also explained how disability ratings and effective dates are determined. The Board notes that the case was subsequently readjudicated by the RO in a statement of the case; therefore, there is no timing error in this case. Prickett v. Nicholson, 20 Vet. App. 370, 377-78 (2006) (VA cured failure to afford statutory notice to claimant prior to initial rating decision by issuing notification letter after decision and readjudicating the claim and notifying claimant of such readjudication in the statement of the case). In the June 2010 remand, the Board noted that the Veteran had not been provided VCAA notice with respect to the propriety of his rating reductions and instructed that this be done on remand. However, the Veteran's ratings were restored and the benefit in that respect was granted; therefore, VCAA notice on that issue is unnecessary at this time. VA also must make reasonable efforts to assist the claimant with obtaining evidence necessary to substantiate the claim for the benefit sought, unless no reasonable possibility exists that such assistance would aid in substantiating the claim. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. In this case, the Veteran's service treatment records as well as all identified and available post-service medical records pertinent to the years after service are in the claims file and were reviewed by both the RO and the Board in connection with the Veteran's claims. He has not indentified any available, outstanding records that are pertinent to the claims being decided herein. In addition, the Veteran was afforded VA examinations in November 2008, March 2009, and August 2010 in connection with his current claims. 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 that the VA examinations obtained in this case are adequate, as they are predicated on a review of the claims file and all pertinent evidence of record as well as on a physical examination and fully address the rating criteria that are relevant to rating the disabilities in this case. There is no objective evidence indicating that there has been a material change in the severity of the Veteran's service-connected disabilities since he was last examined. 38 C.F.R. § 3.327(a). The duty to assist does not require that a claim be remanded solely because of the passage of time since an otherwise adequate VA examination was conducted. VAOPGCPREC 11-95. Thus, there is adequate medical evidence of record to make a determination in this case. Accordingly, the Board finds that VA's duty to assist with respect to obtaining a VA examination or opinion with respect to the issues on appeal has been met. 38 C.F.R. § 3.159(c)(4). The Board concludes the Veteran was provided the opportunity to meaningfully participate in the adjudication of his claims and did in fact participate. Washington v. Nicolson, 21 Vet. App. 191 (2007). For these reasons, the Board concludes that VA has fulfilled the duty to assist the Veteran in this case. Hence, there is no error or issue that precludes the Board from addressing the merits of this appeal. Law and Analysis Disability ratings are determined by applying criteria that are set forth in the VA's Schedule for Rating Disabilities (38 C.F.R. Part 4). Ratings are based on average impairments of earning capacity resulting from particular diseases and injuries and the residuals thereof in civilian occupations. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. Disabilities are described utilizing diagnostic codes set forth in 38 C.F.R. Part 4. Where there is a question as to which of two evaluations shall be applied, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. See 38 C.F.R. § 4.7. Where entitlement to compensation for a service-connected disease or injury already has been established and entitlement to an increase in the disability rating is at issue, the present level of disability is of primary importance. See, e.g., Franciso v. Brown, 7 Vet. App. 55, 58 (1994). Staged ratings are, however, appropriate for an increased rating claim when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. The relevant focus for adjudicating an increased rating claim is on the evidence concerning the state of the disability from the time period one year before the claim was filed until VA makes a final decision on the claim. See generally Hart v. Mansfield, 21 Vet. App. 505 (2007). The Veteran's carpal tunnel syndrome is rated pursuant to 38 C.F.R. 4.124a, Diagnostic Code 8515. A 10 percent rating is assigned for mild incomplete paralysis of the median nerve of either extremity, and a 20 percent is contemplated for moderate incomplete paralysis of the median nerve of the non-dominant extremity. A 30 percent rating is warranted for moderate incomplete paralysis of the median nerve of the dominant extremity or for severe paralysis of the median nerve of the non-dominant extremity. A 40 percent rating is assigned for moderate incomplete paralysis of the median nerve of the dominant extremity or for severe paralysis of the median nerve of the non-dominant extremity. In cases of complete paralysis of the median nerve, a 50 percent rating applies for the minor extremity, and a 60 percent rating applies for the major extremity. When there is complete paralysis of the median nerve, symptoms include the griffin claw deformity, due to flexor contraction of the right and little fingers, atrophy very marked in dorsal interspace and thenar and hypothenar eminences; loss of extension of the ring and little fingers cannot spread the fingers (or reverse), cannot adduct the thumb; flexion of wrist weakened. 38 C.F.R. § 4.124a, Diagnostic Code 8515. The term incomplete paralysis indicates a degree of lost or impaired function substantially less than the type pictured for complete paralysis of 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. Handedness for the purpose of a dominant rating will be determined by the evidence of record, or by testing on VA examination. Only one hand shall be considered dominant. As demonstrated by the evidence of record, including his own statements, the Veteran is left-handed. 38 C.F.R. § 4.69. The Veteran was provided a VA examination in November 2008 following his carpal tunnel release surgery. It was noted that the surgery helped to relieve the symptoms of numbness and tingling in both hands, but the Veteran still had aching on both sides of his wrists. He had discomfort with the wrist if he was pushing something with his hand outstretched or if he rotated the wrist. He also indicated that he sometimes had nocturnal episodes of numbness of the right hand. A physical examination revealed that the Veteran had good sensation in the hands and good strength and mobility of all the finger joints of the hands. There was no edema, effusion, instability, redness, or heat in the wrists. There was a 1 centimeter tender lump on the volar surface of the left wrist overlying the radial bone. He was able to dorsiflex the left wrist to 70 degrees, palmar flex to 60 degrees, ulnar flex 40 degrees, and radial flex 15 degrees. He was also able to dorsiflex the right wrist to 65 degrees, palmar flex to 60 degrees, ulnar flex to 35 degrees, and radial flex to 20 degrees. There was no additional limitation after repetitive motion. The examiner diagnosed him with minimal residual of carpal tunnel release and degenerative joint disease (DJD) of the bilateral wrists. In his notice of disagreement dated in December 2008, the Veteran reported that his wrists still ached. On his VA Form 9 dated in June 2009, the Veteran reported that he still had wrist pain and had a hard time doing push-ups and some other exercises due to wrist pain. He reported that the pain in his wrists was getting worse. The Veteran submitted a letter dated in January 2009 in which noted that, after carpal tunnel release surgery, there can be some residual nerve irritation or damage that persists, which is variable between people and might or might not improve. Heavy work was likely to cause nerve irritation to persist for a longer period than it otherwise would. The Veteran was reexamined in March 2009. At that time, he reported that his symptoms were stable since the prior examination in November 2008. His carpal tunnel release surgery had improved the numbness and tingling of his fingers, but he still had bilateral wrist pain, and he could not do pushups due to wrist pain. He had a palpable cyst versus bony prominence of the left wrist that remained unchanged. The examiner noted that the Veteran was diagnosed with arthritis of the wrists in November 2008. The Veteran reported that he would have numbness in both of his hands at night five or six times per month. The numbness was located in the palm and extended to the fingers. He did not use any assistive devices due to his carpal tunnel syndrome, and he had not been hospitalized or incapacitated due to the condition. He denied having any erythema or edema to the wrists or hands. He was able to perform all of his activities of daily living, despite his carpal tunnel syndrome, and he did not report missing any work due to carpal tunnel syndrome. The Veteran also did not describe any flare ups of this condition. An examination of the peripheral nerves showed no erethyma or edema in the wrists or hands, and there was no thenar or hypothenar atrophy. His grip strength was slightly decreased bilaterally, but was adequate. The Veteran was able to pick up a dime and a paperclip with the thumb and index fingers of each hand, and monofilament and light touch sensation were intact bilaterally. Phalen's was positive bilaterally, and Tinel's was positive on the left side and negative on the right side. The diagnosis was left and right carpal tunnel syndrome, status post surgery in 2007. At a follow-up appointment in March 201,0 the Veteran reported generally feeling well, but indicated that he had ongoing pain in the proximal palm of both hands in the area of his previous surgery. He stated that pushing against any item with force with his wrist extended was painful in that area. The pain radiated proximally up the flexor area of his forearm. He had to do pushups with his hands in a fist because the extension through the wrist was painful. The thumb and first finger of the right hand also fell asleep during the night, and he had a slightly weakened grip. Symptoms occurred approximately one week out of every three weeks. He had no other complaints or concerns. The Veteran testified at a hearing before the undersigned Veterans Law Judge in April 2010. At that time, he testified that he woke up during the night because his hand falls asleep three to four times a week. The area involved was mainly along the side with the thumb and index finger and the middle finger on both hands. He indicated that he has to keep switching hands to do activities at work because he is unable to use his hands for repetitive activities. He also reported having a tendency to drop things because of loss of sensation in the hands and noted that he uses a special tool to pick up items he has dropped while at work. He further testified that he was left-handed, but that the worst problem was with the right hand. He stated that his condition was progressively deteriorating. It was hard to hold a button down for a long period of time at work and he has to switch hands. He also had difficulty picking up small items, such as coins, nuts, bolts, and screws so he has a magnetic tool to help with this. In addition, he reported that his hands get worse throughout the day, that he cannot do push-ups, and that any type of pushing with the hands is uncomfortable. He was not receiving any type of medical care for his wrists and hands at the time of the hearing. A nerve conduction study was performed in August 2010 due to the Veteran's complaints of his hands falling asleep at night and aching, difficulty picking up small items, weak grip, and aching palms. The results of the study showed an abnormal study of the right median nerve consistent with a right distal median neuropathy; however, the left median nerve was normal. There was also an abnormal study of the left ulnar nerve consistent with a clinical diagnosis of an ulnar neuropathy at the elbow; the right ulnar nerve was normal. The Veteran was reexamined on August 10, 2010. At that time, the Veteran reported that he ate and wrote left-handed, but performed other activities with his right hand. He continued to experience numbness and tingling in both hands and aching in both wrists. On several occasions in the past, he had cortisone injections into his wrists, which temporarily relieved the wrist pain. It was noted that he had bilateral carpal tunnel release in November 2007, and since then, he had intermittent numbness and tingling in his hands at night or when driving, right greater than left, although the sensation was not as bad as it was prior to his surgery. His right hand sometimes fell asleep holding things, and he had aching in the volar aspect of both wrists if he pushed with the hands dorsiflexed. If he did a lot of physical activity with his hands at work, such as working with tools or changing tires, his wrists would weaken and his hands would ache. He had difficulty picking up small nuts and bolts. The problems with his wrists and hands did not interfere with his activities of daily living. A physical examination showed a bony prominence on the volar surface of the left wrist at the head of the radial bone. There was no hand muscle atrophy. There were mild Hebeden's nodes at the DIP joints of both hands. The Veteran was able to touch the tip of his thumb to the tip of each of the fingers and the pad of the thumb to the pad of each of the fingers. He could also oppose the fingertips to the palmar crease, and his hand grip strength was good bilaterally. Phalen's test was negative bilaterally. The reverse Phalen's test produced pain in the right wrist but no numbness. On the Tinel's test, the Veteran complained of some throbbing in the right hand, but no numbness or shock like sensation. Tinel's sign on the left hand was negative. The Veteran was able to pick up a paper clip, coin, and key. Scars on both wrists were noted. An EMG study in August 2010 was consistent with a right median nerve neuropathy, but no left median nerve neuropathy. It also showed a left ulnar neuropathy, but no right ulnar nerve neuropathy. The examiner diagnosed the Veteran with right hand numbness due to moderate right median nerve neuropathy (carpal tunnel syndrome) and left hand numbness due to left ulnar nerve neuropathy (unrelated to carpal tunnel syndrome). Prior to the August 10, 2010 examination, the evidence does not show that the symptoms of carpal tunnel in either wrist were more than mildly disabling. Initially, after his carpal tunnel release surgery, the numbness and tingling in both hands was largely relieved, but there was continuing aching in the wrists and episodic numbness of the right wrist at night. His sensation in the hands was preserved, and his finger strength and mobility were good, as was range of motion of the wrists. The Veteran had subjective complaints of weakness, and at an examination in March 2009, his grip strength was shown to be slightly decreased but adequate. Some exercises were difficult to perform due to the Veteran's wrist pain, but he was able to perform his activities of daily living without difficulty. Pain in the wrists increased as time passed, and eventually, it made it difficult to perform repetitive activities for long periods of time, but the Veteran was nonetheless able to perform these activities. He essentially had full use of his hands, but experienced some pain and occasional numbness of both hands. These symptoms, which consist primarily of pain and intermittent numbness of both wrists and hands, are not severe enough to be considered more than mild. Therefore, the Board finds that an evaluation in excess of 10 percent is not warranted prior to August 10, 2010. The RO increased the rating for the Veteran's right carpal tunnel syndrome to 20 percent disabling beginning September 10, 2010, based on the results of the most recent VA examination. However, that examination was actually performed on August 10, 2010; therefore, the 20 percent rating should be effective as of that date. Nevertheless, the evidence does not show that the symptoms of the Veteran's right carpal tunnel, which involves his non-dominant extremity, were more than moderately disabling on or after August 10, 2010. His symptoms had worsened over time, and the Veteran continued to experience right wrist pain and intermittent numbness, which was worse as the day progressed and worse with activities, such as using tools at work or changing tires. However, his mobility of the fingers of both hands was good, there was no hand muscle atrophy, sensation was preserved, and grip strength was good. While the Veteran had subjective complaints of pain and weakness and had to alter the way he performed some work activities, such as alternating hands when performing repetitive activities, he was nonetheless able to carry out all necessary activities at work and all activities of daily living, despite his right carpal tunnel syndrome, which is inconsistent with the disability being considered more than moderately disabling. Moreover, the August 2010 VA examiner even indicated that he had only moderate carpal tunnel syndrome of the right wrist. Therefore, the Board finds that an evaluation in excess of 20 percent on or after August 10, 2010, is not warranted. While the Veteran had some similar symptoms in his left hand, such symptomatology appeared to manifest to a lesser degree of severity. He consistently reported that the symptoms in his right hand were worse, and the evidence does not show more than mild impairment of the left wrist due to the symptoms of carpal tunnel syndrome. His left finger mobility, sensation, and grip strength were preserved, and he has had normal range of motion. Additionally, although the reverse Phalen's test and Tinel's test were positive on the right side, they were negative on the left side. Nerve conduction studies did not show carpal tunnel of the left wrist, and the August 2010 VA examiner did not diagnose carpal tunnel of the left wrist, but rather an unrelated ulnar neuropathy, which was responsible for the Veteran's symptoms on the left side. Given the totality of the evidence, the Board finds that the Veteran's symptoms do not warrant a rating for greater than mild impairment due to left carpal tunnel syndrome. In reaching this decision, the potential application of various provisions of Title 38 Code of Federal Regulations have been considered, whether or not they were raised by the Veteran. Schafrath v. Derwinski, 1 Vet. App. 589 (1991). In particular, the Board has considered the provisions of 38 C.F.R. § 3.321(b)(1). However, in this case, the Board finds that the record does not show that the Veteran's bilateral carpal tunnel syndrome is so exceptional or unusual as to warrant the assignment of a higher rating on an extra-schedular basis. See 38 C.F.R. § 3.321(b)(1). The threshold factor for extraschedular consideration is a finding that the evidence before VA presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. See Thun v. Peake, 22 Vet. App. 111 (2008). In this regard, there must be 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. If the criteria reasonably describe the claimant's disability level and symptomatology, then the claimant's disability picture is contemplated by the rating schedule and the assigned schedular evaluation is therefore adequate, and no extraschedular referral is required. Id., see also VAOGCPREC 6-96 (Aug. 16, 1996). Otherwise, if the schedular evaluation does not contemplate the claimant's level of disability and symptomatology and is found inadequate, VA must determine whether the claimant's exceptional disability picture exhibits other related factors, such as those provided by the extraschedular regulation (38 C.F.R. § 3.321(b)(1) ) as "governing norms"(which include marked interference with employment and frequent periods of hospitalization). The evidence in this case does not show such an exceptional disability picture that the available schedular evaluation for the service-connected disability is inadequate. A comparison between the level of severity and symptomatology of the Veteran's assigned rating with the established criteria found in the rating schedule shows that the rating criteria reasonably describe the Veteran's disability level and symptomatology, which consists primarily of pain and numbness. As discussed above, there are higher ratings available under the diagnostic code, but the Veteran's disability is not productive of such manifestations. As such, it cannot be said that the available schedular evaluation for the disability is inadequate. Based on the foregoing, the Board finds that the requirements for an extraschedular evaluation for the Veteran's service-connected right and left carpal tunnel syndrome under the provisions of 38 C.F.R. § 3.321(b)(1) have not been met. Bagwell v. Brown, 9 Vet. App. 337 (1996); Shipwash v. Brown, 8 Vet. App. 218 (1995); Thun v. Peake, 22 Vet. App. 111 (2008). The Board acknowledges that VA is statutorily required to resolve the benefit of the doubt in favor of the Veteran when there is an approximate balance of positive and negative evidence regarding the merits of an outstanding issue. That doctrine is inapplicable in the instant case because the preponderance of the evidence is against the Veteran's claim, except for the period from August 10, 2010, to September 10, 2010, for which time an increase to 20 percent is granted. See, e.g., Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990); 38 U.S.C.A. § 5107(b). Accordingly, except for that period, higher ratings for the Veteran's bilateral carpal tunnel syndrome are denied. ORDER Prior to August 10, 2010, a rating in excess of 10 percent for right carpal tunnel syndrome is denied. From August 10, 2010, to September 10, 2010, a rating of 20 percent for right carpal tunnel syndrome is granted. A rating in excess of 20 percent for right carpal tunnel syndrome on or after September 10, 2010, is denied. A rating in excess of 10 percent for left carpal tunnel syndrome is denied. ____________________________________________ JESSICA J. WILLS Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs