Citation Nr: 1304102 Decision Date: 02/05/13 Archive Date: 02/08/13 DOCKET NO. 08-24 458 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Atlanta, Georgia THE ISSUES 1. Entitlement to service connection for an eye disability, to include as due to an undiagnosed illness. 2. Entitlement to service connection for chest pain, to include as due to an undiagnosed illness. 3. Entitlement to service connection for residuals of vasectomy, to include a surgical scar. 4. Entitlement to an initial compensable rating for service-connected rhinitis. 5. Entitlement to an initial increased rating for service-connected asthma, evaluated as 30 percent disabling from July 1, 2005 to April 19, 2010 and as 60 percent disabling from April 20, 2010. 6. Entitlement to an initial compensable rating for service-connected hemorrhoids with rectal fissure. 7. Entitlement to an initial compensable rating for service-connected nephrolithiasis. 8. Entitlement to an initial increased rating for service-connected residual scar, status-post ganglion cystectomy of the left wrist, evaluated as noncompensably disabling from July 1, 2005 to April 19, 2010 and as 10 percent disabling from April 20, 2010. 9. Entitlement to an initial increased rating for service-connected residuals of cubital tunnel syndrome, status-post epicondylectomy, and left ulnar nerve transposition of the left elbow with scar, evaluated as noncompensably disabling from July 1, 2005 to April 19, 2010 and as 20 percent disabling since April 20, 2010. 10. Entitlement to an initial increased rating for service-connected residuals of cubital tunnel syndrome, status-post ulnar nerve transposition of the right elbow with scar, evaluated as noncompensably disabling from July 1, 2005 to April 19, 2010 and as 20 percent disabling since April 20, 2010. 11. Entitlement to a total disability evaluation based upon individual unemployability (TDIU). REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD M. Tenner, Counsel INTRODUCTION The Veteran served on active duty in the United States Air Force from August 1982 to June 2005, to include service in Southwest Asia. These matters come before the Board of Veterans' Appeals (Board) on appeal from a December 2005 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Columbia, South Carolina. In December 2005, the RO in Atlanta, Georgia notified the Veteran of the determination. [Due to the location of the Veteran's residence, jurisdiction of his appeal remains with the Atlanta RO.] During the course of the appeal, a March 2011 rating decision increased the disability rating assigned to the service-connected asthma to 60 percent, effective April 20, 2010; service-connected residuals of cubital tunnel syndrome, status-post epicondylectomy and left ulnar nerve transposition of the left elbow with scar to 20 percent, effective April 20, 2010; service-connected residuals of cubital tunnel syndrome of the right elbow, status-post ulnar nerve transposition to 20 percent, effective April 20, 2010; and service-connected residual scar, status-post removal of ganglion cyst, left wrist to 10 percent, effective April 20, 2010. The Veteran has not expressed satisfaction with the increased disability ratings. The issues thus remain in appellate status. See AB v. Brown, 6 Vet. App. 35, 38 (1993) (when a veteran is not granted the maximum benefit allowable under the VA Schedule for Rating Disabilities, the pending appeal as to that issue is not abrogated). In October 2011, the Veteran presented sworn testimony during a personal hearing in Atlanta, Georgia, which was chaired by the undersigned. A transcript of the hearing has been associated with the Veteran's VA claims folder. In March 2012, the Board issued a decision in which it granted a then-pending claim of service connection for pseudofolliculitis barbae. The Board remanded the remaining claims on appeal. The issue of entitlement to a TDIU is addressed in the REMAND portion of the decision below and is REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. FINDINGS OF FACT 1. The Veteran has eye conditions manifested myopia, presbyopia, and dry eye syndrome. Myopia and presbyopia are refractive errors of the eyes and are not disabilities within the meaning of applicable regulations providing for payment of VA disability compensation benefits. Dry eye syndrome was manifested in service and has occurred continuously since service discharge. 2. The Veteran experienced chronic chest pain in service following his service in the Southwest Asia theatre of operations and has a current disability manifested by atypical chest pain that has not been attributed to a known clinical diagnosis. 3. The Veteran underwent an elective vasectomy during service in 1987. He currently has chronic congestive epididymitis, a post-vasectomy pain syndrome that is associated with the in-service surgical procedure. 4. Rhinitis is manifested by seasonal allergies, with drainage to the back of the throat and requiring treatment with nasal sprays, but is not shown to result in a 50 percent obstruction of nasal passages on both sides or complete obstruction of one side, or allergic or vasomotor rhinitis with polyps. 5. Prior to April 20, 2010, asthma required use of inhaled bronchodilators and resulted in FEV1 of 79 percent predicted and a FEV1/FVC ratio of 82 percent. 6. Since April 20, 2010, service-connected asthma resulted in a FEV1 of 55 percent predicted and a FEV1/FVC ratio of 54 percent. 7. For the entire appeal period, the service-connected hemorrhoids have been manifested by occasional, mild, hemorrhoids with bleeding during bowel movements but with no evidence of large or thrombotic, irreducible hemorrhoids with excessive redundant tissue, evidencing frequent recurrence, or hemorrhoids with persistent bleeding and with secondary anemia or with fissures. 8. The Veteran has a hemorrhoidectomy scar but upon objective examination it was not tender or painful. 9. Prior to April 12, 2012, service-connected nephrolithiasis did not result in recurrent stone formations that required diet therapy, drug therapy, or invasive or non-invasive procedures more than two times a year and there have been no attacks of colic. 10. As of April 12, 2012, service-connected nephrolithiasis more closely approximates a disability manifested by an occasional attack of colic. 11. Prior to April 20, 2010, the service-connected residual scar, status-post ganglion cystectomy of the left wrist was 3 centimeters long, not deep, non unstable, did not result in limitation of motion, and was not painful. 12. Since April 20, 2010, the service-connected residual scar, status-post ganglion cystectomy of the left wrist was superficial and painful on objective examination. 13. Prior to April 20, 2010, service-connected residuals of cubital tunnel syndrome, status-post epicondylectomy, and left ulnar nerve transposition of the left elbow with scar resulted in essentially full and painless range of motion and did not approximate a disability manifested by mild incomplete paralysis of the peripheral nerves. 14. Since April 20, 2010, service-connected residuals of cubital tunnel syndrome, status-post epicondylectomy, and left ulnar nerve transposition of the left elbow with scar resulted in essentially full and painless range of motion but were manifested by neurologic impairment comparable to mild incomplete paralysis of the peripheral nerves. 15. Prior to April 20, 2010, service-connected residuals of cubital tunnel syndrome, status-post ulnar nerve transposition of the right elbow with scar resulted in essentially full and painless range of motion and did not approximate a disability manifested by mild incomplete paralysis of the peripheral nerves. 16. Since April 20, 2010, service-connected residuals of cubital tunnel syndrome, status-post ulnar nerve transposition of the right elbow with scar resulted in essentially full and painless range of motion but were manifested by neurologic impairment comparable to mild incomplete paralysis of the peripheral nerves. CONCLUSIONS OF LAW 1. Resolving all reasonable doubt in favor of the Veteran, the criteria for service connection for bilateral eye dryness have been met. 38 U.S.C.A. §§ 1101, 1110, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.303 (2012). 2. Service connection for a disorder manifested by atypical chest pain as a qualifying chronic disability is warranted. 38 U.S.C.A. §§ 1110, 1117, 1154(a), 5107(b) (West 2002); 38 C.F.R. §§ 3.102, 3.303, 3.317 (2012). 3. The criteria for service connection for chronic congestive epididymitis, as a residual of a vasectomy have been met. 38 U.S.C.A. §§ 1110, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.159, 3.303 (2012). 4. The criteria for an initial compensable evaluation for rhinitis have not been met. 38 U.S.C.A. §§ 1155, 5103A, 5107 (West 2002); 38 C.F.R. §§ 4.97, Diagnostic Code 6522 (2012). 5. Prior to April 20, 2010, the criteria for an initial disability rating in excess of 30 percent for service-connected asthma have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 4.1-4.14, 4.97, Diagnostic Code 6602 (2012). 6. Since April 20, 2010, the criteria for a disability rating in excess of 60 percent for service-connected asthma have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 4.1-4.14, 4.97, Diagnostic Code 6602 (2012). 7. The criteria for an initial compensable disability rating for the service-connected hemorrhoids have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 4.7, 4.20, 4.114 including Diagnostic Code 7336 (2012). 8. Prior to April 12, 2012, an initial compensable disability rating for service-connected nephrolithiasis is denied. 38 U.S.C.A. §§ 1155, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 4.7, 4.20, 4.115, Diagnostic Codes 7508, 7509 (2012). 9. As of April 12, 2012, the criteria for a 10 percent rating, but no higher, for service-connected nephrolithiasis have been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 4.7, 4.20, 4.115, Diagnostic Codes 7508, 7509 (2012). 10. The criteria for an increased initial rating for service-connected residual scar, status-post ganglion cystectomy of the left wrist, evaluated as noncompensably disabling prior to April 10, 2010, and as 10 percent disabling from April 20, 2010, have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 4.7, 4.20, 4.118, Diagnostic Codes 7801-7805 (as in effect prior to October 23, 2008) and 38 C.F.R. § 4.118, Diagnostic Code 7801-7805 (2012). 11. The criteria for an increased initial rating for service-connected residuals of cubital tunnel syndrome, status-post epicondylectomy, and left ulnar nerve transposition of the left elbow with scar, evaluated as noncompensably disabling prior to April 20, 2010, and 20 percent disabling since April 20, 2010, have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 4.7, 4.20, 4.71a, 4.124a, Diagnostic Codes 5206, 8511 (2012). 12. The criteria for an increased initial rating for service-connected residuals of cubital tunnel syndrome, status-post ulnar nerve transposition of the right elbow with scar, evaluated as noncompensably disabling prior to April 20, 2010, and as 20 percent disabling since April 20, 2010, have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 4.7, 4.20, 4.71a, 4.124a, Diagnostic Codes 5206, 8511 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. VA's Duties to Notify and Assist With respect to the Veteran's claims decided herein, VA has met all statutory and regulatory notice and duty to assist provisions. See 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326 (2012). Under the VCAA, when VA receives a complete or substantially complete application for benefits, it is required to notify the claimant and his representative, if any, of any information and medical or lay evidence that is necessary to substantiate the claims. 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). In Pelegrini v. Principi, 18 Vet. App. 112, 120-21 (2004) (Pelegrini II), the United States Court of Appeals for Veterans Claims (the Court) held that VA must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claims; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. As the Board will discuss more thoroughly in the following decision, evidence of record supports the grant of the three service connection claims on appeal. As these awards represent a complete grant of those benefits sought on appeal, no further discussion of VA's duty to notify and to assist the Veteran with respect to this portion of his appeal is necessary. Moreover, as it pertains to the claims for higher initial ratings, where, as here, service connection has been granted and the initial rating has been assigned, the claim of entitlement to service connection has been more than substantiated, as it has been proven, thereby rendering 38 U.S.C.A. § 5103(a) notice no longer required, since the purpose that the notice was intended to serve has been fulfilled. Furthermore, once a claim for service connection has been substantiated, the filing of a notice of disagreement with the rating of the disability does not trigger additional 38 U.S.C.A. § 5103(a) notice. See Dunlap v. Nicholson, 21 Vet. App. 112 (2007); see also Goodwin v. Peake, 22 Vet. App. 128, 137 (2008) (where a claim has been substantiated after the enactment of the VCAA, the appellant bears the burden of demonstrating any prejudice from defective VCAA notice with respect to any downstream elements). The Board also concludes VA's duty to assist has been satisfied with respect to the initial increased rating claims adjudicated herein. The Veteran has identified private treatment records and they have been obtained. The Veteran has not referenced outstanding records that he wanted VA to obtain or that he felt were relevant to the claims. The duty to assist includes, when appropriate, the duty to conduct a thorough and contemporaneous examination of the Veteran. See Green v. Derwinski, 1 Vet. App. 121 (1991). In addition, where the evidence of record does not reflect the current state of the Veteran's disability, a VA examination must be conducted. See Schafrath v. Derwinski, 1 Vet. App. 589 (1991); 38 C.F.R. § 3.327(a) (2012). The Veteran underwent VA examinations in September 2005, April 2010, and March and April 2012. Concerning these examinations, when VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate. See Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). Here, the examination reports reflect that the examiners reviewed the Veteran's medical history, recorded his current complaints, conducted an appropriate examination, and rendered appropriate diagnoses and opinions consistent with the remainder of the evidence of record. Regarding the hearing testimony, in Bryant v. Shinseki, 23 Vet. App. 488 (2010), the Court held that 38 C.F.R. § 3.103(c)(2) requires that the hearing officer who chairs a hearing to fulfill two duties: (1) the duty to fully explain the issues and (2) the duty to suggest the submission of evidence that may have been overlooked. Bryant v. Shinseki, 23 Vet. App. 488 (2010). Here, the undersigned explained the issues on appeal and solicited the Veteran to identify evidence relevant to the claims for service connection and for increased ratings. The Veteran did so and further described the impact of the disabilities on his activities of daily living. Finally, there is substantial compliance with the terms of the Board's March 2012 remand directive. See Stegall v. West, 11 Vet. App. 268, 270-71 (1998). The RO/AMC issued a revised VCAA letter. The RO/AMC obtained relevant private treatment records. Finally, the Veteran was afforded several VA examinations as discussed in greater detail herein. Thereafter, the RO/AMC reconsidered the claim and issued a Supplemental Statement of the Case. Nothing further was required. Accordingly, as there is no indication that any failure on the part of VA to provide additional notice or assistance reasonably affects the outcome of this case, the Board finds that any such failure is harmless. Mayfield v. Nicholson, 499 F.3d 1317, 1323 (Fed. Cir. 2007). II. Service Connection Claims Establishing service connection generally requires medical or, in certain circumstances, lay evidence of (1) a current disability; (2) an in-service incurrence or aggravation of a disease or injury; and (3) a nexus between the claimed in-service disease or injury and the present disability. See Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009); Hickson v. West, 12 Vet. App. 247, 253 (1999); Caluza v. Brown, 7 Vet. App. 498, 506 (1995), aff'd per curiam, 78 F.3d 604 (Fed. Cir. 1996) (table). The second and third elements may be established by showing continuity of symptomatology. Continuity of symptomatology may be shown by demonstrating "(1) that a condition was 'noted' during service or any applicable presumption period; (2) evidence of post-service continuity of the same symptomatology; and (3) medical or, in certain circumstances, lay evidence of a nexus between the present disability and the post-service symptomatology." Barr v. Nicholson, 21 Vet. App. 303, 307 (2007); see also Davidson, 581 F.3d at 1316; Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007) (holding that "[w]hether lay evidence is competent and sufficient in a particular case is a factual issue to be addressed by the Board"). A. Eye Disability The Veteran contends that a current eye disability was incurred during active military service. In particular, he testified that his eyes were constantly irritated, runny, red, and resulted in blurry vision. (See Transcript at 11.) He reports that he has myopia and that he uses eye drops, with minimal relief of symptoms. He alleged that the eye symptoms have existed continuously since service. The Veteran's service treatment records do not record an eye condition upon enlistment, but do contain several references to complaints of dry or irritated eyes during active military service. An August 2004 record, for instance, diagnosed myopia, presbyopia, and dry eye syndrome. Post-service, on VA examination in September 2005, there was no assessment of dry eye syndrome; only of mild myopia and presbyopia. During a VA examination in March 2012, the Veteran reported his history of dry eyes, symptoms of watering and irritation, and blurry vision. A physical examination revealed best corrected vision of 20/40 or better. There was no definitive evidence of glaucoma. Rather, the examiner found that the current symptoms were due to refractive problems, presbyopia and dry eyes. His ocular hypertension necessitated routine annual screening for glaucoma. In addition to the laws and regulations cited above, refractive error of the eyes is not a disability within the meaning of applicable regulations providing for payment of VA disability compensation benefits. 38 C.F.R. §§ 3.303, 4.9 (2012). The VA Adjudication Procedure Manual, M21-1MR, Part III, Subpart iv, Chapter 4, Section B provides guidance on evaluating conditions of the organs of special sense (i.e., the eyes). Refractive errors are defined to include astigmatism, myopia, hyperopia, and presbyopia. See M21-1MR, Part III, Subpart iv, 4.B.10.d. The Board notes that, based on the law discussed above, the term "eye disability" is not intended to include refractive error of the eyes. Here, the Board finds that the Veteran has refractive errors of the eyes manifested by myopia and presbyopia that are not disabilities subject to service connection. The Board further finds, however, that he has a disability manifested by dry eyes. The disability was first manifest during service, and there is persuasive lay and medical evidence showing continuity of symptomatology since service. The Board acknowledges that the March 2012 VA examiner did not provide an opinion as to the relationship between dry eye syndrome and military service. Rather, the examiner only provided an opinion as to the unlikely relationship between an eye condition and chest pain. Nevertheless, because the Board finds that continuity of symptomatology has been shown, remand for a supplemental opinion is not required. As such, while service connection for myopia and presbyopia is not warranted, the criteria for service connection for dry eye syndrome of the bilateral eyes have been met. B. Chest Pain The Veteran contends that he has a disability manifested by chest pain that is related to his active military service, to include his service in the Persian Gulf. He alleges that he first had chest pain in 2004. Indeed, the Veteran's service treatment records show that in 2004, he reported chest pains that radiated into the left shoulder. The episodes happened at random, usually at rest and during the day. He underwent a stress test, an EKG, and a cardiac examination but no abnormalities were found. He was also provided a "GI cocktail" but it did not result in improvement in his symptoms. The assessment was atypical chest pain. The Veteran's service records document service in the Southwest Asia theatre of operations. In addition to the laws and regulations cited above, service connection may also be established, however, for a current disability on the basis of a presumption. See, e.g., 38 U.S.C.A. §§ 1112, 1113 and 1137; 38 C.F.R. §§ 3.303, 3.304, 3.307 and 3.309(a). For veterans with service in the Southwest Asia theater of operations during the Persian Gulf War, service connection may be established under 38 U.S.C.A. § 1117 and 38 C.F.R. § 3.317. Because the Veteran served in the Southwest Asia Theater of operations during the Persian Gulf War, service connection may also be established under 38 C.F.R. § 3.317. Under that section, service connection may be warranted for a Persian Gulf Veteran who exhibits objective indications of a qualifying chronic disability that became manifest during active military, naval or air service in the Southwest Asia theater of operations during the Persian Gulf War. For disability due to undiagnosed illness and medically unexplained chronic multi symptom illness, the disability must have been manifest either during active military service in the Southwest Asia theater of operations or to a degree of 10 percent or more not later than December 31, 2016. See 76 Fed. Reg. 81834 (Dec. 29, 2011) (to be codified at 38 C.F.R. § 3.317(a)(1). For purposes of 38 C.F.R. § 3.317 , there are three types of qualifying chronic disabilities: (1) an undiagnosed illness; (2) a medically unexplained chronic multi symptom illness; and (3) a diagnosed illness that the Secretary determines in regulations prescribed under 38 U.S.C.A 1117(d) warrants a presumption of service connection. An undiagnosed illness is defined as a condition that by history, physical examination and laboratory tests cannot be attributed to a known clinical diagnosis. In the case of claims based on undiagnosed illness under 38 U.S.C.A. § 1117; 38 C.F.R. § 3.317, unlike those for "direct service connection," there is no requirement that there be competent evidence of a nexus between the claimed illness and service. Gutierrez v. Principi, 19 Vet. App. at 8-9. Further, lay persons are competent to report objective signs of illness. Id. To determine whether the undiagnosed illness is manifested to a degree of 10 percent or more the condition must be rated by analogy to a disease or injury in which the functions affected, anatomical location or symptomatology are similar. See 38 C.F.R. § 3.317(a)(5); see also Stankevich v. Nicholson, 19 Vet. App. 470 (2006). Here, there is evidence that the Veteran continues to have chest pain that has not been attributed a known clinical diagnosis. Again, however, there is also evidence attributing the symptoms to a known diagnosis. First, during the VA examination in October 2005, the examiner found evidence of a small, sliding hiatal hernia with reflux and mild esophagitis. A heart examination was normal. The examiner attributed the complaints of chest pain to gastroesophageal reflux disease. This is evidence against the claim. However, during a more specialized VA examination in March 2012, the examiner noted that the Veteran did not have an active gastrointestinal disability. Moreover, despite extensive testing, the complaints of chest pain were not attributed to any heart condition. Rather, a stress test was completed without chest discomfort. While there were EKG abnormalities, a nuclear medicine perfusion study was normal, and the examiner noted that there were no abnormalities to explain the Veteran's chest pain and abnormal stress test. This evidence suggests that the Veteran's chronic chest pain remains undiagnosed and has not been attributed to a known disability. Moreover, it contains evidence contradicting the earlier October 2005 finding that the atypical chest pain was associated with gastroesophageal reflux disease. Thus, it remains unclear as to the cause of the current symptoms. What is apparent, however, is that the symptoms began in service and have continued to present. As discussed above, there is no requirement that there be competent evidence of a nexus between the claimed illness and service. Gutierrez v. Principi, 19 Vet. App. at 8-9. Given the foregoing, the Board finds that the criteria for service connection for atypical chest pain, as due to an undiagnosed illness, have been met. Accordingly, the claim is granted. C. Residuals of a Vasectomy During the hearing before the undersigned, the Veteran testified that he had a vasectomy in service and had pain ever since. The Board has reviewed the relevant in-service and post-service records and finds that, after affording the Veteran the benefit of the doubt, the criteria for service connection for post-vasectomy pain syndrome have been met. Here, the service treatment records show that the Veteran underwent an elective vasectomy in August 1997. The surgical record does not note any complications from the surgery. Moreover, during a VA general examination in May 2005, the Veteran denied any complications following the surgery. This constitutes evidence against the claim. However, during a March 2012 specialized VA examination, the Veteran reported chronic pain since the vasectomy. A physical examination showed an enlarged left epididymitis that was tender to palpation. The examiner diagnosed congestive epididymitis and concluded that such was a post-vasectomy pain syndrome that was at least as likely as not related to the vasectomy performed during service. This evidence clearly supports the claim. Here, it is unclear to the Board why the Veteran did not report vasectomy symptoms during the VA examination in 2005. His testimony, however, during the October 2011 hearing was credible. In such cases, the benefit-of-the-doubt rule [38 U.S.C.A. § 5107] provides: The Secretary shall consider all information and lay and medical evidence of record in a case before the Secretary with respect to benefits under laws administered by the Secretary. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. The implementing regulation at 38 C.F.R. § 3.102 restates the provision in terms of "reasonable doubt." Evidence is in "approximate balance" when the evidence in favor or and opposing the veteran's claim is found to be almost exactly or nearly equal. The statutory benefit of the doubt rule applies when the factfinder determines that the positive and negative evidence relating to a veteran's claim are "nearly equal," thus rendering any determination on the merits "too close to call." Ortiz v. Principi, 274 F.3d 1361, 1365 (Fed. Cir. 2001). Because the evidence in this case is at least in equipoise with regard to whether the Veteran has a scrotal disability that is related to a vasectomy procedure during service, service connection is warranted and the claim must be granted. While the Board finds that service connection is warranted for post-vasectomy pain syndrome manifested by chronic congestive epididymitis, the Board finds that the evidence does not show a separate disability caused by any vasectomy scarring. In this respect, while the Veteran described a painful scar during the hearing in 2011, no painful scar was described or found during VA examinations in 2005 or 2012. III. Initial Rating Claims Disability evaluations are determined by comparing a veteran's symptoms with criteria set forth in VA's Schedule for Rating Disabilities, which are based on average impairment in earning capacity. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. Part 4 (2012). When a question arises as to which of two ratings apply under a particular diagnostic code, the higher of the two evaluations is assigned if the disability more closely approximates the criteria for the higher rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7 (2012). 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 reviewed when making disability evaluations. See generally 38 C.F.R. § 4.1 (2012); Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Where, as here, the question for consideration is the propriety of the initial evaluation assigned, consideration of the medical evidence since the effective date of the award of service connection and consideration of the appropriateness of a staged rating are required. See Fenderson v. West, 12 Vet. App. 119, 126 (1999). Disability of the musculoskeletal system is primarily the inability, due to damage or infection in the parts of the system, to perform the normal working movements of the body with normal excursion, strength, speed, coordination, and endurance. 38 C.F.R. § 4.40. Diagnostic Codes predicated on limitation of motion do not prohibit consideration of a higher rating for flare ups or for functional loss due to weakness, excess fatigability, incoordination, or pain on use. 38 C.F.R. § 4.45; see also DeLuca v. Brown, 8 Vet. App. 202 (1995). A finding of functional loss due to pain must be supported by adequate pathology and evidenced by visible behavior, such as facial expression or wincing, of the Veteran undertaking the motion. 38 C.F.R. §§ 4.40, 4.59. Notably, the Court has held that pain alone does not equate with functional loss under 38 C.F.R. §§ 4.40 and 4.45 but may cause functional loss if affecting some aspect of the normal working movements of the body such as excursion, strength, speed, coordination, and endurance. Mitchell v. Shinseki, 25 Vet. App. 32 (2011). A. Rhinitis The Veteran's service treatment records show treatment for allergic rhinitis. During the hearing before the undersigned, the Veteran reported that he had drainage into the back of his throat and was on medication for seasonal allergies. Here, the RO has assigned a non-compensable (0 percent) evaluation for service-connected rhinitis under 38 C.F.R. § 4.97, Diagnostic Code 6522. Under Diagnostic Code 6522, a 10 percent rating is assigned for allergic or vasomotor rhinitis without polyps when there is greater than 50 percent obstruction of nasal passages on both sides or complete obstruction of one side. A 30 percent evaluation is warranted for allergic or vasomotor rhinitis with polyps. 38 C.F.R. § 4.97, Diagnostic Code 6522. Where the Schedule does not provide a zero percent rating, a zero percent shall be assigned if the requirements for a compensable rating are not met. 38 C.F.R. § 4.31 (2012). Here, the Veteran's service treatment records do not reveal the degree to which the Veteran's nasal passages were obstructed due to rhinitis, nor do they reveal allergic or vasomotor rhinitis with polyps. Hence, the service treatment records do not support the assignment of a higher initial rating. Similarly, a VA examination in October 2005 did not include evidence of symptoms typically associated with a compensable evaluation. For instance, the Veteran reported similar symptoms as were discussed during the hearing before the undersigned, including nasal drainage and treatment with Flonase nasal spray. He denied trouble breathing through his nose, purulent drainage, or speech impairment. On examination, his nasal mucosa was slightly boggy and pale without obvious discharge. There was no evidence showing 50 percent obstruction of nasal passages or evidence of polyps. The Veteran underwent additional VA examination in April 2010. At such time, he reported that the condition was intermittent and that he used Flonase for treatment. Physical examination findings, however, did not include evidence of a disability picture that approximated the criteria for a compensable disability evaluation. For instance, there were no signs of nasal obstruction, septal deviation, permanent hypertrophy, or polyps. The examiner noted that the condition had no significant effects on his employment. The Veteran was scheduled but failed to report to a VA examination in April 2012. Private treatment records dated from April 2006 to March 2012, however, do not include findings of obstructed nasal passages or allergic or vasomotor rhinitis with polyps. As such, they do not support the claim for a compensable disability evaluation. In sum, even after considering the Veteran's lay testimony, the evidence does reveal that the service-connected rhinitis warrants a 10 percent or higher evaluation. The Board has considered rating the Veteran's rhinitis under any other potentially applicable diagnostic codes. Schafrath v. Derwinski, 1 Vet. App. 589, 595 (1991). However, the Veteran is already receiving compensation for asthma. The evidence does not show sinusitis. 38 C.F.R. § 4.97, Diagnostic Codes 6510, 6511, 6512, 6514 (2012). Additionally, the medical evidence does not demonstrate that the Veteran has a traumatic deviated nasal septum which causes greater than 50 percent obstruction of nasal passages on both sides, or complete obstruction of one side; loss of part of the nose or scars; chronic or tuberculosis laryngitis; total laryngectomy; complete organic aphonia, stenosis of the larynx; injuries to the pharynx; bacterial rhinitis; or granulomatous rhinitis. 38 C.F.R. § 4.97, Diagnostic Codes 6502, 6504, 6515, 6516, 6518, 6519, 6520, 6521, 6523, 6524 (2012). Accordingly a compensable evaluation for rhinitis is not warranted under any alternative diagnostic codes. Finally, in exceptional cases where the rating is inadequate, it may be appropriate to assign an extraschedular rating. 38 C.F.R. § 3.321(b) (2012). 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. Thun v. Peake, 22 Vet. App. 111, 115 (2008). Therefore, initially, there must be a comparison between the level of severity and symptomatology of the Veteran's service-connected disability with the established criteria found in the Schedule for that disability. Id. If the criteria under the Schedule reasonably describe the Veteran's disability level and symptomatology, then the Veteran's disability picture is contemplated by the Schedule, and the assigned schedular evaluation is adequate, and no referral is required. The Board finds that the Veteran's disability picture is not so unusual or exceptional in nature as to render his rating for seasonal allergic rhinitis inadequate. The Veteran's seasonal allergic rhinitis was evaluated under 38 C.F.R. § 4.97, Diagnostic Code 6522, the criteria of which is found by the Board to specifically contemplate the Veteran's level of disability and symptomatology. When comparing this disability picture with the symptoms contemplated by the Schedule, the Board finds that the Veteran's symptoms are more than adequately contemplated by the disabilities rating for his seasonal allergic rhinitis. A rating in excess of that currently assigned rating is provided for certain manifestations of rhinitis, but the medical evidence reflects that those manifestations are not present in this case. The Veteran's seasonal allergic rhinitis has not been manifested by polyps, greater than 50 percent obstruction of nasal passages on both sides, or complete obstruction of one side, at any point since the initiation of the current claim. The criteria for a noncompensable rating for the Veteran's seasonal allergic rhinitis more than reasonably describe the Veteran's disability level and symptomatology. Therefore, the currently assigned schedular evaluation is adequate, and no referral is required. See VAOGCPREC 06-96, 61 Fed. Reg. 66749 (1996); see also 38 C.F.R. § 4.97, Diagnostic Code 6522. In reaching this decision, the Board considered the doctrine of reasonable doubt. However, as the preponderance of the evidence of record does not show findings that meet the criteria for a separate initial compensable evaluation for rhinitis, the doctrine is not for application. Gilbert, 1 Vet. App. at 54. B. Asthma As noted above, service-connected asthma is rated as 30 percent disabling from July 1, 2005 to April 19, 2010 and as 60 percent disabling from April 20, 2010. The disability is rated pursuant to 38 C.F.R. § 4.97, Diagnostic Code 6602 pertaining to bronchial asthma. Under 38 C.F.R. § 4.97, Diagnostic Code 6602, a 30 percent rating is warranted for FEV-1 of 56 to 70 percent predicted; or, 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 for FEV-1 of 40 to 55 percent predicted; or, 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) course of systemic (oral or parenteral) corticosteroids. A 100 percent rating is warranted for FEV-1 less than 40 percent predicted, or; FEV-1/FVC less than 40 percent, or; more than one attack per week with episodes of respiratory failure, or; required daily use of systemic (oral or parenteral) high dose corticosteroids or immuno-suppressive medications. Post-bronchodilator findings from the pulmonary function tests (PFTs) are the standard in pulmonary assessment. See 61 Fed. Reg. 46720, 46723 (Sept. 5, 1996) (VA assesses pulmonary function after bronchodilation as these results reflect the best possible functioning of an individual). Here, during the VA examination in October 2005, the Veteran reported that asthma was controlled with Albuteral and Asmacort. He used a nebulizer about once a week. He denied any side effects other than occasional headaches. Pulmonary function testing revealed a FEV1 of 79 percent predicted and a FEV1/FVC ratio of 82 percent. Because the Veteran was prescribed daily inhalational or oral bronchodilator therapy, these results support the assignment of the initial 30 percent evaluation. The pulmonary function results, alone, however, would not support the assignment of a rating greater than 30 percent. There is no clinical evidence, whether pre-or post-bronchodilator testing, to show FEV-1 of 40 to 55 percent of predicted value; FEV-1/FVC of 40 to 55 percent; 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 to warrant a 60 percent rating. Private treatment records show treatment for asthma described as "mild, intermittent." See March 2010 treatment record. They do not include pulmonary function studies or document symptoms approximated the criteria for a rating in excess of 30 percent. On April 20, 2010, the Veteran underwent additional VA examination. At such time he reported that he continued to use inhaled bronchodilators and that the response to treatment was "good." Pulmonary function studies revealed a small airway obstructive defect. His lung volume was within normal limits. Pulmonary function testing revealed a FEV1 of 55 percent predicted and a FEV1/FVC ratio of 54 percent. These findings support the assignment of a 60 percent disability rating. A higher, 100 percent rating, however is not warranted as the evidence does not show FEV-1 less than 40 percent predicted, or; FEV-1/FVC less than 40 percent. In addition, there was no evidence documenting episodes of respiratory failure or required daily use of systemic high dose corticosteroids or immuno-suppressive medications. Finally, during VA examination in 2012, the Veteran reported that asthma was stable and controlled with inhalers and nebulizer treatment. He reported that his activity level was restricted and that he exacerbations of symptoms following strenuous activity. Pulmonary function testing revealed pre-bronchodilator findings of an FVC of 87 percent predicted and an FEV1/FVC ratio of 83 percent. These findings, if considered alone, would only support the assignment of a 10 percent evaluation, and, therefore, do not support the assignment of an evaluation in excess of that currently assigned. Here, even after considering the Veteran's lay testimony, since April 20, 2010, the criteria for an evaluation in excess of 60 percent are not met. As the preponderance of the evidence is against any higher rating for this claim, the benefit of the doubt rule does not apply. Gilbert v. Derwinski, 1 Vet. App. 49, 58 (1991). Finally, the Board determines that an exceptional disability picture is not present and that the schedular criteria contemplate the Veteran level of disability and symptomatology. Thun v. Peake, 22 Vet App 111 (2008). Here, the disability is essentially controlled on inhaled bronchodilators. The pulmonary function study scores adequately reflect the level of disability and the Veteran has not described any unusual symptomatology not contemplated by the rating criteria. As such, referral for extraschedular consideration is not warranted pursuant to 38 C.F.R. § 3.321(b)(1). C. Hemorrhoids The Veteran's service treatment records show treatment for hemorrhoids. In the December 2005 rating decision on appeal, the RO granted service connection for hemorrhoids with healed rectal fissure and assigned an initial non-compensable rating. The Veteran's hemorrhoid disability is rated under Diagnostic Code 7336. 38 C.F.R. § 4.114, Diagnostic Code 7336. Under this Diagnostic Code, hemorrhoids, either external or internal, are assigned a noncompensable disability rating when mild or moderate. A 10 percent disability rating is assigned for large or thrombotic, irreducible hemorrhoids with excessive redundant tissue, evidencing frequent recurrence. A 20 percent disability rating is assigned for hemorrhoids with persistent bleeding and with secondary anemia or with fissures. 38 C.F.R. § 4.114, Diagnostic Code 7336. Here, during VA examination in October 2005, the Veteran reported the history of treatment of hemorrhoids with fissure during service, but stated that the fissure healed. He described flare-ups of hemorrhoids that occurred once a month and were accompanied by a small amount of blood. He used a stool softener during a flare-up. A rectal examination revealed no external hemorrhoids or skin lesions or irritations around the rectum. This evidence does not support the assignment of a 10 percent or greater rating. It did not reveal objective evidence of hemorrhoids or complications such as anemia or fissures. Similar findings were noted during VA examination in April 2010. At such time, the Veteran did not report any increase in hemorrhoid-related symptoms. Moreover, the rectal examination did not reveal any external or thrombosed hemorrhoids, fissures, or rectal prolapse. In addition, the private treatment records do not show treatment for large or irreducible hemorrhoids. Finally, during VA examination in 2012, the Veteran reported that hemorrhoids occurred once every 2-3 months. On physical examination, while there was evidence of a small anal fissure, there was no evidence of external hemorrhoids. Given these findings, the Board finds that at no point during the appeals period have the criteria for a compensable disability rating been met. The Board notes that the Veteran testified that he had painful scarring as a result of the hemorrhoid procedure in service. The Board finds, however, that a separate rating for a scar is not warranted. In this respect, no scarring was noted upon examination in 2005 or 2010, nor where there any subjective complaints of a painful scar. While the 2012 VA examiner noted the presence of a scar, on examination it was not painful. Given such, the weight of the evidence is against the assignment of a separate compensable rating for a hemorrhoidectomy scar. Finally, the Board determines that an exceptional disability picture is not present and that the schedular criteria contemplate the Veteran level of disability and symptomatology. Thun v. Peake, 22 Vet App 111 (2008). Here, based on the subjective reports, the disability only flares up occasionally. No unusual symptoms were described. The physical examination findings adequately reflect the level of disability and the Veteran has not described any unusual symptomatology not contemplated by the rating criteria. As such, referral for extraschedular consideration is not warranted pursuant to 38 C.F.R. § 3.321(b)(1). D. Nephrolithiasis The Veteran's service treatment records show treatment for kidney stones. In the December 2005 rating decision on appeal, the RO granted entitlement to service connection for nephrolithiasis and assigned a non-compensable evaluation. During the hearing before the undersigned, the Veteran reported that he always has kidney stones that are painful, was on a special diet and medication, and had undergone non-invasive procedures for treatment. Here, the disability is rated under 38 C.F.R. § 4.115b, Diagnostic Code 7508, pertaining to nephrolithiasis. Under Diagnostic Code 7508, nephrolithiasis is rated as hydronephrosis except when there are recurring stone formations that require one or more of the following: diet therapy, drug therapy, and/or invasive or non-invasive procedures more than 2 times a year; in which case a 30 percent evaluation will be assigned. 38 C.F.R. § 4.115b, Diagnostic Code 7508. Diagnostic Code 7509 provides that hydronephrosis is rated as 10 percent disabling when there is only an occasional attack of colic, not infected and not requiring catheter drainage. A 20 percent evaluation is warranted when there are frequent attacks of colic, requiring catheter drainage. A maximum 30 percent evaluation is for application when there are frequent attacks of colic with infection (pyonephrosis), with impaired kidney function. If hydronephrosis is severe, it is rated as renal dysfunction. 38 C.F.R. § 4.115b, Diagnostic Code 7509. Here, while the Veteran testified as to recurrent kidney stones, during the VA examination in October 2005, he specifically denied any recurrence. He also denied any diet or drug therapy. An x-ray examination did reveal a 3 millimeter calculus in the right kidney. It did not cause any obstruction or inflammation. Private treatment records dated from 2006 through 2010 show no treatment for kidney stones. Given such, the Board finds that the evidence does not support the claim for a compensable evaluation. In addition, during the VA examination in April 2010, the VA examiner found no evidence of recurrent kidney stones. The examiner further noted that in the past 12 months the Veteran was not required to have a special diet, nor were any invasive or non-invasive procedures undertaken. This is further evidence against the claim for a compensable evaluation under Diagnostic Code 7508. Similarly, private treatment records dated in 2011 and 2012 show no treatment for recurrence of kidney stones. In addition, the VA examination in April 2012 showed no evidence of recurrent kidney stones. As such, this evidence directly contradicts the Veteran's testimony and does not support the claim for a compensable evaluation under Diagnostic Code 7508. However, while a compensable disability evaluation is not warranted under Diagnostic Code 7508, on VA examination on April 12, 2012, there were reports of intermittent flank pain but without voiding problems or hematuria. While the Veteran reported protein in the urine, a urinalysis was negative for proteinuria. Significantly, however, the examiner checked a box on the examination report indicating that the Veteran had current signs and symptoms due to urolithiasis that were characterized by occasional attacks of colic. The clinical finding corresponds to the 10 percent criteria for hydronephosis under Diagnostic Code 7509 which is based on evidence of occasional attacks of colic. Given such, the Board finds that since April 12, 2012, a 10 percent rating under Diagnostic Code 7509, but no higher, is warranted. While a 10 percent rating is warranted, there is no evidence of frequent attacks of colic requiring catheter drainage or impaired kidney function. As such, a rating in excess of 10 percent is not warranted. Finally, the Board determines that an exceptional disability picture is not present and that the schedular criteria contemplate the Veteran level of disability and symptomatology. Thun v. Peake, 22 Vet App 111 (2008). Here, based on the subjective reports, the disability only results in intermittent flank pain. No unusual symptoms were described. The physical examination findings adequately reflect the level of disability and the Veteran has not described any unusual symptomatology not contemplated by the rating criteria. As such, referral for extraschedular consideration is not warranted pursuant to 38 C.F.R. § 3.321(b)(1). E. Ganglion Cyst Scar of the Left Wrist During service, in January 1994, the Veteran underwent a surgical removal of a ganglion cyst to the left wrist. The cyst reoccurred, and, in January 1997, he underwent a second ganglionectomy to remove the cyst from the left wrist. In the December 2005 rating decision on appeal, the RO granted service connection for a residual scar and assigned a non-compensable evaluation. During the pendency of the appeal, the RO granted a 10 percent rating for the scar. The rating was effective April 20, 2010. At the hearing before the undersigned, the Veteran reported that following the removal of the ganglion cyst while in service he experienced numbness in two fingers. He contends that 10 percent evaluation should be effective since July 1, 2005, the effective date for the grant of service connection. Here, the residual scar is rated 38 C.F.R. § 4.118, Diagnostic Code 7804. The criteria for ratings under Diagnostic Code 7800-7805 were amended effective October 23, 2008. The Board is required to consider his claim in light of both the former and revised standards to determine whether an increased rating for his skin condition is warranted. But VA's Office of General Counsel has determined that the amended rating criteria, if more favorable to the claim, can be applied only prospectively for periods from and after the effective date of the regulatory change. See VAOPGCPREC 3-2000; 38 U.S.C.A. § 5110(g); and 38 C.F.R. § 3.114. Diagnostic Code 7800 pertains to disfigurement of the head, face, or neck. 38 C.F.R. § 4.118, Diagnostic Code 7800. Under Diagnostic Code 7800 a skin disorder with one characteristic of disfigurement of the head, face, or neck is rated as 10 percent disabling. Note (1) to Diagnostic Code 7800 provides that the 8 characteristics of disfigurement are: (1) scar is 5 or more inches (13 or more cm.) in length; (2) scar is at least one-quarter inch (0.6 cm.) wide at the widest part; (3) surface contour of scar is elevated or depressed on palpation; (4) scar is adherent to underlying tissue; (5) skin is hypo-or hyper-pigmented in an area exceeding six square inches (39 sq. cm.); (6) skin texture is abnormal (irregular, atrophic, shiny, scaly, etc.) in an area exceeding six square inches (39 sq. cm.); (7) underlying soft tissue is missing in an area exceeding six square inches (39 sq. cm.); and (8) skin is indurated and inflexible in an area exceeding six square inches (39 sq. cm.). A 30 percent rating is warranted if there is visible or palpable tissue loss and either gross distortion or asymmetry of one feature or paired set of features (nose, chin, forehead eyes (including eyelids), ears (auricles), cheeks, lips), or; with two or three characteristics of disfigurement. The amendment to Diagnostic Code 7800 is found in Notes (4) which instruct the evaluator to separately evaluate disabling effects other than disfigurement that are associated with individual scar(s) of the head, face, or neck, such as pain, instability, and residuals of associated muscle or nerve injury, under the appropriate diagnostic code(s), and in Note (5) which instructs the evaluator that characteristic(s) of disfigurement may be caused by one scar or by multiple scars. At the time the Veteran filed his claim for increase, a 10 percent disability rating was warranted for a scar that is deep or that causes limited motion in an area or areas exceeding 6 square inches (39 square centimeters); for a superficial scar that does not cause limited motion but which covers an area of 144 square inches (929 sq. cm.) or greater; for an unstable, superficial scar; for a superficial scar that is painful on examination; or for a scar that causes limitation of function of the affected part. 38 C.F.R. § 4.118, Diagnostic Codes 7801, 7802, 7803, 7804, 7805. A 20 percent rating was warranted for a scar that is deep or that causes limited motion in an area or areas exceeding 12 square inches (77 square centimeters). Diagnostic Code 7801. In October 2008, the regulations regarding scars were amended to allow for separate or cumulative ratings for scars on multiple parts of the body. Under the new criteria, Diagnostic Code 7801 provides that deep and nonlinear burn scar(s) or scar(s) due to other causes that are not of the head, face, or neck and that cover an area or areas of 144 square inches (929 sq. cm.) or greater warrant a 40 percent rating, a deep and nonlinear scar covering an area or areas of at least 72 square inches (465 sq. cm.) but less than 144 square inches (929 sq. cm.) warrants a 30% rating; a deep and nonlinear scar covering an area or areas of at least 12 square inches (77 sq. cm.) but less than 72 square inches (465 sq. cm.) warrants a 20% rating; and a deep and nonlinear scar covering an area or areas of at least 6 square inches (39 sq. cm.) but less than 12 square inches (77 sq. cm.) warrants a 10% rating. Note (1): A deep scar is one associated with underlying soft tissue damage. Under Diagnostic Code 7802, superficial and nonlinear burn scar(s) or scar(s) due to other causes that are not of the head, face, or neck that cover an area or areas of 144 square inches (929 sq. cm.) or greater warrant a 10 percent rating. Note (1): A superficial scar is one not associated with underlying soft tissue damage. Under Diagnostic Code 7804, five or more scars that are unstable or painful warrant a 30 percent rating, three or four scars that are unstable or painful warrants a 20 percent rating, one or two scars that are unstable or painful warrant a 10 percent rating. Note (1) defines an unstable scar as one where, for any reason, there is frequent loss of covering of skin over the scar. Under Diagnostic Code 7805 any other scars, including linear scars, are to rated based on any disabling effect(s). 38 C.F.R. § 4.118, DC 7801-7805 (effective October 23, 2008). The Board has considered the Veteran's contentions, but finds that an initial compensable evaluation for the service-connected is not warranted. In addition, for the period since April 20, 2010, the Board finds that an evaluation in excess of 10 percent for the residual scar is not warranted. Here, during a VA examination in September 2005, while there were reports of numbness and tingling in the fingers, such was attributed to the service-connected cubital tunnel syndrome. The Veteran is already in receipt of disability compensation for such symptoms and to compensate him twice would result in impermissible "pyramiding." See 38 C.F.R. § 4.14. As it pertained to the scar, there were no complaints. In addition, the scar was 3 centimeters in length and was non-tender to palpation. Thus, because the scar was not deep, non unstable, did not result in limitation of motion, was not painful, a compensable evaluation is not for assignment. The Board has considered the Veteran's contentions that he is entitled to a 10 percent rating for the entirety of the appeals period. The evidence, however, does not show that the scar was painful, or met other criteria for a 10 percent rating, prior to April 2010. At the time of the April 2010 VA examination, the scar was painful. It did not result in any skin breakdown, was superficial, was not inflamed, did not result in edema or keloid formation, and had no other disabling effects. Because there is evidence of a superficial and painful scar, a 10 percent rating was for application. Evidence during this period, however, does not support the assignment of a disability rating greater than 10 percent. As noted, the scar was not deep or cause limited motion and was limited in length to only 3 centimeters. The VA examiner in 2012 described the scar as slightly thickened, supple, and not particularly sensitive. Interestingly, during this examination, the scar was not painful. Finally, the Board determines that an exceptional disability picture is not present and that the schedular criteria contemplate the Veteran level of disability and symptomatology. Thun v. Peake, 22 Vet App 111 (2008). Here, based on the subjective reports, the disability results in a painful scar. Such symptoms are expressly contemplated in the relevant rating criteria. No unusual symptoms were described. The physical examination findings adequately reflect the level of disability and the Veteran has not described any unusual symptomatology not contemplated by the rating criteria. As such, referral for extraschedular consideration is not warranted pursuant to 38 C.F.R. § 3.321(b)(1). F. Bilateral Cubital Tunnel Syndrome The Veteran's service treatment records reflect that he underwent a left medial epicondylectomy and left ulnar nerve transposition and later underwent entrapment surgery of the right elbow with transposition of the ulnar nerve. In the December 2005 rating decision on appeal, the RO granted service connection for residuals, cubital tunnel syndrome, status post epicondylectomy and left ulnar nerve transposition, left elbow with scar. A noncompensable evaluation was assigned. In addition, the RO granted service connection for cubital tunnel syndrome, right elbow, status-post ulnar nerve transposition. A noncompensable evaluation was assigned. During the pendency of the appeal, the RO assigned 20 percent evaluations for the disabilities. The evaluations were effective April 20, 2010. The left and right elbow disabilities are rated pursuant to Diagnostic Code 5206-8511. Diagnostic Code 5206 is used to rate limitation of flexion of the forearm, while Diagnostic Code 8511 is used to rate paralysis of the peripheral nerves in the middle radicular group. See 38 C.F.R. § 4.27 (2012) (hyphenated Diagnostic Codes are used when a rating under one Diagnostic Code requires use of an additional Diagnostic Code to identify the basis for the evaluation assigned; the additional code is shown after the hyphen). Under Diagnostic Code 5206, limitation of flexion of the forearm of the major/ minor extremity to 100 degrees warrants a 10 percent evaluation; a 20 percent evaluation is for application when flexion is limited to 90 degrees; a 30 percent evaluation is warranted when flexion is limited to 70 degrees; a 40 percent evaluation is warranted when flexion is limited to 55 degrees; and a 50 percent evaluation is warranted when flexion is limited to 45 degrees. 38 C.F.R. § 4.71a, Diagnostic Code 5206. The normal range of motion for the elbow is flexion to 145 degrees and extension to zero degrees. Normal pronation is from zero to 80 degrees and normal supination is from zero to 85 degrees. 38 C.F.R. § 4.71, Plate I. Diagnostic Code 8511 provides ratings for paralysis of the middle radicular group of nerves. Diagnostic Code 8511 provides that mild incomplete paralysis is rated as 20 percent disabling on the major side and 20 percent on the minor side; moderate incomplete paralysis is rated 40 percent disabling on the major side and 30 percent on the minor side; and severe incomplete paralysis is rated 50 percent disabling on the major side and 40 percent on the minor side. Complete paralysis of the middle radicular group, with adduction, abduction, and rotation of arm, flexion of elbow, and extension of wrist lost or severely affected, is rated 70 percent disabling on the major side and 60 percent on the minor side. 38 C.F.R. § 4.124a, DC 8511 (2012). The Veteran is right hand dominant. (See March 2012 VA examination report.) The Board observes that the words "slight," "moderate" and "severe" as used in the various Diagnostic Codes are not defined in the VA Schedule for Rating Disabilities. Rather than applying a mechanical formula, the Board must evaluate all of the evidence, to the end that its decisions are "equitable and just." 38 C.F.R. § 4.6 (2012). Upon review of the evidence of record and the applicable criteria, for the period prior to April 20, 2010, the Board finds that entitlement to an initial compensable rating for the service-connected bilateral cubital tunnel syndrome disabilities. In this respect, on physical examination in 2005, he was able to demonstrate full range of motion of the elbow without pain. These range of motion findings do not support the assignment of a compensable rating under Diagnostic Code 5206. In addition, the examination did not reveal evidence that the disability otherwise results in functional loss. See Mitchell v. Shinseki, 25 Vet. App. 32 (2011). Regarding any impairment in the peripheral nerves, the Veteran reported that on occasion his left hand would fall asleep. As to the right elbow, he denied numbness, but only reported pain with heavy lifting. He had not missed work due to the disabilities and was able to perform all activities of daily living. These findings do not approximate mild incomplete paralysis of the middle radicular group. As such, the evidence does not support the assignment of a compensable disability rating under Diagnostic Code 8511 for either elbow. For the period since April 2010, the evidence does not support the assignment of disability evaluations in excess of 20 percent for either elbow. Here, on VA examination in April 2010, there were subjective reports of increased pain with heavy lifting, however, again, the Veteran was able to perform full, painless, range of motion of the left and right elbows. There was no evidence of weakness, fatigue, incoordination, or lack of endurance following repeated motions. These range of motion findings do not support the assignment of a compensable rating under Diagnostic Code 5206, let alone an evaluation in excess of 20 percent. Regarding any impairment in the peripheral nerves, a sensory examination revealed normal light touch and pin prick, however, there was a positive Tinel's sign (a test designed to detect irritated nerves). The positive Tinel's sign could equate to a finding of mild, incomplete paralysis of the middle radicular group, which support the assignment of a 20 percent evaluation under Diagnostic Code 8511. The neurological findings, however, do not approximate the criteria for a higher rating. Quite simply, they do not reveal moderate incomplete paralysis of the middle radicular group. Similarly, on VA examination in March 2012, the Veteran was able to right elbow flexion to 145 degrees without pain and left elbow flexion to 140 degrees without pain. The Veteran did have pain and localized tenderness on palpation of the joints. However, the examiner did not find evidence of any functional loss. These range of motion findings do not support the assignment of a compensable rating under Diagnostic Code 5206, let alone an evaluation in excess of 20 percent. Regarding any impairment in the peripheral nerves, there was evidence of ulnar nerve innovation, weakness of grip, and hypersensitity to bumping the ulnar nerves at the elbow. These findings correspond the 20 percent evaluations assigned, but do not reflect moderate incomplete paralysis of the middle radicular group. Finally, while there are findings of surgical scars to the bilateral elbows, there were no findings suggesting that the scars were deep, unstable, painful, nonlinear, or resulted in limitation of motion of the affected part. Accordingly, a separate compensable evaluation for surgical scars is not warranted. Finally, the Board determines that an exceptional disability picture is not present and that the schedular criteria contemplate the Veteran level of disability and symptomatology. Thun v. Peake, 22 Vet App 111 (2008). Here, the objective evidence did not reveal limited motion such as to warrant a higher evaluation. However, the subjective symptoms and the neurologic findings were contemplated under Diagnostic Code 8511. No unusual symptoms were described. The physical examination findings adequately reflect the level of disability and the Veteran has not described any unusual symptomatology not contemplated by the rating criteria. As such, referral for extraschedular consideration is not warranted pursuant to 38 C.F.R. § 3.321(b)(1). ORDER Service connection for bilateral dry eye syndrome is granted. Service connection for chronic chest pain as an undiagnosed illness is granted. Service connection for chronic congestive epididymitis is granted. An initial compensable disability rating for rhinitis is denied. An initial increased disability rating for asthma, rated as 30 percent disabling from July 1, 2005 to April 19, 2010, and as 60 percent disabling since April 20, 2010, is denied. An initial compensable disability rating for hemorrhoids is denied. From July 1, 2005 to April 11, 2012, an initial compensable disability evaluation for nephrolithiasis is denied. As of April 12, 2012, a 10 percent rating for nephrolithiasis, but no higher, is granted, subject to the law and regulations governing the payment of monetary benefits. An initial increased rating for service-connected residual scar, status-post ganglion cystectomy of the left wrist, evaluated as noncompensably disabling from July 1, 2005 to April 19, 2010 and as 10 percent disabling from April 20, 2010 is denied. An initial increased rating for service-connected residuals of cubital tunnel syndrome, status-post epicondylectomy, and left ulnar nerve transposition of the left elbow with scar, evaluated as noncompensably disabling from July 1, 2005 to April 19, 2010, and as 20 percent disabling since April 20, 2010 is denied. An initial increased rating for service-connected residuals of cubital tunnel syndrome, status-post ulnar nerve transposition of the right elbow with scar, evaluated as noncompensably disabling from July 1, 2005 to April 19, 2010 and as 20 percent disabling since April 20, 2010 is denied. REMAND The Board finds that a TDIU claim is implicitly raised by the record. Because there is insufficient evidence to adjudicate the claim, however, this issue must be remanded for additional development. Comer v. Peake, 552 F.3d 1362, 1367 (Fed. Cir. 2009) (holding that TDIU is implicitly raised whenever a veteran, who presents cogent evidence of unemployability, seeks to obtain a higher disability rating). A TDIU rating may be assigned where the schedular rating is less than total, when it is found that the disabled person is unable to secure or follow a substantially gainful occupation as a result of a single service-connected disability ratable at 60 percent or more, or as a result of two or more disabilities, provided at least one disability is ratable at 40 percent or more and there is sufficient additional service-connected disability to bring the combined rating to 70 percent or more. 38 C.F.R. §§ 3.340, 3.34l, 4.16(a) (2011). In exceptional circumstances, where the veteran does not meet the aforementioned percentage requirements, a total rating may nonetheless be assigned upon a showing that the individual is unable to obtain or retain substantially gainful employment. Under such circumstances, the rating should submit the matter to the Director, Compensation and Pension Service. 38 C.F.R. § 4.16(b) (2011). Here, the Veteran has a single disability rated at 60 percent, asthma, and additional service-connected disabilities to bring the combined rating to 80 percent. In addition, as a result of the Board's action herein wherein it grants several claims for service connection, following the assignment of initial disability ratings, the combined rating may be even higher. While the Veteran has not expressly claimed entitlement to TDIU, statements made in the course of VA examinations indicate that his several service-connected disabilities are negatively affecting his employability. As stated by the Court in Friscia v. Brown, 7 Vet. App. 294, 297 (1994), the Board may not reject a claim for a TDIU without producing evidence, as distinguished from mere conjecture, that the Veteran can perform work that would produce sufficient income to be other than marginal. Therefore, because the Board cannot adequately determine from the existing record how the Veteran's service-connected disabilities collectively affect his employability, the Board finds that additional development, to include obtaining additional records and affording the Veteran an appropriate VA examination to determine whether he is unable to secure or maintain substantially gainful employment as a result of his service-connected disabilities, is required. Accordingly, this matter is REMANDED for the following action: 1. Issue to the Veteran a VCAA notice letter pertaining to the issue of entitlement to a TDIU. 2. Contact the Veteran and request that he provide up-to-date information concerning his employment and educational history. Specifically, the Veteran should submit any other evidence, such as employment records or statements from employers and physicians, supporting any contention that he is incapable of maintaining employment due to his service-connected disabilities. 3. After completing the above development, accord the Veteran an appropriate VA examination to determine the impact of his service-connected disabilities on his employability. The claims folder should be made available to the examiner prior to the examination, and a notation to the effect that this review has taken place should be made in the evaluation report. All pertinent symptomatology and findings must be reported in detail. Based on the review of the claims file, and an examination of the Veteran, the examiner must provide an opinion as to the effect of all the Veteran's service-connected disabilities, either singularly or jointly, on his ability to secure or follow a substantially gainful occupation. A complete rationale should be given for all opinions and conclusions expressed. 4. Thereafter, the issue of entitlement to a TDIU should be adjudicated based on the entirety of the evidence. If the claim remains denied, the Veteran and his representative should be issued a supplemental statement of the case. An appropriate period of time should be allowed for response. No action is required of the Veteran until he is notified by the RO; however, the Veteran is advised that failure to report for any scheduled examination may result in the denial of his claim. 38 C.F.R. § 3.655 (2012). He has the right to submit additional evidence and argument on the matter that 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 remanded by the Board or the Court for additional development or other appropriate action must be handled in an expeditious manner. 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2012). ______________________________________________ THERESA M. CATINO Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs