Citation Nr: 1305256 Decision Date: 02/13/13 Archive Date: 02/21/13 DOCKET NO. 11-02 710 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Winston-Salem, North Carolina THE ISSUES 1. Entitlement to service connection for a left elbow disorder. 2. Entitlement to service connection for a right elbow disorder. 3. Entitlement to service connection for pseudofolliculitis barbae. 4. Entitlement to service connection for hemorrhoids. 5. Entitlement to an initial compensable rating for obstructive sleep apnea. 6. Entitlement to an initial compensable rating for bilateral pes planus. REPRESENTATION Appellant represented by: Veterans of Foreign Wars of America WITNESSES AT HEARING ON APPEAL The Veteran and LH ATTORNEY FOR THE BOARD David S. Nelson, Counsel INTRODUCTION The Veteran, who is the appellant in this case, had active service from July 1985 to July 2009. These matters come before the Board of Veterans' Appeals (BVA or Board) from an October 2009 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Winston-Salem, North Carolina. In January 2012 the Veteran testified at a Board hearing at the VA Central Office in Washington, D.C., before the undersigned Veterans Law Judge. A transcript of that hearing is of record. Evidence pertinent to the issue of an initial rating for pes planus was received contemporaneously with the Veteran's January 2012 Board hearing. The Veteran has waived initial RO consideration of this evidence. In February 2012 the Veteran submitted evidence pertinent to the issue of an increased rating for sleep apnea. The Veteran has waived initial RO consideration of this evidence. A claim for a total rating based on individual unemployability due to service-connected disability (TDIU) is part of an increased rating issue when such claim is raised by the record. Rice v. Shinseki, 22 Vet. App. 447 (2009). The Board notes, however, that the Veteran has indicated that he is currently employed. As such, the issue of TDIU is not raised in this case. This appeal was processed using the Virtual VA paperless claims processing system. Accordingly, any future consideration of this appellant's case should take into consideration the existence of this electronic record. FINDINGS OF FACT 1. At the January 2012 Board hearing, prior to the promulgation of a decision in the appeal, the Veteran indicated that withdrawal of appeal of the issues of entitlement to service connection for a left and right elbow disorder is requested. 2. The Veteran complained of skin problems (associated with shaving) in service. 3. Symptoms of facial skin problems have been continuous since service separation. 4. The Veteran's currently diagnosed pseudofolliculitis barbae is related to active service. 5. Symptoms of hemorrhoids were not chronic in service. 6. Symptoms of hemorrhoids have not been continuous since service. 7. The Veteran does not have a currently diagnosed hemorrhoids disability. 8. Throughout the appeal, the Veteran has required the use of a CPAP device for treatment of service-connected sleep apnea; symptoms of chronic respiratory failure, cor pulmonale, or the requirement for a tracheostomy are not demonstrated at any time. 9. For the entire period on appeal, the Veteran's bilateral pes planus has been manifested by mild to moderate overall impairment with pain on manipulation and use of the feet. CONCLUSIONS OF LAW 1. The criteria for withdrawal of a Substantive Appeal by the Veteran for the issues of entitlement to service connection for left and right elbow disorder have been met. 38 U.S.C.A. § 7105(b)(2), (d)(5) (West 2002); 38 C.F.R. § 20.204 (2012). 2. Resolving reasonable doubt in the Veteran's favor, pseudofolliculitis barbae was incurred in active service. 38 U.S.C.A. §§ 101, 1110, 1131, 5103, 5103(a), 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.303 (2012). 3. The criteria for service connection for hemorrhoids have not been met. 38 U.S.C.A. §§ 101, 1110, 1131, 5103, 5103(a), 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.303 (2012). 4. Resolving reasonable doubt in the Veteran's favor, the criteria for a 50 percent rating, but no greater, for sleep apnea have been met for the entire initial rating period. 38 U.S.C.A. §§ 1155, 5107(b) (West 2002); 38 C.F.R. §§ 4.7, 4.97, Diagnostic Code 6847 (2012). 5. Resolving reasonable doubt in the Veteran's favor, the criteria for a 10 percent rating, but no greater than 10 percent, for bilateral pes planus have been met for the entire initial rating period. 38 U.S.C.A. §§ 1155, 5107(b) (West 2002); 38 C.F.R. §§ 4.7, 4.71a, Diagnostic Code 5276 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Withdrawn Issues The Board may dismiss any appeal which fails to allege specific error of fact or law in the determination being appealed. 38 U.S.C.A. § 7105. An appeal may be withdrawn as to any or all issues involved in the appeal at any time before the Board promulgates a decision. Withdrawal may be made by the appellant or by his or her authorized representative. 38 C.F.R. § 20.204. In the present case, at the January 2012 Board hearing, the Veteran has indicated a desire to withdraw the issues of service connection for a left and right elbow disorder; hence, there remain no allegations of error of fact or law for appellate consideration as to those issues. Accordingly, the Board does not have jurisdiction to review the appeal as to those issues, and they are dismissed. Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA), in part, describes VA's duties to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126 (West 2002); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2012). The VCAA applies in this case. Duty to Notify As the October 2009 rating decision granted service connection for bilateral pes planus and sleep apnea, those claims are now substantiated. As such, the filing of a notice of disagreement as to the disability ratings assigned does not trigger additional notice obligations under 38 U.S.C.A. § 5103(a). 38 C.F.R. § 3.159(b)(3) (no VCAA notice required because of filing of NOD); Dunlap v. Nicholson, 21 Vet. App. 112, 116-17 (2007) (noting that once an initial VA decision awarding service connection and assigning a disability evaluation and effective date has been made, 38 U.S.C. § 5103(a) notice is no longer required). As for rating the Veteran's sleep apnea and pes planus disability, the relevant disability rating criteria have been provided to the Veteran, including in the October 2010 statement of the case. In an April 2009 VCAA letter, the Veteran received notice regarding the assignment of a disability rating and effective date in the event of an award of VA benefits. Dingess/Hartman v. Nicholson,19 Vet. App. 473 (2006). By correspondence dated in April 2009 the Veteran was informed of the evidence and information necessary to substantiate the claims of service connection for pseudofolliculitis barbae and hemorrhoids, the information required of the Veteran to enable VA to obtain evidence in support of the claims, the assistance that VA would provide to obtain evidence and information in support of the claims, and the evidence that should be submitted if there was no desire for VA to obtain such evidence. During the January 2012 Board hearing, to assist the Veteran, the undersigned asked questions to help direct the Veteran's testimony, and specifically advised the Veteran (hearing transcript, pages 18-19) of the necessity to demonstrate evidence of a current hemorrhoids diagnosis. The undersigned also directed questions to the Veteran's spouse in an effort to obtain additional lay testimony concerning the issues on appeal. The undersigned also indicated that the record would be held open for 60 days in an effort to enable the Veteran to obtain additional evidence in support of his claims. These actions fulfilled the duties under 38 C.F.R. § 3.103 (2011). See Bryant v. Shinseki, 23 Vet. App. 488 (2010). Duty to Assist The Veteran's service separation examination is of record, as are VA treatment records. The Veteran has undergone VA examinations that addressed the rating matters presented by this appeal. 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 examinations obtained in this case are adequate, as they considered the pertinent evidence of record, and included an examination of the Veteran and elicited his subjective complaints and clinical measures and observations reported. The examinations described the Veteran's disabilities in sufficient detail so that the Board is able to fully evaluate the claimed disabilities. Accordingly, the Board finds that VA's duty to assist with respect to obtaining VA examinations in this appeal has been met. The Veteran has not referenced any other pertinent, obtainable evidence that remains outstanding. VA's duties to notify and assist are met, and the Board will address the merits of the claims. Service Connection Legal Criteria Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active military, naval, or air service. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303(a). For the showing of chronic disease in service, there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time. With chronic disease as such in service, subsequent manifestations of the same chronic disease at any later date, however remote, are service connected, unless clearly attributable to intercurrent causes. If a condition noted during service is not shown to be chronic, then generally, a showing of continuity of symptoms after service is required for service connection. 38 C.F.R. § 3.303(b). Service connection may also be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Establishing service connection generally requires (1) medical evidence of a current disability; (2) medical or, in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and (3) medical evidence of a nexus between the claimed in-service disease or injury and the present disability. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). The United States Court of Appeals for Veterans Claims (Court) has held that "Congress specifically limits entitlement for service-connected disease or injury to cases where such incidents have resulted in a disability. In the absence of proof of a present disability there can be no valid claim." Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). Competency of evidence differs from weight and credibility. Competency is a legal concept determining whether testimony may be heard and considered by the trier of fact, while credibility is a factual determination going to the probative value of the evidence to be made after the evidence has been admitted. Rucker v. Brown, 10 Vet. App. 67 (1997); Layno v. Brown, 6 Vet. App. 465 (1994); Cartwright v. Derwinski, 2 Vet. App. 24 (1991) (although interest may affect the credibility of testimony, it does not affect competency to testify). A veteran is competent to report symptoms because this requires only personal knowledge, not medical expertise, as it comes to him through the senses. See Layno, 6 Vet. App. 465. The Board is charged with the duty to assess the credibility and weight given to evidence. Wensch v. Principi, 15 Vet. App. 362, 367 (2001); Wood v. Derwinski, 1 Vet. App. 190, 193 (1991). In weighing credibility, VA may consider interest, bias, inconsistent statements, bad character, internal inconsistency, facial plausibility, self interest, consistency with other evidence of record, malingering, desire for monetary gain, and demeanor of the witness. Caluza v. Brown, 7 Vet. App. 498 (1995). The Board may weigh the absence of contemporaneous medical evidence against the lay evidence in determining credibility, but the Board cannot determine that lay evidence lacks credibility merely because it is unaccompanied by contemporaneous medical evidence. Buchanan v. Nicholson, 451 F. 3d 1331 (Fed. Cir. 2006). Generally, the degree of probative value which may be attributed to a medical opinion issued by a VA or private treatment provider takes into account such factors as its thoroughness and degree of detail, and whether there was review of the veteran's claims file. See Prejean v. West, 13 Vet. App. 444, 448-9 (2000). Also significant is whether the examining medical provider had a sufficiently clear and well-reasoned rationale, as well as a basis in objective supporting clinical data. See Bloom v. West, 12 Vet. App. 185, 187 (1999); Hernandez-Toyens v. West, 11 Vet. App. 379, 382 (1998); see also Claiborne v. Nicholson, 19 Vet. App. 181, 186 (2005) (rejecting medical opinions that did not indicate whether the physicians actually examined the veteran, did not provide the extent of any examination, and did not provide any supporting clinical data). The Court has held that a bare conclusion, even one reached by a health care professional, is not probative without a factual predicate in the record. Miller v. West, 11 Vet. App. 345, 348 (1998). Medical evidence that is speculative, general, or inconclusive in nature cannot support a claim. See Obert v. Brown, 5 Vet. App. 30, 33 (1993); see also Beausoleil v. Brown, 8 Vet. App. 459, 463 (1996); Libertine v. Brown, 9 Vet. App. 521, 523 (1996). A physician's statement framed in terms such as "may" or "could" is not probative. See Warren v. Brown, 6 Vet. App. 4, 6 (1993). A significant factor to be considered for any opinion is the accuracy of the factual predicate, regardless of whether the information supporting the opinion is obtained by review of medical records or lay reports of injury, symptoms and/or treatment. See Harris v. West, 203 F. 3d 1347, 1350-51 (Fed. Cir. 2000) (examiner opinion based on accurate lay history deemed competent medical evidence in support of the claim); Kowalski v. Nicholson, 19 Vet. App. 171, 177 (2005) (holding that a medical opinion cannot be disregarded solely on the rationale that the medical opinion was based on history given by the veteran); Reonal v. Brown, 5 Vet. App. 458, 461 (1993) (holding that the Board may reject a medical opinion based on an inaccurate factual basis). When all the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with a veteran prevailing in either event, or whether a preponderance of the evidence is against a claim, in which case, the claim is denied. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102. The Board has reviewed all the evidence in the Veteran's claims file. Although the Board has an obligation to provide adequate reasons and bases supporting this decision, there is no requirement that the evidence submitted by a veteran or obtained on a veteran's behalf be discussed in detail. Rather, the Board's analysis below will focus specifically on what evidence is needed to substantiate the claims and what the evidence in the claims file shows, or fails to show, with respect to the claims. See Gonzales v. West, 218 F. 3d 1378, 1380-81 (Fed. Cir. 2000); Timberlake v. Gober, 14 Vet. App. 122, 128-30 (2000). Service Connection for Pseudofolliculitis Barbae The Veteran contends that he has a skin problem associated with shaving (pseudofolliculitis barbae) and that this disability originated in service and has continued since that time. After a review of all the evidence of record, lay and medical, the Board finds that the weight of the evidence demonstrates that the Veteran's skin symptoms were chronic in service. The Veteran has provided credible testimony that he did have symptoms of pseudofolliculitis barbae during service. As noted by the RO, the Veteran's testimony is confirmed by service treatment records which reveal that the Veteran was seen for this disorder in service and had been placed on a no shave profile. The Board finds that the weight of the evidence demonstrates that symptoms of pseudofolliculitis barbae have been continuous since service separation. The Veteran and his wife have provided credible testimony that the Veteran's skin problem associated with shaving has continued since service. The weight of the competent evidence is at least in relative equipoise on the question of whether the Veteran's pseudofolliculitis barbae is related to active service. The Veteran suffered symptoms of pseudofolliculitis barbae during service and has suffered those same symptoms since service separation. See Horowitz v. Brown, 5 Vet. App. 217, 221-22 (1993) (finding that lay statements are competent on in-service symptoms and post-service symptoms that later formed the basis of diagnosis). For these reasons, and with resolution of reasonable doubt in favor of the Veteran, the Board finds that the criteria for service connection for pseudofolliculitis barbae are met. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102. Service Connection for Hemorrhoids The Veteran contends that he has hemorrhoids and that this disability originated in service and has continued since that time. After a review of all the evidence of record, lay and medical, the Board finds that the weight of the evidence demonstrates that the Veteran's hemorrhoid symptoms were not chronic in service and have not been continuous since service separation. While a history of hemorrhoids was noted on the service separation examination, the Veteran indicated at the January 2012 Board hearing that he was unsure if he had sought treatment for hemorrhoids during service, and acknowledged that he had not been diagnosed with hemorrhoids during service. The Board can find no indication that the Veteran has a current diagnosis of hemorrhoids, and no such disability was noted on the June 2009 VA (QTC) examination. The Veteran did not assert at his January 2102 Board hearing that he had ever been diagnosed with hemorrhoids. As a service connection claim requires, at a minimum, competent evidence of a current disability, the Board finds that a preponderance of the evidence is against the claim for service connection for hemorrhoids. Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). The Board notes that the Veteran is competent to provide testimony concerning factual matters of which he has first hand knowledge (i.e., experiencing or observing symptoms of hemorrhoids during or after service). Barr v. Nicholson, 21 Vet. App. 303 (2007); Washington v. Nicholson, 19 Vet. App. 362 (2005). Further, under certain circumstances, lay statements may serve to support a claim for service connection by supporting the occurrence of lay-observable events or the presence of disability, or symptoms of disability, susceptible of lay observation. Davidson, 581 F.3d 1313; Jandreau, 492 F.3d 1372. While the Board has found the Veteran's complaints to be credible, there is no indication that the Veteran has the necessary medical training and competency to provide a clinical diagnosis of hemorrhoids. See Jandreau at 1372. For these reasons, the Board finds that a preponderance of the evidence is against the claim for service connection for hemorrhoids, and the claim must be denied. Because the preponderance of the evidence is against the claim, the benefit of the doubt doctrine is not for application. See 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102. Disability Rating Criteria Disability evaluations are determined by evaluating the extent to which a veteran's service-connected disability adversely affects his ability to function under the ordinary conditions of daily life, including employment, by comparing his symptomatology with the criteria set forth in the Schedule for Rating Disabilities (Rating Schedule). 38 U.S.C.A. § 1155; 38 C.F.R. §§ 4.1, 4.2, 4.10 (2011). In evaluating a disability, the Board considers the current examination reports in light of the whole recorded history to ensure that the current rating accurately reflects the severity of the condition. The Board has a duty to acknowledge and consider all regulations that are potentially applicable. Schafrath v. Derwinski, 1 Vet. App. 589 (1991). The medical as well as industrial history is to be considered, and a full description of the effects of the disability upon ordinary activity is also required. 38 C.F.R. §§ 4.1, 4.2, 4.10. Where there is a question as to which of two evaluations shall be applied, the higher evaluation 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. In order to evaluate the level of disability and any changes in severity, it is necessary to consider the complete medical history of a veteran's disability. Schafrath, 1 Vet. App. at 594. Because the appeals are from the initial rating assigned with the grant of service connection, the possibility of "staged" ratings for separate periods during the appeal period, based on the facts found, must also be considered. See Fenderson v. West, 12 Vet. App. 119 (1999). Initial Compensable Rating for Sleep Apnea An October 2009 rating decision granted service connection for sleep apnea and assigned a noncompensable initial rating, effective August 1, 2009. Under Diagnostic Code 6847, a noncompensable rating is assigned for asymptomatic sleep apnea, but with documented sleep disorder breathing. The next higher 30 percent rating is assigned for persistent day-time hypersomnolence. A 50 percent rating is assigned when the sleep apnea requires the use of a breathing assistance device such as continuous airway pressure (CPAP) machine. A 100 percent rating is assigned for sleep apnea that causes chronic respiratory failure with carbon dioxide retention or cor pulmonale, or requires tracheostomy. An April 2009 service sleep study record noted that the Veteran demonstrated obstructive sleep apnea. A February 2012 VA record noted that the Veteran had a diagnosis of obstructive sleep apnea and was being seen for CPAP equipment evaluation. The record noted that the Veteran was to use his CPAP every night. The record shows, including the Veteran's credible January 2012 Board hearing testimony, that shortly after applying for service connection for sleep apnea, the Veteran was shown to require a CPAP system to treat the disability. The need for CPAP therapy warrants a 50 percent rating, and it is found that he has required the therapy from the date of the claim for service connection. As such, the Board finds, with the resolution of reasonable doubt, that the 50 percent rating is to be assigned throughout the entire appeal period. 38 C.F.R. §§ 4.3, 4.7. A complete review of the record does not reveal that the Veteran's sleep apnea causes chronic respiratory failure with carbon dioxide retention, or cor pulmonale, or that the Veteran has required a tracheostomy for treatment of the disability for any period. Thus, none of the criteria for a rating in excess of 50 percent have been met, and a 100 percent schedular rating is not warranted for any period. Initial Compensable Rating for Pes Planus An October 2009 rating decision granted service connection for bilateral pes planus and assigned a noncompensable initial rating, effective August 1, 2009. The October 2009 RO decision found that the Veteran's pes planus had preexisted service and had permanently worsened as a result of service; the RO indicated that the Veteran had a preservice percentage of 0 for the pes planus disability. Under Diagnostic Code 5276, mild flatfoot with symptoms relieved by built-up shoe or arch support is rated as noncompensably (0 percent) disabling. Moderate flatfoot with weight-bearing line over or medial to the great toe, inward bowing of the tendo achillis, pain on manipulation and use of the feet, bilateral or unilateral, is rated 10 percent disabling. Severe flatfoot, with objective evidence of marked deformity (pronation, abduction, etc.), pain on manipulation and use accentuated, indication of swelling on use, characteristic callosities, is rated 20 percent disabling for unilateral disability, and is rated 30 percent disabling for bilateral disability. The Board observes that some of the evidence of record indicates that the Veteran's pes planus produces mild symptoms that are resolved by arch supports in his shoes. At the June 2009 QTC examination, the examiner noted that the Veteran's feet had no tenderness, painful motion, weakness, edema, or disturbed circulation. However, the Veteran has provided lay evidence that his foot problem causes him more than mere mild symptoms. At the January 2012 Board hearing, the Veteran stated that prolonged standing or prolonged walking would result in pain in the "arch section" of his feet. He also indicated that, while he did wear shoe inserts that did help, he still would experience some radiation from the bottom of his feet into the top of his feet, toward the top of the instep. The Veteran also indicated that he was seeking treatment from a private podiatrist. The Veteran's lay statements are of probative value because he is competent to testify regarding the frequency, severity, and duration of pain and discomfort he feels in his feet, as well as related symptoms and impairments during periods of time he is experiencing foot pain. Foot pain is an observable symptom, and the Veteran is competent to offer lay evidence that the foot pain interferes with his ability to ambulate and move about. As such, while the evidence is in equipoise on the questions of whether the Veteran's pes planus causes more than mere mild symptoms, resolving reasonable doubt in the Veteran's favor, the Board finds a compensable rating of 10 percent warranted for moderate symptomatology. The preponderance of the evidence, however, is against a rating in excess of 10 percent for any period. In order to warrant the next higher rating for bilateral pes planus of 30 percent, the evidence would have to show severe flatfoot, with objective evidence of marked deformity (pronation, abduction, etc.), pain on manipulation and use accentuated, indication of swelling on use, and characteristic callosities. As detailed earlier, the evidence simply does not show this level of disability at any time. The Board again notes that the June 2009 VA examiner noted no such findings, and such findings are also absent from the Veteran's June 2010 private podiatrist treatment record. Diagnostic Code 5284 governs foot injuries, which is not consistent with the history of the Veteran's disability. In addition, a combined rating higher than 10 percent under that code would require at least a moderate injury for each foot. As noted above, the Veteran's pes planus is essentially mild, but will be regarded as moderate for purposes of rating here given his complaints of pain and in consideration of 38 C.F.R. §§ 4.40, 4.45, 4.59, and DeLuca v. Brown, 8 Vet. App. 202, 206-07 (1995). As noted, the Veteran is competent to give evidence about what he observes or experiences concerning this disability, including subjective symptomatology that he experiences such as foot pain. See Layno v. Brown, 6 Vet. App. 465 (1994). He is not competent to identify a specific level of disability according to the appropriate diagnostic code, which includes "objective" evidence of marked deformity such as pronation and abduction. In this case, such competent evidence concerning the nature and extent of the Veteran's pes planus disability has been provided by the medical personnel who have examined the Veteran during the current appeal and who have rendered pertinent opinions in conjunction with the evaluations. The medical findings directly address the criteria under which the pes planus disability is evaluated. As such, the Board finds these records to be the most probative evidence with regard to whether a higher rating is warranted. In sum, an initial rating of 10 percent for the Veteran's pes planus disability is warranted for the entire appeal period. The Board has been mindful of the "benefit-of-the-doubt" rule, and has resolved doubt in the Veteran's favor in this case. 38 C.F.R. §§ 4.3, 4.7 (2012). Extraschedular Consideration The potential application of the various other provisions of Title 38 of the Code of Federal Regulations have also been considered, including 38 C.F.R. § 3.321(b)(1) (2011), which provides procedures for referral or assignment of an extraschedular evaluation. Schafrath, at 593. The question of an extraschedular rating is a component of a claim for an increased rating. See Bagwell v. Brown, 9 Vet. App. 337, 339 (1996). Although the Board may not assign an extraschedular rating in the first instance, it must specifically adjudicate whether to refer a case for extraschedular evaluation when the issue either is raised by the claimant or is reasonably raised by the evidence of record. Barringer v. Peake, 22 Vet. App. 242 (2008). The VA Compensation and Pension Service is authorized to approve an extraschedular evaluation if the case "presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization as to render impractical the application of the regular schedular standards." 38 C.F.R. § 3.321(b)(1). If the evidence raises the question of entitlement to an extraschedular rating, 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. Therefore, initially, 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, the assigned schedular evaluation is, therefore, adequate, and no referral is required. Thun v. Peake, 22 Vet. App. 111 (2008). Concerning the issue of a higher initial rating for the Veteran's pes planus disability, the Board finds that the schedular rating criteria contemplate the limitations and impairment caused by that disability. The rating criteria specifically provide for ratings based on the presence of such symptoms as pain on use, swelling, and characteristic callosities. As for the issue of a higher initial rating for the Veteran's sleep apnea, the Board finds that the schedular rating criteria contemplate the limitations and impairment caused by that disability. The rating criteria specifically provide for ratings based on the use of a CPAP device and the presence of chronic respiratory symptoms. Because the schedular rating criteria is adequate to rate the Veteran's service-connected disabilities, there is no exceptional or unusual disability picture to render impractical the application of the regular schedular standards. For these reasons, the Board finds that the criteria for referral for extraschedular rating have not been met. 38 C.F.R. § 3.321(b)(1). ORDER The appeal of the issue of service connection for a left elbow disorder is dismissed. The appeal of the issue of service connection for a right elbow disorder is dismissed. Service connection for pseudofolliculitis barbae is granted. Service connection for hemorrhoids is denied. An initial rating of 50 percent for sleep apnea, for the entire initial rating period, is granted. An initial rating of 10 percent for bilateral pes planus, for the entire initial rating period, is granted. ____________________________________________ J. Parker Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs