Citation Nr: 1305580 Decision Date: 02/15/13 Archive Date: 02/21/13 DOCKET NO. 10-21 257 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Lincoln, Nebraska THE ISSUES 1. Entitlement to service connection for obstructive sleep apnea. 2. Entitlement to an initial evaluation in excess of 10 percent for sleep disorder, insomnia type. 3. Entitlement to service connection for a right wrist disorder, to include tendonitis. 4. Entitlement to service connection for a left elbow disorder, to include tendonitis. 5. Entitlement to an initial compensable evaluation for tachycardia. 6. Entitlement to an initial compensable evaluation prior to January 7, 2011, and thereafter in excess of 10 percent, for musculoligamentous strain of the cervical spine. REPRESENTATION Appellant represented by: Mr. Robert A. Laughlin, Attorney at Law WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD J. Murray, Associate Counsel INTRODUCTION The Veteran served on active duty in the United States Army from June 1991 to September 1991, from January 2004 to March 2005, and from April 2005 to October 2009. These matters come before the Board of Veterans' Appeals (Board) on appeal from a November 2009, a January 2010, an April 2010 and a June 2011 rating decisions of the Department of Veterans Affairs (VA) Regional Office in Lincoln, Nebraska (RO). In pertinent part of the November 2009 rating decision, the RO awarded service connection for tachycardia and assigned a noncompensable evaluation, effective from October 23, 2009. The RO also denied the claim for service connection for sleep disturbance disorder, to include insomnia. In the January 2010 rating decision, the RO denied the claims for service connection for right wrist disorder and left elbow disorder. The RO awarded service connection for cervical spine disability and assigned a noncompensable evaluation in the April 2010 rating decision. By the way of a May 2011 rating decision, the RO increased the assigned evaluation for cervical spine disability to 10 percent disabling, effective from January 7, 2011. In the June 2011 rating decision, the RO awarded service connection for sleep disorder, insomnia type, and assigned a 10 percent evaluation. However, in a June 2011 supplemental statement of the case (SSOC), the RO continued the denial of the claim for service connection for a sleep disorder, identified as sleep apnea. The Veteran had a hearing at the RO before the undersigned Veterans Law Judge in August 2012. A transcript of that proceeding has been associated with the claims file. A review of the Virtual VA paperless claims processing system does not reveal any additional documents pertinent to the present appeal. FINDINGS OF FACT 1. When viewed in the light most favorable to the Veteran, the evidence of record shows that his current diagnosed obstructive sleep apnea had an onset during his third period of service. 2. The Veteran's disability due to sleep disorder, insomnia type, is manifested by sleep impairment that requires no more than medication for control; occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks is not shown. 3. In a June 2011 correspondence, the Veteran specifically stated that he wished to withdraw his appeal of entitlement to service connection for a right wrist disorder. 4. In a June 2011 correspondence, the Veteran specifically stated that he wished to withdraw his appeal of entitlement to service connection for a left elbow disorder. 5. In a June 2011 correspondence, the Veteran specifically stated that he wished to withdraw his appeal of entitlement to an initial compensable evaluation prior to January 7, 2011, and thereafter an evaluation in excess of 10 percent for cervical spine disability. 4. During the August 2012 Travel Board hearing, the Veteran stated that he wished to withdraw his appeal of entitlement to an initial compensable evaluation for tachycardia. CONCLUSIONS OF LAW 1. The criteria for entitlement to service connection for obstructive sleep apnea have been met. 38 U.S.C.A. §§ 1110, 1131, 5107 (West 2002); 38 C.F.R. § 3.303 (2012). 2. The criteria for an initial increased evaluation for sleep disorder, insomnia type, have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 4.1-4.7, 4.130, Diagnostic Code 9410 (2012). 3. The criteria for a withdrawal of the Veteran's substantive appeal have been met as to his claim of entitlement to service connection for a right wrist disorder. 38 U.S.C.A. § 7105(b)(2), (d)(5) (West 2002); 38 C.F.R. §§ 20.200, 20.202, 20.204(b), (c) (2012). 4. The criteria for a withdrawal of the Veteran's substantive appeal have been met as to his claim of entitlement to service connection for a left elbow disorder. 38 U.S.C.A. § 7105(b)(2), (d)(5) (West 2002); 38 C.F.R. §§ 20.200, 20.202, 20.204(b), (c) (2012). 5. The criteria for a withdrawal of the Veteran's substantive appeal have been met as to his claim of entitlement to increased ratings for cervical spine disability. 38 U.S.C.A. § 7105(b)(2), (d)(5) (West 2002); 38 C.F.R. §§ 20.200, 20.202, 20.204(b), (c) (2012). 6. The criteria for a withdrawal of the Veteran's substantive appeal have been met as to his claim of entitlement to an initial increased rating for tachycardia. 38 U.S.C.A. § 7105(b)(2), (d)(5) (West 2002); 38 C.F.R. §§ 20.200, 20.202, 20.204(b), (c) (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS As provided for by the Veterans Claims Assistance Act of 2000 (VCAA), the United States Department of Veterans Affairs has a duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126; 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a). VA is required to notify the claimant of the information and evidence not of record that is necessary to substantiate the claim. VA will inform the Veteran of the type of information and evidence that VA will seek to provide, and of the type of information and evidence, the claimant is expected to provide. 38 C.F.R. § 3.159(b). VA must provide such notice to the claimant prior to an initial unfavorable decision on a claim for VA benefits by the agency of original jurisdiction (AOJ), even if the adjudication occurred prior to the enactment of the VCAA. See Pelegrini v. Principi, 18 Vet. App. 112, 119-120 (2004). VA must also specifically provide notice that a disability rating and an effective date will be assigned if service connection is awarded. Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). Importantly, the VCAA requirements of 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) apply to all elements of a claim for service connection, so that VA must specifically provide notice that a disability rating and an effective date will be assigned if service connection is awarded. Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006); aff'd sub nom., Hartman v. Nicholson, 483 F.3d 1311 (2007). Here, in view of the Board's favorable decision to grant service connection for obstructive sleep apnea, any further discussion as to any lapses in duties to assist and notify, or regarding whether the Veteran was prejudiced by any such lapses, would serve no useful purpose. Regarding the appeal of the rating assigned for a sleep disorder, insomnia type, VA sent a letter to the Veteran in August 2009 that addressed the notice elements concerning his claim. The letters informed the Veteran of what evidence is required to substantiate the claim, and apprised the Veteran as to his and VA's respective duties for obtaining evidence. VA also informed the Veteran how it determines the disability rating and the effective date for the award of benefits if service connection is to be awarded. Dingess v. Nicholson, 19 Vet. App. 473 (2006). The Board finds that all notices required by VCAA and implementing regulations were furnished to the Veteran and that no useful purpose would be served by delaying appellate review to send out additional VCAA notice letters. In addition to its duty to notify, or inform, the Veteran with regard to his claim, VA also has a duty to assist the Veteran in the development of the claim. This duty includes assisting the Veteran in the procurement of service treatment records and records of pertinent medical treatment since service, and providing the Veteran a medical examination when necessary. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. In this case, VA has made reasonable efforts to obtain any available pertinent records as well as all relevant records adequately identified by the Veteran. VA provided the Veteran with a VA psychiatric examination in January 2011, in which the examiners identified the nature and severity of the Veteran's sleep disorder after interview the Veteran and examining him. The Board finds that the examination report is adequate for VA adjudication purposes as it contains sufficient findings to rate the disability under the appropriate rating criteria. The Veteran has not identified, and the record does not otherwise indicate, any additional existing evidence that is necessary for a fair adjudication of the claim that has not been obtained. See Bernard v. Brown, 4 Vet. App. 384 (1993). For the foregoing reasons, the Board therefore finds that VA has satisfied its duty to notify and its duty to assist pursuant to the VCAA. See 38 U.S.C.A. §§ 5102 and 5103; 38 C.F.R. §§ 3.159(b), 20.1102; Pelegrini, supra; Quartuccio v. Principi, 16 Vet. App. 183 (2002). Service Connection for Sleep Apnea Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active military service. 38 U.S.C.A. § 1110; 38 C.F.R. § 3.303. 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. 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. See 38 C.F.R. § 3.303(b). The chronicity provision of 38 U.S.C.A. § 3.303(b) is applicable where the evidence, regardless of its date, shows that the Veteran had a chronic condition in service or during an applicable presumption period and still has such condition. Such evidence must be medical unless it relates to a condition as to which, under the Court's case law, lay observation is competent. Savage v. Gober, 10 Vet. App. 488, 498 (1997). 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). To prevail on the issue of service connection, generally, there must be (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 current disability. See Hickson v. West, 12 Vet. App. 247, 253 (1999). It is noted that lay evidence can be competent and sufficient to establish a diagnosis or to establish etiology of a condition when (1) a layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007); see also Buchanan v. Nicholson, 451 F.3d 1331, 1337 (Fed. Cir. 2006) This does not mean, however, that lay evidence is necessarily always sufficient to identify a medical diagnosis, but rather only that it is sufficient in those cases where the lay person is competent and does not otherwise require specialized medical training and expertise to do so, i.e., the Board must determine whether the claimed disability is a type of disability for which a lay person is competent to provide etiology or nexus evidence. See Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). "Symptoms, not treatment, are the essence of any evidence of continuity of symptomatology." Savage, 10 Vet. App. at 496 (citing Wilson v. Derwinski, 2 Vet. App. 16, 19 (1991). Once evidence is determined to be competent, the Board must determine whether such evidence is also credible. See Layno v. Brown, 6 Vet. App. 465 (1994) (distinguishing between competency ("a legal concept determining whether testimony may be heard and considered") and credibility ("a factual determination going to the probative value of the evidence to be made after the evidence has been admitted"). The Board may not reject the credibility of the veteran's lay testimony simply because it is not corroborated by contemporaneous medical records. Buchanan, 451 F.3d at 1336. Except as otherwise provided by law, a claimant has the responsibility to present and support a claim for benefits. The Secretary shall consider all information and lay and medical evidence of record in a case 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. 38 U.S.C.A. § 5107. To deny a claim on its merits, the evidence must preponderate against the claim. Alemany v. Brown, 9 Vet. App. 518, 519 (1996). In this case, the Veteran seeks entitlement to service connection for sleep disturbance, currently identify as obstructive sleep apnea. The Veteran reports that he has had trouble sleeping since 2007. He further reports that he has continuously experienced symptoms of snoring since his third period of service. A review of the service treatment records show that the Veteran complained of sleep impairment and problems with obtaining restful sleep. These symptoms were associated with insomnia disability, and he was prescribed medication to help him sleep better. Shortly after his separation from his third and last period of service, the Veteran was afforded a VA general medical examination in November 2009. Although the Veteran complained of sleep impairment, the VA examiner found that there was insufficient evidence in the record to warrant a diagnosis of any acute or chronic disease or residual thereof. In January 2011, only fourteen months after his separation from his last period of service, the Veteran was diagnosed with mild obstructed sleep apnea based on the findings from a clinical sleep study. He was subsequently prescribed a C-PAC machine to treat his sleep apnea in April 2011. See VA treatment records dated in 2011. The record also contains the Veteran's testimony from the August 2012 Travel Board hearing. He reported that his prescribed sleep medication would provide him with some relief in getting to sleep and staying asleep, but he continued to have restless and interrupted sleep until he was treated for obstructive sleep apnea with a C-PAP. See August 2012 Travel Board hearing transcript, page 12. Here, a review of the record shows that the Veteran has been diagnosed with obstructive sleep apnea, and the first element of Hickson is satisfied. Also, the service treatment records show that he complained of sleep impairment during his last period of service, albeit he was diagnosed with insomnia and not with obstructive sleep apnea. The Veteran has credibly reported that he first experienced symptoms of snoring during service, which the Board observes is a known characteristic of sleep apnea. The Board acknowledges that the record lacks a medical nexus opinion that addresses a possible link between the Veteran's current diagnosed obstructive sleep apnea and his periods of service. No medical opinion has been sought for the purpose of obtaining such medical opinion. Instead, a medical opinion was only sought in January 2011 that addressed the question of service connection on a secondary basis. To this extent, the Board notes that the Veteran is competent and credible to report on what he sees and feels, such as the onset and continuity of snoring and difficulty obtaining restful sleep since his period of service. See Layno v. Brown, 6 Vet. App. 465, 469 (1994); 38 C.F.R. § 3.159(a)(2). The Board has no reason to doubt the credibility of the Veteran's statements, especially given the diagnosis of obstructive sleep apnea only fourteen months after his separation from service. See Curry v. Brown, 7 Vet. App. 59 (1994) (contemporaneous evidence can have greater probative value than inconsistent testimony provided by the claimant at a later date). The Board also places great weight on the fact that the first clinical evidence of obstructive sleep apnea was demonstrative only fourteen months after the Veteran's separation from service. Moreover, the Board notes that the Veteran was unavailable to undergo a clinical sleep study prior to January 2011 because he was he was working outside the country on a defense contract during the year following his separation from his last period of service. It is highly conceivable that the Veteran would have been diagnosed with obstructive sleep apnea prior to January 2011, if he has been afforded a clinical sleep study earlier. In this case, the Board has placed great weight on the Veteran's lay assertions that he has experienced trouble sleeping and symptoms of snoring continuously since his active duty service. His statements in this regard are both competent and credible. Indeed the medical evidence of record, to include in-service treatment for sleep problems as well as post-service diagnoses of sleep apnea in the fourteen months following the Veteran's separation from service, supports the Veteran's assertions of in-service onset and continuity of sleeping problems and snoring since service. The Board again resolves all doubt in favor of the Veteran and finds that the Hickson elements (2), in-service disease or injury, and (3) nexus or relationship, are satisfied as to this claim. Considering the totality of the evidence, the credible reports of continuous symptomatology in service and since service, the diagnostic evidence only fourteen months after separation, and the nature of the disability, the Board finds that the Veteran's current obstructive sleep apnea likely had its onset during his period of service. Affording the Veteran the benefit of the doubt, the Board determines that the criteria for service connection for obstructive sleep apnea are met. 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102. Higher Evaluation for Sleep Problems, Insomnia Type Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities, found in 38 C.F.R., Part 4. The rating schedule is primarily a guide in the evaluation of disability resulting from all types of diseases and injuries encountered as a result of or incident to military service. The ratings are intended to compensate, as far as can practicably be determined, the average impairment of earning capacity resulting from such diseases and injuries and their residual conditions in civilian occupations. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. 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 for that rating. 38 C.F.R. § 4.7. In considering the severity of a disability, it is essential to trace the medical history of the veteran. 38 C.F.R. §§ 4.1, 4.2, 4.41. Consideration of the whole-recorded history is necessary so that a rating may accurately reflect the elements of disability present. 38 C.F.R. § 4.2; Peyton v. Derwinski, 1 Vet. App. 282 (1991). While the regulations require review of the recorded history of a disability by the adjudicator to ensure a more accurate evaluation, the regulations do not give past medical reports precedence over the current medical findings. Where an increase in the disability rating is at issue, the present level of the veteran's disability is the primary concern. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). Where a veteran appeals the initial rating assigned for a disability when a claim for service connection for that disability has been granted, evidence contemporaneous with the claim for service connection and with the rating decision granting service connection would be most probative of the degree of disability existing at the time that the initial rating was assigned and should be the evidence "used to decide whether an [initial] rating on appeal was erroneous . . . ." Fenderson v. West, 12 Vet. App. 119, 126 (1999). If later evidence obtained during the appeal period indicates that the degree of disability increased or decreased following the assignment of the initial rating, "staged" ratings may be assigned for separate periods of time based on facts found. Id.; see also Hart v. Mansfield, 21 Vet. App. 505 (2007) (VA's determination of the "present level" of a disability may result in a conclusion that the disability has undergone varying and distinct levels of severity throughout the entire time period the increased rating claim has been pending). Here, the RO awarded the Veteran a 10 percent evaluation for his disability due to sleep disorder, insomnia type. The disability as been rated analogously to a mental disorder under Diagnostic Code 9410 (unspecified neurosis). See 38 C.F.R. § 4.130. Under Diagnostic Code 9410, a 10 percent evaluation is warranted where there is occupational and social impairment due to mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress; or, symptoms controlled by continuous medication. 38 C.F.R. § 4.130. A 30 percent evaluation is warranted where there is occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, mild memory loss (such as forgetting names, directions, and recent events). 38 C.F.R. § 4.130. Higher evaluations are warranted for more severe symptomatology. See Id. It is noted that the use of "such as" in 38 C.F.R. § 4.130 demonstrates that the specified factors for each incremental psychiatric rating are not requirements for a particular rating but are examples providing guidance as to the type and degree of severity, or their effects on social and work situations. Thus, any analysis should not be limited solely to whether the symptoms listed in the rating scheme are exhibited; rather, consideration must be given to factors outside the specific rating criteria in determining the level of occupational and social impairment. See Mauerhan v. Principi, 16 Vet. App. 436, 442 (2002). In this case, since the initial grant of service connection, the Veteran's sleep disorder, insomnia type, has been manifested by no more than sleep impairment with difficulty falling asleep and staying asleep. His symptomatology caused the Veteran to feel tired even after sleeping. His service treatment records and post-service treatment records show he was diagnosed with insomnia and he has been prescribed medication such as Ambien to help him sleep better. This symptomatology is consistent with the criteria for the current assigned 10 percent evaluation. See 38 C.F.R. § 4.130, Diagnostic Code 9410. In January 2011, the Veteran was afforded a VA psychiatric examination to identify the nature and severity of his claimed disorder. The examination report shows that the Veteran was diagnosed with sleep disorder, insomnia type, as secondary to his service-connected disabilities. He complained of sleep impairment where he only gets about five hours of sleep a night and he does not feel rested after sleep. He denied that his symptoms affected his ability to function at work. It was noted that the Veteran had a history of sleep impairment and he takes medication to help control his symptomatology. Mental status examination of the Veteran revealed findings of pleasant and cooperative attitude, appropriate dress, good eye contact, normal and unremarkable speech, appropriate to euthymic mood, appropriate and mood congruent affect, fair to good insight, adequate judgment, logical and goal directed thought process, no suicidal or homicidal ideations, no delusions or hallucinations, normal psychomotor activity, and complaints of recurrent nightmares, intrusive thoughts, memory problems, and difficulty sleeping. The VA examiner opined that the Veteran's mental health symptoms were controlled by continuous medication. During the August 2012 Travel Board hearing, the Veteran testified that he has been taking medication such as Ambien to help him sleep since 2007. He further reported that he has recently been diagnosed with obstructive sleep apnea and been prescribed a C-PAP machine. He felt that he experiences more restful and uninterrupted sleep since using a C-PAP machine. See August 2012 Travel Board hearing transcript, page 12. At no point during the period under appeal has the Veteran's sleep disorder, insomnia type, been manifested by no more than occupational and social impairment due to mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress, or by symptoms controlled by continuous medication. See 38 C.F.R. § 4.130, Diagnostic Code 9410. The evidence does not show a disability productive of occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to symptoms identified as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, and mild memory loss (such as forgetting names, directions, recent events). 38 C.F.R. § 4.130, Diagnostic Code 9410. Rather, the lay and medical evidence of record shows that the Veteran's disability causes him sleep impairment that results in him feeling unrested and tired. He has not asserted that his symptomatology affects his ability to function at work or in social settings. It cannot be stated that the Veteran's disability causes him more than mild impairment. The Veteran's symptomatology does not support the assignment of an evaluation in excess of 10 percent at any point during the period under appeal. See 38 C.F.R. § 4.130, Diagnostic Code 9410. The preponderance of the evidence is against the claim; there is no doubt to be resolved; and an increased evaluation in excess of 10 percent for service-connected sleep disorder, insomnia type, is not warranted at any time since the initial grant of service connection. In reaching this conclusion, the Board is cognizant of the grant of service connection for sleep apnea. The RO will have the opportunity to assign an intitial disability evaluation and effective date for this disability when it effectuates the Board's decision. Extraschedular Considerations The Board has also considered whether an extraschedular rating is warranted, noting that if an exceptional case arises where ratings based on the statutory schedules are found to be inadequate, consideration of an "extra-schedular" evaluation commensurate with the average earning capacity impairment due exclusively to the service-connected disability or disabilities will be made. 38 C.F.R. § 3.321(b)(1). The Court has held that the determination of whether a claimant is entitled to an extraschedular rating under § 3.321(b) is a three-step inquiry, the responsibility for which may be shared among the RO, the Board, and the Under Secretary for Benefits or the Director, Compensation and Pension Service. Thun v. Peake, 22 Vet. App. 111 (2008). 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. This means that 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 adequate, and no referral is required. If the criteria do not reasonably describe the claimant's disability level and symptomatology, a determination must be made whether the claimant's exceptional disability picture exhibits other related factors such as those provided by the regulation as "governing norms." 38 C.F.R. § 3.321(b)(1) (related factors include "marked interference with employment" and "frequent periods of hospitalization"). See id. However, in this case, the medical evidence fails to show anything unique or unusual about the disabilities at issue that would render the schedular criteria inadequate. The Veteran's main symptom of sleep impairement and treatment through continuous medication are contemplated in the current assigned 10 percent. A rating in excess of that assigned is provided for certain manifestations of each service-connected disorder but the probative evidence reflects that those manifestations are not present in this case. The rating criteria adequately describe the severity and symptomatology of the Veteran's service-connected disability due to sleep disorder, insomnia type. Therefore, the Veteran's disability is contemplated by the rating schedule and no extraschedular referral is required. Additionally, there is no showing that the disabilities cause any significant functional impairment. As such, it would not be found that they meet the "governing norms" of an extraschedular rating. Accordingly, an extraschedular rating is not warranted. The Board also notes that this case does not raise a claim of entitlement to a total disability evaluation based upon individual unemployability due to service-connected disability (TDIU). Rather, the Veteran testified during his hearing that he is currently employed. Rice v. Shinseki, 22 Vet. App. 447 (2009) (a request for TDIU, whether expressly raised by a veteran or reasonably raised by the record, is not a separate claim for benefits, but is rather part of the adjudication of a claim for increased compensation). Service Connection for Right and Left Elbow Disorders and Higher Evaluations for Tachycardia and Cervical Spine Disability An appeal consists of a timely filed Notice of Disagreement in writing, and after a Statement of the Case has been furnished, a timely filed Substantive Appeal. See 38 U.S.C.A. § 7105(a); 38 C.F.R. § 20.200. A Substantive Appeal may be withdrawn in writing at any time before the Board promulgates a decision. See 38 C.F.R. §§ 20.202, 20.204(b). Except for appeals withdrawn on the record at a hearing, appeal withdrawals must be in writing. See 38 C.F.R. § 20.204(b). The Veteran perfected his appeals as to the denial of the claims for entitlement to service connection for a right wrist disorder and a left elbow disorder as well has his claims for increased ratings for tachycardia and cervical spine disability. Significantly, in a correspondence received by VA in June 2011, the Veteran specifically stated that he wished to withdraw his appeal as to the service connection claims and the increased rating claim for cervical spine disability. See the Veteran's June 2011 Statement in Support of Claim. Also, during the August 2012 Travel Board hearing, the Veteran stated that he wished to withdraw his appeal as to the increase rating claim for tachycardia. See August 2012 Travel Board hearing transcript, page 2. As is required by 38 C.F.R. § 20.204(b), the Veteran's request to withdraw these issues were made in writing, on letters containing the Veteran's name and file number, as well as on the record at the August 2012 Travel Board hearing. The Board accordingly finds that the Veteran's withdrawal requests qualify as valid withdrawals of these issues. See 38 C.F.R. § 20.204. Accordingly, there remains no allegation of error of fact or law for appellate consideration as to these issues, and they are dismissed. ORDER Entitlement to service connection for obstructive sleep apnea is granted. Entitlement to an initial evaluation in excess of 10 percent for sleep disorder, insomnia type, is denied. Entitlement to service connection for a right wrist disorder, to include tendonitis, is dismissed. Entitlement to service connection for a left elbow disorder, to include tendonitis, is dismissed. Entitlement to an initial compensable evaluation for tachycardia is dismissed. Entitlement to an initial compensable evaluation prior to January 7, 2011, and thereafter in excess of 10 percent, for musculoligamentous strain of the cervical spine, is dismissed. ____________________________________________ DAVID L. WIGHT Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs