Citation Nr: 1306364 Decision Date: 02/25/13 Archive Date: 03/01/13 DOCKET NO. 11-05 310A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Manila, the Republic of the Philippines THE ISSUES 1. Whether new and material evidence has been received in order to reopen a claim for service connection for myopia with hyperopia. 2. Entitlement to service connection for a right thumb disorder. 3. Entitlement to service connection for headaches, including as secondary to the service-connected cervical spine disability. 4. Entitlement to service connection for a left ear disorder, including hearing loss, claimed as deaf left ear with shooting pains. 5. Entitlement to service connection for a disorder manifested by memory loss, including as secondary to the service-connected cervical spine disability. 6. Entitlement to service connection for a disorder manifested by drowsiness, including as secondary to the service-connected cervical spine disability. 7. Entitlement to service connection for Koch's infection, claimed as bronchitis. 8. Entitlement to service connection for a wrist disorder. 9. Entitlement to a disability rating in excess of 30 percent for residuals of a gunshot wound to the right arm with damage to Muscle Groups V and VI. REPRESENTATION Veteran represented by: The American Legion ATTORNEY FOR THE BOARD A. Lindio, Counsel INTRODUCTION The Veteran had service from June 1944 to April 1946. This matter comes to the Board of Veterans' Appeals (Board) on appeal from an October 2009 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Manila, the Republic of the Philippines. In a September 2008 rating decision, the RO denied, in pertinent part, claims of entitlement to service connection for headaches, a left ear disorder, a disorder manifested by memory loss, a disorder manifested by drowsiness, Koch's infection, and a wrist disorder. The rating decision also included a denial of an increased rating for residuals, gunshot wound of the right arm with damage to Muscle Groups V and VI. Following the receipt of additional evidence, the RO issued another rating decision in October 2009, which included those issues, and additional issues of entitlement to service connection for a right thumb disorder and a claim to reopen the claim for myopia with hyperopia. See 38 C.F.R. § 3.156(b) (2012). Thereafter, the Veteran appealed the October 2009 rating decision. The Board notes that, in addition to the paper claims file, there is a paperless, electronic (Virtual VA) claims file associated with the Veteran's claims. A review of the Virtual VA claims file does not reveal any additional documents pertinent to the present appeal. The Board notes that, in February 2008, the Veteran filed a claim for service connection for chest pain. The RO denied that claim, which was characterized as coronary artery disease, in the September 2008 rating decision. The Veteran filed a notice of disagreement (NOD) in May 2009. The RO issued a statement of the case (SOC) in November 2009. At that time, the RO also informed the Veteran that he had 60 days from the date of that letter (November 10, 2009) to appeal his claim. The Veteran subsequently filed a NOD dated November 10, 2009, with the other claims on appeal, which included an indication of disagreement with the coronary artery disease claim. The Board finds, however, that the Veteran had not intended the November 2009 communication to be a substantive appeal. That communication was clearly made as a NOD for his other claims and did not set forth specific arguments relating to errors of the SOC. Indeed, his NOD did not reference his SOC at all. Moreover, as they are the same date, it is clear that the documents crossed in the mail as November 10, 2009, was the mailing date of the SOC and the date that the Veteran drafted his correspondence. Furthermore, the Veteran later filed a substantive appeal in February 2010 for the SOC. That filing further indicates that the Veteran had not intended his prior November 2009 NOD to be considered a substantive appeal. The February 2010 substantive appeal, however, was received after the time period allotted. In August 2010, the RO informed the Veteran that his February 2010 substantive appeal was not timely and that, therefore, the decision had become final. The Veteran has not disputed that determination by the RO. Consequently, inasmuch as the RO has not taken any action to indicate to the Veteran that this issue remains on appeal and it took steps to close the appeal (see certification of Appeal [VA Form 8]), the requirement that there be a substantive appeal is not waived. The facts of this case are clearly distinguished from the United States Court of Appeals for Veterans Claims (Court)'s holding in Percy v. Shinseki, 23 Vet. App. 37 (2009), because in this appeal the Veteran was not mislead by actions on the part of VA into believing that he had perfected an appeal as to this issue. As such, the Board finds that the claim for service connection for coronary artery disease (claimed as chest pain) is not properly before the Board. The Board also notes that the September 2008 rating decision denied a compensable rating for entry and exit scars of the posterior and medial aspects of the right arm. In November 2009, the Veteran expressed disagreement as to such denial; however, such cannot be excepted as a timely NOD as it was received by VA over a year after the issuance of the September 2008 rating decision. Therefore, the Veteran is advised that, if he wishes to file a claim for a compensable rating for entry and exit scars of the posterior and medial aspects of the right arm, he should so inform the RO. The Veteran submitted additional evidence and argument in support of his claims on appeal. This evidence was accompanied without waiver of initial agency of original jurisdiction (AOJ) consideration. 38 C.F.R. § 20.1304(c) (2012). Those private medical records, however, are duplicative of medical records previously considered by the AOJ (in regard to the December 2009 record from Dr. A.T. Tactay), are not relevant to the claims decided by the Board herein (records regarding the Veteran's heart), or are only relevant to a claim that will be remanded (June 2011 record by Dr. R.O. Abiog regarding headaches). As such, there is no prejudice in the Board reviewing this evidence in the first instance. Please note this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2012). 38 U.S.C.A. § 7107(a) (2) (West 2002). The issues of service connection for a wrist disorder, headaches, and a left ear disorder are addressed in the REMAND portion of the decision below and are REMANDED to the RO via the Appeals Management Center (AMC), in Washington, D.C. FINDINGS OF FACT 1. In a final December 1950 rating decision, the RO denied a claim for service connection for myopia with hyperopia, finding that it was a constitutional or developmental abnormality. 2. The evidence added to the record since the December 1950 final denial is cumulative and redundant of the evidence of record at the time of such decision and does not raise a reasonable possibility of substantiating the Veteran's claim for service connection for myopia with hyperopia. 3. For the entire appeal period, the Veteran does not have a current diagnosis of a right thumb disorder separate and distinct from his already service-connected disabilities. 4. For the entire appeal period, the Veteran does not have a current diagnosis of a disorder manifested by memory loss. 5. For the entire appeal period, the Veteran does not have a current diagnosis of a disorder manifested by drowsiness. 6. For the entire appeal period, the Veteran does not have a current diagnosis of bronchitis or Koch's infection. 7. The Veteran's residuals of a gunshot wound to the right arm with damage to Muscle Groups V and VI does not result in functional loss more nearly approximating a severe muscle disability. CONCLUSIONS OF LAW 1. The December 1950 rating decision that denied service connection for myopia with hyperopia is final. 38 U.S.C. § 709 (1946) [38 U.S.C.A. § 7105 (West 2002); Veterans Regulation No. 2(a), Part II, Par. III; Department of Veterans Affairs Regulation 1008 [38 C.F.R. §§ 3.104, 20.302, 20.1103 (2000)]. 2. Evidence received since the December 1950 rating decision is not new and material; the claim of entitlement to service connection for myopia with hyperopia is not reopened. 38 U.S.C.A. § 5108 (West 2002 & Supp. 2012); 38 C.F.R. § 3.156(a) (2012). 3. The criteria for the establishment of service connection for a right thumb disorder have not been met. 38 U.S.C.A. §§ 1110, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304 (2012). 4. The criteria for the establishment of service connection for a disorder manifested by memory loss have not been met. 38 U.S.C.A. §§ 1110, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304, 3.310 (2012). 5. The criteria for the establishment of service connection for a disorder manifested by drowsiness have not been met. 38 U.S.C.A. §§ 1110, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304, 3.310 (2012). 6. The criteria for the establishment of service connection for Koch's infection, claimed as bronchitis, have not been met. 38 U.S.C.A. §§ 1101, 1110, 1112, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304, 3.307, 3.309 (2012). 7. The criteria for an evaluation in excess of 30 percent for residuals of a gunshot wound to the right arm with damage to Muscle Groups V and VI have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.3, 4.7, 4.73, Diagnostic Code 5305 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS VA's Duties to Notify and Assist With regard to the claims on appeal, VA has met the duty to notify and assist the claimant in substantiating this claim for VA benefits, as provided by the Veterans Claims Assistance Act of 2000 (VCAA). 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). Proper notice from VA must inform the claimant of any information and medical or lay evidence not of record that is necessary to substantiate the claim. Proper notice will inform the Veteran of what evidence VA will seek to provide, and of what evidence the claimant is expected to provide, in accordance with 38 C.F.R. § 3.159(b)(1) (2011). Quartuccio v. Principi, 16 Vet. App. 183 (2002). This notice must be provided prior to an initial unfavorable decision on a claim by the RO. Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004). In addition, the notice requirements of the VCAA apply to all five elements of a service-connection claim, including: (1) Veteran status; (2) existence of a disability; (3) a connection between the Veteran's service and the disability; (4) degree of disability; and (5) effective date of the disability. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). Further, this notice must include information regarding the disability rating and effective date for the award of benefits if service connection is awarded. Id. at 486. The U.S. Court of Appeals for the Federal Circuit previously held that any errors in notice required under the VCAA should be presumed to be prejudicial to the claimant unless VA shows that the error did not affect the essential fairness of the adjudication. See Sanders v. Nicholson, 487 F.3d 881 (Fed. Cir. 2007). Under Sanders, VA bore the burden of proving that such an error did not cause harm. Id. In the case Shinseki v. Sanders, 129 S.Ct. 1696 (2009), however, the U.S. Supreme Court held that the Federal Circuit's blanket presumption of prejudicial error in all cases imposed an unreasonable evidentiary burden upon VA. Rather, in Shinseki v. Sanders, the Supreme Court suggested that determinations concerning prejudicial error and harmless error should be made on a case-by-case basis. Id. As such, in conformance with the precedents set forth above, on appellate review the Board must consider, on a case-by-case basis, whether any potential VCAA notice errors are prejudicial to the claimant. In Kent v. Nicholson, 20 Vet. App. 1 (2006), the Court held that the VCAA notice requirements in regard to new and material evidence claims require VA to send a specific notice letter to the claimant that: (1) notifies him or her of the evidence and information necessary to reopen the claim (i.e., describes what is meant by new and material evidence); (2) identifies what specific evidence is required to substantiate the element or elements needed for service connection that were found insufficient in the prior denial on the merits; and (3) provides general VCAA notice for the underlying service connection claim. In this case, the notice letter provided to the Veteran in July 2009, which was issued prior to the initial October 2009 rating decision, advised him that such claim had been previously denied in December 1950 on the basis that such disorder was a constitutional or developmental abnormality. The Veteran was also provided with the definition of new and material evidence as well as advised of the information and evidence necessary to substantiate his underlying service connection claim. Such letter also advised him of the information and evidence necessary to establish a disability rating and an effective date in accordance with Dingess/Hartman, supra. Therefore, the Board finds that such letter has satisfied the requirements as articulated in Kent, supra. For the service connection claims decided herein, VA satisfied the VCAA duty to notify by way of a letters sent to the Veteran in July 2008 and July 2009 that fully addressed all of the notice elements and was sent prior to the initial RO decision in October 2009. Through such letters, VA informed him of what evidence was required to substantiate his service connection claims and of his and VA's respective duties for obtaining evidence. VA also informed him that his service connection claim must be supported by evidence indicating a current disability, evidence that the injury or disease was incurred or aggravated during service, and medical evidence of a nexus between the current disability and the in-service injury or disease. VA informed him that VA would seek to provide federal records and that it was his responsibility to support his claim with appropriate evidence, though VA would help him obtain records from any non-federal sources. VA also informed the Veteran that service connection can be awarded on a secondary basis, when a disorder is either caused or aggravated by a service-connected disability In a claim for increase, the VCAA requirement is generic notice, that is, the type of evidence needed to substantiate the claim, namely, evidence demonstrating a worsening or increase in severity of the disability and the effect that worsening has on employment, as well as general notice regarding how disability ratings and effective dates are assigned. Vazquez-Flores v. Shinseki, 580 F.3d 1270 (Fed. Cir. Sept. 4, 2009). In this case, the July 2009 letter also informed the Veteran that the evidence must support a worsening of his disability to substantiate the increased rating claim. The letter also informed him of VA's duty for obtaining pertinent evidence under federal control and that it would aid him in obtaining pertinent evidence not under federal control, but that it was his responsibility to obtain such evidence. The July 2008 and July 2009 letters also advised him of the information and evidence necessary to establish a disability rating and an effective date in accordance with Dingess/Hartman, supra. Under these circumstances, the Board finds that the notification requirements of the VCAA have been satisfied as to both timing and content. Therefore, adequate notice was provided to the Veteran prior to the transfer and certification of his case to the Board and VA has complied with the requirements of 38 U.S.C. § 5103(a) and 38 C.F.R. § 3.159(b). Next, VA has a duty to assist the Veteran in the development of the claim. This duty includes assisting the Veteran in obtaining any outstanding records of identified VA or private medical treatment relevant to his claim, and affording him an examination when appropriate. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. With regard to records, VA has associated with the claims folder the Veteran's service treatment records and pertinent VA medical records. The Veteran has also submitted private medical records and lay statements. The Veteran has not indicated that there exist any records of VA or private medical treatment relative to the claims decided herein that are not already in the claims file. The duty to assist under 38 U.S.C.A. § 5103A (d) and 38 C.F.R. § 3.159(c)(4) is triggered when it is necessary to obtain an examination to make a decision in the case. Factors to consider in determining whether an examination is necessary include whether there is evidence of a current disability, and whether there is evidence that the disability may be associated with the appellant's military service or another service-connected disability but there is not sufficient medical evidence to make a decision on the claim. See McLendon v. Nicholson, 20 Vet. App. 79, 81 (2006). The Board does not find that examinations are not necessary to decide the claims for service connection for disorders manifested by memory loss or drowsiness, bronchitis (including Koch's infection) or a right thumb disorder. The claims file contains no competent evidence of current diagnoses of memory loss, drowsiness, bronchitis, or Koch's infection. Additionally, as will be explained herein, there is no competent evidence to indicate that he has a current diagnosis of a right thumb disorder that is separate and distinct from his already service-connected disabilities. Therefore, the Board finds that a VA examination and/or opinion is not necessary to decide the claims. In addition, the Veteran was afforded a VA medical examination in July 2009 for his increased rating claim. Neither the Veteran nor his representative has alleged that such is inadequate for rating purposes or that such disability has increased in severity since such time. Moreover, the Board finds that the examination is adequate in order to evaluate the Veteran's service-connected residuals of a gunshot wound to the right arm as it includes an interview with the Veteran, a review of the record, and a full physical examination, addressing the relevant rating criteria. Therefore, the Board finds that the examination report of record is adequate to adjudicate the Veteran's increased rating claim and no further examination is necessary. The Board notes that the Veteran has not been provided with a VA examination in connection with his application to reopen his previously denied claim of entitlement to service connection for myopia with hyperopia; however, the VCAA and its implementing regulations include clear guidelines consistent with the intent of Congress regarding the timing and the scope of assistance VA will provide to a claimant who attempts to reopen a previously denied claim. See 38 C.F.R. § 3.159(c)(1),(2) and (3). Such assistance includes obtaining service records, records in the custody of a Federal agency, and private records adequately identified by the claimant, but, prior to reopening a claim, there is no duty to obtain a VA medical examination or opinion. As the Veteran's claim of entitlement to service connection for myopia with hyperopia is not reopened herein, there is no obligation on the part of VA to provide a medical examination or opinion in connection with his appeal. Significantly, neither the Veteran nor his representative has 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. The Board finds that all necessary development has been accomplished, and therefore appellate review may proceed without prejudice to the Veteran. See Bernard v. Brown, 4 Vet. App. 384 (1993). Hence, no further notice or assistance to the Veteran is required to fulfill VA's duty to assist in the development of the claim. Smith v. Gober, 14 Vet. App. 227 (2000), aff'd, 281 F.3d 1384 (Fed. Cir. 2002); Dela Cruz v. Principi, 15 Vet. App. 143 (2001); see also Quartuccio v. Principi, 16 Vet. App. 183 (2002). Service Connection Law Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C.A. § 1110; 38 C.F.R. § 3.303(a). Service connection may also be granted for any disease diagnosed after discharge, when all of the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Direct service connection may not be granted without evidence of a current disability; in-service incurrence or aggravation of a disease or injury; and a nexus between the claimed in-service disease or injury and the present disease or injury. 38 U.S.C.A. § 1112; 38 C.F.R. § 3.304. See also Caluza v. Brown, 7 Vet. App. 498, 506 (1995) aff'd, 78 F.3d 604 (Fed. Cir. 1996) [(table)]. Alternatively, service connection may be established under 38 C.F.R. § 3.303(b) by (a) evidence of (i) the existence of a chronic disease in service or during an applicable presumption period under 38 C.F.R. § 3.307 and (ii) present manifestations of the same chronic disease, or (b) when a chronic disease is not present during service, evidence of continuity of symptomatology. Where a Veteran served for at least 90 days during a period of war or after December 31, 1946, and manifests certain chronic diseases, to include tuberculosis, to a degree of 10 percent within three years from the date of termination of such service, such disease shall be presumed to have been incurred or aggravated in service, even though there is no evidence of such disease during the period of service. 38 U.S.C.A. §§ 1101, 1112; 38 C.F.R. §§ 3.307, 3.309. Service connection can also be granted when a disability is the proximate result of or due to a service-connected disease or injury. 38 C.F.R. § 3.310(a). See Libertine v. Brown, 9 Vet. App. 521, 522 (1996); Harder v. Brown, 5 Vet. App. 183, 187 (1993). Additionally, the aggravation of a nonservice-connected condition by a service-connected condition is also compensable under 38 C.F.R. § 3.310(a). Allen v. Brown, 7 Vet. App. 439, 448 (en banc). Establishing service connection on a secondary basis therefore requires evidence sufficient to show (1) that a current disability exists and (2) that the current disability was either caused by or aggravated by a service connected disability. Id. 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; 38 C.F.R. § 3.102; see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). New and Material Evidence Claim The Veteran currently contends that he has myopia with hyperopia due to service. Under the law, congenital or developmental defects, to include a refractive error of the eye such as myopia and hyperopia are not diseases or injuries in the meaning of applicable legislation for disability compensation purposes. 38 C.F.R. §§ 3.303(c), 4.9. A congenital defect can be subject to superimposed disease or injury, and if that superimposed disease or injury occurs during military service, service-connection may be warranted for the resultant disability. VAOPGCPREC 82-90. The RO originally denied service connection for an eye condition in a December 1950 rating decision, finding him to have for myopia with hyperopia, which was a constitutional or developmental abnormality and not a disability under the law. The Veteran did not file an application for review on appeal within one year of the decision. Therefore, such decision is final. 38 U.S.C. § 709 (1946) [38 U.S.C.A. § 7105 (West 2002); Veterans Regulation No. 2(a), Part II, Par. III; Department of Veterans Affairs Regulation 1008 [38 C.F.R. §§ 3.104, 20.302, 20.1103 (2000)]. In this regard, the Board has considered the applicability of 38 C.F.R. § 3.156(b), which provides that, when new and material evidence is received prior to the expiration of the appeal period, it will be considered as having been filed in connection with the claim which was pending at the beginning of the appeal period. However, in the instant case, such regulation is inapplicable as no evidence pertaining to the Veteran's claim for service connection for myopia with hyperopia was received prior to the expiration of the appeal period stemming from the December 1950 rating decision. See also Bond v. Shinseki, 659 F.3d 1362, 1367 (Fed. Cir. 2011); Roebuck v. Nicholson, 20 Vet. App. 307, 316 (2006); Muehl v. West, 13 Vet. App. 159, 161-62 (1999). Thereafter, the RO received the Veteran's petition to reopen the claim in October 2008. Rating actions are final and binding based on evidence on file at the time the claimant is notified of the decision and may not be revised on the same factual basis except by a duly constituted appellate authority. 38 C.F.R. § 3.104(a). The claimant has one year from notification of an RO decision to initiate an appeal by filing a notice of disagreement with the decision, and the decision becomes final if an appeal is not perfected within the allowed time period. 38 U.S.C.A. § 7105(b) and (c); 38 C.F.R. §§ 3.160(d), 20.200, 20.201, 20.202, and 20.302(a). Generally, a claim which has been denied in an unappealed Board decision or an unappealed RO decision may not thereafter be reopened and allowed. 38 U.S.C.A. §§ 7104(b) , 7105(c). The exception to this rule is 38 U.S.C.A. § 5108 , which provides that if new and material evidence is presented or secured with respect to a claim which has been disallowed, the Secretary shall reopen the claim and review the former disposition of the claim. New evidence means existing evidence not previously submitted to agency decisionmakers. Material evidence means existing evidence that, by itself or when considered with previous evidence of record, relates to an unestablished fact necessary to substantiate the claim. New and material evidence can be neither cumulative nor redundant of the evidence of record at the time of the last prior final denial of the claim sought to be reopened, and must raise a reasonable possibility of substantiating the claim. 38 C.F.R. § 3.156(a) . The Court has held that the determination of whether newly submitted evidence raises a reasonable possibility of substantiating the claim should be considered a component of the question of what is new and material evidence, rather than a separate determination to be made after the Board has found that evidence is new and material. See Shade v. Shinseki, 24 Vet. App. 110 (2010). The Court further held that new evidence would raise a reasonable possibility of substantiating the claim if, when considered with the old evidence, it would at least trigger the Secretary's duty to assist by providing a medical opinion. Id. For the purpose of establishing whether new and material evidence has been submitted, the credibility of the evidence is to be presumed. Justus v. Principi, 3 Vet. App. 510, 513 (1992). Since December 1950, the RO received VA and private medical records without any indication of complaints of, or treatment for, the eyes. The RO also received lay evidence from the Veteran repetitive of his previous reports of an eye disorder since service. The Board concludes that the Veteran's statements regarding the relationship between his myopia with hyperopia and service are duplicative of the evidence of record at the time of the December 1950 rating decision and, therefore, is not new. On the other hand, the medical evidence received since the December 1950 rating decision is new, as it has not been previously considered. However, the evidence is not material because it does not show that the Veteran's diagnosed refractive error of the eye, i.e., myopia with hyperopia was subject to superimposed disease or injury during service that resulted in additional disability. Therefore, the additional evidence received, while new, is not material since it does not relate to an unestablished fact necessary to substantiate the service connection claim, and does not raise a reasonable possibility of substantiating the claim. Accordingly, the Board finds that the claim for service connection may not be reopened. Service Connection Claims Right Thumb Disorder The Veteran contends that he is unable to use his right thumb and such loss is due to service. In an August 1995 statement, the Veteran reported that his thumb gave him severe pain and that he could not move it due to his damaged nerves. The Board notes VA has previously found the Veteran to be right hand dominant. Additionally, the Veteran is already service-connected for: a) residuals of a gunshot wound of the right arm with injury to the brachial plexus and ankylosis of the middle, ring and little fingers; b) residuals of a gunshot wound of the right arm with damage to Muscle Groups V and VI; c) residuals of a gunshot wound of the right arm with damage to Muscle Group II; d) degenerative disc disease of the cervical spine and e) cervical radiculopathy of the right upper extremity. The Board finds that service connection is not warranted for a right thumb disorder as a separately rated disability. In making this determination, the Board notes that the Veteran sustained a gunshot wound to the right arm March 1945 and developed a poor grip in service, as documented in his abbreviated clinical record received by VA in December 1946. In a December 1950 rating decision, the RO granted the Veteran a separate rating of 20 percent for his brachial plexus injury, as a residual of his gunshot wound of the right arm. The RO treated that disability as separate from the Veteran's other already service-connected gunshot wound residuals. After service, VA and private medical records generally document continued nerve complaints following service through the right arm and hand. For example, August 1954 and September 1965 records from Dr. E.R. Elaydo and the December 1965 VA examination report documented such findings. In a December 1965 rating decision, the RO granted a 40 percent disability rating for the brachial plexus injury residuals of a gunshot wound, with favorable ankylosis of three fingers. Subsequent VA and private medical records continued to document some paralysis of the right arm through the hand. For example, in March 1967 and August 1975, Dr. E.L. Reyes reported paralysis of the right arm, forearm and hand. In a February 1976 VA examination report, the examiner noted weakness of extension and flexion of the fingers. Similarly, a February 1982 VA examiner noted limitation of motion of the right fingers. In a December 1992 VA discharge report, the VA medical provider found the Veteran to have electrodiagnostic evidence of right cervical radiculopathy. The report of a March 1995 VA hand examination indicated that the Veteran was unable to grasp small objects, especially with the middle, ring, and little fingers. The right thumb could approximate the middle, ring, and small fingers and could approximate the median transverse fold of the palm by one half inch. The Veteran could carry five pounds in the right hand for about two to three minutes, was limited in lifting, carrying, or transporting loads and in repetitive action or movement of his hands and fingers. In a September 1996 VA examination, the Veteran received a diagnosis of radiculopathy of the C6/C7 bilateral. In an August 2004 VA examination report, the Veteran complained of having a right powerless grip and numbness. The examiner found right, chronic radial neuropathy and bilateral, mild carpal tunnel syndrome. In an in August 2004 VA muscle, joint, hand, and bones examinations, the examiner indicated that the right hand grip was fair. The Veteran reported weakness, flare-ups two to three times per week and that he could not hold objects for too long. Physical examination revealed that the Veteran was able to approximate the proximal transverse crease of the palm, but could not approximate the finger by 0.5 centimeter with the right thumb or oppose the fingers by one inch. Grip strength was 4/5. The diagnosis was residual of gunshot wound to the right arm with brachial plexus injury with limitation of the elbow. In June 2006, the Board granted service connection for a chronic cervical disorder. In a VA hand examination in April 2007, the examiner concluded that the Veteran had mild or moderate impairment of his right upper extremity. In April 2007, the Veteran received an aid and attendance examination. The Veteran complained of right hand pain and numbness. The examiner noted a less than one inch gap between the right thumb pad the tips of finger and found the right hand grip to be fair. The examiner found pain on the right hand and numbness. In May 2007, the Veteran received a peripheral neuropathy VA examination. The Veteran complained of having a poor grip of the right hand. The Veteran complained of upper arm and forearm weakness, numbness and paresthesias. The examiner found the Veteran to have a poor grip bilaterally. The examiner diagnosed the Veteran with chronic, right radial neuropathy and bilateral carpal tunnel syndrome. The examiner found the poor grip to be related to the diagnoses. In an August 2007 rating decision, the RO initiated the Board's grant of service connection for degenerative disc disease of the cervical spine. At that time, the RO also granted service connection for cervical radiculopathy or the right upper extremity, as secondary to the service-connected cervical spine. In a June 2008 VA peripheral neuropathy examination, the examiner noted a history of poor grip since March 1945. The examiner diagnosed the Veteran chronic, right radial neuropathy and bilateral carpal tunnel syndrome. A June 2008 VA hand examiner noted a history of flare-ups of right hand symptoms to include all fingers. The Veteran reported flare-ups two times per week and being unable to grasp firmly or hold light objects with his right hand at those times. There was a gap of less than on inch on attempt to approximate the thumb pad and tips of the fingers. There was moderate decreased strength for pushing, pulling, and twisting. The examiner noted that the long, ring, and little fingers were extended due to the brachial nerve injury. There was pain on active motion and after repetitive use. The diagnosis was injury to the right brachial plexus with ankylosis of three fingers due to gunshot wound. In a December 2009 private medical record, Dr. A.T. Tactay diagnosed the Veteran with cervical disc disease, with spinal stenosis; paresis right upper extremity. The examiner found sensory loss to the right hand. In a November 2010 VA spine examination, the examiner found the cervical spine to have sensory involvement of the right upper extremity peripheral nerve. The examiner found the right thumb to have active movement against full resistance. None of the medical evidence of record indicates that the Veteran has a right thumb disorder that has not already been considered as part of his already service-connected disabilities. In fact, the foregoing evidence indicates that the Veteran's symptomatology associated with his right thumb, include limitation of motion and poor grip strength, are manifestations of his service-connected disabilities and are already compensated in the disability ratings assigned to such disabilities. In this regard, the Veteran is already service-connected for a brachial plexus injury, as a residual of his gunshot wound to the right arm, with ankylosis of the middle, ring and little fingers (granted a separate rating in a December 1950 rating decision). That service-connected disability contemplates consideration of the thumb and is rated under Diagnostic Codes 8512-5222. Diagnostic Code 8512 contemplates paralysis of the lower radicular group and Diagnostic Code 5222 contemplates favorable ankylosis if three digits of one hand. The Veteran was granted a 30 percent disability rating in consideration of three fingers. A higher rating would contemplate additional ankylosis of the thumb (under Diagnostic Code 5222 for three digits including the thumb or Diagnostic Code 5221 for four digits including the thumb). As such, the Veteran's thumb was already considered to be part of the service-connected brachial plexus injury and was considered in determining the rating of that injury. The Board further notes, that any additional nerve impairment to the thumb not already contemplated by the brachial plexus injury is already contemplated by the service-connected cervical radiculopathy of the right upper extremity (granted in an August 2007 rating decision). That disability is rated under Diagnostic Code 8699-8615. The RO rated the Veteran's radiculopathy of the right upper extremity by analogy to for paralysis of the median nerve. See 38 C.F.R. § 4.20 (when an unlisted condition is encountered it will be permissible to rate it under a closely related disease or injury, in which not only the functions affected, but the anatomical localization and symptomatology are closely analogous); see also 38 C.F.R. § 4.27. Diagnostic Code 8615 contemplates incomplete and complete paralysis of the median nerve, including to the hand and fingers, and specifically including the thumb. The Board thus finds that the Veteran's thumb has already been contemplated in rating his already service-connected gunshot wound to the right arm, with injury to the brachial plexus and ankylosis of the three fingers, and his cervical radiculopathy of the right upper extremity. In general, all disabilities, including those arising from a single disease entity, are rated separately, and all disability ratings are then combined in accordance with 38 C.F.R. § 4.25. Pyramiding, the evaluation of the same disability, or the same manifestation of a disability, under different diagnostic codes, is to be avoided when rating a Veteran's service-connected disabilities. 38 C.F.R. § 4.14. It is possible for a Veteran to have separate and distinct manifestations from the same injury which would permit rating under several diagnostic codes, however, the critical element in permitting the assignment of several ratings under various diagnostic codes is that none of the symptomatology for any one of the conditions is duplicative or overlapping with the symptomatology of the other condition. See Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994). In reaching such a decision, the Board has considered the Veteran's own statements indicating that he has a current right thumb disorder separate and distinct from his service-connected disabilities; however, the Board finds that, as a lay person, he is not competent to render such an etiological opinion. In this regard, the question of causation involves a medical subject concerning an internal physical process extending beyond an immediately observable cause-and-effect relationship. As such, the question of etiology in this case may not be competently addressed by lay evidence, and the Veteran's own opinion is nonprobative evidence. See Woehlaert v. Nicholson, 21 Vet. App. 456 (2007) (although the claimant is competent in certain situations to provide a diagnosis of a simple condition such as a broken leg or varicose veins, the claimant is not competent to provide evidence as to more complex medical questions). Therefore, as the Veteran does not have a thumb disability separate from his already service-connected disabilities, to assign a separate rating for the thumb alone would compensate the Veteran for the same symptoms already considered and violate the rule against pyramiding. See 38 C.F.R. § 4.14; Esteban, 6 Vet. App. at 261-62. As the preponderance of the evidence is against the claim, the benefit of the doubt rule does not apply. Gilbert v. Derwinski, 1 Vet. App. 49, 58 (1990). The Veteran's claim for service connection for a thumb disorder is denied. Disorders Manifested by Memory Loss & Drowsiness The Veteran contends that he has a disorder manifested by memory loss, including as secondary to his service-connected cervical spine disability. He similarly contends to have a disorder manifested by drowsiness, including as secondary to his service-connected cervical spine disability. In a May 1953 statement, the Veteran reported that he was losing his memories and easily tired. In a November 1997 statement, the Veteran reported that following his cervical spine operation, he developed loss of memory. In a July 1998 statement, the Veteran reported that he has daily drowsiness when looking up or down, which began following his cervical spine surgery. The Veteran underwent an operation to the cervical spine in June 1993. The Veteran's service treatment records do not document any complaints of, or treatment for, either memory loss or drowsiness. The medical evidence of record also does not document that the Veteran has been diagnosed with disorders manifested by either memory loss or drowsiness. Indeed, at most, a December 1992 VA discharge record noted that the Veteran had been prescribed Elavil for neurological treatment, but because of marked lethargy that treatment was cancelled. That record did not indicate that the lethargy continued after that time. Additionally, in an October 2001 VA medical record, the Veteran complained of short-term memory loss, which he said began after his 1993 cervical spine surgery. None of the medical evidence, however includes a diagnosis of memory loss or drowsiness, or for a disorder manifested by either memory loss or drowsiness. The only evidence of record supportive of the Veteran's claims is his contention that he has memory loss and drowsiness due to his service or his service-connected cervical spine disability. Although lay persons are competent to provide opinions on some medical issues, see Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011), as to the specific issues in this case, i.e., whether the Veteran has a medically diagnosed disorder manifested by memory loss or drowsiness and whether such disorder is etiologically related to service or the Veteran's service-connected cervical spine disability, such questions falls outside the realm of common knowledge of a lay person as they involve a medical subject concerning an internal physical process extending beyond an immediately observable cause-and-effect relationship. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007) (lay persons not competent to diagnose cancer); see also Woehlaert, supra. The existence of a current disability is the cornerstone of a claim for VA disability compensation. See Degmetich v. Brown, 104 F. 3d 1328 (1997) (holding that the VA's and the Court's interpretation of sections 1110 and 1131 of the statute as requiring the existence of a present disability for VA compensation purposes cannot be considered arbitrary and therefore the decision based on that interpretation must be affirmed); see also Gilpin v. West, 155 F.3d 1353 (Fed. Cir. 1998). The requirement that a current disability be present is satisfied when a claimant has a disability at the time a claim for VA disability compensation is filed or during the pendency of that claim, even if the disability resolves prior to the adjudication of the claim. See McClain v. Nicholson, 21 Vet. App. 319 (2007). As the Veteran does not have a current diagnosis of disorders characterized by memory loss or drowsiness at any point during the appeal period, service connection cannot be granted. As the preponderance of the evidence is against the claims, the benefit of the doubt rule does not apply. Gilbert, 1 Vet. App. at 58. The Veteran's claims for service connection for memory loss and drowsiness, including as secondary to the service-connected cervical spine disability, are denied. Koch's Infection/Bronchitis The Veteran contends that he has had bronchitis or Koch's infection chronically since service. The Board notes that Koch's infection is also known as tuberculosis. See http://www.thefreedictionary.com/Koch%27s+Disease. The Veteran's abbreviated clinical record documents that he contracted malaria in October 1945, which lasted for three days. The malaria recurred in November 1945 for two days. The record also noted that the Veteran's family did not have a history of tuberculosis. The records do not indicate that the Veteran contracted bronchitis or Koch's infection in service. In September 1952, Dr. L.O. Dacanay reported that noted that the Veteran had a diagnosis of bronchitis, chronic. In August 1954, Dr. E. R. Elaydo also diagnosed the Veteran with bronchitis, chronic. Subsequent VA and private medical records do not document any diagnoses of bronchitis or Koch's infection/tuberculosis. The Veteran contends that he has had as bronchitis, including Koch's infection, chronically since service. Although lay persons are competent to provide opinions on some medical issues, see Kahana, 24 Vet. App. at 435, as to the specific issues in this case, of whether the Veteran has current diagnoses of bronchitis or Koch's infection/tuberculosis, such questions falls outside the realm of common knowledge of a lay person as they involve a medical subject concerning an internal physical process extending beyond an immediately observable cause-and-effect relationship. See Jandreau, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007) (lay persons not competent to diagnose cancer); see also Woehlaert, supra. The Veteran does not have a current medical diagnosis of bronchitis or Koch's infection/tuberculosis. The existence of a current disability is the cornerstone of a claim for VA disability compensation. See Degmetich, supra; see also Gilpin, supra. The Board notes that the Veteran received diagnoses of bronchitis in the 1950's, several decades prior to the current claim (which was initiated in October 2008). However, the record does not show that he currently continues to have bronchitis. Compensation only may be awarded to an applicant who has disability existing on the date of application, not for past disability. See McClain, supra (the requirement that a current disability be present is satisfied when a claimant has a disability at the time a claim for VA disability compensation is filed or during the pendency of that claim, even if the disability resolves prior to the adjudication of the claim). As the preponderance of the evidence is against the claim, the benefit of the doubt rule does not apply. Gilbert, 1 Vet. App. at 58. The Veteran's claim for service connection for as bronchitis, including Koch's infection/tuberculosis, is denied. Increased Rating Claim The Veteran contends that his service-connected residuals, gunshot wound of the right arm with damage to Muscle Groups V and VI, is more severe than indicated by his current 30 percent disability rating. The Board notes that the Veteran also receives separate disability ratings for other residuals of his gunshot wound. In this regard, he has a 40 percent disability rating for residuals of gunshot wound with injury to the brachial plexus and ankylosis of three fingers. He further has a 20 percent disability rating for residuals of gunshot wound to Muscle Group II. However, such issues are not currently before the Board. Historical Background Service treatment records, specifically his abbreviated clinical record received by VA in December 1946, document that the Veteran sustained a gunshot wound to the right arm in March 1945, was given first aid and transferred to a Base Hospital at Camp Spencer and discharged and returned to his unit in May 1945. On physical examination, there was a linear scar on the upper third of his right arm on the posterolateral surface, which was about one centimeter long. The Veteran complained of pain over the extreme surface of his forearm and along the lower third. He could not flex his fingers completely. He complained of pain at the exit wound downwards to the elbow. X-rays indicated no fracture of the right humerus. The diagnosis was inability to flex the right hand completely and pain along the exterior surface of the right forearm secondary to through and through gunshot wound of the upper third of the right arm. The examiner found the Veteran to be unfit for duty due and recommended a disability discharge. During the present appeal (following the final Board decision of January 2009 wherein the Board denied an increased rating for the same disability), the only pertinent evidence of record with medical findings for rating purposes is the July 2009 VA muscles and joints examinations, which included a review of the claims file, and were both performed by the same VA examiner. The July 2009 VA examiner noted that the Veteran was struck by a single bullet with injury to Muscle Groups V, VI and II. As previously noted, the Veteran's injury to Muscle Group II is not on appeal. The July 2009 VA examiner noted that the injury was a through and through injury and that the wound was not initially infected before healing. The examiner found associated bone, nerve, vascular or tendon injury of weakness of right hand grip. The examiner also noted a history of pain, increased fatigability, weakness, numbness and tingling sensation of the right upper extremity and fingers. The Veteran reported moderate flare-ups weekly, lasting hours. There was no decreased coordination or uncertainty of movement. On physical examination, the July 2009 VA examiner found Muscle Group V (biceps) muscle strength to be 3, with tissue loss. Muscle Group VI (triceps) muscle strength was also 3, with tissue loss. The examiner found no intermuscular scarring. The examiner found functional weakness to the right upper arm and poor hand grip. The examiner also found the scars to be healed and not painful or tender to touch. The entry wound scar was slightly depressed and non-adherent, measuring about 0.5 x 1 cm. The exit wound scar was slightly depressed and adherent, about 1 x 1.5 cm. The examiner noted residual nerve damage of the right brachial plexus, which the Veteran is separately service-connected for and, as previously noted, is not part of the current appeal. In the muscles examination, the VA examiner found no residuals of tendon or bone damage or any muscle herniation. The examiner also found a loss of deep fascia or muscle substance and limitation of motion of the right shoulder. Per the joints VA examination report, the right elbow/forearm had flexion/extension from 0 to 145 degrees, pronation from 0 to 80 degrees and supination from 0 to 75 degrees. There was also additional pain with repetitive motion and a loss of 10 degrees of flexion and 5 degrees of pronation and supination. In July 2009 joints examination report, the examiner found the Veteran's condition to have moderate to severe effects on usual daily activities. In the July 2009 muscles examination report, the examiner diagnosed the Veteran with residual of gunshot wound, through and through, right arm with injury to Muscle Group V and VI. The examiner found limitation of motion of elbow and pain of the right arm and shoulder. The examiner also noted decreased manual dexterity and problems lifting and carrying. The examiner found it to generally have a moderate effect on usual daily activities. Analysis 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 the symptomatology with the criteria set forth in the Schedule for Rating Disabilities. The percentage ratings represent, as far as can practicably be determined, the average impairment in earning capacity resulting from such diseases and injuries and the residual conditions in civilian life. Generally, the degree of disability specified are considered adequate to compensate for considerable loss of working time from exacerbations or illnesses proportionate to the severity to the several grades of disability. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. Separate Diagnostic Codes identify the various disabilities and the criteria for specific ratings. If two disability evaluations are potentially applicable, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that evaluation. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. After careful consideration of the evidence, any reasonable doubt remaining will be resolved in favor of the Veteran. 38 C.F.R. § 4.3. While the Veteran's entire history is reviewed when making a disability determination, where service connection has already been established and an increase in the disability rating is at issue, it is a present level of disability that is of primary concern. Francisco v. Brown, 7 Vet. App. 55 (1994). The United States Court of Appeals for Veterans Claims (Court) has held that in determining the present level of a disability for any increased evaluation claim, the Board must consider the application of staged ratings. See Hart v. Mansfield, 21 Vet. App. 505 (2007). In other words, where the evidence contains factual findings that demonstrate distinct time periods in which the service-connected disability exhibited diverse symptoms meeting the criteria for different ratings during the course of the appeal, the assignment of staged ratings would be necessary In determining the degree of limitation of motion, the provisions of 38 C.F.R. §§ 4.10, 4.40, and 4.45 are for consideration. DeLuca v. Brown, 8 Vet. App. 202 (1995). The basis of disability evaluation is the ability of the body as a whole, or of the psyche, or of a system or organ of the body to function under the ordinary conditions of daily life including employment. 38 C.F.R. § 4.10. Disability of the musculoskeletal system is primarily the inability, due to damage or infection in parts of the system, to perform the normal working movements of the body with normal excursion, strength, speed, coordination, and endurance. Functional loss may be due to the absence or deformity of structures or other pathology, or it may be due to pain, supported by adequate pathology and evidenced by the visible behavior in undertaking the motion. Weakness is as important as limitation of motion, and a part that becomes painful on use must be regarded as seriously disabled. 38 C.F.R. § 4.40. With respect to joints, in particular, the factors of disability reside in reductions of normal excursion of movements in different planes. Inquiry will be directed to more or less than normal movement, weakened movement, excess fatigability, incoordination, pain on movement, swelling, deformity or atrophy of disuse. 38 C.F.R. § 4.45. The Court clarified that although pain may be a cause or manifestation of functional loss, limitation of motion due to pain is not necessarily rated at the same level as functional loss where motion is impeded. See Mitchell v. Shinseki, 25 Vet. App. 32 (2011); cf. Powell v. West, 13 Vet. App. 31, 34 (1999); Hicks v. Brown, 8 Vet. App. 417, 421 (1995); Schafrath v. Derwinski, 1 Vet. App. 589, 592 (1991). Instead, the Mitchell Court explained that pursuant to 38 C.F.R. §§ 4.40 and 4.45, the possible manifestations of functional loss include decreased or abnormal excursion, strength, speed, coordination, or endurance, as well as less or more movement than is normal, weakened movement, excess fatigability, and pain on movement (as well as swelling, deformity, and atrophy) that affects stability, standing, and weight-bearing. See 38 C.F.R. §§ 4.40, 4.45. Thus, functional loss caused by pain must be rated at the same level as if the functional loss were caused by any of the other factors cited above. The intent of the Rating Schedule is to recognize actually painful, unstable or malaligned joints, due to healed injury, as entitled to at least the minimum compensable rating for the joint. 38 C.F.R. § 4.59. The provisions of 38 C.F.R. § 4.59 are not limited to arthritis and must be considered when raised by the claimant or when reasonably raised by the record. Burton v. Shinseki, 25 Vet. App. 1 (2011). The factors to be considered in evaluating disabilities residual to healed wounds involving muscle groups are set forth in 38 C.F.R. §§ 4.55, 4.56. A muscle injury evaluation will not be combined with a peripheral nerve paralysis evaluation of the same body part unless the injuries affect entirely different functions. 38 C.F.R. § 4.55(a). A through-and-through injury with muscle damage shall be evaluated as no less than a moderate injury for each group of muscles damaged. 38 C.F.R. § 4.56(b). The type of injury associated with a moderately severe muscle disability is a through and through or deep penetrating wound by a small high-velocity missile or large low-velocity missile, with debridement, prolonged infection, or sloughing of soft parts, and intermuscular scarring. A history with regard to this type of injury should include prolonged hospitalization in service for treatment of wound, consistent complaints of cardinal signs and symptoms of muscle disability, and, if present, evidence of inability to keep up with work requirements. Objective findings should include entrance and (if present) exit scars indicating the track of the missile through one or more muscle groups, and indications on palpation of loss of deep fascia, muscle substance, or normal firm resistance of muscles compared with the sound side. Tests of strength and endurance compared with sound side should demonstrate positive evidence of impairment. 38 C.F.R. § 4.56(d)(3). The type of injury associated with a severe muscle disability is a through and through or deep penetrating wound by a small high-velocity missile or large or multiple low-velocity missiles, or with shattering bone fracture or open comminuted fracture with extensive debridement, prolonged infection, or sloughing of soft parts, and intermuscular binding and scarring. A history with regard to this type of injury should include prolonged hospitalization in service for treatment of wound, consistent complaints of cardinal signs and symptoms of muscle disability, worse than those shown for moderately severe muscle injuries, and, if present, evidence of inability to keep up with work requirements. Objective findings should include ragged, depressed, and adherent scars indicating wide damage to muscle groups in missile track, and indications on palpation of loss of deep fascia, muscle substance, or soft flabby muscles in wound area. Also, muscles swell and harden abnormally in contraction. Tests of strength, endurance, or coordinated movements compared with the corresponding muscles of the uninjured side should indicate severe impairment of function. If present, the following are also signs of severe muscle disability: (A) X- ray evidence of minute multiple scattered foreign bodies indicating intermuscular trauma and explosive effect of missile; (B) adhesion of scar to one of the long bones, scapula, pelvic bone, sacrum, or vertebrae, with epithelial sealing over the bone, rather than true skin covering in an area where bone is normally protected by muscle; (C) diminished muscle excitability to pulsed electrical current in electrodiagnostic tests; (D) visible or measurable atrophy; (E) adaptive contraction of an opposing group of muscles; (F) atrophy of muscle groups not in the track of the missile, particularly of the trapezius and serratus in wounds of the shoulder girdle; and (G) induration or atrophy of an entire muscle following simple piercing by a projectile. 38 C.F.R. § 4.56(d)(4). For VA rating purposes, the cardinal signs and symptoms of muscle disability are loss of power, weakness, lowered threshold of fatigue, fatigue-pain, impairment of coordination and uncertainty of movement. 38 C.F.R. § 4.56(c). The Veteran is service-connected for residuals of a gunshot wound of the right (dominant) arm with damage to Muscle Groups V and VI, with a disability rating of 30 percent, since April 18, 1946. Muscle Group V encompasses the flexor muscles of the elbow, including the biceps, brachialis and brachioradialis. The function of Muscle Group V is supination of the elbow. The Veteran is rated under Diagnostic Code 5305, which provides for a 10 percent evaluation for a moderate disability of the dominant elbow, a 30 percent evaluation for a moderately severe disability of the dominant elbow, and a 40 percent evaluation for a severe disability of the dominant elbow. 38 C.F.R. § 4.73, Diagnostic Code 5305. Disabilities of Muscle Group VI are usually rated according to Diagnostic Code 5306. The function of Muscle Group VI is extension of the elbow, and this group encompasses the extensor muscles of the elbow, including the triceps aconeus. A 10 percent rating is assignable for moderate disability of Muscle Group VI of the dominant extremity, a 30 percent rating is assignable for a moderately severe disability, and a 40 percent rating is assignable for a severe disability. 38 C.F.R. § 4.73, Diagnostic Code 5305. The Board has reviewed all the evidence of record, the statements of the case and the rating decisions contained in the file. The basis of the assignment of the 30 percent evaluation is not clear. However, historically, when there were two muscle injuries in the same region affecting the same joint, there would be a single evaluation with elevation if each wound were compensably disabling. The Board concludes that it is most likely, based upon through and through wounds to muscle groups V and VI, that each was moderate in degree and the disability was elevated one step so that the combined evaluation was rated as moderately severe. The rating schedule was amended in 1997. In pertinent part, through and through wounds with muscle damage shall be evaluated as no less than a moderate injury for each group of muscles damaged. The rating code no longer specifically provides for elevation of the assigned evaluation when there are two muscle injuries affecting a single joint. Therefore, muscle groups V and VI would be entitled to separate evaluations of 10 percent each, based upon the facts and the provisions of 38 C.F.R. § 4.56(b). However, the Board has no intent to reduce the Veteran's evaluation. 38 U.S.C.A. § 1155. Clearly, the Veteran is better off receiving a single 30 percent evaluation than two separate 10 percent evaluations. The record also establishes that the Veteran has a separate evaluation for Muscle Group II. The current regulation would seem to require that since there are two muscle group injuries in the same area that act upon separate joints, a single evaluation would be assigned for the most severely injured muscle group which would be increased by one level and used for the combined evaluation. However, it stands that if groups V and VI are to remain as a single evaluation, then muscle group II should be separately rated. (A separate 20 percent evaluation and a separate 30 percent evaluation are better than the alternative.) In sum, the change to the rating schedule is not beneficial to the Veteran. With the above discussion in mind, and upon review of the evidence pertaining to this disability, the Board finds that a disability rating in excess of 30 percent (specifically a 40 percent disability rating for a severe disability of muscles under Diagnostic Code 5305) is not indicated by the evidence. The Veteran's service treatment records, as well as the July 2009 VA muscles examination report, fail to reveal extensive debridement, prolonged infection, sloughing of soft parts, or intermuscular binding and scarring. Also, the medical evidence does not show ragged scars. The abbreviated clinical record received by VA in December 1946 noted a linear scar. The July 2009 muscles VA examiner indicated the scars measured 0.5 X 1 cm and 1 x 1.5 cm. Additionally, the VA examiner only found the scars to be slightly depressed and only one of the scars to be adherent. In this regard, the Board notes that the Veteran is separately service-connected for such entry and exit scars of the posterior and medial aspects of the right arm. There is also no indication that the muscles swell and harden abnormally in contraction. Moreover, there is no evidence that tests of strength, endurance or coordinated movements indicate severe impairment of function. In this regard, while the July 2009 VA joints examiner found that the Veteran's right arm had moderate to severe effects on usual daily activities, the July 2009 VA muscles examiner noted only a moderate effect on usual daily activities. Furthermore, at times of flare-ups, the examiner found only moderate functional impairment, in both the joints and muscles examinations. As such, the preponderance of the evidence indicates that the Veteran only has moderate functional impairment. Additionally, the record does not indicate that the Veteran as the additional signs of severe muscle disability as listed in 38 C.F.R. § 4.56(d)(4)(A)-(G). As such, the Veteran is not entitled to a 40 percent evaluation for his residuals of a gunshot wound of the right arm with damage to Muscle Groups V and VI. The Board has also considered an evaluation based on limitation of motion. Under Diagnostic Code 5206, limitation of flexion of the major forearm to 55 degrees or less will warrant the next higher evaluation of 40 percent, while under Diagnostic Code 5207, limitation of major forearm extension to 100 degrees or more would warrant the next higher evaluation of 40 percent. See 38 C.F.R. § 4.71a, Diagnostic Codes 5206, 5207. The right elbow/forearm had flexion/extension range of motion from 0 to 145 degrees, with only an additional loss of 10 degrees with repetitive motion. Such findings are not even consistent with a compensable evaluation under Diagnostic Codes 5206 or 5207, even when considering the complaints of pain. See 38 C.F.R. § 4.40, 4.45, see also DeLuca, supra; Mitchell, supra. There is also no evidence of ankylosis of the right elbow, thus Diagnostic Code 5205 is not for application. Additionally, to the extent that the Veteran has neurological impairment as part of his right arm gunshot wound residuals, such disability is contemplated by his separately rated brachial plexus disability. In reaching such decision, the Board has considered the Veteran's lay statements regarding the nature and severity of such disability; however, such symptomatology is specifically contemplated by his 30 percent rating for a moderately severe muscle group disability. Therefore, the Board finds that, based on the medical and lay evidence of record, the Veteran's residuals of a gunshot wound to the right arm with damage to Muscle Groups V and VI does not result in functional loss more nearly approximating a severe muscle disability. The Board thus concludes that a higher evaluation is not warranted. The Board has considered whether staged ratings under Hart, supra, are appropriate for the Veteran's service-connected disability; however, the Board finds that his symptomatology has been stable throughout the appeal period. Therefore, assigning staged ratings for such disability is not warranted. Additionally, the Board has contemplated whether the case should be referred for extra-schedular consideration. An extra-schedular disability rating is warranted 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 that application of the regular schedular standards would be impracticable. 38 C.F.R. § 3.321(b)(1). In Thun v. Peake, 22 Vet. App. 111, 115-16 (2008), the Court explained how the provisions of 38 C.F.R. § 3.321 are applied. Specifically, the Court stated that the determination of whether a claimant is entitled to an extra-schedular rating under § 3.321 is a three-step inquiry. First, it must be determined whether the evidence presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. In this regard, the Court indicated that 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. Under the approach prescribed by VA, 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. Second, if the schedular evaluation does not contemplate the claimant's level of disability and symptomatology and is found inadequate, the RO or Board must determine whether the claimant's exceptional disability picture exhibits other related factors such as "marked interference with employment" and "frequent periods of hospitalization." Third, when an analysis of the first two steps reveals that the rating schedule is inadequate to evaluate a claimant's disability picture and that picture has attendant thereto related factors such as marked interference with employment or frequent periods of hospitalization, then the case must be referred to the Under Secretary for Benefits or the Director of the Compensation and Pension Service to determine whether, to accord justice, the Veteran's disability picture requires the assignment of an extra-schedular rating. Id. The Board has carefully compared the level of severity and symptomatology of the Veteran's service-connected gunshot wound of the right arm with injury to Muscle Group V & VI with limitation of elbow motion, with the established criteria found in the rating schedule. While the Veteran has described the functional impairment he experiences as a result of such service-connected disability, the Board finds that such symptomatology is fully addressed by the rating criteria under which his disability is rated. Specifically, the rating criteria contemplates the overall functional loss resulting from the gunshot wound to the two muscle groups with resulting limitation of elbow motion. There are no additional symptoms of his disability that are not addressed by the rating schedule. Therefore, the Board finds that the rating criteria reasonably describe the Veteran's disability level and symptomatology for his service-connected disability. As such, the rating schedule is adequate to evaluate the Veteran's disability picture. Therefore, the Board need not proceed to consider the second factor, viz., whether there are attendant thereto related factors such as marked interference with employment or frequent periods of hospitalization. Consequently, the Board concludes that referral of this case for consideration of an extra-schedular rating is not warranted. Id.; Bagwell v. Brown, 9 Vet. App. 337, 338-39 (1996); Floyd v. Brown, 9 Vet. App. 88, 96 (1996). Additionally, the Board notes that the Court held in Rice v. Shinseki, 22 Vet. App. 447 (2009) that every claim for a higher evaluation includes a claim for a total rating based on individual unemployability (TDIU) where the Veteran claims that his service-connected disability prevents him from working. In this case, however, the Veteran already receives TDIU and has received it throughout the course of the current increased rating appeal. As such, consideration of TDIU is not for applicable in the present claim. As the preponderance of the evidence is against the claim, the benefit of the doubt rule does not apply. Gilbert, 1 Vet. App. 49, 58 (1990). The Veteran's claim for a disability rating in excess of 30 percent for residuals of a gunshot wound of the right arm with damage to Muscle Groups V and VI is denied. ORDER New and material evidence having not been received, the claim for entitlement to service connection for myopia with hyperopia is denied. Service connection for right thumb disorder is denied. Service connection for a disorder manifested by memory loss is denied. Service connection for a disorder manifested by drowsiness is denied. Service connection for Koch's infection, claimed as bronchitis, is denied. An evaluation in excess of 30 percent for residuals of a gunshot wound to the right arm with damage to Muscle Groups V and VI is denied. REMAND Although the Board regrets the additional delay, a remand is necessary to ensure that due process is followed and that there is a complete record upon which to decide the remainder of the Veteran's claims so that he is afforded every possible consideration. 38 U.S.C.A. § 5103A (West 2002); 38 C.F.R. § 3.159 (2012). In an October 2009 rating decision, the RO continued a denial of service connection for a wrist disorder. The Veteran filed a notice of disagreement with that decision in November 2009. When there has been an initial AOJ adjudication of a claim and a notice of disagreement as to its denial, the claimant is entitled to a statement of the case. See 38 C.F.R. § 19.26. Thus, remand for issuance of a statement of the case on this issue is needed. See Manlincon v. West, 12 Vet. App. 238 (1999). However, this issue will be returned to the Board after issuance of the statement of the case only if perfected by the filing of a timely substantive appeal. See Smallwood v. Brown, 10 Vet. App. 93, 97 (1997). In regard to the claim for service connection for headaches, the Veteran currently contends that he developed headaches in service, from his gunshot wound to the upper right arm (February 2010 statement), or due to his service-connected degenerative disc disease of the cervical spine (June 2011 private medical record by Dr. R.O. Abiog). He has also previously reported that it developed following an operation to the cervical spine (November 1997 VA Form 9). The evidence of record is inconsistent as to whether the Veteran complained of headaches in the years following service (October 1950 and September 1952 L.O. Dacanay private medical records, July and December 1947 VA examinations). In a May 1953 statement, he reported constant headaches. In a May 1957 VA discharge summary, the medical provider noted that the Veteran complained of headaches, and was referred to a neurologist. The neurologist found the Veteran to have tension headaches. The Veteran was also referred for psychiatric evaluation for his complaints. Subsequent records indicate occasional reports regarding headaches (February 1976 and September 1996 VA examinations). Additionally, the Board notes that headaches are capable of lay observation, so the Veteran is competent to state the he currently experiences headaches. The Veteran never received a VA examination to determine whether his headaches are etiologically related to service or his service-connected cervical spine disability. The Board thus finds that a VA examination is necessary to ascertain the etiology of the claimed headaches. 38 C.F.R. § 3.159(c)(4) (a medical examination or opinion is necessary if the information and evidence of record does not contain sufficient competent medical evidence to decide the claim). The Board notes that if the Veteran fails to appear or is unable to appear for his VA examination, the VA examiner should provide a medical opinion based on the evidence of record. In regard to the claim for service connection for a left ear disorder, to include hearing loss, the Veteran contends that he developed left ear hearing loss in service and has had pain in his left ear since his gunshot wound to the upper right arm (February 2012 statement). Although the July and December 1947 VA examinations noted normal hearing, they did not involve audiogram findings. In a September 1965, Dr. E.L. Reyes found the Veteran's hearing to be concomitant to his age. In March 1967, however, that same doctor found him to have defective left ear hearing loss. In May 2007, the Veteran received an ear disease examination in regard to a different claim. The examiner noted that the Veteran had hearing loss; however, the examiner did not provide a medical opinion as to whether the Veteran had a left ear disorder, including hearing loss, related to his service. The Board finds that a VA examination is necessary to ascertain the etiology of the claimed left ear disorder, including hearing loss. 38 C.F.R. § 3.159(c)(4). The Board notes that if the Veteran fails to appear or is unable to appear for his VA examination, the VA examiner should go ahead and provide a medical opinion based on the evidence of record. Additionally, while on remand, the AOJ should contact the Veteran and request that identify any VA or non-VA treatment providers for his headaches and left ear disorder. Thereafter, the AOJ should attempt to obtain any identified treatment records. Accordingly, the case is REMANDED for the following actions: (Please note, this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2012). Expedited handling is requested.) 1. Provide the Veteran and his representative with statement of the case on the issue of entitlement to service connection for a wrist disorder. Please advise the Veteran of the time period in which to perfect his appeal. If the Veteran perfects his appeal of this issue in a timely fashion, then return the case to the Board for its review, as appropriate. 2. The Veteran should be given an opportunity to identify any VA or non-VA healthcare provider who treated him for his headaches or left ear disorder since service. After securing any necessary authorization from him, obtain all identified treatment records. All reasonable attempts should be made to obtain such records. If any records cannot be obtained after reasonable efforts have been made, the AOJ should issue a formal determination that such records do not exist or that further efforts to obtain such records would be futile, which should be documented in the claims file. The Veteran must be notified of the attempts made and why further attempts would be futile, and allowed the opportunity to provide such records, as provided in 38 U.S.C.A. § 5103A(b)(2) and 38 C.F.R. § 3.159(e) . 3. After all outstanding records have been associated with the claims file, the Veteran should be afforded an appropriate VA examination to determine the current nature and etiology of his claimed headaches. The claims file, to include a copy of this Remand, must be made available to and be reviewed by the examiner. Any indicated evaluations, studies, and tests should be conducted. The Board notes that if the Veteran fails to appear or is unable to appear for his VA examination, the VA examiner should provide a medical opinion based on the evidence of record. Based on examination findings (if available) and a review of the record, to include the Veteran's service treatment records, private medical records, various VA examination reports and lay statements, the VA examiner should determine: a) Does the Veteran currently have a disorder characterized by headaches? If so, please clarify his diagnosed disorder(s). b) Is it at least as likely as not (50% probability or greater) that the any currently diagnosed headaches disorder(s) is related to his military service, including his in-service gunshot wound to the right arm? c) Is it at least as likely as not (50% probability or greater) that any currently diagnosed headaches disorder(s) has been caused or aggravated by the Veteran's service-connected cervical spine disability? (d) Is it at least as likely as not (50% probability or greater) that any currently diagnosed headaches disorder(s) has been caused or aggravated by the Veteran's service-connected gunshot wound to the right arm? A complete explanation must be given for all opinions and conclusions expressed. 4. After all outstanding records have been associated with the claims file, the Veteran should be afforded an appropriate VA examination to determine the current nature and etiology of his claimed left ear disorder, to include hearing loss. The claims file, to include a copy of this Remand, must be made available to and be reviewed by the examiner. Any indicated evaluations, studies, and tests should be conducted. The Board notes that if the Veteran fails to appear or is unable to appear for his VA examination, the VA examiner should go ahead and provide a medical opinion based on the evidence of record. Based on examination findings (if available) and a review of the record, to include the Veteran's, service treatment records, private medical records, various VA examination reports and lay statements, the VA examiner should determine: a) Does the Veteran currently have a left ear disorder? If so, please clarify his diagnosed disorder(s). The examiner should specifically indicate whether the Veteran has left ear hearing loss. b) Is it at least as likely as not (50% probability or greater) that the any currently diagnosed left ear disorder(s) were caused by the Veteran's service, including his in-service gunshot wound to the right arm? A complete explanation must be given for all opinions and conclusions expressed. 5. After completing the above, and any other development as may be indicated by any response received as a consequence of the actions taken in the preceding paragraphs, the Veteran's claims should be readjudicated based on the entirety of the evidence. If the claims remain 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. Thereafter, the case should be returned to the Board for further appellate consideration, if otherwise in order. The Board intimates no opinion as to the outcome of this case. The Veteran need take no action until so informed. The purpose of this REMAND is to ensure compliance with due process considerations. The Veteran has the right to submit additional evidence and argument on the matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). These claims must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2012). ______________________________________________ A. JAEGER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs