Citation Nr: 1310689 Decision Date: 04/01/13 Archive Date: 04/11/13 DOCKET NO. 08-10 326 ) DATE ) ) On appeal from the Department of Veterans Affairs Medical and Regional Office Center in Wichita, Kansas THE ISSUES 1. Entitlement to an initial compensable rating for migraine headaches. 2. Entitlement to an initial compensable rating for status post viral syndrome for the period prior to January 9, 2012. 3. Entitlement to an initial rating in excess of 60 percent for status post viral syndrome for the period since January 9, 2012. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD James A. DeFrank, Counsel INTRODUCTION The Veteran had active service from August 2003 to February 2007. This matter comes before the Board of Veterans' Appeals (Board) from August 2007 and and August 2012 rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in Wichita, Kansas. In the August 2007 rating decision, in part, granted service connection for migraine headaches and status post viral syndrome, both at noncompensable (0 percent) evaluations, effective February 2, 2007. In the August 2012 rating decision, the RO granted a higher disability rating of 60 percent for status post viral syndrome, effective January 9, 2012. As a higher schedular evaluation for this disability is possible, the issue of entitlement to an initial rating in excess of 60 percent since January 9, 2012 remains before the Board on appeal. See AB v. Brown, 6 Vet. App. 35 (1993). In an October 2011 decision, the Board remanded these issues for additional development. FINDINGS OF FACT 1. The Veteran does not suffer from characteristic prostrating migraine headache attacks averaging one in two months over the last several months. 2. For the period prior to January 9, 2012, the Veteran's status post viral syndrome did not result in a workload of greater than 7 METs but not greater than 10 METs or the need for continuous medication. 3. For the period since January 9, 2012, the Veteran's status post viral syndrome did not result in chronic congestive heart failure or; workload of 3 METs or less results in dyspnea, fatigue, angina, dizziness or syncope, or; left ventricular dysfunction with an ejection fraction of less than 30 percent. CONCLUSIONS OF LAW 1. The criteria for an initial compensable disability rating for the Veteran's migraine headaches have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.321, 4.124a, Part 4, Diagnostic Code 8100 (2012). 2. For the period prior to January 9, 2012, the criteria for an initial compensable disability rating for the Veteran's status post viral syndrome have not been met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 4.1, 4.2, 4.7, 4.104, Diagnostic Code 7002 (2012). 3. For the period since January 9, 2012, the criteria for a 60 percent disability rating for the Veteran's status post viral syndrome have not been met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 4.1, 4.2, 4.7, 4.104, Diagnostic Code 7002 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Veterans Claims Assistance Act of 2000 (VCAA) VA's duties to notify and assist claimants in substantiating a claim for VA benefits are found at 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002) and 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2012). See also 73 Fed. Reg. 23,353-23,356 (April 30, 2008) (concerning revisions to 38 C.F.R. § 3.159). In a correspondence dated September 2007, the RO satisfied its duty to notify the Veteran under 38 U.S.C.A. §5103(a) (West 2002) and 38 C.F.R. § 3.159(b) (2012). Specifically, the RO notified the Veteran of: information and evidence necessary to substantiate the claim; information and evidence that VA would seek to provide; and information and evidence that the Veteran was expected to provide. The September 2007 letter also notified the Veteran of the process by which disability ratings and effective dates are established. Dingess v. Nicholson, 19 Vet. App. 473 (2006). Since this claim is the appeal of an initial rating, fully satisfactory notice was delivered after it was adjudicated. However, the RO subsequently readjudicated the claim based on all the evidence in various supplemental statements of the case. The Veteran was able to participate effectively in the processing of his claim. There is no indication in the record or reason to believe that the ultimate decision of the originating agency on the merits of the claim would have been different had complete notice been provided at an earlier time. VA has done everything reasonably possible to assist the Veteran with respect to his claim for benefits in accordance with 38 U.S.C.A. § 5103A (West 2002) and 38 C.F.R. § 3.159(c) (2012). Service treatment records have been associated with the claims file. All identified and available treatment records have been secured. As the Board will discuss in detail in the analysis below, the Veteran was provided with VA examinations throughout the appeal period. The Board notes that the Veteran's representative has contended that the January 2012 VA examinations are not adequate as the Veteran's conditions are far worse than represented by the January 2012 examinations. The representative also requested that "current" examinations be conducted. Significantly, the representative did not assert a worsening of his disabilities since these examinations, but rather argued that they incorrectly assessed the severity of his disabilities. However, the only rationale provided by the representative was the assertion that the Veteran believed his ejection fraction should be worse than what was noted by the VA examiner. The Board finds such an assertion without additional support to be insufficient to establish the inadequacy of the VA examinations. The reports of these January 2012 VA examinations reflect that the examiners reviewed the Veteran's past medical history, recorded his current complaints, conducted appropriate evaluations of the Veteran, and rendered appropriate diagnoses and opinions consistent with the remainder of the evidence of record. Thus, the Board finds that the examination reports of record are adequate for purposes of rendering a decision in the instant appeal. See 38 C.F.R. § 4.2 (2012); see also Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). As there is no indication that any failure on the part of VA to provide additional notice or assistance reasonably affects the outcome of this case, the Board finds that any such failure is harmless. See Mayfield v. Nicholson, 19 Vet. App. 103 (2005), rev'd on other grounds, Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). Accordingly, the Board finds that VA's duty to assist with respect to obtaining a VA examination or opinion has been met. 38 C.F.R. § 3.159(c) (4) (2012); Barr, 21 Vet. App. at 312. Overall, there is no evidence of any VA error in notifying or assisting the Veteran that reasonably affects the fairness of this adjudication. Laws and Regulations The Board must assess the credibility and weight of all evidence, including the medical evidence, to determine its probative value, accounting for evidence which it finds to be persuasive or unpersuasive, and providing reasons for rejecting any evidence favorable to the claimant. Equal weight is not accorded to each piece of evidence contained in the record; every item of evidence does not have the same probative value. When all the evidence is assembled, VA is responsible for determining whether the evidence supports the claims or is in relative equipoise, with the Veteran prevailing in either event, or whether a preponderance of the evidence is against the claims, in which case, the claims are denied. See Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Disability evaluations are determined by evaluating the extent to which a Veteran's service-connected disability adversely affects his or her ability to function under the ordinary conditions of daily life, including employment, by comparing his or her 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 occupations. Generally, the degree of disabilities specified are considered adequate to compensate for considerable loss of working time from exacerbation or illness proportionate to the severity of the several grades of disability. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. § 4.1 (2012). 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 to the disability picture that more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7 (2012). Any reasonable doubt regarding the degree of disability will be resolved in favor of the Veteran. 38 C.F.R. § 4.3 (2012). The Veteran's entire history is reviewed when making a disability determination. See 38 C.F.R. § 4.1 (2012). Where service connection has already been established, and increase in the disability rating is at issue, it is the present level of the disability that is of primary concern. See Francisco v. Brown, 7 Vet. App. 55 (1994). However, in Fenderson v. West, 12 Vet. App. 119 (1999), it was held that evidence to be considered in the appeal of an initial assignment of a disability rating was not limited to that reflecting the then current severity of the disorder. The Court also discussed the concept of the "staging" of ratings, finding that, in cases where an initially assigned disability evaluation has been disagreed with, it was possible for a veteran to be awarded separate percentage evaluations for separate periods based on the facts found during the appeal period. See also Hart v. Mansfield, 21 Vet. App. 505 (2008). The evaluation of the same disability under various diagnoses, known as pyramiding, is generally to be avoided. 38 C.F.R. § 4.14 (2012). 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 disabilities is duplicative or overlapping with the symptomatology of the other disability. See Esteban v. Brown, 6 Vet. App. 259, 261- 62 (1994). Where there is a question as to which of two ratings shall be applied, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. §4.7 (2012). I. Entitlement to an initial compensable rating for migraine headaches. The Veteran's migraine headaches are rated as noncompensable under Diagnostic Code 8100. The Veteran claims that the current rating does not accurately reflect the true nature and degree of his disability. Diagnostic Code 8100 provides ratings for migraine headaches. Migraine headaches with less frequent attacks than the criteria for a 10 percent rating are rated as noncompensably (0 percent) disabling. Migraine headaches with characteristic prostrating attacks averaging one in 2 months over the last several months are rated 10 percent disabling. Migraine headaches with characteristic prostrating attacks occurring on an average once a month over last several months are rated 30 percent disabling. Migraine headaches with very frequent completely prostrating and prolonged attacks productive of severe economic inadaptability are rated 50 percent disabling. 38 C.F.R. § 4.124a, Diagnostic Code 8100 (2012). The rating criteria do not define "prostrating," and the Board observes that the Court has not undertaken to define "prostrating." Cf. Fenderson, supra., in which the Court quoted Diagnostic Code 8100 verbatim but did not specifically address the matter of what is a prostrating attack. According to Webster's New World Dictionary of American English, Third College Edition (1986), p.1080, "prostration" is defined as "utter physical exhaustion or helplessness." The rating criteria also do not define "severe economic inadaptability." However, the Court noted that nothing in Diagnostic Code 8100 required the claimant to be completely unable to work in order to qualify for a 50 percent rating. See Pierce v. Principi, 18 Vet. App. 440 (2004). The Veteran underwent a general VA medical examination in July 2007. He reported that the onset of his headaches was in 2006 where he experienced severe headaches, right eye moving to left eye, blurred vision and constant pain. A CT of his head was negative and he was given medications to which he had good response. His last severe headache was in June 2007. He averaged about 2 headaches per month of forehead pain. If he took his medication, the medication helped within 5 to 10 minutes. He has found that if he does not take the medication it lasts the entire day. Sleep was also helpful. The Veteran was currently employed at a golf course and had not loss any time from work in the last year. The Veteran underwent a VA examination in January 2012. It was noted that the Veteran used Tylenol on an as needed basis for headache management. He was currently working as a busboy at a local restaurant. Over the last 12 months he missed work approximately 7 times due to an injured right wrist. The Veteran reported that his first episode of a headache occurred in the summer of 2006 which resulted in him going to the emergency room for treatment. He had a similar episode in 2008 which again resulted in him going to the hospital. He also described a milder type of head pain and headache which occurred on average once every 6 months. Those headaches complaints where somewhere between a 4-7 on a pain scale of 1-10. When they occurred they caused dysfunctional features where he usually could only function at somewhere between 50-70 percent of his normal capacity as opposed to the 2 previous episodes which were more of severe, prostrating headache complaints, where he had to seek the solace of a quiet, dark room and lie down and pursue bedrest until the headache complaints resolved. Those more severe headaches complaints were rated on an 8-10 on a pain scale. The more modest headaches usually persisted for somewhere between 5-30 minutes before resolving. Early treatment was usually more helpful and more effective in aborting and alleviating those symptoms. Finally, the Veteran described a mild type of head problem which on a pain scale was somewhere between a 1-3. Those headache complaints on average occurred once each month. They were not associated with any type of visual impairment nor are they accompanied by dysfunctional features or disabling complaints of prostrating features. They rarely were to the degree where the Veteran felt that he needed to medicate for his symptoms. Alleviating factors were a hot shower, medication, rest and/or sleep. The examiner noted that the Veteran's disabling and prostrating headache complaints occurred on average once every 3 years where his moderate dysfunctional headache symptoms occurred once every 6 months. He denied symptoms of aura preceding his headache complaints and was unaware of any premonitory symptoms prior to headache onset. The diagnosis was migraine and migraine headache disorder without associated features of aura which only occur on an infrequent basis. Occasionally, these migraines were accompanied by complicated features of visual distortion characterized by homonymous hemianopsis and/or visual scotomata. The examiner also noted that the Veteran's complaints occurred infrequently on average. He also experienced 1 mild headache each month which on a scale of 1-10 was rated somewhere between a 1-3. These mild headaches required little or no treatment and did not interfere with his ability to interact with others or with his normal performance in daily activities. In addition, the Veteran described 1 headache every 6 months which tended to be of moderate severity which may cause some dysfunctional symptoms and would be rated somewhere at a 4-7 on a pain scale. Those headache complaints may compromise his ability to function between 50-70 percent of his normal capacity and even though they require medication, they rarely persist for longer than 30 minutes before resolving. Finally, the examiner noted that once every 3 years the Veteran experienced a severe headache which required him to go to a dark room and sleep until his symptoms resolved. The examiner indicated that the only time the Veteran could not work with any of his headache complaints was when the suffered from one of his severe disabling and prostrating symptoms of headache and since they occurred on an extremely infrequent basis, there was no severe economic inadaptability. Based on the evidence of record, the Board finds that the Veteran's migraine headaches do not warrant an initial compensable rating. As noted above, to warrant a 10 percent rating under Diagnostic Code 8100, the Veteran's headaches had to be characteristic of prostrating attacks averaging one in 2 months over the last several months. As indicated by the most recent VA examination in January 2012, the Veteran suffered severe, prostrating attacks, but these severe headaches only occurred once every 3 years. Additionally, while the Veteran suffered attacks of moderate severity that may compromise his ability to function between 50-70 percent of his normal capacity, these types of headaches only occurred once every 6 months. Accordingly, as these types of prostrating migraine headache attacks did not average 1 in two months over the last several months, an initial compensable rating is not warranted. The Board also notes that while the Veteran experienced mild headaches once a month, these headaches were not characteristic prostrating migraine headache attacks which would warrant a compensable rating. The January 2012 VA examiner specifically noted that these mild headaches required little or no treatment and did not interfere with his ability to interact with others or with his normal performance in daily activities. While the Board has considered the Veteran's subjective reports, the Board ultimately places the most probative weight on the conclusions of the competent VA examiner as to determining the nature and severity of his headache disorder. Thus, the Board finds that the Veteran does not suffer characteristic prostrating migraine headache attacks averaging one in two months over the last several months, as is required for a 10 percent rating. Higher ratings under this diagnostic code require even more frequent prostrating headache attacks (a 30 percent rating requires headaches of prostrating severity occurring on average once a month over the last several months). Further, the Veteran does not meet the 50 percent rating which requires very frequent completely prostrating and prolonged attacks productive of severe economic inadaptability. Therefore, the preponderance of the evidence is against the Veteran's claim that he is entitled to an initial compensable rating for his service connected migraine headaches. See 38 U.S.C.A. § 5107(a) (West 2002); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). The benefit of the doubt rule enunciated in 38 U.S.C.A. § 5107(b) is not for application. There is not an approximate balance of evidence. See generally Gilbert, supra; Ortiz v. Principi, 274 F. 3d 1361 (Fed. Cir. 2001). Assignment of staged ratings has been considered and is not for application. Hart, supra. II. Entitlement to an initial compensable rating for the period prior to January 9, 2012 and an initial rating in excess of 60 percent for the period since January 9, 2012 for status post viral syndrome. The Veteran's status post viral syndrome is currently rated at a noncompensable evaluation prior to January 9, 2012 and a 60 percent rating since January 9, 2012 under 38 C.F.R. § 4.104, Diagnostic Code 7002. Under this Diagnostic Code, a 10 percent rating is assigned when a workload of greater than 7 METs but not greater than 10 METs results in dyspnea, fatigue, angina, dizziness, or syncope; or when continuous medication is required. A 30 percent rating is assigned when a workload of greater than 5 METs but not greater than 7 METs results in dyspnea, fatigue, angina, dizziness, or syncope; or, when there is evidence of cardiac hypertrophy or dilatation on an electro-cardiogram, echocardiogram, or X-ray. A 60 percent rating is assigned when there is more than one episode of acute congestive heart failure in the past year; where a workload of greater than 3 METs but not greater than 5 METs results in dyspnea, fatigue, angina, dizziness, or syncope; or when there is left ventricular dysfunction with an ejection fraction of between 30 and 50 percent. A 100 percent evaluation is warranted for chronic congestive heart failure, or; workload of 3 METs or less results in dyspnea, fatigue, angina, dizziness or syncope, or; left ventricular dysfunction with an ejection fraction of less than 30 percent. 38 C.F.R. § 4.104, Code 7002. One MET is the energy cost of standing quietly at rest and represents an oxygen uptake of 3.5 millimeters per kilogram of body weight per minute. When the level of METS at which dyspnea, fatigue, angina, dizziness or syncope develops is required for evaluation and a laboratory determination of METs by exercise testing cannot be done for medical reasons, an estimation by a medical examiner of the level of activity (expressed in METs and supported by specific examples, such as slow stair climbing or shoveling snow) that results in dyspnea, fatigue, angina, dizziness or syncope may be used. NOTE 2 above diagnostic code 7000. In every instance where the rating schedule does not provide a zero percent evaluation for a diagnostic code, a zero percent evaluation shall be assigned when the requirements for a compensable evaluation are not met. 38 C.F.R. § 4.31 (2012). Period prior to January 9, 2012 In December 2003, the Veteran presented with complaints of chest pain. A cardiology consultation revealed acute myopericarditis with suspected viral etiology as this was usually secondary to Coxasackievirus. A December 2003 heart catherization demonstrated severe left ventricular dysfunction with an ejection fraction of about 25 percent. There was no angiographic stenosis of the coronary arteries. A March 2004 consultation diagnosed the Veteran with chest pain and ruled out myocardial infarction/pericarditis. In a May 2004 letter, a private cardiologist noted that the Veteran's physical examination was totally unremarkable. His echocardiogram showed normal left ventricular function with an ejection fraction of 55 percent. The cardiologist thought that the Veteran's myocarditis had resolved completely. A September 2004 report reflects a finding that the Veteran's left ventricular dysfunction had almost completely resolved. The Veteran underwent a VA examination in July 2007. The examiner noted that the Veteran's cardiac condition began in December 2003 as he presented with complaints of chest pain, dyspnea and numbness of the left arm. It was noted that a cardiac catheter at that time had revealed severe left ventricular dysfunction with an ejection fraction of 25 percent with no angiographic stenosis of the coronary arteries. He had a history of dyspnea, fatigue and angina. He did not have a history of syncope or dizziness. Continuous medication was not required. On examination, a murmur, click and pericardial rub were absent. His rhythm was regular and his NYHA classification of heart disease was Class I. X-rays of the chest showed no acute pathology. The diagnosis was status post viral syndrome, viral syndrome/viral myocarditis/acute pericarditis resolved. There was no history of myocardial infarction or current evidence of myocardial infarction. There was no current evidence of angina, diffuse global hypokinesis, CHF or cardiomyopathy. There was asymptomatic mild tricuspid and pulmonary insufficiency. The METS were estimated above 10. There were no effects of the problem on usual daily activities. The examiner noted that there were no limitations on physical activity. Ordinary (moderate to heavy) physical activity did not result in cardiac symptoms such as fatigue, dyspnea, etc. An addendum to this report reflects that testing revealed normal left ventricular function with an ejection fraction of 55 percent. A July 2007 private consultation noted that the Veteran was diagnosed with viral myocarditis and cardiomyopathy and had a complete work-up done in 2003. Gradually over a period of time and it seems to have improved as his ejection fraction (EF) went from 25 percent to 50 to 55 percent. Currently he denied any complaints suggestive of cardiac disease, particularly no shortness of breath, paroxysmal nocturnal dyspnea (PND), or orthopnea. He denied limitation in daily activities, nausea, vomiting, diaphoresis, presyncope or syncope. There were no palpitations. He had occasional episodes of chest discomfort that were not related to exertion, posture or meas. He had no symptoms suggestive of cerebral vascular or peripheral vascular disease. He reported no fatigue, fever, weight loss or weight gain. There were no audible murmurs or rub. The diagnosis was viral cardiomyopathy for which the Veteran had recovered. Based on the evidence of record, the Board finds that for the period prior to January 9, 2012, the Veteran's status post viral syndrome does not warrant an initial compensable rating. As noted above, to warrant a 10 percent rating under Diagnostic Code 7002, a workload of greater than 7 METs but not greater than 10 METs results in dyspnea, fatigue, angina, dizziness, or syncope; or when continuous medication is required. At no time prior to January 9, 2012 did the Veteran have a workload of greater than 7 METs but not greater than 10 METs. The only recorded MET during this time period was the July 2007 VA examination in which the VA examiner noted that the METS were estimated above 10. Further, the evidence did not demonstrate that the Veteran had continuous medication as the July 2007 specifically noted that continuous medication was not required. Although the evidence revealed a past history of left ventricular dysfunction with an ejection fraction of only 25 percent in 2003, the 2007 VA examination revealed an normal left ventricular dysfunction with an ejection fraction of 55 percent. This is consistent with the 2004 finding of an ejection fraction of 55 percent, and the 2007 private consultation that explained that gradually since 2003 his ejection fraction (EF) had improved from 25 percent to 50 to 55 percent. Given the findings of the private physician that his ejection fraction was in the range of "50 to 55 percent," the Board has considered whether a 60 percent is warranted for this period under the applicable criteria, which provides for a 60 percent when there is left ventricular dysfunction with an ejection fraction of between 30 and 50 percent. However, given that 50 was the lowest number provided among a range of 50 to 55, the interim finding of 55 percent in 2004, and that the VA examination specifically revealed a finding of 55 percent, the Board concludes that the greater weight of the evidence supports the conclusion that the Veteran's ejection fraction was predominately above 50 percent during the period under consideration. Again, this conclusion is consistent with the fact that the evidence for this time period demonstrates that multiple physicians noted that the Veteran's myocarditis had resolved completely. Accordingly, for the reasons and bases set forth above, the Board finds that an initial compensable rating for the period prior to January 9, 2012 is not warranted. Period since January 9, 2012 The Veteran underwent a VA examination in January 2012. The examiner noted that the Veteran had not been hospitalized since 2009. The Veteran reported that he could easily run 2 to 3 miles without apparent difficulty. He could climb stairs with no difficulty and apparently had not had to alter his activities of daily living for any cardiovascular cause in over two years. He presently appeared to be in excellent health and denied episodes of chest pain, exertional dyspnea, orthopnea, paroxysmal nocturnal dyspnea, palpitations, lightheadedness, syncope, peripheral edema and had not had any treatment for any form of heart disease since he received beta-blockers and angiotensin-converting inhibitors several years ago. Hypertension was absent. On examination, there was no evidence of fatigue, exertional dyspnea or other abnormalities. His resting heart rate varied from approximately 55 with a regular rhythm to 57 with a regular rhythm 10 minutes later. There was no evidence of cyanosis or clubbing. Heart sounds were perfectly normal with no clicks, rubs or murmurs present. An echocardiogram demonstrated moderate systolic dysfunction and LVEF estimated at 35-40 percent. There were no valvular abnormalities. The examiner noted that the Veteran's METS level was well above 10 at any time. The evidence of residual of myocarditis was global systolic dysfunction of the left ventricle. The examiner noted that there was an obvious disparity between the Veteran's history and the LVEF of 35-40 percent. This was not a rare finding and may be explained by the likely excellent conditioning of a man who was a runner in high school. Despite his lack of symptoms, he had residual effect of myocarditis manifested by the abnormal echocardiogram. The diagnosis was myocarditis with residual global systolic dysfunction per echocardiogram. METS estimate per the echocardiogram was 35-40 percent with symptoms of diminishing exercise tolerance. Based on the evidence of record, the Board finds that for the period since January 9, 2012, the Veteran's status post viral syndrome does not warrant an initial rating in excess of 60 percent. The medical evidence reveals that the residuals of the post viral syndrome are manifested primarily by global systolic dysfunction of the left ventricle with a LVEF of 35-40 percent, as shown on the report of the Veteran's VA heart examination in January 2012. The evidence does not show a workload of 3 METs or less or an ejection fraction of less than 30 percent to support the assignment of a total rating under Diagnostic Code 7002. The Board has considered the representative's assertion that the Veteran's ejection fraction should be worse than noted on VA examination. However, the Board notes that such a clinical finding is beyond the competence of a lay person and, absent some further basis for questioning the VA examiner's finding, the representative's argument is unpersuasive. Therefore, the preponderance of the evidence is against the Veteran's claim that he is entitled to an initial compensable rating for the period prior to January 9, 2012 and an initial rating in excess of 60 percent for the period since January 9, 2012 for status post viral syndrome. See 38 U.S.C.A. § 5107(a) (West 2002); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). The benefit of the doubt rule enunciated in 38 U.S.C.A. § 5107(b) is not for application. There is not an approximate balance of evidence. See generally Gilbert, supra; Ortiz v. Principi, 274 F. 3d 1361 (Fed. Cir. 2001). Assignment of staged ratings has been considered and is not for application. Hart, supra. Extraschedular Rating The Board has also considered the potential application of other various provisions, including 38 C.F.R. § 3.321(b) (1), for exceptional cases where scheduler evaluations are found to be inadequate. See Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Under Thun v. Peake, 22 Vet App 111 (2008), there is a three- step inquiry for determining whether a Veteran is entitled to an extraschedular rating. First, the Board must first determine whether the evidence presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. Second, if the schedular evaluation does not contemplate the Veteran's level of disability and symptomatology and is found inadequate, the Board must determine whether the Veteran's disability picture exhibits other related factors such as those provided by the regulation as "governing norms." Third, if the rating schedule is inadequate to evaluate a Veteran'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 extraschedular rating. With respect to the first prong of Thun, the evidence in this case does not show such an exceptional disability picture that the available schedular evaluation for the Veteran's service-connected migraine headaches and status post viral syndrome is inadequate. A comparison between the level of severity and symptomatology of the Veteran's disabilities with the established criteria shows that the rating criteria reasonably describe the Veteran's disability level and symptomatology for migraine headaches and status post viral syndrome. There is no evidence in the medical records of an exceptional or unusual clinical picture. The Board, therefore, has determined that referral of this case for extra-schedular consideration pursuant to 38 C.F.R. 3.321(b) (1) is not warranted. ORDER Entitlement to an initial compensable rating for migraine headaches is denied. Entitlement to an initial compensable rating for status post viral syndrome for the period prior to January 9, 2012 is denied. Entitlement to an initial rating in excess of 60 percent for status post viral syndrome for the period since January 9, 2012 is denied. ____________________________________________ MICHAEL LANE Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs