Citation Nr: 1314930 Decision Date: 05/06/13 Archive Date: 05/15/13 DOCKET NO. 09-22 968A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Los Angeles, California THE ISSUES 1. Entitlement to service connection for a left lower leg disability. 2. Entitlement to a disability rating in excess of 10 percent for residuals of a right pleural effusion with chronic right fibrous pleuritis. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD T. Sherrard, Counsel INTRODUCTION The Veteran, who is the Appellant in this case, had active service from August 1947 to January 1950, and from June 1951 to October 1953. This matter comes before the Board of Veterans' Appeals (BVA or Board) from an April 2003 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in San Diego, California, and a July 2008 rating decision from the above VA RO in Los Angeles, California. On his VA Form 9s (appeal to the Board) as to the issues of entitlement to service connection for a left lower leg disability and to an increased rating for residuals of a right pleural effusion, the Veteran requested a Board hearing. However, in September 2011, he submitted correspondence indicating he wished to withdraw his request for a hearing. Under 38 C.F.R. § 20.704(e), a request for hearing may be withdrawn by an appellant at any time before the hearing. In March 2012, the Board remanded the issues of entitlement to service connection for a left lower leg disability and a left foot disability. In a February 2013 rating decision, the RO granted service connection for the left foot disability. Moreover, the development requested by the Board as to the left leg disability claim has been completed, as discussed below. Thus, the Board will proceed with appellate review. The Board has not only reviewed the Veteran's physical claims file but also the Veteran's file on the "Virtual VA" system to insure a total review of the evidence. 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). FINDINGS OF FACT 1. With the exception of a single episode of left leg pain that resolved prior to service separation, the Veteran did not incur a left lower leg injury or disease during active service, symptoms of a left lower leg disability were not chronic in service, and symptoms of a left lower leg disability have not been continuous since service separation. 2. The Veteran does not have a current left lower leg disability, at this time, based on the best evidence. 3. The Veteran's service-connected residuals of a right pleural effusion with chronic right fibrous pleuritis manifests in, at worst, pre-bronchodilator FEV-1 of 99 percent predicted value and FEV-1/FVC of 104 percent, and post-bronchodilator FEV-1 of 35 percent predicted value and FEV-1/FVC of 83 percent. CONCLUSIONS OF LAW 1. The criteria for service connection for a left lower leg disability have not been met. 38 U.S.C.A. §§ 101, 1101, 1110, 1131, 5103(a), 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304 (2012). 2. The criteria for a disability evaluation in excess of 10 percent for residuals of a right pleural effusion with chronic right fibrous pleuritis have not been met for any period at this time. 38 U.S.C.A. §§ 1155, 5103(a), 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.2, 4.3, 4.7, 4.10, 4.96, 4.97, Diagnostic Code 6845 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Service Connection for Left Lower Leg Disability Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active military, naval, or air service. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303(a). For the showing of chronic disease in service, there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time. With chronic disease as such in service, subsequent manifestations of the same chronic disease at any later date, however remote, are service connected, unless clearly attributable to intercurrent causes. The claimed condition at issue is not a "chronic disease" listed under 38 C.F.R. § 3.309(a); therefore, 38 C.F.R. § 3.309(b) (requiring continuity of a condition after service if chronicity is not found in service) does not apply. See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Service connection may also be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Establishing service connection generally requires (1) medical evidence of a current disability; (2) medical or, in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and (3) medical evidence of a nexus between the claimed in-service disease or injury and the present disability. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). The Court has held that "Congress specifically limits entitlement for service-connected disease or injury to cases where such incidents have resulted in a disability. In the absence of proof of a present disability there can be no valid claim." Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992); see also Rabideau v. Derwinski, 2 Vet. App. 141, 143-44 (1992). In rendering a decision on appeal, the Board must analyze the credibility and probative value of the evidence, account for the evidence which it finds to be persuasive or unpersuasive, and provide the reasons for its rejection of any material evidence favorable to the claimant. See Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994); Gilbert v. Derwinski, 1 Vet. App. 49, 57 (1990). Competency of evidence differs from weight and credibility. Competency is a legal concept determining whether testimony may be heard and considered by the trier of fact, while credibility is a factual determination going to the probative value of the evidence to be made after the evidence has been admitted. Rucker v. Brown, 10 Vet. App. 67, 74 (1997); Layno v. Brown, 6 Vet. App. 465, 469 (1994); see also Cartright v. Derwinski, 2 Vet. App. 24, 25 (1991) ("although interest may affect the credibility of testimony, it does not affect competency to testify"). Lay testimony is competent when it regards the readily observable features or symptoms of injury or illness and "may provide sufficient support for a claim of service connection." See Layno, 6 Vet. App. at 469; 38 C.F.R. § 3.159(a)(2). The Court has emphasized that when a condition may be diagnosed by its unique and readily identifiable features, the presence of the disorder is not a determination "medical in nature" and is capable of lay observation. In such cases, the Board is within its province to weigh that testimony and to make a credibility determination as to whether that evidence supports a finding of service incurrence and continuity of symptomatology sufficient to establish service connection. See Barr v. Nicholson, 21 Vet. App. 303 (2007); Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. Sept. 14, 2009). Lay statements may serve to support a claim for service connection by supporting the occurrence of lay-observable events or the presence of disability or symptoms of disability subject to lay observation. See Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007); Buchanan v. Nicholson, 451 F.3d 1331, 1336 (Fed. Cir. 2006) (addressing lay evidence as potentially competent to support presence of disability even where not corroborated by contemporaneous medical evidence). Generally, the degree of probative value which may be attributed to a medical opinion issued by a VA or private treatment provider takes into account such factors as its thoroughness and degree of detail, and whether there was review of a veteran's claims file. See Prejean v. West, 13 Vet. App. 444, 448-9 (2000). Also significant is whether the examining medical provider had a sufficiently clear and well-reasoned rationale, as well as a basis in objective supporting clinical data. See Bloom v. West, 12 Vet. App. 185, 187 (1999); Hernandez-Toyens v. West, 11 Vet. App. 379, 382 (1998); see also Claiborne v. Nicholson, 19 Vet. App. 181, 186 (2005) (rejecting medical opinions that did not indicate whether the physicians actually examined the veteran, did not provide the extent of any examination, and did not provide any supporting clinical data). The Court has held that a bare conclusion, even one reached by a health care professional, is not probative without a factual predicate in the record. Miller v. West, 11 Vet. App. 345, 348 (1998). A significant factor to be considered for any opinion is the accuracy of the factual predicate, regardless of whether the information supporting the opinion is obtained by review of medical records or lay reports of injury, symptoms and/or treatment. See Harris v. West, 203 F.3d 1347, 1350-51 (Fed. Cir. 2000) (examiner opinion based on accurate lay history deemed competent medical evidence in support of the claim); Kowalski v. Nicholson, 19 Vet. App. 171, 177 (2005) (holding that a medical opinion cannot be disregarded solely on the rationale that the medical opinion was based on history given by the veteran); Reonal v. Brown, 5 Vet. App. 458, 461 (1993) (holding that the Board may reject a medical opinion based on an inaccurate factual basis). When all the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with a veteran prevailing in either event, or whether a preponderance of the evidence is against a claim, in which case, the claim is denied. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102. The Board has reviewed all the evidence in the Veteran's claims file. Although the Board has an obligation to provide adequate reasons and bases supporting this decision, there is no requirement that the evidence submitted by a veteran or obtained on his behalf be discussed in detail. Rather, the Board's analysis below will focus specifically on what evidence is needed to substantiate the claim and what the evidence in the claims file shows, or fails to show, with respect to the claim. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000); Timberlake v. Gober, 14 Vet. App. 122, 128-30 (2000). In this case, the Veteran contends that he has a current left lower leg disability that is related to active service. Specifically, he avers that he first sought treatment for left lower leg pain during active service, and that the pain continued following service separation, as demonstrated by the documented complaints of left foot pain on many occasions following active service. Moreover, with regard to the gap of documented left foot complaints from 1952 to 1968, he states that he did not seek treatment during those years because the pain was likely masked by over-the-counter medication he was taking for a shoulder condition. The Board notes that the Veteran has been granted service connection for left calcaneal bursitis and left medial plantar nerve sensory neuropathy, both claimed as a left foot condition. These issues are not on appeal. After a review of all the evidence of record, lay and medical, the Board finds that the weight of the evidence demonstrates that, although the Veteran reported left leg pain on one occasion during his second period of active service, the condition resolved with treatment prior to separation, and that the weight of the evidence demonstrates that symptoms of a left lower leg disability were not chronic in either period of service from August 1947 to January 1950 and June 1951 to October 1953. Both the August 1947 enlistment and January 1950 separation examination reports are negative for any complaints or diagnoses of left leg problems. The June 1951 enlistment examination report is also negative for any left leg problems. A September 1952 treatment note indicates the Veteran was admitted into a therapy program for cervical spine and right arm problems. It further indicates that occasional left leg pain of unknown origin was present remittingly with no relation to therapy, but that, in the last two weeks, symptoms had subsided markedly and the Veteran was now asymptomatic. There are no other treatment records documenting complaints of left leg pain. Thus, it appears that the left leg pain resolved on its own, as further demonstrated by the negative September 1953 separation examination report, on which clinical evaluation of the lower extremities was marked as "normal." The Board next finds that the weight of the evidence demonstrates that symptoms of a left lower leg disability have not been continuous since separation from active service in October 1953. As noted above, the September 1953 separation examination report is negative for any left leg problems. Following service separation in October 1953, the evidence of record does not show any complaints, diagnosis, or treatment for left leg pain until October 2007, when VA treatment notes show complaints of right hip and left leg pain for fifty years. When asked for more detail about the pain, however, the Veteran focused on right hip pain that radiated to his right knee, and did not discuss the left leg pain. The VA clinician assessed nonspecific left leg pain. The Board acknowledges that post-service private treatment records demonstrate complaints of left heel and foot pain as early as 1968 and on various occasions thereafter. However, no complaints of left lower leg pain are mentioned in these treatment notes, and, as mentioned above, the Veteran has been granted service connection for a separate left foot disability. The absence of post-service complaints, findings, diagnosis, or treatment for 54 years after service separation until 2007 is one factor that tends to weigh against a finding of continuous symptoms of a left leg disability after service separation. See Buchanan, 451 F.3d 1336 (the lack of contemporaneous medical records is one fact the Board can consider and weigh against the other evidence, although the lack of such medical records does not, in and of itself, render the lay evidence not credible). Additional evidence demonstrating that symptoms of a left lower leg disability have not been continuous since service separation includes private treatment records from 1964 to 2002 that show no complaints, findings, treatment, or diagnoses of a left leg disability. These records are highly probative evidence against the Veteran's contention of continuous left lower leg symptoms since service separation. With regard to the Veteran's more recent assertions made as part of the current compensation claim that he has had left lower leg disability symptoms since separation from service in October 1953, the Board finds that, while the Veteran is competent to report the onset of left leg disability symptoms, his recent reports of continuous left leg symptoms since service are outweighed by the other, more contemporaneous, lay and medical evidence of record, both in service and after service, and are not reliable. See Charles v. Principi, 16 Vet. App. 370 (2002). The Board finds that the statements of the Veteran as to continuous left leg symptoms after service are not accurate because they are outweighed by other evidence of record that includes the more contemporaneous service treatment records which are negative for any findings or diagnoses of a left lower leg disability (with the exception of the complaint of left leg pain that resolved prior to separation), the lack of any post-service documentation of treatment or diagnoses of a left leg problem for 54 years after service separation until 2007, and the Veteran's prior claims for service connection in December 1953 and April 2002 with no mention of left leg symptoms. The Board acknowledges that symptoms, not treatment, are the essence of any evidence of continuity of symptomatology (Savage v. Gober, 10 Vet. App. 488, 496 (1997)); however, here, the Veteran filed claims for service connection in 1953 and 2002, but did not mention any left leg symptoms at that time. This suggests to the Board that there was no pertinent left leg symptomatology at that time. While inaction regarding filing a claim is not necessarily indicative of the absence of symptomatology, where, as here, a veteran takes action regarding other claims, it becomes reasonable to expect that the Veteran is presenting all issues for which he is experiencing symptoms that he believes are related to service. In other words, the Veteran demonstrated that he understood the procedure for filing a claim for VA disability compensation, and he followed that procedure in other instances where he believed he was entitled to those benefits. In such circumstances, it is more reasonable to expect a complete reporting than for certain symptomatology to be omitted. Thus, the Veteran's inaction regarding a claim for a left lower leg disability, when viewed in the context of his action regarding other claims for compensation, may reasonably be interpreted as indicative of the Veteran's belief that he did not sustain a left lower leg disability in service, or the lack of left leg symptomatology at the time he filed the claim, or both. Further, the Board finds that the weight of the evidence is against a finding that the Veteran has a current left lower leg disability. He was afforded a VA examination in July 2012. The VA examiner reviewed the claims file, including service treatment records, and conducted an interview and physical examination of the Veteran. The VA examiner noted that the Veteran had a long history of left heel pain radiating up his Achilles tendon, but had never injured his left lower leg, nor had he been treated for left lower leg pain since the one occasion in September 1952 (described above) when he reported occasional left leg pain. Rather, his pain had always been located in the left heel and Achilles region. An X-ray study of the left leg showed no evidence of acute fracture or dislocation, minimal posterior calcaneal enthesophyte, and vascular calcification within the soft tissue. The VA examiner opined that the claimed left lower leg condition was less likely than not incurred in or caused by an in-service injury, event, or illness, reasoning that the Veteran did not have left lower leg pain. Rather, he had let heel pain radiating up the back of the heel over the Achilles tendon. The 2012 VA opinion is competent and probative medical evidence because it is factually accurate, and is supported by an adequate rationale. The VA examiner was informed of the pertinent evidence, reviewed the claims file, conducted a thorough physical examination and interview of the Veteran, and fully articulated the opinion. VA does not generally grant service connection for symptoms alone, such as left lower leg pain, without an identified basis for those symptoms. The VA needs to identify a disability, not symptoms of a disability. Accordingly, service connection cannot be granted for symptoms of a disability. Accordingly, in light of the July 2012 VA opinion as well as the lack of any findings or diagnoses related to the left lower leg in the post-service treatment records, the greater weight of the probative evidence is against finding that the Veteran has a current left lower leg disability. As noted above, pain alone does not constitute a disability for VA benefits purposes. As a result, the claim must be denied. Indeed, in the absence of proof of a present disability there can be no valid claim. Brammer, 3 Vet. App. at 225. The Board recognizes that the Court has held that the presence of a chronic disability at any time during the claim process can justify a grant of service connection, even where the most recent diagnosis is negative. McClain v. Nicholson, 21 Vet. App. 319 (2007). However, where the overall record fails to support a current diagnosis of the claimed disability, as is the case here, that holding would not apply. Even if the Board were to find that the evidence established a diagnosis of a left lower leg disability, based on the evidence of record, the weight of the competent evidence demonstrates no relationship between the Veteran's current left lower leg disability and his military service, including no credible evidence of either an in-service knee disease or injury (other than the left leg pain that resolved prior to separation), chronic symptoms of a left lower leg disability during active service, or continuity of symptomatology of a left lower leg disability, which would serve either as a nexus to service or as the factual basis for a favorable medical nexus opinion. For these reasons, service connection for a left lower leg disability must be denied. As the preponderance of the evidence weighs against the Veteran's claim for service connection for a left lower leg disability, the benefit of the doubt doctrine is not applicable, and the claim for service connection must be denied. See 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102. Increased Rating for Residuals of a Right Pleural Effusion with Chronic Right Fibrous Pleuritis Disability evaluations (ratings) 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 (Rating Schedule). 38 U.S.C.A. § 1155; 38 C.F.R. §§ 4.1, 4.2, 4.10. In evaluating a disability, the Board considers the current examination reports in light of the whole recorded history to ensure that the current rating accurately reflects the severity of the condition. The Board has a duty to acknowledge and consider all regulations that are potentially applicable. Schafrath v. Derwinski, 1 Vet. App. 589 (1991). The medical as well as industrial history is to be considered, and a full description of the effects of the disability upon ordinary activity is also required. 38 C.F.R. §§ 4.1, 4.2, 4.10. Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. See 38 C.F.R. § 4.7. Reasonable doubt regarding the degree of disability will be resolved in the veteran's favor. 38 C.F.R. § 4.3. In this case, the Veteran's service-connected residuals of a right pleural effusion have been rated under Diagnostic Code 6845. 38 C.F.R. § 4.97. Diagnostic Codes 6840-6845 are evaluated under criteria for evaluation of restrictive lung disease. 38 C.F.R. § 4.97. A 10 percent rating requires a forced expiratory volume in one second (FEV-1) of 71 to 80 percent predicted, or ratio of FEV-1 to forced vital capacity (FEV-1/FVC) of 71 to 80 percent, or Diffusion Capacity of the Lung for Carbon Monoxide by the Single Breath Method (DLCO (SB)) of 66 to 80 percent predicted. Important for this case, a 30 percent rating requires a FEV-1 of 56 to 70 percent predicted, or FEV-1/FVC of 56 to 70 percent, or DLCO (SB) of 56 to 65 percent predicted. A 60 percent rating requires FEV-1 of 40 to 55 percent predicted, or FEV-1/FVC of 40 to 55 percent, or DLCO (SB) of 40 to 55 percent predicted, or maximum oxygen consumption of 15 to 20 ml/kg/min (with cardiorespiratory limit). A 100 percent evaluation is warranted where testing reveals FEV-1 of less than 40 percent of predicted value; or the ration of Forced Expiratory Volume in one second to Forced Vital Capacity (FEV-1/FVC) less than 40 percent; or Diffusion Capacity of the Lung for Carbon Monoxide by the Single Breath Method (DLCO (SB)) less than 40 percent predicted; or maximum exercise capacity less than 15 ml/kg/min oxygen consumption (with cardiac or respiratory limitation); or cor pulmonale (right heart failure); or right ventricular hypertrophy; or pulmonary hypertension (shown by Echo or cardiac catheterization; or episode(s) of acute respiratory failure; or requires outpatient oxygen therapy. 38 C.F.R. § 4.97, Diagnostic Code 6845. The Board notes that during the pendency of this appeal, VA amended the Rating Schedule concerning respiratory conditions, effective from October 6, 2006. VA added provisions that clarify the use of pulmonary function tests (PFTs) in evaluating respiratory conditions. A new paragraph (d) to 38 C.F.R. § 4.96, titled "Special provisions for the application of evaluation criteria for diagnostic codes 6600, 6603, 6604, 6825-6833, and 6840-6845" has seven provisions, which state: (1) PFTs are required to evaluate respiratory conditions except: (i) When the results of a maximum exercise capacity test are of record and are 20 ml/kg/min or less. If a maximum exercise capacity test is not of record, evaluation should be based on alternative criteria. (ii) When pulmonary hypertension (documented by an echocardiogram or cardiac catheterization), cor pulmonale, or right ventricular hypertrophy has been diagnosed. (iii) When there have been one or more episodes of acute respiratory failure. (iv) When outpatient oxygen therapy is required. (2) If the DLCO (SB) test is not of record, evaluation should be based on alternative criteria as long as the examiner states why the DLCO (SB) test would not be useful or valid in a particular case. (3) When the PFTs are not consistent with clinical findings, evaluation should be based on the PFTs unless the examiner states why they are not a valid indication of respiratory functional impairment in a particular case. (4) Post-bronchodilator studies are required when PFTs are done for disability evaluation purposes except when the results of pre-bronchodilator PFTs are normal or when the examiner determines that post-bronchodilator studies should not be done and states why. (5) When evaluating based on PFTs, post-bronchodilator results are to be used unless the post-bronchodilator results were poorer than the pre-bronchodilator results. In those cases, the pre- bronchodilator values should be used for rating purposes. (6) When the results of different PFTs (FEV-1, FVC, etc.) are disparate (so that the level of evaluation would differ depending on which test result is used), the test result that the examiner states most accurately reflects the level of disability should be used for evaluation. (7) If the FEV-1 and the FVC are both greater than 100 percent, a compensable evaluation based on a decreased FEV- 1/FVC ratio should not be assigned. The Veteran submitted his claim in April 2002, prior to the effective date of the amendment to 38 C.F.R. § 4.96 on October 6, 2006. In general, amended rating criteria can be applied only for periods beginning on the effective date of the regulatory change. The Board can only apply the prior regulation when evaluating a disability during periods prior to the effective date of the regulatory change. However, the prior regulation can be applied during the entire pendency of the appeal if more favorable than the amended regulation. VAOPGCPREC 3-00 (Apr. 10, 2000), 65 Fed. Reg. 33,422 (May 23, 2000); VAOPGCPREC 7-2003 (Nov. 19, 2003), 69 Fed. Reg. 25,179 (May 4, 2004); Kuzma v. Principi, 341 F.3d 1327 (Fed. Cir. 2003). Important in this case, as the claim was submitted prior to the effective date of the amendment to 38 C.F.R. § 4.96, the Board will use both pre-bronchodilator and post-bronchodilator results when evaluating the Veteran's PFTs, whichever is more favorable. In view of the number of atypical instances it is not expected, especially with the more fully described grades of disabilities, that all cases will show all the findings specified. Findings sufficiently characteristic to identify the disease and the disability therefrom, and above all, coordination of rating with impairment of function will, however, be expected in all instances. 38 C.F.R. § 4.21 (2011). As is the case here, where entitlement to compensation has already been established and an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). Nevertheless, where the evidence contains factual findings that show a change in the severity of symptoms during the course of the rating period on appeal, assignment of staged ratings would be permissible. Hart v. Mansfield, 21 Vet. App. 505 (2007). In rendering a decision on appeal, the Board must analyze the credibility and probative value of the evidence, account for the evidence which it finds to be persuasive or unpersuasive, and provide the reasons for its rejection of any material evidence favorable to the claimant. See Gabrielson, 7 Vet. App. at 39-40; Gilbert, 1 Vet. App. at 57. Competency of evidence differs from weight and credibility. Competency is a legal concept determining whether testimony may be heard and considered by the trier of fact, while credibility is a factual determination going to the probative value of the evidence to be made after the evidence has been admitted. Rucker, 10 Vet. App. at 74; Layno, 6 Vet. App. at 469; see also Cartright, 2 Vet. App. at 25 ("although interest may affect the credibility of testimony, it does not affect competency to testify"). Lay testimony is competent when it regards the readily observable features or symptoms of injury or illness and "may provide sufficient support for a claim of service connection." See Layno; 38 C.F.R. § 3.159(a)(2). When all the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with a veteran prevailing in either event, or whether a preponderance of the evidence is against a claim, in which case, the claim is denied. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102. The Board has reviewed all the evidence in the Veteran's claims file. Although the Board has an obligation to provide adequate reasons and bases supporting this decision, there is no requirement that the evidence submitted by a veteran or obtained on his behalf be discussed in detail. Rather, the Board's analysis below will focus specifically on what evidence is needed to substantiate the claim and what the evidence in the claims file shows, or fails to show, with respect to the claim. See Gonzales, 218 F.3d at 1380-81; Timberlake, 14 Vet. App. at 128-30. In this case, the Veteran is in receipt of a 10 percent disability rating for residuals of a right pleural effusion with chronic right fibrous pleuritis for the entire rating period on appeal. He filed a claim for an increased rating in April 2002. He avers that he has occasional twinges and pain in his lung while walking and sometimes even while sitting. A June 2002 VA treatment note indicates the Veteran expressed interest in his service-connected residuals of a right pleural effusion, stating that he used to have annual check-ups at VA twenty years prior. He denied shortness of breath, cough, and hemoptysis, but stated that his lung area still ached occasionally. Moreover, he stated that his right lung collapsed when he had his gallbladder removed in 1965. The lungs were clear to auscultation. It does not appear that any treatment was rendered or recommended at this visit. The Veteran was afforded a VA examination in March 2003. He stated that since his lung collapsed during surgery in 1965, he had no further problems. He denied shortness of breath, and denied pain, although he reported feeling a little "twinge" on the right side when he rested on his right side. The only time had lost time from work due to the residuals of a pleural effusion was in 1965 when he had the surgery and apparent pneumothorax. On physical examination, there was questionable decrease in breath sounds at the right base compared to the left; this difference was subtle. There were no rhonchi or rales, and the expiratory phase was within normal limits. A chest X-ray showed normal lungs. The March 2003 spirometry test revealed FEV-1 of 99 percent predicted (pre-bronchodilator) and FEV-1/FVC of 104 percent predicted (pre-bronchodilator). PFT results also showed an FEV-1 of 35 percent predicted (post-bronchodilator) and FEV-1/FVC of 83 percent (post-bronchodilator). The interpretation was a normal spirometry. The March 2003 VA examiner concluded that the Veteran was in no respiratory distress, noting that he had no significant problems associated with the original episode in 1953 except for a collapsed lung in 1965. VA and private treatment records dated thereafter are negative for complaints or treatment for any respiratory condition, and examination of the pulmonary system is consistently indicated as normal. A March 2007 VA treatment note indicates that the Veteran denied coughing, shortness of breath, dyspnea on exertion, or hemoptysis. The lungs were clear to auscultation, with no wheezes, crackles, or ronchi. A February 2008 VA treatment note also indicates that the Veteran denied coughing, hemoptysis, shortness of breath, dyspnea on exertion, paroxysmal nocturnal dyspnea, and history of asthma or tuberculosis. Based on the foregoing, even taking the Veteran's complaints of occasional pain and twinges in the right lung area into account, the Board finds that the weight of the evidence is against a grant of a higher 30 percent evaluation for residuals of a right pleural effusion with chronic right fibrous pleuritis. Specifically, the minimum criteria of a FEV-1 of 56 to 70 percent predicted, or FEV-1/FVC of 56 to 70 percent, or DLCO (SB) of 56 to 65 percent predicted for a 30 percent evaluation under Diagnostic Code 6845 are not met. 38 C.F.R. § 4.97. In this case, the pre-bronchodilator results of FEV-1 of 99 percent predicted and FEV-1/FVC of 104 percent predicted are well above the minimum criteria for even the currently assigned 10 percent rating. Moreover, the post-bronchodilator FEV-1/FVC of 83 percent predicted is also above the minimum criteria for the currently assigned 10 percent rating. The Board acknowledges that the post-bronchodilator FEV1 reading of 35 percent predicted falls into the criteria for a 100 percent rating. However, given the other results, which do not even meet the criteria for a compensable rating, as well as the interpretation of a normal spirometry and the lack of any respiratory complaints in VA and private treatment records following the 2003 VA examination to the present, the Board finds that this single PFT result is an outlier, does not accurately reflect the severity of the Veteran's respiratory disability, and does not warrant a disability rating in excess of 10 percent. The overwhelming preponderance of the evidence demonstrates that the Veteran's disability picture is adequately reflected by the currently assigned 10 percent disability rating. Indeed, it is important for Veteran to also understand that without some problems associated with his lungs there would be no basis for the current 10 percent disability rating. In this regard, as stated above, it is important to note that the March 2003 PFT results (with the exception of the post-bronchodilator FEV1 reading) would not even meet the requirements of a 10 percent evaluation, let alone higher evaluation. Without consideration of the problems he has cited and the pain he has in the lung area at this time, the current evaluation could not be justified. The Board has considered whether other applicable diagnostic codes would warrant a higher evaluation for his service-connected residuals of a right pleural effusion. However, there are no other applicable diagnostic codes. The Board has also considered the Veteran's statements that his disability is worse than currently evaluated. The Veteran is competent to report symptoms, such as shortness of breath, as this requires only personal knowledge as it comes to him through his senses. Layno, 6 Vet. App. at 470. He is not, however, competent to identify a specific level of disability of this disorder according to the appropriate diagnostic code. Such competent evidence concerning the nature and extent of the Veteran's disability has been provided by the medical personnel who have examined him during the current appeal and who have rendered pertinent opinions in conjunction with the evaluations. The medical findings (as provided in the examination reports and clinical records) directly address the criteria under which this disability is evaluated. For these reasons, the Board finds that the weight of the evidence is against a finding of an increased evaluation in excess of 10 percent for residuals of a right pleural effusion with chronic right fibrous pleuritis for any period. To the extent any higher level of compensation is sought, the preponderance of the evidence is against this claim, and hence the benefit-of-the-doubt doctrine does not apply. 38 U.S.C.A. § 5107(b); 38 C.F.R. §§ 4.3, 4.7. Extraschedular Consideration In addition to the foregoing, the Board has considered whether referral for an extraschedular evaluation is warranted for the Veteran's residuals of a right pleural effusion. In exceptional cases an extraschedular rating may be provided. 38 C.F.R. § 3.321 (2012). The threshold factor for extraschedular consideration is a finding that the evidence before VA presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. Therefore, initially, there must be a comparison between the level of severity and symptomatology of the claimant's service-connected disability with the established criteria found in the rating schedule for that disability. Thun v. Peake, 22 Vet. App. 111 (2008). 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. In the second step of the inquiry, however, 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 those provided by the regulation as "governing norms." 38 C.F.R. 3.321(b)(1) (related factors include "marked interference with employment" and "frequent periods of hospitalization"). When the rating schedule is inadequate to evaluate a claimant's disability picture and that picture has 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 for completion of the third step - a determination of whether, to accord justice, the claimant's disability picture requires the assignment of an extraschedular rating. Id. Turning to the first step of the extraschedular analysis, the Veteran's pleural effusion disability has manifested in occasional pain and twinges, but a normal spirometry. The schedular criteria for rating the respiratory disability (38 C.F.R. § 4.97, Diagnostic Code 6845) specifically provide for ratings based on the results of PFTs and other respiratory complaints. In this case, comparing the Veteran's disability level and symptomatology of the right lung to the rating schedule, the degree of disability of the right lung throughout the entire period under consideration is contemplated by the rating schedule and the assigned rating is, therefore, adequate. The schedule is intended to compensate for average impairments in earning capacity resulting from service-connected disability in civil occupations. 38 U.S.C.A. § 1155. "Generally, the degrees of disability specified [in the rating schedule] are considered adequate to compensate for considerable loss of working time from exacerbations or illnesses proportionate to the severity of the several grades of disability." 38 C.F.R. § 4.1. In this case, the problems reported by the Veteran are specifically contemplated by the criteria discussed above, including the effect on his daily life, and he has not missed work due to the respiratory disability since 1965. In the absence of exceptional factors associated with the pleural effusion disability, the Board finds that the criteria for submission for assignment of an extraschedular rating pursuant to 38 C.F.R. § 3.321(b)(1) are not met. See Bagwell v. Brown, 9 Vet. App. 337 (1996); Shipwash v. Brown, 8 Vet. App. 218, 227 (1995). Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA) and implementing regulations impose obligations on VA to provide claimants with notice and assistance. 38 U.S.C.A. §§ 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2012). The notice requirements of VCAA require VA to notify the claimant of what information or evidence is necessary to substantiate the claim; what subset of the necessary information or evidence, if any, the claimant is to provide; and what subset of the necessary information or evidence, if any, the VA will attempt to obtain. The Board notes that a "fourth element" of the notice requirement requesting the claimant to provide any evidence in the claimant's possession that pertains to the claim was removed from the language of 38 C.F.R. § 3.159(b)(1). See 73 Fed. Reg. 23,353-356 (April 30, 2008). The Court issued a decision in the appeal of Dingess v. Nicholson, 19 Vet. App. 473 (2006), which held that the notice requirements of 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) apply to all five elements of a service connection claim, including the degree of disability and the effective date of an award. Those five elements include: (1) veteran status; (2) existence of a disability; (3) a connection between a veteran's service and the disability; (4) degree of disability; and (5) effective date of the 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 and earning capacity, as well as general notice regarding how disability ratings and effective dates are assigned. Vazquez-Flores v. Shinseki, 580 F.3d 1270 (2009). With regard to the service connection claim, in a timely April 2008 letter, the RO provided notice to the Veteran regarding what information and evidence is needed to substantiate a claim for service connection, including secondary service connection, what information and evidence must be submitted by the Veteran, and what information or evidence VA will attempt to obtain. Although Dingess notice was not issued prior to initial adjudication of the claim, the Board finds that the Veteran was not prejudiced by any untimeliness in notice, as it will not reach the issues of disability rating and effective date herein. With regard to the increased rating claim, in a timely May 2002 letter, the Veteran was informed of the requirements needed to establish an increased evaluation for residuals of a right pleural effusion. The notice letter advised the Veteran that VA used a published schedule for rating disabilities that determined the rating assigned and that evidence considered in determining the disability rating included the nature and symptoms of the condition, the severity and duration of the symptoms, and the impact of the condition and symptoms on employment. In accordance with the requirements of VCAA, the VA letter informed the Veteran what evidence and information he was responsible for obtaining and the evidence that was considered VA's responsibility to obtain. The April 2003 rating decision informed the Veteran of the specific rating criteria used to evaluate his service-connected disability. The Board is also satisfied VA has made reasonable efforts to obtain relevant records and evidence. Specifically, the information and evidence that has been associated with the claims file includes the Veteran's service treatment records, post-service VA and private treatment records, VA examinations and opinions, and the Veteran's statements. A VA examination and opinion was obtained in July 2012 with regard to the question of whether the Veteran has a left leg disability that is related to active service. To that end, when VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). The Board finds that the July 2012 VA opinion obtained in this case is adequate as to the question of whether the Veteran has a current left leg disability that is related to active service. The opinion was predicated on a complete physical examination and a full reading of the private and VA medical records in the Veteran's claims file. The VA opinion (that the Veteran does not have a current left lower leg disability) considered all of the pertinent evidence of record, to include VA treatment records, comprehensive physical examinations, and the statements of the Veteran, and provides a complete rationale for the opinion stated, relying on and citing to the records reviewed. Accordingly, the Board finds that VA's duty to assist with respect to obtaining a VA examination or opinion with respect to the claim decided herein has been met. 38 C.F.R. § 3.159(c)(4). Further, the Veteran has been afforded an adequate examination on the issue of an increased rating for service-connected residuals of a right pleural effusion. VA provided the Veteran with an examination in March 2003. The Veteran's history was taken, and a complete examination with clinical measures was conducted, to include a PFT. Conclusions reached and diagnoses given were consistent with the examination report. For these reasons, the Board finds that the Veteran has been afforded an adequate examination on the issue of an increased rating for service-connected residuals of a right pleural effusion. Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). Notably, the Veteran has not identified, and the record does not otherwise indicate, any additional existing evidence that is necessary for a fair adjudication of the claim that has not been obtained. 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). ORDER Service connection for a left lower leg disability is denied. A disability rating in excess of 10 percent for residuals of a right pleural effusion with chronic right fibrous pleuritis is denied. ______________________________________________ JOHN J. CROWLEY Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs