Citation Nr: 1315247 Decision Date: 05/08/13 Archive Date: 05/15/13 DOCKET NO. 08-27 667 ) DATE ) ) On appeal from the Department of Veterans Affairs (VA) Regional Office (RO) in Anchorage, Alaska THE ISSUES 1. Entitlement to a disability rating in excess of 10 percent for service-connected recurrent pilonidal cyst with tender scar on an extraschedular basis. 2. Entitlement to a disability rating in excess of 30 percent for service-connected incomplete rupture, rectus femoris muscle, left leg, on an extraschedular basis. 3. Entitlement to a total disability rating based on individual unemployability (TDIU). REPRESENTATION Veteran represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD Matthew Blackwelder, Counsel INTRODUCTION The Veteran had active military service from February 1960 to February 1963. This appeal initially came to the Board of Veterans' Appeals (Board) from an April 2006 rating decision. In December 2010, the Veteran testified before the undersigned Veterans Law Judge via video conference at the RO. A transcript of the hearing has been associated with the claims folder. In February 2011, the Board denied a rating in excess of 10 percent for service-connected recurrent pilonidal cyst with tender scar and granted a 30 percent disability evaluation for an incomplete rupture of the rectus femoris muscle of the left leg. The Veteran appealed the ratings that were assigned to the Court of Appeals for Veterans Claims (Court). In October 2011, the Court vacated the Board decision and remanded the Veteran's claim for action consistent with the directives of a Joint Motion for Partial Remand (JMPR). In February 2012, the Board increased the rating for the incomplete rupture of the rectus femoral muscle of the left leg to 40 percent on a schedular basis; denied a rating in excess of 10 percent for the recurrent pilonidal cyst with tender scar on a schedular basis; and remanded both issues for extraschedular consideration. The Veteran did not appeal this decision. As such, the two issues on appeal involve extraschedular consideration only. The Board must note that in reviewing this case the Board has not only reviewed the Veteran's physical claims file, but also his file on the "Virtual VA" system to insure a total review of the evidence. The Veteran did not file a formal claim for a TDIU during the course of this appeal. However, in an April 2013 brief, the Veteran's representative suggested that the issue of total disability rating based on individual unemployability (TDIU) had been raised by the record, but not adjudicated. In Rice v. Shinseki, 22 Vet. App. 447 (2009), the U.S. Court of Appeals for Veterans Claims held that a TDIU claim is part of an increased rating claim when such claim is reasonably raised by the record. In light of the assertion by the Veteran's representative, the Board finds that the issue of entitlement to a TDIU is reasonably raised by the record and considered to be part of the Veteran's increased rating claims, as reflected on the first page of this decision. The issue of a TDIU is addressed in the REMAND portion of the decision below and is REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. FINDINGS OF FACT 1. The weight of the evidence is against a finding that the Veteran's recurrent pilonidal cyst with tender scar creates an exceptional disability picture with factors such as marked interference with employment or frequent periods of hospitalization. 2. The weight of the evidence is against a finding that the residual symptoms from the Veteran's left leg disability are not reasonably described by the schedular rating criteria, and even they are not, the weight of the evidence is against a finding that the leg disability creates an exceptional disability picture with factors such as marked interference with employment or frequent periods of hospitalization. CONCLUSIONS OF LAW 1. The criteria for an extraschedular disability rating, beyond the 10 percent schedular rating already assigned, for the Veteran's recurrent pilonidal cyst with tender scar have not been met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 3.321, 4.7, 4.118, Diagnostic Code 7819-7804 (2008). 2. The criteria for an extraschedular disability rating, beyond the 40 percent schedular rating already assigned, for the Veteran's left rectus femoris muscle disability have not been met. 38 U.S.C.A. § 1155; 38 C.F.R. §§ 3.321, 4.7, 4.73, Diagnostic Code 5314 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Increased Rating Disability ratings are determined by applying a schedule of ratings that is based on average impairment of earning capacity. Separate diagnostic codes identify the various disabilities. 38 U.S.C.A. § 1155; 38 C.F.R., Part 4. Each disability must be viewed in relation to its history and the limitation of activity imposed by the disabling condition should be emphasized. 38 C.F.R. § 4.1. Examination reports are to be interpreted in light of the whole recorded history, and each disability must be considered from the point of view of the appellant working or seeking work. 38 C.F.R. § 4.2. Where there is a question as to which of two disability evaluations shall be applied, the higher evaluation is to be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating is to be assigned. 38 C.F.R. § 4.7. The Board notes that while the regulations require review of the recorded history of a disability by the adjudicator to ensure an accurate evaluation, the regulations do not give past medical reports precedence over the current medical findings. Where an increase in the disability rating is at issue, the present level of the veteran's disability is the primary concern. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). It is also noted that staged ratings are appropriate for an increased rating claim whenever the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. See Hart v. Mansfield, 21 Vet. App. 505 (2007). In April 2005, the Veteran filed a claim seeking a higher disability rating for his service-connected recurrent cyst disability and left rectus femoris muscle disability. The Veteran appealed his claim to the Court, and the claim was remanded to the Board to address the possibility of extraschedular rating(s). As noted in the introduction, the Board already addressed the Veteran's service connected disabilities on a schedular basis in a February 2012 decision, which the Veteran does not appear to have appealed. Therefore, the schedular issues are final, and this decision addresses only whether higher ratings are warranted for either disability on an extraschedular basis. In the JMPR, it was suggested that the Board had failed to adequately address whether an extra-schedular rating was appropriate in this case. The JMPR noted that the Veteran's pilonidal cyst with tender scar had been rated by analogy as 10 percent disabling under DC 7819-7804; but pointed out that the Diagnostic Codes which had been considered by the Board were generally based on the size of the scar, which the JMPR did not feel adequately contemplated the Veteran's cyst symptomatology. The JMPR noted that the Veteran's service-connected pilonidal cyst disability was manifested by recurrent eruptions on the tailbone, approximately three to four times a year and by swelling of the tailbone that would eventually erupt and drain bloody, purulent discharge for four to ten days every two to four months. The JMPR also pointed out that the April 2010 VA examination had observed the Veteran's condition to have a "significant effect on his daily life" and that his "activities [we]re significantly curtailed." With regard to the Veteran's service-connected incomplete rupture, rectus femoris muscle of the left leg, the JMPR noted that the condition is rated as 30 percent disabling under 38 C.F.R. § 4.73, DC 5314 (the schedular rating has since been increased to 40 percent), which deals with muscle group injuries of the pelvic girdle and thigh, specifically the anterior thigh group including (1) sartorius; (2) rectus femoris; (3) vastus externus; (4) vastus intermedius; (5) vastus internus; (6) tensor vaginae femoris. 38 C.F.R. § 4.73 (DC 5314). However, the JMPR asserted that the Veteran's service-connected incomplete rupture, rectus femoris muscle of the left leg had been found to affect all muscle groups in the girdle and thigh, which are manifested by "fair" muscle strength, and pointed out that an April 2010 VA examiner had specifically reported that the Veteran's muscle disability resulted in functional limitation (pain and weakness) of the left knee and left ankle. An extraschedular rating is considered to be warranted when an exceptional case arises where ratings based on the statutory schedules are found to be inadequate. In such rare cases, consideration of an "extra-schedular" evaluation commensurate with the average earning capacity impairment due exclusively to the service-connected disability or disabilities will be made. 38 C.F.R. § 3.321(b)(1). The Court has held that the determination of whether a claimant is entitled to an extraschedular rating under § 3.321(b) is a three-step inquiry, the responsibility for which may be shared among the RO, the Board, and the Under Secretary for Benefits or the Director, Compensation and Pension Service. Thun v. Peake, 22 Vet. App. 111 (2008). The threshold factor for extraschedular consideration is a finding that the evidence before VA presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. This means that initially there must be a comparison between the level of severity and symptomatology of the claimant's service-connected disability with the established criteria found in the rating schedule for that disability. If the criteria reasonably describe the claimant's disability level and symptomatology, then the claimant's disability picture is contemplated by the rating schedule, the assigned schedular evaluation is adequate, and no referral is required. If the criteria do not reasonably describe the claimant's disability level and symptomatology, a determination must be made whether the claimant's exceptional disability picture exhibits other related factors such as those provided by the regulation as "governing norms." 38 C.F.R. § 3.321(b)(1) (related factors include "marked interference with employment" and "frequent periods of hospitalization"). See id. At his Board hearing in December 2010, the Veteran was asked what symptoms he had as a result of the ruptured muscle in his left leg to which he responded that it had progressively worsened over the previous five years. He stated that he used to be able to walk a lot and liked to walk a lot, but his leg had gotten to the point that the discomfort, including pain and weakness, was curtailing his walking ability down to a quarter or less of what it used to be. He added that even walking 50 yards out to the mailbox and back caused occasional trouble, and noted that sometimes he would not even leave the house on account of pain. Most of the time he stated it was the discomfort and weakness, and he noted experiencing loss of power in the leg. He suggested that at his last evaluation he had been told that he had lost 90 percent of the use of his leg. The Veteran was asked whether his left leg had provided an inability to keep up with work requirements or had prevented him from doing certain types of work, to which he responded that it did in that he used to be letter carrier, walking five-and-a-half miles a day, five days a week, and he did not have the ability he used to. It is noted that the Veteran's leg disability is rated as severe, which specifically contemplates evidence of inability to keep up with work requirements. With regard to his tailbone cyst, the Veteran stated that he had 3-4 eruptions each year, but he denied generally needing to get medically treated for the flare-ups, although he acknowledged that he had received surgical treatment on several occasions. He stated that the cyst would break through the skin and then start draining. VA treatment records have been obtained dating back to 2004, but they fail to provide additional information, beyond what is discussed in the VA examination reports, as to the impairment caused by the two service connected disabilities on appeal here. The Veteran has undergone several VA examinations during the course of his appeal. At a March 2006 VA examination, the Veteran reported experiencing a constant ache in his left thigh, with progressive weakness over the previous 5-10 years. He indicated that in the previous 2-3 years his walking endurance had decreased to only 1/4-1/2 mile before stopping due to discomfort. However, he denied any interference with his activities of daily living. With regard to the cyst, the Veteran stated that the scar tissue caused mild discomfort, and the examiner noted that the cyst had a minimal effect on the Veteran's overall functioning, even during flare-ups. In his March 2007 notice of disagreement, the Veteran asserted that his conditions had become increasingly bothersome and affected his everyday life, causing leg weakness to the point that there were days he did not leave the house. In April 2010, the Veteran underwent a VA examination at which he reported that he has limited activity with his left leg due to tiredness, estimating that his daily activities were reduced by 90 to 95 percent from their levels five years earlier as a result of his service-connected left rectus femoris muscle disability. The examiner added that the leg condition had a significant effect on the Veteran's daily activities in that pain and decrease in function had significantly altered the amount of activity he was able to tolerate. In February 2012, the Board observed that the April 2010 VA examiner had not specifically indicated whether the Veteran's recurrent pilonidal cyst with tender scar or his incomplete rupture of the left rectus femoris muscle of the left lower extremity had resulted in marked interference with employment, and accordingly remanded for clarification. In March 2012, the examiner from the 2010 VA examination reexamined the Veteran, opining that the Veteran's cyst had significantly affected his day to day activities as well as his ability to keep gainful employment. The cyst was noted to flare-up 4-5 times per year, lasting 7-10 days at a time. The examiner stated that during these times, the Veteran's ability to be employed was significantly curtailed. Additionally, the doctor stated that the Veteran's leg condition resulted in marked interference with employment, as it caused daily symptoms such as muscle pain, limited activity, and inability to move a joint normally. He added that the Veteran was no longer able to walk the 5 miles a day he previous had, and in fact was only able to walk 40-50 yards at a time. As a result, the doctor stated that the Veteran's activities of daily living were significantly curtailed and had resulted in marked interference with employment. In August 2012, another VA medical opinion was obtained. The examiner opined that it was less likely than not that the Veteran's recurrent pilonidal cyst with tender scar caused marked interference with employment. The rationale for the examiner's opinion was the Veteran's denial of the use of donut or other pillow for the pilonidal cyst; as well as the fact that the Veteran had never needed antibiotics for treatment, and had denied any recent hospitalization or physician visits for the condition. The examiner also noted that the Veteran ambulated three miles daily on a treadmill in 2003, prior to the onset of heart and lung issues; and observed that while the Veteran reported only being able to continuously walk 50 yards before his leg and thigh began to ache, he used no cane or brace, and on observation he walked without grimace or instability and appeared comfortable during ambulation, providing evidence against this claim. Additionally, the examiner concluded that the Veteran's leg functioning was not so diminished that amputation with prosthesis would equally serve him. The Veteran reported that his cyst would become sore, swollen, and warm, followed by draining, but he conceded that it generally resolved on its own within 5-10 days. Additionally, the examiner observed that the Veteran had no pain with sitting. Another opinion was obtained in February 2013. The examiner opined that the Veteran's service connected conditions would cause marked interference with employment with physically active jobs, such as the Veteran's former job as a letter carrier, but would not cause marked interference with sedentary employment. The rationale for the examiner's opinion was that the Veteran's ambulation was limited to only 40-50 yards, due to the incomplete rupture, rectus femoris, left, with weakness of the left lower extremity, and this would cause marked interference only with physically active employment. However, concurring with an earlier examiner, the examiner pointed out that the Veteran had not required hospitalization or physician visits for treatment of his cyst, had never needed antibiotics and did not use a pillow or donut. The examiner conceded that the Veteran might need to lean or sit slightly to the right during flare-ups, and acknowledged that the draining pilonidal cyst would be inconvenient, but the examiner felt that with retraining the Veteran could be gainfully employed in a sedentary job. Based on the evidence of record as described above, the Veteran's claim was referred to the Director of Compensation and Pension for a determination of whether an extraschedular rating was warranted for either of the Veteran's service connected disabilities. The Director concluded that it was not. The Board must also address the same question, but for the reasons set forth below, the Board ultimately finds that an extraschedular rating is not warranted for either of the Veteran's service connected disabilities. Turning first to the Veteran's cyst, the Board will concede that the first prong of the Thun analysis was not met. That is, the schedular rating criteria by which the Veteran's disability is rated does not reasonably describe the disability level and symptomatology of the Veteran's cyst in that the schedular rating criteria that is used rates based on scarring alone and does not specifically consider the flare-ups when the cyst ruptures and drains. As such, a determination must be made in this decision whether the Veteran's exceptional cyst 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"). The Board acknowledges that the Veteran's cyst is likely to cause frustration and annoyance. However, the fact remains that the Veteran has not been hospitalized for the condition and, in fact, he does not even appear to have received any medical treatment of the condition in quite some time. The VA examiner in March 2012 did suggest that the cyst caused some interference with employment, noting that during flare-ups the Veteran's ability to be employed was significantly curtailed. However, flare-ups only were reported to occur 4-5 times per year, meaning that the vast majority of the time the Veteran does not have flare-ups. It is not disputed that this might cause some interference with employment, but some interference with employment is specifically contemplated by the compensable schedular rating that is already assigned. In this regard, it is very important for the Veteran to understand that if these problems did not cause difficulties, there would be no basis for a compensable evaluations, let alone the current evaluations. Importantly, this examiner did not appear to provide much, if any, rationale for his opinion. Conversely, the two examiners who subsequently reviewed the Veteran's claim noted that the Veteran had not required a donut or other pillow, and had never needed antibiotics for treatment. The Veteran argued in an April 2013 statement that no doctor had ever mentioned antibiotics or any other procedure, however, the fact that antibiotics were not required is indicative of the fact that his cyst had not become infected and thus was not of such severity that would require significant medical care or hospitalization. When evaluating the evidence of record, the Board must assess the credibility and probative value of the evidence, and, provided that it offers an adequate statement of reasons or bases, the Board may favor one medical opinion over another. See Owens v. Brown, 7 Vet. App. 429, 433 (1995); Wood v. Derwinski, 1 Vet. App. 190 (1991). While the Board is not free to ignore the opinion of a treating physician, it is free to discount the credibility of that physician's statement. See Guerrieri v. Brown, 4 Vet. App. 467, 471-73 (1993); Sanden v. Derwinski, 2 Vet. App. 97, 101 (1992). Here, all the medical opinions appear to have been provided by competent medical professionals and each opinion is therefore found to be probative evidence. However, looking at the entirety of the evidence, the Board simply does not believe that the Veteran's cyst causes frequent hospitalizations, marked interference with employment, or other complications that would warrant the assignment of an extraschedular rating. The Veteran has acknowledged that he is able to effectively treat the symptoms of his cyst with pads. The medical evidence does not show that he is unable to sit, even during flare-ups. Moreover, the Veteran does not appear to require any medical care for the condition, much less hospitalization. Moreover, he has not required special pillows, antibiotics, or other treatment for his cyst. Given these findings, the Board simply finds the multiple medical opinions which concluded that his condition did not cause marked interference with employment to be better supported by the evidence of record than the single opinion which reached a contrary conclusion, and for that reason the negative opinions will be afforded greater weight. In April 2013, the Veteran wrote a statement indicating that his condition was very painful and annoying, and the Board does not doubt that the Veteran's cyst does cause considerable consternation, but it does not appear to cause sufficient impairment to warrant an extraschedular rating. The Veteran also suggested that his other medical conditions would not allow further treatment, but this assertion also goes to further show that significant intervention is not medically required. As described, the weight of the evidence, including the Veteran's statements, simply does not establish that his exceptional disability picture exhibits any of the governing norms for an extraschedular rating to be assigned. As such, an extraschedular rating is denied. With regard to the Veteran's leg condition, the result is the same in that the evidence does not support the assignment of an extraschedular rating, although the analysis is somewhat different. Under the Thun analysis, the threshold factor for consideration is whether the evidence before VA presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. That is, the Board must determine whether the schedular rating criteria reasonably describe the symptomatology of the service connected disability. In this case, the JMPR noted that Veteran's service-connected incomplete rupture, rectus femoris muscle of the left leg had been found to affect all muscle groups in the girdle and thigh, which are manifested by "fair" muscle strength, and pointed out that an April 2010 VA examiner specifically reported that this muscle disability resulted in functional limitation (pain and weakness) of the left knee and left ankle. The examiner added in March 2012 that the Veteran's leg condition resulted in marked interference with employment, as it caused daily symptoms such as muscle pain, limited activity, and inability to move a joint normally. However, as noted, the Veteran's left leg disability is rated as a severe muscle disability, which takes this into consideration. 38 C.F.R. § 4.56(c) provides that 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(d)(4) provides that a severe muscle disability anticipates consistent complaints of cardinal signs and symptoms of muscle disability that worse than those shown for moderately severe muscle injuries, and, if present, evidence of inability to keep up with work requirements. Moreover, tests of strength, endurance, or coordinated movements compared with the corresponding muscles of the uninjured side indicate severe impairment of function. Here, the Veteran's complaints at his hearing were essentially that pain and weakness in his left leg prevented him from engaging in physical activities such as walking. The Veteran again emphasized these limitations in an April 2013 statement suggesting that his leg interfered with physical employment, and with personal activities, and stating that it was often highly painful. The Board does not wish to minimize the severity of the Veteran's service connected leg disability. However, symptoms such as weakness and pain are specifically enumerated in the list of cardinal signs of muscle problems which form a baseline for the schedular rating that is assigned. As such, the Veteran would be expected to constantly have such symptoms if his left leg disability is accurately rated as a severe muscle injury. Additionally, the schedular rating provides that there is likely going to be evidence of an inability to keep up with work requirements. As such, it would appear that the schedular rating criteria address specifically the Veteran's main reported symptoms, and therefore an extraschedular rating would not be found to be warranted. However, even if it was found that the Veteran's left leg disability was not reasonably described by the schedular rating criteria, the fact remains that the weight of the evidence is against the finding that the Veteran's condition is so exceptional as to warrant an extraschedular rating as the Veteran's left leg disability has not exhibited other related factors such as those provided by the regulation as "governing norms" of an extraschedular rating. That is, factors such as "marked interference with employment" and "frequent periods of hospitalization". 38 C.F.R. § 3.321. As an initial point, there is no allegation that the Veteran has been hospitalized for treatment of his left leg at any point during the course of his appeal. In fact, it does not appear that he even receives any medical treatment for the disability. The issue must be considered whether the Veteran's left leg disability causes marked interference with employment. There is no dispute that the Veteran's leg would impede his prior line of work as a mail carrier, although it appears that the majority of the Veteran's medical treatment is for heart and lung problems which have both contributed to decreased mobility, and not on account of his leg. Moreover, the Veteran has not required any brace or cane to support his ambulating. Additionally, the schedular rating that is assigned contemplates a severe muscle injury that renders a person unable to keep up with work requirements. As such, the fact that the Veteran might no longer be able to work as a mail carrier on account of a severe muscle injury, does not in any way render his disability unique or unusual. Rather, it is precisely what is contemplated by the schedular rating that is assigned. It is noted that the examiner in March 2012 found that the Veteran's leg condition resulted in marked interference with employment, citing to the fact that it caused daily symptoms such as muscle pain, limited activity, and inability to move a joint normally. However, these are precisely the symptoms which are being compensated by the schedular rating that is assigned. Moreover, this examiner did not address whether there would be marked interference with all employment, or just with physically demanding employment. VA endeavored to obtain a medical opinion on this issue, and in February 2013 an examiner opined that with retraining the Veteran could successfully be gainfully employed in a sedentary job. This opinion is considered to be more thorough in that it considered the entire spectrum of possible employment, not simply limiting the inquiry to past jobs that the Veteran might have had. As such, the 2013 opinion is found to be the most probative evidence and therefore entitled to the greatest amount of weight. Given this conclusion, the Board finds that the weight of the evidence is against a finding that an extraschedular rating is warranted for the Veteran's left leg disability, and the Veteran's claim is therefore denied. II. Duties to Notify and Assist Under applicable criteria, VA has certain notice and assistance obligations to claimants. See 38 U.S.C.A. §§ 5102, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a). Notice must be provided to a claimant before the initial unfavorable agency of original jurisdiction (AOJ) decision on a claim for VA benefits and must: (1) inform the claimant about the information and evidence not of record that is necessary to substantiate the claim; (2) inform the claimant about the information and evidence that VA will seek to provide; and (3) inform the claimant about the information and evidence the claimant is expected to provide. Pelegrini v. Principi, 18 Vet. App. 112, 120-21 (2004) (Pelegrini II). With respect to service connection claims, a section 5103(a) notice should also advise a claimant of the criteria for establishing a disability rating and effective date of award. Dingess/Hartman v. Nicholson, 19 Vet. App. 473, 486 (2006). In the present case, required notice was provided by a letter dated in August 2005, which informed the Veteran of all the elements required by the Pelegrini II Court as stated above. A March 2006 letter also informed the Veteran how disability ratings and effective dates were established. Under these circumstances, the Board finds that the notification requirements of the VCAA have been satisfied as to content. The Board finds that any defect concerning the timing of the notice requirement was harmless error. Although the notice provided to the Veteran was not given prior to the first adjudication of the claim, the Veteran has been provided with every opportunity to submit evidence and argument in support of his claim and ample time to respond to VA notices. See Mayfield v. Nicholson, 19 Vet. App. 103 (2005), rev'd on other grounds, 444 F.3d 1328 (Fed. Cir. 2006). Additionally, the Veteran's claim was readjudicated following completion of the notice requirements. As to VA's duty to assist, 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). Private and VA treatment records have been obtained. Additionally, the Veteran testified at a hearing before the Board. The Veteran was also provided with several VA examinations (the reports of which have been associated with the claims file). In an April 2013 brief, the Veteran's representative argued that the credentials of the VA examiner who provided the 2013 medical opinion were not readily apparent in the examination report. However, the Board may assume the competency of any VA medical examiner as long as he/she is qualified through education, training, or experience to offer medical diagnoses, statements, or opinions. 38 C.F.R. § 3.159(a)(1); Cox v. Nicholson, 20 Vet. App. 563 (2007). Here, the examiner has a medical degree and he will therefore be presumed to be competent (i.e. medically trained) until and unless the Veteran's representative provides actual evidence that would call his credentials into question. The representative also suggested that the 2013 examiner's opinion was contradictory and therefore inadequate. Specifically, he indicated that the examiner failed to discuss precisely what occupation would allow a Veteran to deal with the problems with sitting from his cyst problems while dealing with the ambulatory problems caused by his leg disability. However, it appears that the representative is blurring the distinction between extraschedular ratings and a TDIU. An extraschedular rating is made on a disability-by-disability basis, not on consideration of the impact of the disabilities together. See Johnson v. Shinseki, No. 10-1785 (Vet. App. Mar. 27, 2013). Conversely, a TDIU, which it is noted has been remanded in this decision, is a claim that is based on the impact of all of a veteran's service connected disabilities. As such, the Board finds the 2013 VA examination, as well as the earlier VA examinations which are of record, to be fully adequate. The VA examiners were fully apprised of the Veteran's service connected disabilities and their resultant symptomatology, and they provided the information necessary to evaluate his disability. In February 2012, the Board remanded the Veteran's claim to comply with the directives of the JMPR. As described, the directed development (including obtaining a fully adequate medical opinion and referring the Veteran's claim to the Director of Compensation and Pension) has been completed, and because the Board's order was fully complied with, there is no prejudice for the Board to proceed. See Stegall v. West, 11 Vet. App. 268 (1998). At the Veteran's August 2012 VA examination, it was noted that he was retired on Social Security due to his heart and lungs. The United States Court of Appeals for the Federal Circuit (Federal Circuit) has held that "not all medical records or all SSA disability records must be sought-only those that are relevant to the [V]eteran's claim. To conclude that all medical records or all SSA disability records are relevant would render the word 'relevant' superfluous in the statute [governing VA's duty to assist]." Golz v. Shinseki, 590 F.3d 1317, 1321 (Fed. Cir. 2010). The Federal Circuit further held that "relevant records for the purpose of § 5103A are those records that relate to the injury for which the claimant is seeking benefits and have a reasonable possibility of helping to substantiate the [V]eteran's claim." Id. In this regard, the Board notes that in Golz, the Federal Circuit found that the Board did not err as a matter of law when it determined that VA met its duty to assist the Veteran, even though VA did not request his SSA records. The Veteran was claiming service connection for PTSD and the Board found that the SSA decision did not mention a psychiatric disorder. Thus, although the medical records accompanying the SSA decision were not in the file, the Board in that case found that they would not be relevant to the claim on appeal. In this case, the Board finds that the outstanding SSA records are not even potentially relevant to the Veteran's extraschedular claim decided herein for several reasons. As an initial point, the Veteran was specifically noted to be on SSA for lung and heart, neither of which is on appeal. Secondly, the Veteran's VA treatment records have been obtained and routinely updated throughout the course of his appeal, and the Veteran has not identified any private medical treatment for either condition on appeal. Moreover, he has been specifically asked if he was receiving any private treatment. Finally, multiple medical opinions have been obtained to address the specific limited questions relevant to this appeal at this time. The medical professionals who provided the opinions demonstrated that they had full and accurate knowledge of the Veteran's service connected disabilities, and the provided opinions were supported by well-reasoned rationales. As such, it is simply not plausible to suggest that the SSA records even might change the opinions of the examiners. The Veteran has had an opportunity to describe his symptoms to the examiners and there is no suggestion that a review of additional, and likely unrelated medical records, would change any of the rendered opinions. Thus, a remand would only serve to further delay resolution of a claim that has already been pending for the better part of a decade. Further delay of the full adjudication of this case, beyond the delays already encountered in this case, is totally intolerable. Therefore, the Board concludes that the outstanding SSA records are irrelevant to the instant claim and it is not necessary to obtain them for a fair adjudication. As described, VA has satisfied its duties to notify and assist, and additional development efforts would serve no useful purpose. See Soyini v. Derwinski, 1 Vet. App. 540, 546 (1991); Sabonis v. Brown, 6 Vet. App. 426, 430 (1994). Because VA's duties to notify and assist have been met, there is no prejudice to the Veteran in adjudicating this appeal. ORDER A disability rating in excess of 10 percent for service-connected recurrent pilonidal cyst with tender scar on an extraschedular basis is denied. A disability rating in excess of 40 percent for service-connected incomplete rupture, rectus femoris muscle, left leg, on an extraschedular basis is denied. REMAND As noted above, the Court has held that a request for a TDIU is not a separate claim for benefits, but rather, can be part of any claim for increased compensation. See Rice v. Shinseki, supra, at 453-54. If the claimant or the evidence of record reasonably raises the question of whether a veteran is unemployable due to a disability for which an increased rating is sought, then part and parcel with the increased rating claim is the issue of whether a TDIU is warranted as a result of that disability. Id. In this case, the Veteran's representative argued in a March 2013 brief that he was unemployable as a result of his service connected disabilities on appeal (namely his leg condition and his cyst residuals). As such, the question of TDIU is raised by the record, and it is appropriate for the Board to address this matter. Accordingly, the case is REMANDED for the following action: 1. Provide the Veteran a VCAA notice letter notifying him and his representative of what is necessary to substantiate a claim for TDIU. The notice must also explain what information or evidence the Veteran must provide, and what information or evidence VA will attempt to obtain on his behalf. The Veteran and his representative should be provided with an opportunity to respond. 2. Then adjudicate a claim for total disability rating based on individual unemployability (TDIU). If the claim is denied, provide the Veteran and his representative with a supplemental statement of the case and allow an appropriate time for response. The Veteran has the right to submit additional evidence and argument on the matter the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals 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). ____________________________________________ JOHN J. CROWLEY Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs