Citation Nr: 1318304 Decision Date: 06/05/13 Archive Date: 06/11/13 DOCKET NO. 09-33 803 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Hartford, Connecticut THE ISSUES 1. Entitlement to service connection for left ear hearing loss. 2. Entitlement to service connection for a chronic respiratory disability, to include a collapsed lung, chronic obstructive pulmonary disease, and asthma as due to asbestos exposure. 3. Entitlement to service connection for obstructive sleep apnea. 4. Entitlement to service connection for a chronic cardiac disability to include arrhythmias, claimed as palpitations of the heart. 5. Entitlement to service connection for a headache disability. 6. What evaluation is warranted for the residuals of traumatic injury to the left (minor) hand, evaluated as noncompensably disabling from September 11, 2007. REPRESENTATION Appellant represented by: Veterans of the Vietnam War, Inc. WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD P. Olson, Counsel INTRODUCTION The Veteran served on active duty from May 1977 to December 1997. This matter is before the Board of Veterans' Appeals (Board) on appeal from rating decisions dated in September 2008 and July 2010 of the Department of Veterans Affairs (VA) Regional Office (RO) in Hartford, Connecticut. In March 2011, the Veteran testified at a videoconference hearing. A transcript of that hearing is of record. The case was remanded in February 2012 The issues of entitlement to service connection for a disability manifested by chest pain, to include costochondritis; entitlement to service connection for a disability manifested by an inability to vomit; and entitlement to an increased evaluation for cervical degenerative changes have been raised by the record, but has not been adjudicated by the Agency of Original Jurisdiction (AOJ). Therefore, the Board does not have jurisdiction over them, and they are referred to the AOJ for appropriate action. The issue of entitlement to service connection for a left ear hearing loss 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. A chronic respiratory disability was not manifested during service and is not causally or etiologically related to service. 2. Obstructive sleep apnea was not manifested during service and is not causally or etiologically related to service. 3. A chronic cardiac disability was not manifested during service and is not causally or etiologically related to service. 4. A chronic headache disability was not was not manifested during service and is not causally or etiologically related to service or service-connected disability. 5. At no time during the appeal period has the Veteran's left hand fingers demonstrated a gap of one inch (2.5 cm.) or more between the fingertip and the proximal transverse crease of the palm or extension limited by more than 30 degrees; the left hand finger disabilities have not been found to be equivalent to amputations; and there is no finger scar that is painful, unstable, or having the total area greater and 39 square centimeters or six square inches. CONCLUSIONS OF LAW 1. A chronic respiratory disability was not incurred in or aggravated by active service. 38 U.S.C.A. §§ 1110, 1131, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.159, 3.303 (2012). 2. Obstructive sleep apnea was not incurred in or aggravated by active service. 38 U.S.C.A. §§ 1110, 1131, 5103, 5103A, 5107; 38 C.F.R. §§ 3.159, 3.303. 3. A cardiac disability was not incurred in or aggravated by active service, and such a disorder may not be presumed to have been so incurred. 38 U.S.C.A. §§ 1110, 1131, 5103, 5103A, 5107; 38 C.F.R. §§ 3.159, 3.303, 3.307, 3.309 (2012). 4. A chronic headache disability was not incurred in or aggravated by active service and is not causally related to service-connected disability. 38 U.S.C.A. §§ 1110, 1131, 5103, 5103A, 5107; 38 C.F.R. §§ 3.159, 3.303, 3.310 (2012). 5. The criteria for an initial compensable evaluation for left hand finger disability have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.159, 4.1, 4.7, 4.71a Diagnostic Codes 5153, 5154, 5155, 5225, 5229 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Preliminary Matter Pursuant to the Board's February 2012 Remand, the Appeals Management Center (AMC) obtained additional treatment records prepared since May 2011, afforded the Veteran VA respiratory, cardiovascular, neurologic, and orthopedic examinations in March 2012, and readjudicated the claims under provision of the Veterans Claims Assistance Act of 2000 (VCAA), Pub. L. No. 106-475, 114 Stat. 2096 (2000) as discussed in more detail below, and issued a Supplemental Statement of the Case. Based on the foregoing actions, the Board finds that there has been compliance with the Board's February 2012 Remand. Stegall v. West, 11 Vet. App. 268 (1998). Veterans Claims Assistance Act of 2000 With respect to the claims of entitlement to service connection the requirements of 38 U.S.C.A. §§ 5103 and 5103A have been met. There is no issue as to providing an appropriate application form or completeness of the application. VA notified the Veteran in September 2007, April 2010, and February 2012 of the information and evidence needed to substantiate and complete a claim, to include notice of what part of that evidence is to be provided by the claimant, what part VA will attempt to obtain, and how disability ratings and effective dates are determined. The case was readjudicated in October 2012. Thus, any timing error was cured and rendered nonprejudicial. Prickett v. Nicholson, 20 Vet. App. 370, 376 (2006). With respect to increased rating claim as service connection, an initial rating, and an effective date have been assigned he notice requirements of 38 U.S.C.A. § 5103(a) have been met. Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007). VA has fulfilled its duty to assist the Veteran in obtaining identified and available evidence needed to substantiate a claim, and as warranted by law, affording VA examinations. He was provided the opportunity to present pertinent evidence and testimony. During the March 2011 Board hearing, the undersigned explained the issues on appeal and asked questions designed to elicit evidence that may have been overlooked with regard to the claim. These actions provided an opportunity for the Veteran and his representative to introduce material evidence and pertinent arguments, in compliance with 38 C.F.R. § 3.103(c)(2) and consistent with the duty to assist. See Bryant v. Shinseki, 23 Vet. App. 488, 492 (2010). In sum, there is no evidence of any VA error in notifying or assisting him that reasonably affects the fairness of this adjudication. 38 C.F.R. § 3.159(c). Service Connection The Veteran seeks entitlement to service connection for a chronic respiratory disability, obstructive sleep apnea, a chronic cardiac disability, and a headache disability. Service connection is warranted where the evidence of record establishes that a particular injury or disease resulting in disability was incurred in the line of duty in the active military service or, if pre-existing such service, was aggravated thereby. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303. Service connection may also be warranted 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). Cardiovascular-renal disease, if manifest to a degree of 10 percent within one year after separation from active duty, may be presumed to have been incurred in service. 38 U.S.C.A. §§ 1101, 1112, 1113; 38 C.F.R. §§ 3.303(b), 3.307, 3.309. Alternatively, when a chronic disease is not present during service, service connection may be established under 38 C.F.R. § 3.303(b) by evidence of continuity of symptomatology. To prevail on the issue of service connection there must be evidence of a current disability, in-service incurrence or aggravation of a disease or injury; and a causal relationship between the present disability and the disease or injury incurred or aggravated during service. See Shedden v. Principi, 381 F.3d 1163, 1166-67 (Fed. Cir. 2004). A disability may be found to be service connected on a secondary basis if the claimant demonstrates that the disability is either (1) proximately due to or the result of an already service-connected disease or injury or (2) aggravated by an already service-connected disease or injury. See Allen v. Brown, 7 Vet. App. 439, 448 (1995) (en banc); 38 C.F.R. § 3.310. Service treatment records indicate that in April 1979, the Veteran presented with report of intermittent episodes of stabbing left chest pain since high school. His current symptom had been present for almost three-weeks. He also reported sharp pains aggravated by smoking. Physical examination yielded a clinical assessment of possible pleural irritation. In May 1979, the Veteran returned for follow-up appointment. An April 1979 chest x- was noted as normal. In his September 1981 Report of Medical History the Veteran reported a history of asthma, shortness of breath, chest pain or pressure, and palpitation or pounding heart. The examiner noted a history of asthma at age two to three, not considered disabling; occasional shortness of breath after prolonged time without sleep, a history of smoking, not considered disabling; occasional chest pain, work-up negative, not considered disabling; and palpitations occasionally while lying down, work-up with electrocardiographic study negative, not considered disabling. In a May 1983 the Veteran reported a history of frequent or severe headaches. The examiner noted an occasional tension headache which was not considered disabling. In addition, the appellant reported asthma, shortness of breath, pain or pressure in chest, and palpation or pounding heart. In February 1987, the Veteran presented with complaints of dull chest pain which radiated to left arm, shortness of breath, and labored breathing since the day before. He reported a history of chest pain since age 14 with left upper sternal pain occurring at rest with stress, and after prolonged standing. He denied having pain with exertion. The Veteran reported daily palpitations which he described as his heart fluttering three to four seconds. After physical examination, the Veteran was assessed as having non-cardiac chest pain and benign palpitations. An electrocardiogram was normal. In January 1989, a diagnosis of noncardiac chest pain was rendered. In March 1994, the Veteran presented with symptoms of cough and green sputum which allegedly kept him awake at night. He was diagnosed with bronchitis. An echocardiogram indicated incomplete right bundle branch block, moderate voltage criteria for left ventricular hypertrophy, may be normal variant, borderline electrocardiogram In April 1994, the Veteran presented with complaints of palpitations occurring at rest. These were not associated with chest pain, pressure, shortness of breath, or anxiety. The complaints of chest pain resolved once the appellant started treatment for reflux. The assessment included palpitations. No suggestion of underlying medical problem such as thyroid by history, labs, or physical. He was placed on a Holter monitor. In June 1994, the Veteran completed reported a history of a heart murmur. A June 1994 echocardiogram showed normal findings with mild aortic valvular sclerosis but no significant stenosis. The Veteran suffered a left pneumothorax as a complication of a laparoscopic Nissen fundoplication performed in June 1995. In response to the Veteran's request for a waiver of medical hold, in July 1995, the military medicine department noted that the claimant was status post a successful Nissen but that during the procedure, a left pneumothorax resulted after working at the left mediastinum. Although the Veteran experienced a brief febrile illness with some atelectasis, he recovered completely and was found fit for full duty. It was noted that as this was not a spontaneous pneumothorax, and as he did not have the typical habitus for a spontaneous pneumothorax, the likelihood of future complications was low. In July 1996, the Veteran presented with left anterior chest pain "10" with radiation to left arm and tightness. Following a physical examination the impression was paroxysmal supraventricular tachycardia. Echocardiograms indicated sinus bradycardia, incomplete right bundle branch block, and borderline electrocardiogram. In August 1996, the Veteran reported that he had always had chest pain. He noted that before service he had sharp chest pains and that through service, he suffered occasional chest pain about once a week which he described as sharp pain lasting for a minute but severe enough to make him double over. The Veteran reported that since 1995, he suffered from daily minor chest pain with associated palpation, clamminess, and weakness lasting up to 10 minutes. After physical examination, the provider noted that the Veteran's history raised question of paroxysmal supraventricular tachycardia. The examiner he doubted "cardiac pain" was assign of coronary artery disease. The appellant was placed on a Holter monitor to rule out paroxysmal supraventricular tachycardia. Holter monitoring in August 1996 showed no significant findings with a single premature beat. X-rays showed heart size was normal, lung fields showed no acute infiltrates or pleural effusions, some changes due to chronic obstructive pulmonary disease were seen, no active disease is seen in the chest. Repeat Holter showed no sustained arrhythmias. There were rare supraventricular premature beats and ventricular premature beats. An echocardiogram was conducted in January 1997 and it was normal save for trace mitral regurgitation. While the Veteran did suffer an inservice pneumothorax resulting in complaints of shortness of breath, chest pain, palpitation, and headaches during service, the evidence preponderates against concluding that a "chronic" respiratory, cardiac, or headache condition was incurred during service. Treatment for a disorder in service cannot be considered treatment for a chronic disorder unless there is some indication that a chronic disorder exists. That an injury occurred in service alone is not enough; there must be chronic disability resulting from that injury. For a showing of chronic disability in service there is required a combination of manifestations sufficient to identify the disorder, and sufficient observation to establish chronicity at the time, as distinguished from merely isolated findings or a diagnosis including the word "chronic." In addition, clinical examinations in February and December 1997 revealed the Veteran's lungs, chest, heart, and neurologic systems to be normal. Further, in a February 1997 Report of Medical History the Veteran denied ever having frequent or severe headache, heart trouble. Similarly, previous Reports of Medical Examination dated in November 1977, September 1981, May 1983, February 1987, March 1989, March 1994, and December 1997 showed that the Veteran had clinically normal lungs, chest, heart, and neurologic system. Thus, there is no evidence that shows that the Veteran suffered from chronic respiratory disorder, a chronic cardiac disorder, or a chronic headache disorder during service. With respect to sleep apnea, the service treatment records are absent complaints, findings or diagnoses of that disorder during service. In his February 1997 Report of Medical History the appellant denied ever having frequent trouble sleeping. Thus, there is no evidence that shows that the Veteran suffered from obstructive sleep apnea during service. As for statutory presumptions, as will be discussed below in more detail, the Veteran has never been diagnosed as having a cardiovascular disease. As such, 38 C.F.R. § 3.303(b) is not applicable. When a disease is first diagnosed after service, service connection can still be granted for that condition if the evidence shows it was incurred in service. 38 C.F.R. § 3.303(d). Since service the Veteran has been diagnosed as having asthma and obstructive sleep apnea. In March 2012 a VA examination yielded diagnoses of asthma and obstructive sleep apnea, however, the examiner found no objective evidence of chronic obstructive pulmonary disease or any residuals of a collapsed lung. The March 2012 examiner noted that the Veteran had smoked for 40 years. The Veteran reported always feeling short of breath in-service. The examiner noted, however, that service medical records did not reveal a diagnosis of a chronic respiratory condition. The examiner noted that the Veteran was diagnosed with possible asthma in 2008 (eleven years after service) and pulmonary function tests in 2008 suggested early small airway obstruction. The Veteran reported shortness of breath for years and wheezing. The examiner noted that the Veteran had history of asbestos exposure but the primary physician in 2008 found "No overt asbestos lung disease by way of history/examination nor pulmonary function studies." The examiner also noted that the 1995 left pneumothorax resolved. The examiner noted that an August 1996 film revealed some chronic obstructive pulmonary disease but all following films were normal including a 2008 assessment. The Board has reviewed all service treatment and post-service medical records. These records do not include any diagnoses of any other current, chronic respiratory disorder. In December 1998, the Veteran presented with complaints of shortness of breath on exertion. Pulmonary function tests showed mild obstructive lung dysfunction which responded to bronchodilators. The assessment was mild obstructive pulmonary disease. X-rays of the chest in July 2001 showed no acute pulmonary or cardiac disease. In October 2008, the Veteran presented to VA and stated that he had been diagnosed with breathing issues, and that he worked on submarines and near asbestos. X-rays revealed no acute pulmonary or cardiac disease. Pulmonary function tests indicated early small airways obstruction. A methacoline challenge test suggested the presence of asthma/bronchial hyper-reactivity. At a follow-up visit, asthma was assessed. A December 2008 Outpatient Respiratory Consultation report indicates an assessment of asthma but no overt asbestos lung disease. An April 2010 radiology report indicates that chest CT with contrast demonstrated no acute/significant abnormalities and no substantial evidence for pulmonary embolism. The Board notes that a December 2008 Outpatient Respiratory Consultation report indicates an assessment of asthma but no overt asbestos lung disease. The physician noted, "If anything he may have asbestos related lung disease where asbestos may have left its footprint with no physiologic impairment." Such conjecture or mere possibility, however, is not useful for VA adjudicative purposes. A diagnosis and etiology based on speculation (i.e. "may have") is too tenuous a basis on which to grant service connection. The reasonable doubt doctrine requires that there be a "substantial" doubt and "one within the range of probability as distinguished from pure speculation or remote possibility." 38 C.F.R. § 3.102. As such, while competent evidence indicates that the Veteran has a current diagnosis of asthma, no other respiratory disorder including chronic obstructive pulmonary disease and residuals of a collapsed lung is currently diagnosed. Most importantly, no medical evidence links a current respiratory disorder to service. Specifically, with respect to asthma, the question is whether there is medical evidence of a relationship between the current disability and military service. The Veteran contends that his respiratory disability is due to his in-service asbestos exposure. There is no specific statutory guidance with regard to claims for service connection for asbestosis and other asbestos-related diseases, nor has the Secretary promulgated any regulations. McGinty v. Brown, 4 Vet. App. 428, 432 (1993). Rather, VA's Adjudication Procedure Manual, M21-MR, contains guidelines for considering compensation claims based on exposure to asbestos. See Ennis v. Brown, 4 Vet. App. 523 (1993). VA's Manual 21-1MR, Part IV, subpart ii, Chapter 2, Section C, essentially acknowledges that inhalation of asbestos fibers can result in fibrosis and tumors, and produce pleural effusions and fibrosis, pleural plaques, mesotheliomas of the pleura and peritoneum, and cancer of the lung, gastrointestinal tract, larynx, pharynx and urogenital system (except the prostate), with the most common resulting disease being interstitial pulmonary fibrosis (asbestosis). Also noted is the increased risk of bronchial cancer in individuals who smoke cigarettes and have had prior asbestos exposure. Id. With respect to claims involving asbestos exposure, VA must determine whether or not military records demonstrate evidence of asbestos exposure during service, develop whether or not there was pre-service and/or post-service occupational or other asbestos exposure, and determine whether there is a relationship between asbestos exposure and the claimed disease. M21-1MR, Part IV, Subpart ii, Chapter 1, Section H, Topic 29; DVB Circular 21-88-8, Asbestos-Related Diseases (May 11, 1988). Neither M21-1 nor the circular creates a presumption of exposure to asbestos solely from shipboard service. Rather, they are guidelines which serve to inform and educate adjudicators as to the high exposure of asbestos and the prevalence of disease found in insulation and shipyard workers, and they direct that the raters develop the record; ascertain whether there is evidence of exposure before, during, or after service; and determine whether the disease is related to the putative exposure. Dyment v. West, 13 Vet. App. 141 (1999); VAOGCPREC 4-2000. The clinical diagnosis of asbestosis requires a history of exposure and radiographic evidence of parenchymal lung disease. The Veteran claims that his current respiratory disability is a result of his exposure to asbestos during active military service. His service personnel records reveal that he served on active duty in the Navy from May 1977 to December 1997 as an auxiliary electrician. Service personnel records reveal that at times he served on a submarine. Based on the nature of the Veteran's service, the Board will assume that he was exposed to asbestos during active service. The Board has reviewed all service treatment records and post-service medical records. These records do not include any opinions linking either asthma or obstructive sleep apnea to the appellant's active duty service, including any asbestos exposure. The March 2012 VA examiner noted that as documented by his pulmonary physician, the Veteran had no current evidence of asbestos-related lung disease. The examiner also noted that the Veteran had no objective residual of his left pneumothorax. There was no objective evidence of asthma diagnosed in service and the Veteran's 1997 separation examination was negative for any respiratory disorder. The examiner opined that asbestos exposure is not a documented cause of asthma. Further, after a review of the claims file and physical examination of the Veteran, the examiner opined, "As such, his current asthma (which was diagnosed 11 years post discharge) is less likely as not the result of the Veteran's period of active military service, to include as the residual of exposure to asbestos." There is no medical opinion of record to the contrary. As such, after weighing and balancing the evidence of record, the Board finds that the preponderance of the evidence of record is against a finding that the Veteran's asthma had its onset during active service or is related to any in-service disease, event, or injury including asbestos exposure. Without competent evidence linking asthma to service, the benefit sought on appeal cannot be granted. With respect to a cardiac disability, the Board has reviewed all service treatment records and post-service medical records. These records do not include any diagnosis a chronic cardiac disability. In November 1998, the Veteran presented with complaints of occasional left upper chest pain occurring with activity, and some shortness of breath which resolved on its own in 10-20 minutes. The pain did not radiate. The provider noted that there was no cardiac history and that the Veteran had been diagnosed with palpitations/anxiety. July 2001 chest X-rays showed no acute pulmonary or cardiac disease. The Veteran presented in April 2002 with report of an episode of left-sided chest pain with some palpitations. An April 2002 myocardial profusion scan was normal. A June 2002 clinical record noted, "Heart palpation with negative Holter results and normal nuclear medicine study with an ejection fraction of 49% from April 2002." The provider noted that the Veteran's palpitations were fleeting and had been longstanding, that he had had this worked up in the past with a Holter monitor as well as a recent stress, both of which had been negative. In October 2004, the Veteran presented with a history of shortness of breath, and left upper chest discomfort for more than a month. After physical examination of the Veteran, he was diagnosed as having, "chest pain - non cardiac, most likely costochondritis." In January 2010, the Veteran presented complained of palpitations throughout his service career but that when he had his heart evaluation, results were negative. At a March 2012 VA examination the Veteran reported a history of occasional episodes of feeling as if his heart raced, skipped a beat, and paused. The Veteran stated that workups included normal Holter, stress test, and echocardiogram studies. The Veteran reported being told that his symptoms were related to caffeine and stress, and that he should decrease the amount of caffeine in his diet. The Veteran stated that he had not had any episodes in many years. After review of the claims file and physical examination of the Veteran, the examiner found no objective documentation that he current suffered from a chronic, clinically identifiable cardiovascular disorder including one characterized by arrhythmias and/or palpitations. There is no medical opinion of record to the contrary. As such, after weighing and balancing the evidence of record, the Board finds that the preponderance of the evidence of record is against a finding that the Veteran suffers from a current cardiac disability which had its onset during active service or which is related to any in-service disease, event, or injury; or which was compensably disabling within one year of his discharge from active duty. See 38 U.S.C.A. §§ 1110, 1131. Without competent evidence linking a current, chronic cardiac disability to service, the benefit sought on appeal cannot be granted. The Board, however, has referred a claim for service connection for costochondritis to the RO for consideration. With respect to a headache disability, the Board has reviewed all service treatment records and post-service medical records. These records do not include any opinions linking the Veteran's complaints of headaches to his active duty service. A May 2001 Health Record indicates that the Veteran noted a three to four month history of daily episodes of "sharp" pain lasting 10 to 15 seconds occurring three to four times daily in either the occipital area or right temporal area. Although the physician did not provide a diagnosis, he noted that he suspected this was related to the Veteran's chronic neck pain. The physician also indicated that given the quality of the pain, it might also be neuropathic. In July 2006, the Veteran was diagnosed as having intermittent tension-type headache. At a March 2012 VA examination the appellant reported a history of posterior neck and occiput pain since a hatch injury in the late 1990s. The Veteran described tension and pain in his neck shooting up to his occiput area occurring daily and worse at work with stress and with lifting. The Veteran stated that the discomfort was associated with neck and radiating pain to the shoulder. Following an examination and review of the evidence the VA examiner found no objective documentation that the Veteran currently suffered from a chronically, clinically identifiable headache disorder. Rather, his symptoms were consistent with muscle tension related to his cervical spine disorder. As such, after weighing and balancing the evidence of record, the Board finds that the preponderance of the evidence of record is against finding that the Veteran suffers from a current headache disability which had its onset during active service or which is related to any in-service disease, event, or injury. See 38 U.S.C.A. §§ 1110, 1131. Without competent evidence linking a current headache disability to service, the benefit sought on appeal cannot be granted. The Board acknowledges that a lay witness is competent to testify as to the occurrence of an in-service injury or incident where such issue is factual in nature. Grottveit v. Brown, 5 Vet. App. 91, 93 (1993). In some cases, lay evidence will also be competent on the issues of diagnosis and etiology. See Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). Although the Veteran is competent in certain situations to describe symptoms such as shortness of breath, chest pain, palpitations, and headaches, he is not competent to provide evidence as to more complex medical questions, such as a respiratory or cardiac diagnosis or etiology of a disability. See e.g., Woehlaert v. Nicholson, 21 Vet. App. 456 (2007). In this case, the Veteran is not competent to diagnose any respiratory or cardiac disability, and he is not competent to address the etiology of his asthma, sleep apnea or headaches. The Board notes that the record contains evidence of current diagnoses of asthma, sleep apnea, and tension headaches. In addition, the record contains evidence of reported symptoms of shortness of breath, chest pain, palpitations, and headaches during service. Without competent evidence providing a diagnosis of a cardiac disorder and linking such disorder to service, and without competent evidence linking the Veteran's asthma, obstructive sleep apnea, and tension headaches to service, the benefits sought on appeal are denied. Increased Rating Disability ratings are determined by applying the criteria set forth in the VA's Schedule for Rating Disabilities, which is based on the average impairment of earning capacity. Individual disabilities are assigned separate diagnostic codes. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. If two evaluations are potentially applicable, 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. 38 C.F.R. § 4.7. The Veteran is appealing the original assignment of a disability evaluation following an award of service connection for residuals of a traumatic injury to the left hand. As such, it is not the present level of disability which is of primary importance, but rather the entire period is to be considered to ensure that consideration is given to the possibility of staged ratings; that is, separate ratings for separate periods of time based on the facts found. Fenderson v. West, 12 Vet. App. 119 (1999). When evaluating disabilities of the musculoskeletal system, under 38 C.F.R. § 4.40, functional loss may be due to pain, supported by adequate pathology and evidenced by the visible behavior of the claimant on motion. Disability of the musculoskeletal system is the inability to perform normal working movement with normal excursion, strength, speed, coordination, and endurance, and that weakness is as important as limitation of motion, and that a part that becomes disabled on use must be regarded as seriously disabled. A little used part of the musculoskeletal system may be expected to show evidence of disuse, through atrophy, for example. 38 C.F.R. § 4.40. The provisions of 38 C.F.R. §§ 4.45 and 4.59 also contemplate inquiry into whether there is limitation of motion, weakness, excess fatigability, incoordination, and impaired ability to execute skilled movements smoothly, and pain on movement, swelling, deformity, or atrophy of disuse. Instability of station, disturbance of locomotion, interference with sitting, standing, and weight-bearing are also related considerations. Diagnostic codes predicated on limitation of motion require consideration of a higher rating based on functional loss due to pain on use or due to flare-ups. 38 C.F.R. §§ 4.40, 4.45, 4.59; DeLuca v. Brown, 8 Vet. App. 202, 206 (1995). Ratings for functional impairment of the upper extremities depend on which extremity is the major extremity, i.e., the one predominantly used by the individual. As the Veteran is right-handed, see February 1997 discharge physical and a March 2012 VA examination, the ratings for his left hand disability are made on the basis of the left upper extremity being the minor extremity. The Veteran's service-connected residuals of a traumatic left hand injury have been rated as noncompensably disabling pursuant to 38 C.F.R. § 4.71a, Diagnostic Code 5229 for limitation of motion of the index or long finger. Limitation of motion of the fingers is rated under Diagnostic Codes 5229 to 5230. Under Diagnostic Code 5229, limitation of motion of the index or long finger warrants a 10 percent disability rating for a gap of one inch (2.5 cm.) or more between the fingertip and the proximal transverse crease of the palm, with the finger flexed to the extent possible, or; with extension limited by more than 30 degrees. A gap of less than one inch (2.5 cm.) between the fingertip and the proximal transverse crease of the palm, with the finger flexed to the extent possible, and extension is limited by no more than 30 degrees, warrants a noncompensable evaluation. Diagnostic Codes 5225 and 5226 provide a 10 percent rating for ankylosis of the index or the long finger, of either the major or minor extremity. Diagnostic Code 5227 provides a noncompensable rating for favorable or unfavorable ankylosis of the ring or little finger of either hand. The rating schedule indicates that VA also consider whether evaluation as amputation is warranted and whether an additional evaluation is warranted for resulting limitation of motion of other digits or interference with overall function of the hand. See 38 C.F.R. § 4.71a, Diagnostic Codes 5152 through 5156. A July 2006 physical examination demonstrated no left hand diffuse dorsal swelling, no swelling of the palmar aspect, and no swelling and tenderness of the anatomical snuff box. The Veteran's left hand was not erythematous, warm, or tender on palpation. There was no hypothenar or thenar atrophy, no limitation of motion, and no pain elicited by motion. An axial load test of the thumb was negative, and there was no weakness. At a May 2008 VA examination the examiner noted that historically the Veteran sustained a crushing injury as a result of a faulty hatch falling directly onto the left hand resulting in a laceration of the extensor tendons in the left middle finger, with additional trauma to the left second, third, and fourth digits. The examiner noted that according to the report, at the third digit, the Veteran had a complete open injury at the distal interphalangeal joint with complete laceration to the extensor tendon, the second digit small split to the nail with a small distal phalanx fracture, and at the fourth digit there was a small laceration to the pulp of the fourth digit and the nail bed. All digits had normal neurovascular and capillary refill. In March 1996, the Veteran underwent a repair to the middle finger on the left hand at the distal interphalangeal joint, resulting in complications of flexor deformity. At the May 2008 VA examination, the Veteran reported some swelling, overall weakness and fatigue in the left third (middle) digit at the distal interphalangeal joint resulting in a flexor deformity. Functionally, the Veteran was able to use the left hand fully but was only partially able to perform the same activities as prior due to intermittent weakness of that digit when grasping. The Veteran reported that some days that were worse than others, usually if he had increased use of the left hand. The Veteran denied any pain, but reported chronic swelling at the distal interphalangeal joint as well as chronic stiffness brought on by overuse and increased gripping. The Veteran denied flare-ups. The Veteran also stated that he had no hand symptoms while inactive such as resting during sleep but that if he performed strenuous activities with his left hand or repetitive activity for long period of time such as typing continually for an hour or more, he developed symptoms of left hand mild weakness in the middle finger. Physical examination demonstrated 4/5 left hand grip strength to the contralateral hand in comparison. Range of left index finger motion at the metacarpophalangeal joint was from zero to 90 degrees, proximal interphalangeal joint was from zero to 100 degrees, and distal interphalangeal joint was from zero to 55 degrees. Range of motion after three repetitions was unchanged and was not additionally limited by pain, fatigue, weakness, lack of endurance, or stiffness. Range of left middle finger motion at the metacarpophalangeal joint was from zero to 90 degrees, proximal interphalangeal joint was from zero to 100 degrees, and distal interphalangeal joint was from -5 to 55 degrees. Range of motion after three repetitions was unchanged and was not additionally limited by pain, fatigue, weakness, lack of endurance, or stiffness. Range of motion of the left ring finger at the metacarpophalangeal joint was from zero to 90 degrees, proximal interphalangeal joint was from zero to 110 degrees, and distal interphalangeal joint was from zero to 55 degrees. Range of motion after three repetitions was unchanged and was not additionally limited by pain, fatigue, weakness, lack of endurance, or stiffness. Evaluation of hand as a unit demonstrated no gap, and good opposition tip of the thumb and fingers. The fingers were able to approximate the proximal transverse crease of the palm with the exception of the middle digit which revealed a gap of 1/2 inch and was unable to approximate the crease of the palm. There was 4/5 strength for pushing, pulling, and twisting of the left versus the right. The examiner noted that the third middle digit had slightly reduced flexion at the distal interphalangeal joint of approximately 5 to 10 degrees. There were negative Tinel and Phalen signs as well as normal thenar and hypothenar eminence. There were normal radial and ulnar pulses as well as intact sensation to sharp, light touch, and monofilament testing. There was no point tenderness at the wrist, metacarpophalangeal, proximal interphalangeal or distal interphalangeal joints. There was also no functional loss or limitation due to repetitive use. The Veteran underwent VA examination in March 2012 at which time he reported poor grip due to limited finger movement but no pain. The Veteran stated that he wrote with his right hand but played sports with his left and that he had to give up golf due to residual limited range of motion and grip from his left hand. The Veteran denied flare-ups. On physical examination, the Veteran demonstrated no gap between the thumb pad and the fingers, no gap between any fingers and the proximal transverse crease of the palm, and no evidence of painful motion in attempting to touch the palm with the fingertips. There was no limitation of extension or evidence of painful motion for the index finger and middle finger. Range of motion of the left index and ring fingers at the metacarpophalangeal joint was from zero to 90 degrees, proximal interphalangeal joint was from zero to 45 degrees and stops due to stiffness but no pain, and distal interphalangeal joint was from zero to 10 degrees and stops due to stiffness and no pain. Range of motion after three repetitions was unchanged, and was not additionally limited by pain, fatigue, weakness, lack of endurance, or stiffness. Range of motion of the left middle finger at the metacarpophalangeal joint was from zero to 90 degrees, proximal interphalangeal joint was from zero to 30 degrees and stops due to stiffness but no pain, and distal interphalangeal joint was from zero to 10 degrees and stops due to stiffness and no pain. There was no additional limitation of motion for any finger after three repetitions. The examiner noted functional loss after repetitive use with less movement than normal of the index finger, middle finger, and ring finger. There was no ankylosis in any left hand finger. Left hand X-rays did not reveal arthritis. With respect to the left index and middle fingers, a compensable evaluation is not warranted as the clinical evidence does not show a gap of one inch (2.5 cm.) or more between the fingertip and the proximal transverse crease of the palm, with the finger flexed to the extent possible, or; with extension limited by more than 30 degrees. In addition, the Veteran's index and middle finger disabilities cannot be considered equivalent to amputations since he still has his index and middle fingers and he still has function in all parts of the fingers, albeit with limited motion. With respect to the left ring and little fingers, as noted above, a noncompensable rating is the maximum rating available for limitation of motion or ankylosis of the little finger under Diagnostic Codes 5227 or 5230. A higher schedular rating would only be warranted if the ring and little fingers were amputated. The Veteran's ring and little finger disabilities cannot be considered equivalent to amputations since he still has his ring and little fingers and he still has function in all parts of the fingers, even if he does have limited motion. The Board has considered whether a compensable evaluation is warranted for left hand injury scars. During the pendency of this appeal for an increased rating, the applicable rating criteria for skin disorders, including residual scarring, 38 C.F.R. § 4.118, were amended effective October 23, 2008. However, the revisions are applicable to applications for benefits received by VA on or after October 23, 2008. See 73 Fed. Reg. 54,708 (Sept. 23, 2008), and the appellant has not requested a review under the new regulations. In the present case, the Veteran's application for benefits was received before the October 2008 effective date of the amendment. In such circumstances, only the previous criteria apply as discussed above in the Federal Register. Scars, other than of the head, face, or neck, are to be rated under Diagnostic Codes 7801 to 7805. Under Diagnostic Code 7801, which governs scars, other than the head, face, or neck, that are deep or cause limited motion, a 10 percent evaluation is assignable when the area or areas exceed six square inches (39 square centimeters). A 20 percent evaluation is assignable when the area or areas exceed 12 square inches (77 square centimeters). 38 C.F.R. § 4.118, Diagnostic Code 7801. Scars in widely separated areas, as on two or more extremities or on anterior and posterior surfaces of extremities or trunk, will be separately rated and combined in accordance with 38 C.F.R. § 4.25 of this part. A deep scar is one associated with underlying soft tissue damage. 38 C.F.R. § 4.118, Diagnostic Code 7801, Note (1), (2). Under Diagnostic Code 7802, which governs scars other than the head, face, or neck, that are superficial and do not cause limited motion, a 10 percent evaluation is assignable for area or areas of 144 square inches (929 square centimeters) or greater. 38 C.F.R. § 4.118, Diagnostic Code 7802. Under Diagnostic Code 7803, a 10 percent evaluation is assignable for scars that are superficial and unstable. 38 C.F.R. § 4.118, Diagnostic Code 7803. An unstable scar is one where, for any reason, there is frequent loss of covering of skin over the scar. A superficial scar is one not associated with underlying soft tissue damage. 38 C.F.R. § 4.118, Diagnostic Code 7803, Note (1), (2). Under Diagnostic Code 7804, a 10 percent evaluation is assignable for scars that are superficial and painful on examination. 38 C.F.R. § 4.118, Diagnostic Code 7804. A superficial scar is one not associated with underlying soft tissue damage. A 10 percent evaluation will be assigned for a scar on the tip of a finger or toe even though amputation of the part would not warrant a compensable evaluation. (See 38 C.F.R. § 4.68 of this part on the amputation rule.) 38 C.F.R. § 4.118, Diagnostic Code 7804, Note (1), (2). Under Diagnostic Code 7805, other types of scars will be rated based on limitation of function of affected part. 38 C.F.R. § 4.118, Diagnostic Code 7804. As shown by the March 2012 VA examination, the Veteran's left finger scars are not objectively painful or unstable. They do not cover a total area greater than 39 square centimeters. Consequently, they do not meet the criteria for a compensable evaluation under any applicable diagnostic code. The Board is aware that an extraschedular rating is a component of an increased rating claim. Barringer v. Peake, 22 Vet. App. 242 (2008). The threshold factor for extraschedular consideration is a finding on the part of the RO or the Board that the evidence presents such an exceptional disability picture that the available schedular evaluations for the service-connected disability at issue are inadequate. Thun v. Peake, 22 Vet. App. 111 (2008); 38 C.F.R. § 3.321(b)(1). If so, factors for consideration in determining whether referral for an extraschedular rating is warranted include marked interference with employment or frequent periods of hospitalization that indicate that application of the regular schedular standards would be impracticable. Thun, citing 38 C.F.R. § 3.321(b)(1) (2008). In the present case, the Board finds no evidence that the Veteran's service-connected residuals of traumatic injury to the left hand presents such an unusual or exceptional disability picture at any time so as to require consideration of an extra-schedular evaluation pursuant to the provisions of 38 C.F.R. § 3.321(b)(1). The criteria pertaining to finger disabilities in the Rating Schedule focus on finger motion and function. 38 C.F.R. § 4.71a, Diagnostic Codes 5216 to 5230 and 5138 to 5151 which also include consideration of functional loss due to pain, weakness, excess fatigability, incoordination, impaired ability to execute skilled movements smoothly, swelling, deformity, or atrophy of disuse. As discussed above, such symptomatology encompasses the Veteran's current disability picture. Thus, the schedular criteria adequately compensate for any loss in earning capacity, and referral for extraschedular consideration is not warranted. Id. The Board acknowledges the holding in Rice v. Shinseki, 22 Vet. App. 447, 453-54 (2009), that a request for a total rating based on individual unemployability, whether expressly raised by the Veteran or reasonably raised by the record, is not a separate 'claim' for benefits, but rather, can be part of a claim for increased compensation. In the present case, there is no evidence which reasonably raises a claim of entitlement to a total disability evaluation based on individual unemployability due to service connected disorders. ORDER Entitlement to service connection for a chronic respiratory disability, to include residuals of a collapsed lung, chronic obstructive pulmonary disease, and asthma as due to asbestos exposure, is denied. Entitlement to service connection for obstructive sleep apnea is denied. Entitlement to service connection for a chronic cardiac disability to include arrhythmias, claimed as palpitations of the heart, is denied. Entitlement to service connection for a headache disability is denied. A compensable evaluation is not warranted for the residuals of traumatic injury to the left hand from September 11, 2007. REMAND Service treatment records indicate that the Veteran had hearing within normal limits at entrance examinations in January and November 1977. He also had normal left ear audiometry findings from 500 Hertz to 4000 Hertz in May 1983, April 1984, February 1987, March 1989, March 1994, and February 1997. On examination in April 1982, the Veteran demonstrated left ear hearing above normal threshold at 3000 Hertz. Similarly, in June 1983, the Veteran showed left ear hearing above normal thresholds at 500 but within normal limits after a minimum of 15 hours noise free; in February 1986, the Veteran showed left ear hearing above normal thresholds at 1000, 3000, and 4000 Hertz. In October 2001, the Veteran presented for follow-up appointment for previous two-week sensation of left ear fullness which had resolved. In August 2002, the Veteran presented to a VA otolaryngology/head and neck surgery clinic with complaints of a two week history of a loss of hearing. After physical examination, the Veteran was diagnosed as having otitis externa/media with small perforation, and mild conductive hearing loss. By September 2002, his otitis externa/media had resolved, and the tympanic membrane perforation was healed. The Veteran was assessed with subjective hearing loss possibly secondary to mild residual Eustachian tube dysfunction after ear infection. Audiogram conducted at the end of September 2002 showed a mild sensorineural hearing loss from 3000 to 8000 in the left ear. In February 2007, the Veteran presented with complaints of hearing loss. He reported hearing loss for at least a year, that he had a screening hearing test in September 2006, and that he was told that he had left-sided hearing loss. The Veteran also reported longstanding wax issues and had to use plugs at work as he worked with a grinder. There was no former history of hearing loss but had some noise exposure throughout his life. The Veteran was diagnosed with left ear pain and hearing loss. It was noted that the Veteran worked around loud equipment and stated that he had left ear pain and left ear hearing loss according to his hearing test at work. Following a June 2009 VA examination, and a review of the claims file the Veteran was diagnosed with mild left ear sensorineural hearing loss. The examiner opined that it was not likely that the hearing loss was related to military service based on medical examination dated in February 1997 which noted hearing sensitivity to be within normal limits through 6000 Hertz and the Veteran's release from active service in December 1997. In this case, the Board finds that the June 2009 VA examiner's opinion is inadequate. Although the Veteran did not have hearing loss at separation, his service treatment records showed decreased in hearing acuity while in service. The requirements for service connection for hearing loss as defined in 38 C.F.R. § 3.385 need not be shown by the results of audiometric testing during a claimant's period of active military service in order for service connection to be granted. The June 2009 VA examination is inadequate, as the rationale provided by the examiner is only based upon the Veteran's February 1997 examination. Accordingly, a new medical examination is necessary. Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). Accordingly, the case is REMANDED for the following action: 1. The Veteran should be afforded a VA otolaryngological examination to determine the etiology of any diagnosed left ear hearing loss disability. The examiner must be provided access to the claims file and Virtual VA for review, and the examination report should reflect that such a review was made. All pertinent symptomatology and findings should be reported in detail. Any indicated diagnostic tests and studies should be accomplished. The examiner must opine whether it is at least as likely as not that the Veteran's current left ear hearing loss disability had its onset during service or is in any way related to service. 2. The Veteran is to be notified that it is his responsibility to report for the examinations and to cooperate in the development of the claim. The consequences for failure to report for a VA examination without good cause may include denial of the claim. 38 C.F.R. §§ 3.158 , 3.655 (2012). In the event that the Veteran does not report for the aforementioned examinations, documentation should be obtained which shows that notice scheduling the examinations was sent to the last known address. It should also be indicated whether any notice that was sent was returned as undeliverable. 3. After the development requested has been completed, the RO must review the examination report to ensure that it is in complete compliance with the directives of this REMAND. The AMC/RO must ensure that the examining physician documented their consideration of Virtual VA. If any report is deficient in any manner, the RO must implement corrective procedures at once. 4. The case should then be reviewed on the basis of the additional evidence. If the benefit sought is not granted in full, the Veteran should be furnished a Supplemental Statement of the Case and be afforded a reasonable opportunity to respond before the record is returned to the Board for further review. The appellant has the right to submit additional evidence and argument on the matter or matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). ______________________________________________ DEREK R. BROWN Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs