Citation Nr: 1318489 Decision Date: 06/06/13 Archive Date: 06/11/13 DOCKET NO. 05-22 324 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Louis, Missouri THE ISSUES 1. Whether the severance of service connection for cough/shortness of breath as due to undiagnosed illness, status post uvuloplasty, effective February 1, 2005, was proper. 2. Entitlement to a compensable rating for bilateral hydrocele/spermatocele on a schedular basis. 3. Entitlement to a compensable rating for bilateral hydrocele/spermatocele on an extraschedular basis. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD G. A. Wasik, Counsel INTRODUCTION The Veteran had active duty service from October 1974 to July 1995. This matter comes before the Board of Veterans' Appeals (Board) on appeal from rating decisions by a Regional Office (RO) of the Department of Veterans Affairs (VA). The issue of entitlement to a compensable rating for bilateral hydrocele/spermatocele on an extraschedular basis is remanded to the RO via the Appeals Management Center in Washington, DC. FINDINGS OF FACT 1. The grant of service connection for cough/shortness of breath as due to undiagnosed illness, status post uvuloplasty, pursuant to a February 1997 rating decision, was clearly and unmistakably erroneous. 2. A compensable evaluation for a respiratory disorder was not shown by the evidence of record within two years of the Veteran's last service in the Southwest Asia theater of operations. 3. The medical evidence shows a diagnosis of chronic obstructive pulmonary disorder due to post service employment as a painter. 4. During the entire appeal period, the service-connected bilateral hydrocele/spermatocele was manifested by complaints of pain, but was not manifested by any urinary tract infection symptomatology. CONCLUSIONS OF LAW 1. Service connection for cough/shortness of breath as due to undiagnosed illness, status post uvuloplasty was properly severed, and the criteria for restoration of service connection for the disorder have not been met. 38 U.S.C.A. §§ 1110, 1131, 1117, 5109A (West 1991) (West 2002); 38 C.F.R. §§ 3.105(d), 3.103(b)(2), 3.303, 3.317 (1995) (2012). 2. The criteria for a compensable schedular rating for bilateral hydrocele/spermatocele, have not been met. 38 U.S.C.A. § 1155, 5107 (West 2002); 38 C.F.R. §§ 4.115a, 4.115b, Diagnostic Code 7525 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Duty to Notify and Assist With respect to the Veteran's claim for whether severance of service connection for cough/shortness of breath as due to undiagnosed illness, status post uvuloplasty was proper, VA has met all statutory and regulatory notice and duty to assist provisions. See 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326 (2012). As will be discussed in further detail below, the procedural requirements pertaining to severance of service connection for cough/shortness of breath due to an undiagnosed illness have been met. 38 C.F.R. §§ 3.103(b)(2), 3.105(d). With regard to the claim of entitlement to an increased rating for bilateral hydrocele/spermatocele on a schedular basis, the Board finds that the duty to notify was satisfied by way of a letters sent to the Veteran in February 2004, March 2008, and April 2012, that fully addressed all notice elements. The letters informed the Veteran of what evidence was required to substantiate the claim and of his and VA's respective duties for obtaining evidence. The Veteran was also asked to submit evidence and/or information in his possession. In this case, the RO's decision came before complete notification of the Veteran's rights. However, any defect with respect to the timing of the notice in this case was harmless error. Subsequent to the rating decision on appeal, the RO provided notice to the Veteran regarding what information and evidence was needed to substantiate the claim and the Veteran had the chance to submit evidence in response to the notice letters. Under these circumstances, the Board finds that all notification and development action needed to render a fair decision on this claim has been accomplished and that adjudication of the claim of entitlement to an increased rating for bilateral hydrocele/spermatocele, without directing or accomplishing any additional notification and/or development action, poses no risk of prejudice to the appellant. See, e.g., Bernard v. Brown, 4 Vet. App. 384, 394 (1993). VA must also make reasonable efforts to assist the claimant in obtaining evidence necessary to substantiate the claim for the benefit sought, unless no reasonable possibility exists that such assistance would aid in substantiating the claim. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. In connection with the current appeal, VA has of record Social Security records, private medical records, VA treatment records, service personnel records, and service treatment records. There is no indication that any other treatment records exist that should be requested, or that any pertinent available evidence has not been received. When VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). The Board finds that the VA examination conducted in July 2012 in connection with the claim adjudicated herein is more than adequate. Physical examination was conducted and the Veteran's self-reported history was recorded. The claims file was reviewed. Pertinent symptomatology, or the lack thereof, noted on examination was reported sufficient to accurately apply the criteria of the pertinent diagnostic code on schedular basis. For the foregoing reasons, the Board therefore finds that VA has satisfied its statutory and regulatory duty to notify and the duty to assist. See 38 U.S.C.A. §§ 5102, 5103; 38 C.F.R. §§ 3.159(b), 20.1102. Whether The Severance Of Service Connection For Cough/Shortness Of Breath As Due To Undiagnosed Illness, Status Post Uvuloplasty, Effective February 1, 2005, Was Proper In a rating decision dated in November 1995, the RO denied entitlement to service connection for a chronic cough/shortness of breath as due to an undiagnosed illness as this disorder was not shown to a compensable degree within two years subsequent to his last tour of duty in the Southwest Asia theater of operations. In February 1997, the RO found that a chronic cough was shown to a compensable degree within two years subsequent to his last tour of duty in the Southwest Asia theater of operations and therefore, the November 1995 rating decision contained clear and unmistakable error. Therefore, the February 1997 rating decision granted service connection for chronic cough/shortness of breath as due to undiagnosed illness and assigned a noncompensable evaluation under Diagnostic Code 8866-6600. In November 2004, the RO severed service connection for the disability, effective from February 1, 2005. The Veteran has perfected an appeal of the propriety of the severance. Service connection may be established for disability resulting from personal injury incurred or disease contracted in line of duty, or for aggravation of a pre-existing injury incurred or disease contracted in line of duty. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303. The law also provides that service connection may be granted for any disease diagnosed after discharge when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). In addition, service connection may also be warranted under current law for a Veteran who exhibits objective indications of a qualifying chronic disability that became manifest during active military, naval, or air service in Southwest Asia theater of operations during the Persian Gulf War, or to a degree of 10 percent or more not later than December 31, 2011. 38 U.S.C.A. § 1117; 38 C.F.R. § 3.317. At the time of the 1995 rating decision, service connection was warranted under for a Veteran who exhibited objective indications of a qualifying chronic disability that became manifest during active military, naval, or air service in Southwest Asia theater of operations during the Persian Gulf War, or to a degree of 10 percent or more not later than two years after the date on which the Veteran last served in the Southwest Asia theater of operations during the Persian Gulf War. 38 U.S.C.A. § 1117; 38 C.F.R. § 3.317. Evidence in the claims file demonstrates that the Veteran served in the Persian Gulf during the pertinent time period. A qualifying chronic disability is defined as that which results from an undiagnosed illness, a medically unexplained chronic multi-symptom illness that is defined by a cluster of signs or symptoms, such as chronic fatigue syndrome, fibromyalgia, and irritable bowel syndrome, or any diagnosed illness that VA determines in regulations warrants a presumption of service connection. Id. Moreover, signs or symptoms that may be manifestations of an undiagnosed illness or a chronic multi-symptom illness include: (1) fatigue; (2) unexplained rashes or other dermatological signs or symptoms; (3) headache; (4) muscle pain; (5) joint pain; (6) neurological signs and symptoms; (7) neuropsychological signs or symptoms; (8) signs or symptoms involving the upper or lower respiratory system; (9) sleep disturbances; (10) gastrointestinal signs or symptoms; (11) cardiovascular signs or symptoms; and (12) abnormal weight loss. Id. Once service connection has been granted, it can be severed only upon VA's showing that the final rating decision granting service connection was "clearly and unmistakably erroneous," and only after certain procedural safeguards have been met. 38 U.S.C.A. § 5109A; 38 C.F.R. § 3.105(d); Daniels v. Gober, 10 Vet. App. 474, 478 (1997). Specifically, when severance of service connection is warranted, a rating proposing severance will be prepared setting forth all material facts and reasons. The Veteran will be notified at his latest address of record of the contemplated action and furnished detailed reasons therefore and will be given 60 days for the presentation of additional evidence to show that service connection should be maintained. 38 C.F.R. § 3.103(b)(2), 3.105(d); Baughman v. Derwinski, 1 Vet. App. 563, 566 (1991). With respect to due process, the Board finds that the severance was procedurally proper. The RO complied with its notification obligations. 38 C.F.R. § 3.105(d). In this regard, the RO proposed to sever service connection for cough/shortness of breath due to undiagnosed illness, status post uvuloplasty, in an August 2004 rating decision. The Veteran was advised of the proposed severance by an August 2004 letter, which included a copy of the August 2004 rating decision. This correspondence and accompanying rating decision provided an adequate explanation concerning the reasons for the proposed severance, notified him that he had 60 days to submit additional evidence, and that he could request a hearing. The 60-day period in which the Veteran had to submit additional evidence or request a hearing expired without any response from the Veteran or his representative prior to the RO's promulgation of the proposed severance of service connection. The RO then issued a November 2004 rating decision, severing service connection for cough/shortness of breath due to undiagnosed illness, status post uvuloplasty, effective February 1, 2005. See 38 C.F.R. § 3.105(d). In short, the RO satisfied the procedural requirements of 38 C.F.R. § 3.105(d). As such, no prejudice exists in adjudicating the appeal. Bernard v. Brown, 4 Vet. App. 384, 394 (1993). Service connection will be severed only where evidence establishes that a previous grant of service connection was clearly and unmistakably erroneous, with the burden of proof being upon VA. Baughman v. Derwinski, 1 Vet. App. 563, 566 (1991). Clear and unmistakable error (CUE) is defined as a very specific and rare kind of error. It is the kind of error, of fact or of law, that when called to the attention of later reviewers compels the conclusion, to which reasonable minds could not differ, that the result would have been manifestly different but for the error. Fugo v. Brown, 6 Vet. App. 40 (1993). To determine whether CUE was present in a prior determination, either the correct facts, as they were known at the time, were not before the adjudicator (i.e., more than a simple disagreement as to how the facts were weighed or evaluated) or the statutory or regulatory provisions extant at the time were incorrectly applied; the error must be undebatable and of the sort which, had it not been made, would have manifestly changed the outcome at the time it was made; and a determination that there was CUE must be based on the record and law that existed at the time of the prior adjudication in question. Damrel v. Brown, 6 Vet. App. 242, 245 (1994); Russell v. Principi, 3 Vet. App. 310, 313-14 (1992) (en banc). CUE is an administrative failure to apply the correct statutory and regulatory provisions to the correct and relevant facts. It is not mere misinterpretation of facts. Oppenheimer v. Derwinski, 1 Vet. App. 370, 372 (1991). There are differences in application of the standards for severance of service connection and for demonstrating CUE in a prior final VA decision. See Stallworth v. Nicholson, 20 Vet. App. 482, 488 (2006). In a severance case, VA is not limited to the law and the record that existed at the time of the original decision in adjudicating a matter of severance of service connection; i.e. the provisions of 38 C.F.R. § 3.105(d) do not limit the reviewable evidence to only that which was before the RO in making its initial service connection award. Daniels v. Gober, 10 Vet. App. 474, 480 (1998); see also Venturella v. Gober, 10 Vet. App. 340, 342- 43 (1997). Further, "the severance decision focuses--not on whether the original decision was clearly erroneous--but on whether the current 'evidence establishes that [service connection] is clearly erroneous.'" Stallworth, 20 Vet. App. at 488 (quoting 38 C.F.R. § 3.105(d) (emphasis in original). In this case, the 2004 rating decision severing service connection for cough/shortness of breath due to undiagnosed illness, status post uvuloplasty, was based on a determination that the grant of service connection was clearly and unmistakably erroneous because the evidence did not show a compensable evaluation for a respiratory disorder was warranted within two years of the Veteran's last service in the Southwest Asia theatre, and that current findings attributed the Veteran's respiratory symptoms to chronic obstructive pulmonary disease caused by his post-service employment as a painter. A review of the service treatment records reveals the Veteran complained of chronic cough and shortness of breath while on active duty. While the Veteran underwent evaluations and testing to determine the etiology of the claimed symptomatology, no actual pathology was found and no respiratory disorder was diagnosed. The Board finds that the severance of service connection for the respiratory disorder must be upheld as the preponderance of the competent probative evidence of record demonstrates that the Veteran's complaints of respiratory symptomatology have been attributed to a known diagnosis of chronic obstructive pulmonary disease which has been etiologically linked to the Veteran's post-service employment. The Veteran's service treatment records show complaints and treatment for a chronic, productive cough, with symptoms of shortness of breath, immediately following his service in the Southwest Asia theater of operations that continued until November 1994. After extensive testing, the diagnosis was chronic cough, unknown etiology. The Veteran underwent an uvuloplasty in November 1994. The report of an October 1995 VA examination reveals the Veteran reported he had a chronic cough which began in May 1991. The cough resolved after a uvuloplasty which was conducted in November 1994. The physical examination revealed the lungs were clear to auscultation. There was normal inspiratory volume. Pulmonary function testing conducted in October 1995 revealed that forced expiratory volume in 1 second was 104% of the predicted value, forced expiratory volume in 1 second/forced vital capacity was 81%. The pertinent diagnosis was chronic cough which resolved status post uvuloplasty. Subsequent to October 1995, the next pertinent medical records associated with the claims file are dated in beginning in 2004. At the time of a June 2004 VA examination, the Veteran reported that after military service, he had worked painting electric motors for eight to twelve hours per day in a paint booth. He stated that he rarely wore a respirator as it tended to fog up his glasses. The Veteran reported that he was no longer able to handle the chronic cough that he experienced and because of the inability to perform the job without coughing, including coughing up blood, the Veteran quit work. The Veteran reported his cough was worsening and that he had a cough since his return from the Persian Gulf. The examiner wrote that chest x-ray, pulmonary function testing, methacholine challenge tests were all negative. The examiner noted that an October 1995 chest x-ray was referenced as being normal. The records showed that an uvuloplasty was conducted in October 1994 due to excessive snoring. The examiner observed the medical notes indicated that the Veteran's cough resolved after the surgery, but the Veteran denied this. He reported coughing on a daily basis but since quitting work, he was no longer coughing up blood. The Veteran complained of being short of breath if "very" physically active. He was on no medication for his breathing. Physical examination revealed no shortness of breath and no coughing. The pertinent diagnosis was subjective complaints of a cough of unknown etiology with numerous evaluations, negative pulmonary function testing for obstructive or reactive airway disease, negative chest x-ray, and negative methacholine challenge test. The pulmonary function testing revealed mild decrease in diffusion capacity of carbon monoxide, with mild obstruction. The examiner opined that it was "as likely as not" that these symptoms were due to the Veteran's post military occupation painting in a booth without a respirator as his active duty pulmonary function testing results were normal. Forced expiratory volume in 1 second was 76.4 percent of predicted value and forced expiratory volume in 1 second/forced vital capacity was 76%. The diffusion capacity of carbon monoxide-single breath was 31.30% In July 2004, an addendum to the June 2004 VA examination was prepared. The examiner noted the Veteran's reported history and reviewed the test results. The examiner found that the pulmonary function testing revealed mild decrease in DLCO, with mild obstruction which could be directly attributed to the Veteran's painting in a booth without any form of respirator protection for a period of nine years, as he had a normal pulmonary function testing while on active duty. The examiner noted the Veteran underwent numerous evaluations and testing during active duty for his subjective complaint of a cough, all of which were interpreted as being within normal limits. The examiner wrote that the diagnosis was subjective complaint of cough, without any underlying physiology which could be identified. The examiner was unable to resolve the issue of what caused the Veteran's reported chronic cough during active duty without resort to speculation. The examiner opined that the current pulmonary function testing that showed slight obstruction was secondary to the Veteran's post military occupation working in a paint booth without a respirator. A VA outpatient treatment records dated in May 2005, November 2005, January 2006, June 2006, and August 2006 reported there were no problems with the Veteran's respiratory system. In February 2007, a VA examiner wrote that he was not sure about the etiology of the Veteran's shortness of breath; that it could be anxiety related versus reactive airway disease based on exposure at work. In a March 2007 VA outpatient treatment record, it was noted that recent pulmonary function testing had been interpreted as showing mild obstruction, with significant bronchodilator response. The assessment was chronic obstructive pulmonary disease. In September 2007, the Veteran complained of increased problems breathing. He had a past history of reactive airway disease. The pertinent assessment was difficulty breathing (dyspnea). In January 2008, the Veteran complained of a cough and trouble breathing at night. The assessment was bronchitis. Another record dated the same month reveals the Veteran reported he had had a cough for two weeks. A January 2008 chest X-ray revealed small pulmonary nodules. In March 2008, the Veteran complained of chest pain but denied dyspnea. He also denied a cough. In April 2008, the Veteran denied chest pain or shortness of breath. Review of the pulmonary system revealed a chronic cough. In May 2008, the Veteran informed a private clinician that he had dyspnea since 1991 and was exposed to burning oil well fires while in the Persian Gulf. He also reported dyspnea, a cough and wheezing. He denied ever smoking. The diagnosis was chronic obstructive pulmonary disease "as part of the Gulf War Syndrome." Other diagnoses included obstructive sleep apnea and an abnormal chest CT which revealed very small nodules. In a December 2009 VA outpatient treatment record, the Veteran complained of increasing shortness of breath. Oxygen saturation was at 99 percent. It was noted that the Veteran used inhalers. The assessment was stable, chronic obstructive pulmonary disease. The Board finds that the competent probative evidence of record demonstrates that the Veteran had sought treatment for a chronic cough while on active duty and the etiology of the cough was undetermined. Significantly, this evidence also demonstrates that the Veteran's cough ended after a uvuloplasty was conducted in November 1994 while the Veteran was still on active duty. To the extent that the Veteran had an undiagnosed illness during active duty, this also ended during active duty. The Board finds the competent probative evidence of record demonstrates that a cough due to a undiagnosed illness was not present to a compensable degree within two years of the Veteran's discharge. Under Diagnostic Code 6600 in effect prior to 1996, a 10 percent rating was warranted for moderate chronic bronchitis with considerable night or morning cough, slight dyspnea on exercise and scattered bilateral rales. Higher rating required greater levels of disability including beginning chronic airway obstruction. Significantly, at the time of the October 1995 VA examination, the Veteran informed the examiner that his cough had resolved after the uvuloplasty. Physical examination of the lungs did not reveal any pertinent symptomatology. Pulmonary function testing did not reveal any obstructions. The report of the October 1995 VA examination is the only pertinent medical evidence associated with the claims file dated within two years of the Veteran's discharge from active duty. The next pertinent medical evidence of record is dated in the 2000's. The Board finds the report of the October 1995 VA examination documents a lack of symptomatology required for a 10 percent or greater rating under Diagnostic Code 6600. The Board notes the Veteran has informed health care professionals many years after discharge that he had continued to experience a chronic cough from the time of discharge to the present. Significantly, the Veteran's self-reported symptomatology at the time of the October 1995 VA examination cuts against this allegation. It is not apparent why the Veteran would inform the VA examiner in October 1995 that he did not experience a chronic cough at that time if, in fact, a chronic cough was actually present at that time. The Board places greater probative value on the Veteran's report of his medical history as provided in October 1995 over the subsequent allegations of continuous cough symptomatology made years later. See Caluza v. Brown, 7 Vet. App. 498, 506 (1995) (finding that in weighing the credibility, VA may consider inconsistent statements, internal inconsistency, and consistency with other evidence of record); see also Cartright v. Derwinski, 2 Vet. App. 24, 25 (1991) (holding that self-interest may affect the credibility of testimony). The physical findings included in the report of the October 1995 VA examination support the Board's determination that the Veteran did not have a chronic cough at the time of the October 1995 VA examination. See Curry v. Brown, 7 Vet. App. 59, 68 (1994) (holding that contemporaneous evidence has greater probative value than history as reported by the veteran). While the Veteran is competent to report that he had a chronic cough from the time of discharge to the present, the credibility of the statements is a separate determination the Board must make. In this case, the Board finds the Veteran's prior statements denying a lack of a chronic cough in October 1995 coupled with the lack of pertinent physical findings outweighs the Veteran's allegations made years later. There is no other pertinent evidence dated within two years of the Veteran's discharge. Based on the above, the Board finds that a chronic cough due to a undiagnosed illness was not present to a compensable degree within two years of the Veteran's discharge. The Board finds the competent probative post-service medical evidence of record demonstrates that the Veteran's respiratory complaints have been attributed to know diagnoses and linked to post-service employment. The October 1995 report of the VA examination found no cough at that time, and found no respiratory disorder. The February 2007 VA examination indicated that the Veteran's shortness of breath was due to anxiety or as a result of the Veteran's post-service work. The Veteran's service in the Persian Gulf was not referenced in any way as a possible link nor was there any suggestion that any respiratory disorder was due to an undiagnosed illness. The Board notes that the May 2008 clinical record includes a diagnosis of chronic obstructive pulmonary disease as part of the Gulf War Syndrome. To the extent that this evidence attributes the Veteran's breathing problems to Gulf War Syndrome, it also includes a known diagnosis of chronic obstructive pulmonary disease. This conflict essentially cancels the probative value of the statement. The Board finds that the rest of the post-service medical evidence which addresses the Veteran's respiratory symptomatology all indicate that the symptomatology was attributed to a known diagnosis and/or to post-service employment and not to active duty. The Veteran has not introduced any evidence which contradicts the Board's findings and there is no other evidence in the record which supports a determination that the Veteran has a respiratory disorder which is due to a undiagnosed illness or to any incident of active duty service. The competent probative medical evidence of record clearly and unmistakably demonstrates that the Veteran's respiratory disorder is not due to an undiagnosed illness linked to his active duty service and the evidence also clearly and unmistakably demonstrates that the reported symptomatology does not satisfy the criteria set out under 38 C.F.R. § 3.317. The law was not correctly applied for service connection based on an undiagnosed illness. The evidence is be undebatable that the Veteran does not meet the criteria for an award of service connection based on an undiagnosed illness. His respiratory symptomatology has been attributed to a known diagnosis due to post-service employment. Entitlement To A Compensable Rating For Bilateral Hydrocele/Spermatocele In January 2004, the Veteran submitted a claim of entitlement to an increased rating for his service-connected hydrocele/spermatocele. Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (Rating Schedule). 38 C.F.R. Part 4 (2012). The Rating Schedule is primarily a guide in the evaluation of disability resulting from all types of diseases and injuries encountered as a result of or incident to military service. The ratings are intended to compensate, as far as can practicably be determined, the average impairment of earning capacity resulting from such diseases and injuries and their residual conditions in civilian occupations. 38 C.F.R. §38 U.S.C.A. § 1155; 38 C.F.R. § 4.1 (2012). In evaluating the severity of a particular disability, it is essential to consider its history. 38 C.F.R. § 4.1; Peyton v. Derwinski, 1 Vet. App. 282 (1991). Where entitlement to compensation has already been established and an increase in the evaluation is at issue, the present level of disability is of primary importance. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). However, separate ratings may be assigned for separate periods of time based on the facts found. This practice is known as "staged" ratings. Hart v. Mansfield, 21 Vet. App. 505 (2007). In a rating decision dated in February 1995, service connection for bilateral hydrocele/spermatocele was denied. Thereafter, a rating decision dated in February 1997, found clear and unmistakable error in the February 1995 denial, and service connection for bilateral hydrocele/spermatocele was granted, and was assigned a noncompensable evaluation, effective August 1, 1995, the day after the Veteran's retirement from the military. See 38 C.F.R. § 3.400 (2012). The Veteran's service-connected disability was evaluated by analogy to Diagnostic Code 7525. See 38 C.F.R. § 4.115b, Diagnostic Code 7525. Under Diagnostic Code 7525, chronic epididymo-orchitis is rated as a urinary tract infection. Id.; see also 38 C.F.R. § 4.115a. A urinary tract infection that requires long-term drug therapy, one to two hospitalizations per year, and/or intermittent intensive management will result in the assignment of a 10 percent disability evaluation. Id. The next higher rating of 30 percent requires evidence of either poor renal function or evidence of recurrent symptomatic infection requiring drainage, more than two hospitalizations per year, and/or continuous intensive management. Id. "Drug" is defined, in part, as any chemical compound used on or administered to humans for the relief of pain or suffering. This includes nonsteroidal anti-inflammatory (NSAID). See DORLAND'S ILLUSTRATED MEDICAL DICTIONARY 575 (31st ed. 2007).] The Board finds a compensable rating on a schedular basis is not warranted at any time during the appeal period. The evidence of record demonstrates that the service-connected hydrocele/spermatocele is manifested by complaints of pain, but without any urinary tract infection symptomatology, to include long term medication for the pain. There are very few references to the hydrocele/spermatocele in the medical records. Frequently, the Veteran denied experiencing any genitourinary symptoms. At the time of a June 2004 VA examination, the Veteran reported some aching in his left testicle after standing eight to ten hours per day. He took no medication for the problem. He denied urinary symptoms of frequency, hesitation, or dysuria. There was no incontinence. There were no recurrent urinary tract infections or history of kidney stones or acute nephritis. There was no treatment for malignancies and no cathertization. Physical examination revealed a mildly, tender nodule in the left upper testicle. The pertinent diagnosis was left hydrocele, unchanged from previous notes in 1995, with the only symptoms being mild aching after prolonged weight bearing. In August 2006, a VA outpatient treatment record noted large palpable masses in both scrotum since 1991, that were increasing in size. Later that month, reported a bilateral scrotal masses, with pain. He stated the masses were increasing in size and discomfort. An ultrasound in September 2006, indicated epididymal cysts, hydroceles, left sided variococele, and an area of decreased echotexture. In a September 2006 VA outpatient treatment record, a physical examination found a left paratesticular mass, separate from testis, left testis without masses, and the right testis without paratesticular or testicular mass. The assessment was left paratesticular mass and bilateral orchalgia. In October 2006, a VA operative report indicated that the pre-operative diagnosis was left spermatocele. Findings included bilateral spermatoceles, left greater than the right, with a left spermatocelectomy performed. The post-operative diagnosis was left spermatocele. The most recent VA examination was conducted in July 2012. It was observed that in 2006, the Veteran had a left spermatocele removed. Since that time, a right spermatocele grew, and became a painful and limiting condition. The Veteran did not take continuous medication for treatment. There was no voiding dysfunction or urinary tract or kidney infections. He did not have erectile dysfunction or retrograde ejaculation. A history of chronic epididymitis, epididymo-orchitis, or prostatitis was not shown. Physical examination of the penis was normal. Physical examination of the testes was abnormal. The right testicle had a spermatocele, which was tender. The examiner opined that the spermatocele impacted the Veteran's ability to work because he was unable to stand or work on his feet for prolonged periods. Other than complaints of pain, the Veteran has not alleged that his service-connected bilateral hydrocele/spermatocele is productive of any other pertinent symptomatology. As the medical evidence and the Veteran's statements do not support a finding that the service-connected bilateral hydrocele/spermatocele is manifested by urinary tract infection symptomatology, a compensable schedular rating is not warranted under Diagnostic Code 7525. The lack of pertinent symptomatology at any time during the appeal period demonstrates that a staged rating is not appropriate for assignment at any time. The Board finds no other diagnostic code for the genitourinary system is more appropriate for evaluation of this claim on a schedular basis. Furthermore, the competent probative evidence of record demonstrates that the Veteran has not experienced renal dysfunction, voiding dysfunction, urinary frequency, or obstructed voiding as a result of the service-connected bilateral hydrocele/spermatocele, all of which are used to evaluate the genitourinary system. Generally, evaluating a disability using either the corresponding or the analogous diagnostic codes contained in the Rating Schedule is sufficient. See 38 C.F.R. § 4.20, 4.27 (2012). However, because the ratings are averages, it follows that an assigned rating may not completely account for each individual veteran's circumstance, but nevertheless would still be adequate to address the average impairment in earning capacity caused by disability. Nevertheless, in exceptional cases where the rating is inadequate, it may be appropriate to assign an extraschedular rating. 38 C.F.R. § 3.321(b) (2012). The threshold factor for extraschedular consideration is a finding that the evidence before VA presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. 38 C.F.R. § 3.321(b) (2012); see also Thun v. Peake, 22 Vet. App. 111, 115 (2008), aff'd, 572 F.3d 1366 (Fed. Cir. 2009); see also Fisher v. Principi, 4 Vet. App. 57, 60 (1993) ("[R]ating [S]chedule will apply unless there are 'exceptional or unusual' factors which render application of the schedule impractical."). Therefore, there must be a comparison between the level of severity and symptomatology of the Veteran's service-connected disability with the established criteria found in the Rating Schedule for that disability. Thun, 22 Vet. App. at 115. If the criteria reasonably describe the Veteran's disability level and symptomatology, the Rating Schedule contemplates the Veteran's disability picture, and the assigned schedular evaluation is adequate, and no referral is required. The Board finds that the Veteran's hearing disability picture is unusual and exceptional in nature so as to render the assigned rating inadequate. The Veteran's service-connected hydrocele/spermatocele is evaluated based on a urinary tract infection under Diagnostic Code 7525, the criteria of which is found by the Board not to contemplate the level of occupational and social impairment caused by this disability. Over the period of the appeal, the Veteran's bilateral hydrocele/spermatocele has been manifested by tenderness of the area involved, as well as pain on weightbearing. In this case, when comparing this disability picture with the symptoms contemplated by the Rating Schedule, the Veteran's experiences are incongruent with the disability picture represented by a noncompensable disability rating. The criteria for a noncompensable rating do not reasonably describe the Veteran's disability level and symptomatology throughout the pendency of this appeal. Consequently, the Board concludes that a schedular evaluation is inadequate and that referral of the Veteran's case for extraschedular consideration is required. See 38 C.F.R. § 4.115a, 4.115b, Diagnostic Code 7525; see also VAOGCPREC 6-96; 61 Fed. Reg. 66749 (1996). In reaching this decision, the Board considered the doctrine of reasonable doubt. However, as the preponderance of the evidence is against the Veteran's claim of entitlement to a compensable schedular evaluation for bilateral hydrocele/spermatocele, the doctrine is not for application. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). ORDER The severance of service connection for cough/shortness of breath as due to undiagnosed illness, status post uvuloplasty, effective February 1, 2005, was proper, and restoration of service connection is for the disorder is denied. A compensable rating for bilateral hydrocele on a schedular basis is denied. REMAND The Board is remanding the issue of entitlement to a compensable rating for bilateral hydrocele/spermatocele for consideration of an extraschedular rating. The Board cannot assign an extraschedular rating in the first instance. 38 C.F.R. § 3.321(b). Referral must be made to the Under Secretary for Benefits or the Director of the Compensation and Pension Service to determine whether, to accord justice, the assignment of an extraschedular rating is warranted for the Veteran's service-connected bilateral hydrocele/spermatocele. A remand is necessary to accomplish this task. Accordingly, the case is remanded for the following action: 1. The issue of whether an extraschedular rating for bilateral hydrocele/spermatocele must be referred to the Under Secretary for Benefits or the Director of the Compensation and Pension Service. 2. Thereafter, if the benefit on appeal remains denied, the Veteran and his representative must be provided with a supplemental statement of the case. After the Veteran and his representative have had an adequate opportunity to respond, the appeal must be returned to the Board for appellate review. No action is required by the Veteran until he receives further notice; however, he may present additional evidence or argument while the case is in remand status at the RO. Kutscherousky v. West, 12 Vet. App. 369 (1999). ______________________________________________ JOY A. MCDONALD Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs