Citation Nr: 1320655 Decision Date: 06/26/13 Archive Date: 07/05/13 DOCKET NO. 07-23 335 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Waco, Texas THE ISSUES 1. Entitlement to an increased rating for residuals of a cerebrovascular accident, currently assigned a 10 percent evaluation. 2. Entitlement to an initial compensable evaluation for aphasia. REPRESENTATION Appellant represented by: Texas Veterans Commission WITNESSES AT HEARING ON APPEAL Appellant and sister ATTORNEY FOR THE BOARD K. Hudson, Counsel INTRODUCTION The Veteran had active service from July 1980 to June 1984. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a November 2006 regional office (RO) decision. In May 2010, the Veteran and his sister appeared at a hearing held at the RO before the undersigned Veterans Law Judge (VLJ). In a decision dated in July 2010, the Board granted an increased evaluation to 40 percent, but no more, for hemiparesis of the right lower extremity, and an evaluation of 50 percent, but no more, for hemiparesis of the right upper extremity, both associated with residuals of a cerebrovascular accident (CVA). Therefore, a final decision having been entered, those issues are no longer before the Board. At that time, the Board also remanded the issues of entitlement to an evaluation in excess of 10 percent for residuals of a cerebrovascular accident, and entitlement to a total disability rating based on individual unemployability due to service-connected disabilities (TDIU rating) to the RO for additional development. In the course of appellate development, the RO granted a TDIU rating in a September 2012 rating decision; therefore, that issue is no longer before the Board. The Veteran was granted a separate noncompensable rating for aphasia, as associated with CVA residuals in a March 2008 rating decision. Although he did not separately appeal that decision, he has made relevant contentions, and the Board finds that it must be considered as included within the increased rating for CVA residuals claim on appeal. In this regard, aphasia was one of the primary symptoms shown at the time of the actual CVA in 1985. The Veteran also claims that he has cervical and lumbar spine disabilities, as well as a shoulder disability, which are associated with cerebrovascular accident (CVA) residuals. However, unlike the claim concerning aphasia, the cervical and lumbar spine conditions are not claimed or shown to be residuals of the CVA. Instead, they are disabilities which the Veteran claims are secondary (i.e., caused or aggravated by) to the service-connected CVA residuals. For example, he contends that the cervical spine disability was caused by a fall resulting from his CVA residuals. Therefore, the Board finds that these claims are not inextricably intertwined with the issues currently on appeal, and are not properly before the Board. Nevertheless, they have been raised by the record. Claims for service connection for cervical spine, lumbar spine, and right shoulder disabilities, all asserted to be secondary to the service-connected cerebrovascular accident residuals, including hemiparesis, have been raised by the record, but have not been adjudicated by the Agency of Original Jurisdiction (AOJ). Therefore, the Board does not have jurisdiction over the claims, and they are referred to the AOJ for appropriate action. FINDINGS OF FACT 1. CVA residuals are manifested by mild cognitive impairment and occasional or intermittent headaches of short duration. 2. Aphasia associated with CVA residuals is manifested by mild to moderate speech impairment and mild 7th cranial nerve impairment. CONCLUSIONS OF LAW 1. The criteria for an evaluation in excess of 10 percent for CVA residuals have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.321, 4.1, 4.2, 4.3, 4.7, 4.124a, Diagnostic Code 8008 (2012). 2. The criteria for an evaluation of 10 percent, but no higher, for aphasia associated with CVA residuals have been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.321, 4.1, 4.2, 4.3, 4.7, 4.124a, Diagnostic Code 8207 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Duties to Notify and Assist As provided by the Veterans Claims Assistance Act of 2000 (VCAA), VA has a duty to notify and assist a claimant in substantiating a claim for VA benefits. U.S.C.A. §§ 5103, 5103A (West 2002 & Supp. 2012); see 38 C.F.R. § 3.159 (2012). Here, in a letter dated in August 2006, prior to the initial adjudication of the claims, the RO notified the claimant of the information necessary to substantiate the increased rating claims currently before the Board. He was advised of various types of lay, medical, and employment evidence that could substantiate his claim, and of his and VA's respective obligations in obtaining such evidence. In addition, the letter provided information regarding assigned ratings and effective dates. Dingess v. Nicholson, 19 Vet. App. 473 (2006). Specifically, the Veteran was advised that a disability rating will be determined by applying relevant Diagnostic Codes, which typically provide for a range in severity of a particular disability from noncompensable to as much as 100 percent (depending on the disability involved), based on the nature of the symptoms of the condition for which disability compensation is being sought, their severity and duration, and their impact upon employment. More specific information was provided in a letter dated in June 2008. See Vazquez-Flores v. Peake, 22 Vet. App. 37 (2008) vacated on other grounds sub nom. Vazquez-Flores v. Shinseki, 580 F.3d 1270 (Fed. Cir. 2009). The Veteran was afforded a hearing before a VLJ in which he and his sister presented oral argument in support of his claim. In Bryant v. Shinseki, 23 Vet. App. 488 (2010), the United States Court of Appeals for Veterans Claims (Court) held that 38 C.F.R. § 3.103(c)(2) (2010) requires that the VLJ who chairs a hearing fulfill two duties to comply with the above the regulation. These duties consist of (1) the duty to fully explain the issues and (2) the duty to suggest the submission of evidence that may have been overlooked. Here, while the VLJ did not note the bases of the prior determinations or the elements that were lacking to substantiate the claims at the hearing, she did ask specific questions directed at identifying whether the Veteran had symptoms meeting the criteria for a higher rating. The VLJ sought to identify any pertinent evidence not currently associated with the claims folder. The issues on appeal were subsequently remanded by the Board to obtain and develop such additional evidence. Finally, neither the Veteran nor his representative has asserted that VA failed to comply with 38 C.F.R. § 3.103(c)(2), nor has he identified any prejudice in the conduct of the Board hearing. As such, the Board finds that, consistent with Bryant, the VLJ complied with the duties set forth in 38 C.F.R. § 3.103(c)(2). VA also has a duty to assist the Veteran by making all reasonable efforts to help a claimant obtain evidence necessary to substantiate a claim. 38 U.S.C.A. § 5103A (West 2002); 38 C.F.R. § 3.159(c). This duty includes assistance in the procurement of service treatment records and other relevant treatment records, and providing necessary examination(s). 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. The Veteran's service treatment records have been obtained, as have identified VA treatment records, and the Veteran stated that he received all of his treatment at the Dallas VA Medical Center (VAMC). Records were obtained from Social Security Administration (SSA). VA examinations were provided in November 2006, October 2007, April 2009, and December 2010, which, in conjunction with the other evidence of record, describe the disabilities in sufficient detail for the Board to make an informed decision. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007); Acevedo v. Shinseki, 25 Vet. App. 286, 293 (2012) (noting that the law imposes no reasons-or-bases requirement on examiners). The Board also finds that there was substantial compliance with the remand directives. Dyment v. West, 13 Vet. App. 141, 146-47 (1999) (the veteran is entitled to substantial compliance with the Board's remand directives). The examination requested in the July 2010 remand was obtained in December 2010, and deficiencies were rectified by the August 2012 VA examination performed pursuant to the March 2012 Board remand. The claims on appeal were adjudicated, and supplemental statements of the case furnished to the appellant. Thus, the Board finds that all necessary notification and development has been accomplished, and therefore appellate review may proceed without prejudice to the appellant. See Bernard v. Brown, 4 Vet. App. 384 (1993). Significantly, neither the appellant nor his representative has identified, and the record does not otherwise indicate, any additional existing evidence that is necessary for a fair adjudication of the claim that has not been obtained. Hence, no further notice or assistance to the appellant is required to fulfill VA's duty to assist the appellant in the development of the claims. Smith v. Gober, 14 Vet. App. 227 (2000), aff'd 281 F.3d 1384 (Fed. Cir. 2002); Dela Cruz v. Principi, 15 Vet. App. 143 (2001); see also Quartuccio v. Principi, 16 Vet. App. 183 (2002). II. Increased Ratings Disability ratings are determined by applying a schedule of ratings that is based on average impairment of earning capacity. Separate diagnostic codes identify the various disabilities. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4. Each disability must be viewed in relation to its history and the limitation of activity imposed by the disabling condition should be emphasized. 38 C.F.R. § 4.1. Examination reports are to be interpreted in light of the whole recorded history, and each disability must be considered from the point of view of the appellant working or seeking work. 38 C.F.R. § 4.2. Where there is a question as to which of two disability evaluations shall be applied, the higher evaluation is to be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating is to be assigned. 38 C.F.R. § 4.7. Although the disability must be considered in the context of the whole recorded history, including service treatment records, the present level of disability is of primary concern in determining the current rating to be assigned. Francisco v. Brown, 7 Vet. App. 55 (1994); Schafrath v. Derwinski, 1 Vet. App. 589 (1991). If the disability has undergone varying and distinct levels of severity throughout the appeal period, staged ratings may be assigned. Hart v. Mansfield, 21 Vet. App. 505 (2007). Hart v. Mansfield, 21 Vet. App. 505 (2007); Fenderson v. West, 12 Vet. App. 119 (1999); 38 C.F.R. § 4.2. In making all determinations, the Board must fully consider the lay assertions of record. A layperson is competent to report on the onset and continuity of his current symptomatology. See Layno v. Brown, 6 Vet. App. 465, 470 (1994) (a Veteran is competent to report on that of which he or she has personal knowledge). Lay evidence can also be competent and sufficient evidence of a diagnosis or to establish etiology if (1) the layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009); Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). When considering whether lay evidence is competent the Board must determine, on a case by case basis, whether the Veteran's particular disability is the type of disability for which lay evidence may be competent. Kahana v. Shinseki, 24 Vet. App. 428 (2011); see also Jandreau v. Nicholson, 492 F.3d 1372, 1376-77. The Board is charged with the duty to assess the credibility and weight given to evidence. Madden v. Gober, 125 F.3d 1477, 1481 (Fed. Cir. 1997), cert. denied, 523 U.S. 1046 (1998); Wensch v. Principi, 15 Vet. App. 362, 367 (2001). Indeed, in Jefferson v. Principi, 271 F.3d 1072 (Fed. Cir. 2001), the United States Court of Appeals for the Federal Circuit (Federal Circuit), citing its decision in Madden, recognized that that Board had inherent fact-finding ability. Id. at 1076; see also 38 U.S.C.A. § 7104(a) (West 2002). Moreover, the Court has declared that in adjudicating a claim, the Board has the responsibility to weigh and assess the evidence. Bryan v. West, 13 Vet. App. 482, 488-89 (2000); Wilson v. Derwinski, 2 Vet. App. 614, 618 (1992). Records of the Veteran's hospitalization in Baylor University Medical Center and the VAMC in Dallas from February to March, 1985, show that the Veteran awoke the morning of admission with a right hemiparesis and aphasia. A computerized tomography (CT) scan of the head revealed a left middle cerebral artery CVA. During the course of the hospitalizations, his condition stabilized, and he improved somewhat. In a May 1985 rating decision, he was granted service connection for residuals of a CVA, assigned a 100 percent rating from February 1985, and a 10 percent rating beginning in September 1985. The current claim for an increased rating was received in August 2006. A. Residuals of CVA Concerning the issue of entitlement to an evaluation in excess of 10 percent for residuals of a CVA, the Veteran's CVA is rated under Diagnostic Code 8008, which calls for a 100 percent rating for the first six months following the stroke, followed by ratings based on residuals, with a minimum rating of 10 percent. 38 C.F.R. § 4.124a, Diagnostic Code 8008. He has been assigned a 10 percent rating under Diagnostic Code 8008 for residuals that are not otherwise compensable under analogous rating codes. He has also been assigned separate ratings for CVA residuals of hemiparesis of the right lower extremity and right upper extremity, as well as for aphasia; symptoms associated with those conditions may not also be rated under Diagnostic Code 8008. See 38 C.F.R. § 4.14 (2012). The only symptoms for consideration in this issue are manifestations which have not been separately rated. As noted in the record, including written statements from the Veteran and his sister, the hearing testimony, and the prior remands, the Veteran claims that he has memory loss, fatigue or drowsiness, headaches, dizziness, and episodes of loss of consciousness which he believes are manifestations of CVA residuals, and which are severe enough to warrant one or more separate evaluations. In December 2005, the Veteran reported intermittent headaches, which he said were not bad or sustained, but did occasionally wake him up from sleep. MRI/MRA of the head was to be obtained. On an outpatient treatment record dated in March 2006, the Veteran was noted to still complain of headaches, which would be in the frontal or temporal area, and would come and go. They mostly occurred in the morning. He did not have any vision changes, and he was not taking pain medication. The assessment was that MRI/MRA of the head had been negative, and Tylenol was recommended for the headaches. On a VA examination for hypertension in February 2006, the Veteran reported that he had been feeling tired since another medication for his hypertension had been added to his regimen 2 months earlier. According to a VA outpatient note dated in October 2006, the Veteran stated that he had experienced an episode of dizziness associated with decreased vision of the right eye. He denied other symptoms including shortness of breath, loss of consciousness, and seizure-like activity. However, on a VA examination in November 2006, the Veteran denied headaches, dizziness, blurred vision or diplopia. On a VA aid and attendance examination in April 2007, the Veteran was described as status post CVA, with no dizziness or loss of memory. On a VA examination in October 2007, the Veteran said he was having intermittent headaches on the right side of his head and face, as if he had a toothache; the last episode had been about two weeks ago, and the headaches lasted about an hour and were relieved by aspirin. A January 2008 outpatient treatment record noted that the Veteran did not have symptoms including headaches and confusion. In April 2008, the Veteran sought treatment, stating that a day or two earlier, he had stood up to go to the kitchen, and "blacked out" after taking a few steps, hitting his head on the floor. He did not recall feeling dizzy upon standing, or any other associated symptoms. He had not had any neurological changes, changes to mental clarity, or severe headaches since the incident. He reported a previous incident a few months earlier. Several tests were planned, to try to find the cause of the episode of loss of consciousness. The first was a computerized tomography (CT) scan in April 2008, which disclosed stable encephalomalacia within the deep white matter of the left temporal lobe, likely from a prior CVA; scattered low densities within the deep white matter from chronic small vessel disease; and no evidence of an acute ischemic event. An electrocardiogram was normal. In June 2008, he was seen for follow-up of the syncope. An MRI of the brain in May 2008 had revealed old left basal ganglia infarct with white matter encephalomalacia in the left corona radiata. Cardiac tests including echocardiogram and Holter monitor did not show any significant abnormality. It was also noted that he had had no further syncope. The assessment was syncopal episode about 2 months ago, work-up unrevealing. In September 2008, he again reported no syncope. In December 2008, he was seen for routine follow-up; it was noted that he had had no further episodes of syncope, and work-up had been negative. The assessment, concerning CVA, was that he was on aspirin and had no recurrent difficulties. On a VA examination in April 2009, the Veteran reported right-sided headaches that could last from 1-3 hours about once a week. Headaches were not noted as a diagnosis. In August 2009, the Veteran was seen for follow-up of Grave's hyperthyroidism, which had been diagnosed in 2008. He reported compliance with his thyroid medication, and said that his fainting spells, especially when ambulating, had improved since taking the medication. However, he reported 2 episodes of presyncopal symptoms associated with coughing. He was to be seen for further evaluation of vasovagal syncope. In November 2009, he was evaluated for his multiple medical conditions. Concerning thyroid condition, he denied fatigue. He said he had been having episodic dizziness without the syncope/fall/loss of consciousness that had started prior to the development of the thyroid condition. The dizziness occurred a few times per week when he bent over, and was unrelated to other symptoms. The assessment was that the dizziness was likely related to orthostatic hypotension from thiazide therapy for hypertension. It was planned to discontinue that medication. In December 2009, when seen for thyroid follow-up, the Veteran complained of weight gain and feeling slow and sleepy. The dose of his thyroid medication was reduced. In July 2010, it was noted that the dizziness had resolved after the Veteran discontinued the thiazide medication for hypertension. He was compliant with his other medication. He reported no dizziness. On the report of a VA examination in December 2010, the examiner stated that the claims file had been reviewed. The Veteran complained of headaches which occurred one or two times per month and lasted a few minutes. They were moderate in severity and alleviated by aspirin. He had no current complaints of dizziness, although he did have some in the past. He said he had noticed some cognitive impairment with short-term memory, forgetfulness, and occasional confusion. He still drove, and handled his own financial affairs. He was fully functional in normal activities of daily living, and did his own household chores. He was not currently using any assistive devices for walking. On examination, there was no autonomic nervous system dysfunction. There were no significant abnormalities of behavior, comprehension, coherence, emotional reaction, or judgment. There was no recent history of loss of consciousness or syncope. Other than the separately rated CVA residuals, the only CVA residual found was mild cognitive impairment. It is required for the minimum ratings for residuals under diagnostic codes 8000-8025, that there be ascertainable residuals. Determinations as to the presence of residuals not capable of objective verification, i.e., headaches, dizziness, fatigability, must be approached on the basis of the diagnosis recorded; subjective residuals will be accepted when consistent with the disease and not more likely attributable to other disease or no disease. It is of exceptional importance that when ratings in excess of the prescribed minimum ratings are assigned, the diagnostic codes utilized as bases of evaluation be cited, in addition to the codes identifying the diagnoses. 38 C.F.R. § 4.124a, Note following Diagnostic Code 8025 (2012). These records show that the symptoms claimed by the Veteran have not been attributed to his CVA residuals, except for mild cognitive impairment. The fatigue and dizziness were found to be related to medication taken for other, unrelated conditions. The cause of the "black-outs," or syncope, has not been definitively established, but after reviewing CT and MRI scans, which showed residuals of the CVA, the treatment providers did not associate the syncope with the CVA. The Veteran also has reported on occasion intermittent headaches, which have not been medically attributed to the CVA residuals. However, such a connection has not been excluded, but they have not been shown to result in any functional impairment, are of short duration, and are alleviated by over-the-counter medication. No other symptoms have been associated with the CVA residuals. Thus, the only clearly established, not separately rated residual is cognitive impairment, and this has been shown to be mild. Even assuming the headaches of the severity shown in the record cannot be dissociated from CVA residuals, these symptoms together are contemplated by the ascertainable residuals required for the minimum rating of 10 percent, under Diagnostic Code 8008. Therefore, mild cognitive impairment and mild, intermittent headaches do not exceed the criteria for the current 10 percent rating. In reaching this determination, the Board is mindful that all reasonable doubt is to be resolved in the Veteran's favor. Moreover, the Board has accepted the statements and testimony of the Veteran and his sister as credible regarding the symptoms as described. However, they are not competent to associate a given symptom with the CVA; such a connection requires medical evidence. The preponderance of the evidence is against the claim, and the claim must be denied. 38 U.S.C. § 5107(b); see Ortiz v. Principi, 274 F.3d 1361 (Fed. Cir. 2001); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). In exceptional cases an extraschedular rating may be provided. 38 C.F.R. § 3.321. The Court has set out a three-part test, based on the language of 38 C.F.R. § 3.321(b)(1), for determining whether a Veteran is entitled to an extraschedular rating: (1) the established schedular criteria must be inadequate to describe the severity and symptoms of the claimant's disability; (2) the case must present other indicia of an exceptional or unusual disability picture, such as marked interference with employment or frequent periods of hospitalization; and (3) the award of an extraschedular disability rating must be in the interest of justice. Thun v. Peake, 22 Vet. App. 111 (2008), aff'd, Thun v. Shinseki, 572 F.3d 1366 (Fed. Cir. 2009). The Board finds that the rating criteria contemplate the Veteran's CVA residuals. In this regard, the rating schedule provides for higher ratings, and there are no symptoms which have been attributed to the Veteran's CVA residuals which have not been considered. The rating criteria are therefore adequate to evaluate the Veteran's CVA residuals, and referral for consideration of extraschedular rating is not warranted. B. Aphasia In August 2006, the Veteran filed the current claim for an increased rating for CVA residuals. A VA examination in November 2006 disclosed right sided weakness with no other residuals. However, on a VA examination in October 2007, it was noted as medical history that the Veteran "has aphasia." On examination, speech was slow, and he had dysarthria. In a January 2008 addendum, the physician wrote that the nerve involved in the Veteran's aphasia was the 7th nerve and that the severity was mild. Based on this examination, in a March 2008 rating decision, the RO entered a separate grant of service connection for aphasia, associated with CVA residuals, effective October 19, 2007, the date of the VA examination. A noncompensable evaluation was assigned. On a VA examination in April 2009, it was noted that the Veteran presented for evaluation of his service-connected disability of CVA with residuals including facial nerve palsy. On examination, he had mild facial palsy on the right but could easily close his eyes. He had moderate dysarthria and was difficult to understand at times. The pertinent diagnosis was CVA, remote, with residuals of facial nerve palsy and dysarthria, moderately severe. It was commented that his dysarthria was a major obstacle in his ability to communicate, and that he was difficult to understand at times. On a VA examination in December 2010, the Veteran said that people were usually able to understand his speech, but he often had to repeat himself. On examination, cranial nerves II-XII were intact with the exception of mild weakness of the right nerve VII. There was mild dysphasia. The Veteran was able to be understood about 90 percent of the time. Because the examiner in October 2007 stated that the involved nerve was the 7th cranial nerve, the Veteran's aphasia has been rated under Diagnostic Code 8207, which pertains to the 7th cranial nerve. Rating under this Diagnostic Code is dependent upon the relative loss of innervation of the facial muscles. A 10 percent rating is warranted if there is moderate incomplete paralysis of the seventh (facial) cranial nerve. A 20 percent rating is warranted if there is severe incomplete paralysis. A 30 percent rating is warranted if there is complete paralysis of the nerve. 38 C.F.R. § 4.124a, Diagnostic Code 8207. Aphasia is defined as the loss of power of expression by speech, writing or signs, or of comprehending spoken or written language, due to injury or disease of the brain. Dorland's Illustrated Medical Dictionary 114 (30th ed. 2000). Less severe forms are known as dysphasia. Id. Dysphasia may also be defined as the impairment of speech consisting of lack of coordination and failure to arrange words in their proper order. Id., at 576. Dysarthria is a speech disorder consisting of imperfect articulation due to loss of muscle control after damage to the central or peripheral nervous system. Id., at 572. Thus, whether the Veteran's condition is described as aphasia, dysphasia, or dysarthria, it contemplates a speech impairment caused, in this case, by the 1985 CVA. Indeed, at the time of the CVA, aphasia was one of the primary symptoms, but subsequently improved, to the extent where he was noted to have recovered from it long ago in an October 2005 VA examination report. To avoid confusion, the condition will be referred to as "aphasia" in the following discussion. As can be seen, the level of severity as observed on VA examinations throughout the appeal period has varied. In April 2009 the aphasia was noted to be moderate, but he had a mild facial palsy which led the examiner to conclude that there was moderately severe impairment. However, a facial palsy has not been shown in general; in November 2006, he did not have any facial nerve or speech symptoms. Also, the aphasia in October 2007 and in December 2010 was noted to be mild. The Veteran's sister, in a May 2010 letter describing the Veteran's symptoms, noted that it was hard for his family to understand him, despite being around him all the time. Although the Veteran was able to communicate adequately at his Board hearing in May 2010, some difficulties, in particular, hesitation, were demonstrated at that time. In view of the involvement of the 7th cranial nerve, although not generally shown as a palsy, together with the aphasia, which has consistently been shown to be at least mild, and on one occasion moderate, the Board is of the opinion that the manifestations of aphasia more closely approximate moderate incomplete paralysis, and, therefore, a separate 10 percent rating, but no higher, is warranted. See 4.7. In reaching this determination, the benefit-of-the-doubt rule has been applied. See 38 U.S.C.A. § 5107(b). Moreover, the rating criteria contemplate the Veteran's aphasia, and are therefore adequate to evaluate the Veteran's aphasia; referral for consideration of extraschedular rating is not warranted. See 38 C.F.R. § 3.321(b)(1); Thun, supra. ORDER A rating in excess of 10 percent for CVA residuals is denied. A 10 percent rating for aphasia is granted, subject to the statutes and regulations governing the payment of monetary benefits. ______________________________________________ THERESA M. CATINO Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs