Citation Nr: 1323782 Decision Date: 07/25/13 Archive Date: 08/06/13 DOCKET NO. 09-46 870 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUES 1. Entitlement to service connection for tooth number 19. 2. Entitlement to service connection for diabetes mellitus. 3. Entitlement to service connection for reactive airway disease. 4. Entitlement to an initial evaluation in excess of 10 percent for degenerative disc disease of the lumbar spine. 5. Entitlement to an initial evaluation in excess of 10 percent for neuropathy and sciatica of the left lower extremity. 6. Entitlement to an initial evaluation in excess of 10 percent for neuropathy and sciatica of the right lower extremity. 7. Entitlement to an initial evaluation in excess of 10 percent for gastroesophageal reflux disease (GERD). 8. Entitlement to an initial evaluation in excess of 10 percent for residuals of a sprain of the right wrist. 9. Entitlement to an initial compensable evaluation for degenerative disc disease of the cervical spine. 10. Entitlement to an initial compensable evaluation for chondromalacia of the right knee. 11. Entitlement to an initial compensable evaluation for chondromalacia of the left knee. 12. Entitlement to an initial compensable evaluation for residuals of a tendon tear of the left fourth digit. 13. Entitlement to an initial compensable evaluation for ulnar neuritis of the right hand prior to April 4, 2012. 14. Entitlement to an initial evaluation in excess of 10 percent for ulnar neuritis of the right hand since April 4, 2012. 15. Entitlement to an initial compensable evaluation for hearing loss in the left ear. 16. Entitlement to an initial compensable evaluation for hypertension. 17. Entitlement to an initial compensable evaluation for actinic keratosis prior to April 4, 2012. 18. Entitlement to an initial evaluation in excess of 10 percent for actinic keratosis since April 4, 2012. 19. Entitlement to an initial evaluation in excess of 10 percent for carpal tunnel syndrome of the left hand. REPRESENTATION Appellant represented by: David P. Mitchell, Attorney WITNESS AT HEARING ON APPEAL Veteran ATTORNEY FOR THE BOARD Anthony M. Flamini, Counsel INTRODUCTION The Veteran served on active duty from April 1979 to July 1979, November 1990 to November 1991, January 2003 to March 2004, and from September 2004 to June 2005. This matter comes to the Board of Veterans' Appeals (Board) on appeal from February 2008 and March 2008 rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) that denied the Veteran's claim for service connection for tooth number 19, diabetes mellitus and reactive airway disease. The rating decisions also granted service connection for the remaining claims, and assigned the evaluations now in effect. The Veteran has disagreed with the assigned ratings, and with the denials of service connection. This case was previously remanded by the Board in March 2012. A remand by the Board confers on the claimant, as a matter of law, the right to compliance with the remand orders. Stegall v. West, 11 Vet. App. 268, 271 (1998). In this regard, the Board is satisfied as to compliance with the instructions from its March 2012 remand. Specifically, with respect to the issues adjudicated herein, the Board directed the RO to obtain additional treatment records and to afford the Veteran VA examinations. The Board finds that the RO has complied with these instructions. Stegall, 11 Vet. App. at 268. The issues of entitlement to service connection for tooth number 19, diabetes mellitus, and reactive airway disease, as well as increased initial ratings for degenerative disc disease of the lumbar spine, residuals of a right wrist sprain, degenerative disc disease of the cervical spine, chondromalacia of the right knee, and chondromalacia of the left knee are addressed in the REMAND portion of the decision below and are REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. FINDINGS OF FACT 1. The Veteran's service-connected neuropathy and sciatica of the left lower extremity is manifested by incomplete paralysis of the sciatic nerve, resulting in "mild" symptomatology, to include decreased light touch and vibration sense, hypoactive ankle reflex, and subjective complaints of pain, numbness, and paresthesias. 2. The Veteran's service-connected neuropathy and sciatica of the right lower extremity is manifested by incomplete paralysis of the sciatic nerve, resulting in "mild" symptomatology, to include decreased light touch and vibration sense, hypoactive ankle reflex, and subjective complaints of pain, numbness, and paresthesias. 3. The Veteran's service-connected GERD is manifested by recurrent epigastric distress characterized as "mild" in nature. 4. The Veteran's service-connected residuals of a tendon tear of the left fourth digit are manifested by normal flexion and extension in all finger joints, with subjective complaints of pain, decreased strength, and decreased dexterity. 5. The Veteran's service-connected ulnar neuritis of the right hand has been manifested by mild incomplete paralysis of the right upper extremity prior to April 4, 2012, and by moderate incomplete paralysis of the right upper extremity since April 4, 2012. 6. The Veteran's service-connected left ear hearing loss equates to no more than level II hearing loss in the left ear. 7. The Veteran's service-connected hypertension is manifested by diastolic blood pressure readings which are predominantly below 100 and systolic blood pressure readings which are predominantly below 160. 8. The Veteran's service-connected actinic keratosis did not involve at least 5 percent of the entire body or at least 5 percent of the exposed areas affected, or require any intermittent systemic therapy such as corticosteroids or other immunosuppressive drugs, prior to April 4, 2012; the actinic keratosis has involved 20 to 40 percent of his entire body and less than 5 percent of the exposed area affected, but has not required any systemic therapy such as corticosteroids or other immunosuppressive drugs since April 4, 2012. 9. The Veteran's service-connected left hand carpal tunnel syndrome is manifested by subjective complaints of pain, numbness, and paresthesias of the upper left extremity, as well as decreased strength and sensation in the left wrist and hand, which equates, at most, to mild incomplete paralysis of the median nerve. CONCLUSIONS OF LAW 1. The criteria for the assignment of an evaluation in excess of 10 percent for neuropathy and sciatica of the left lower extremity have not been met. 38 U.S.C.A. §§ 1155, 5103A, 5107 (West 2002); 38 C.F.R. §§ 4.7, 3.159, 3.321, 4.7, 4.124a, including Diagnostic Code 8521 (2012). 2. The criteria for the assignment of an evaluation in excess of 10 percent for neuropathy and sciatica of the right lower extremity have not been met. 38 U.S.C.A. §§ 1155, 5103A, 5107 (West 2002); 38 C.F.R. §§ 4.7, 3.159, 3.321, 4.7, 4.124a, including Diagnostic Code 8521 (2012). 3. The criteria for the assignment of an evaluation in excess of 10 percent for GERD have not been met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 4.20, 4.114, Diagnostic Code 7346 (2012). 4. The criteria for a compensable evaluation for residuals of a tendon tear of the left fourth digit 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, 4.71a, Diagnostic Code 5230 (2012). 5. The criteria for the assignment of an evaluation of 10 percent, but no more, prior to April 4, 2012, and an evaluation of 20 percent, but no more, since April 4, 2012, for ulnar neuritis of the right hand have been met. 38 U.S.C.A. §§ 1155, 5103A, 5107 (West 2002); 38 C.F.R. §§ 4.7, 3.159, 3.321, 4.7, 4.124a, including Diagnostic Code 8516 (2012). 6. The criteria for a compensable evaluation for left ear hearing loss have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.159, 3.385, 4.1, 4.2, 4.7, 4.85, Diagnostic Code 6100, 4.86 (2012). 7. The criteria for a compensable evaluation for hypertension have not been met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. § 4.104, Diagnostic Code 7101 (2012). 8. The criteria for an initial compensable evaluation for the period prior to April 4, 2012, for actinic keratosis, have not been met; the criteria for an evaluation of 30 percent, but no more, for the period since April 4, 2012, for actinic keratosis have been met. 38 U.S.C.A. §§ 1155, 5103A, 5107 (West 2002); 38 C.F.R. §§ 4.118, Diagnostic Code 7820 (2012). 9. The criteria for the assignment of an evaluation in excess of 10 percent for left carpal tunnel syndrome have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107, 5110 (West 2002); 38 C.F.R. §§ 4.1, 4.2, 4.124a, Diagnostic Code 8515 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. The Duty to Notify and the Duty to Assist The Veterans Claims Assistance Act of 2000 (VCAA) enhanced VA's duty to notify and assist claimants in substantiating their claims for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2012). Proper notice from VA must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b); Quartuccio v. Principi, 16 Vet. App. 183 (2002). This notice must be provided prior to an initial decision on a claim by the RO. Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004). In addition, the decision of the U.S. Court of Appeals for Veterans Claims (Court) in Dingess v. Nicholson, 19 Vet. App. 473 (2006), requires more extensive notice in claims for compensation, e.g., as to potential downstream issues such as disability rating and effective date. Here, VA has fulfilled the above requirements with regard to the claims decided herein. VCAA notice was provided in letters dated in August 2007 and November 2007, prior to the initial adjudication of the claims. In addition, the November 2007 letter informed the Veteran how VA determines disability ratings and effective dates for ratings, in general compliance with the requirements of Dingess v. Nicholson, 19 Vet. App. 473 (2006). Moreover, the Board notes that the Veteran's claims here arise from his disagreement with initial evaluations following the grants of service connection. Judicial precedent holds that, once service connection is granted, the claim has been substantiated, additional notice is not required, and any defect in previous notice is not prejudicial. Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007); Dunlap v. Nicholson, 21 Vet. App. 112 (2007). Therefore, no further notice, beyond that afforded in the context of the Veteran's initial claim for service connection, is needed under the VCAA. VA's duty to assist the Veteran in the development of the claim includes assisting him in the procurement of service medical records and pertinent treatment records, and providing an examination when necessary. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. The Board finds that the RO and the Appeals Management Center (AMC) appropriately assisted the Veteran in obtaining indicated treatment and evaluation records. As discussed below, although it does not appear that all service records have yet been associated with the claims file, the Board finds that these records are not relevant to the increased rating claims adjudicating herein. VA's duty to assist the Veteran by providing examinations when necessary was also adequately fulfilled with respect to the claims decided herein. 38 U.S.C.A. § 5103A. The Board finds that the VA examinations afforded the Veteran in February 2008 and March 2012, and their findings and analyses, as discussed infra, taken together with the balance of the evidence of record, are adequate for the Board's adjudications herein. Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). The examinations provided sufficient detail, and supported their conclusions with analyses fully supported by review of the evidence presented, which analyses are readily weighed against contrary evidence. Stefl v. Nicholson, 21 Vet. App. 120, 124-25 (2007). Further, the evidence so considered by the examination reports was sufficient and encompassed the evidence of record. Id. Based on the evidence presented, the Board finds no reasonable likelihood that further evaluation would produce findings supporting more beneficial outcomes in this case for the issues decided herein. The Veteran has not indicated the existence of additional pertinent evidence with respect to the issues adjudicated herein. The case presents no reasonable possibility that additional evidentiary requests would further the appealed claim. 38 U.S.C.A. § 5103A(a)(2); 38 C.F.R. § 3.159. 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 claim. Smith v. Gober, 14 Vet. App. 227 (2000), aff'd 281 F.3d 1384 (Fed. Cir. 2002); Dela Cruz v. Principi, 15 Vet. App. 143 (2001); see also Quartuccio, supra. The Veteran also testified at a Travel Board hearing before the undersigned Acting Veterans Law Judge in June 2011. 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) (2012) requires that any Veterans Law Judge who chairs a hearing fulfill two duties to comply with the VCAA. 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. Bryant, 23 Vet. App. at 488. The Board finds that these duties were adequately fulfilled at the June 2011 hearing. At that hearing the Veteran and his authorized representative demonstrated adequate knowledge of the issues and also expressed intention of submitting additional relevant records. Thus, no prejudice could have reasonably resulted from any deficiency in the undersigned's fulfillment of the requirements of Bryant v. Shinseki. In short, in this case, with respect to the claims herein adjudicated, the Board finds that any error in notice and development assistance cannot "reasonably affect the outcome of the case," and hence will not affect "the essential fairness of the [adjudication]" for the rating assigned for the rating period in question, for the appealed claim. ATD Corp. v. Lydall, Inc., 159 F.3d 534, 549 (Fed. Cir. 1998); Mayfield v. Nicholson, 19 Vet. App. 103 (2005). The Veteran was duly afforded the opportunity to produce additional evidence to support his claims. Thus, the Board determines that the evidentiary record is adequate, and the only significant medical questions remaining pertaining to the Veteran's claims were in this case, based on development already undertaken, the responsibility of the Veteran. See 38 C.F.R. §§ 3.303, Part 4. In view of the foregoing, the Board finds that all notification and development actions needed to render a decision on the Veteran's claims on appeal herein adjudicated have been accomplished. II. Increased Rating Claims Disability evaluations are determined by the application of a schedule of ratings which is based on the average impairment of earning capacity resulting from a disability. Separate diagnostic codes identify the various disabilities. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4. When there is a question as to which of two evaluations should be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. In order to evaluate the level of disability and any changes in condition, it is necessary to consider the complete medical history of the Veteran's condition. Schafrath v. Derwinski, 1 Vet. App. 589, 594 (1991). However, where an increase in the level of a service-connected disability is at issue, the primary concern is the present level of disability. Francisco v. Brown, 7 Vet. App. 55 (1994). Nevertheless, the Board acknowledges that a claimant may experience multiple distinct degrees of disability that might result in different levels of compensation from the time the increased rating claim was filed until a final decision is made. The analysis in the following decision is therefore undertaken with consideration of the possibility that different ratings may be warranted for different time periods. Hart v. Mansfield, 21 Vet. App. 505 (2007); Fenderson v. West, 12 Vet. App. 119 (1999). When all the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the appellant prevailing in either event, or whether a preponderance of the evidence is against a claim, in which case, the claim is denied. Gilbert v. Derwinski, 1 Vet. App. 49 (1990); 38 C.F.R. §§ 3.102, 4.3. Neuropathy and Sciatica of the Left and Right Lower Extremities The Veteran seeks higher initial ratings for his neuropathy and sciatica of the left and right lower extremities, each of which have been assigned separate 10 percent ratings under Diagnostic Code 8521, which provides ratings for paralysis of the external popliteal nerve. Diagnostic Code 8521 provides that mild incomplete paralysis is rated as 10 percent disabling; moderate incomplete paralysis is rated 20 percent disabling; and severe incomplete paralysis is rated 30 percent disabling. Complete paralysis of the external popliteal nerve, foot drop and slight droop of first phalanges of all toes, cannot dorsiflex the foot, extension (dorsal flexion) of proximal phalanges of toes lost; abduction of foot lost, adduction weakened; anesthesia covers entire dorsum of foot and toes, is rated 40 percent disabling. 38 C.F.R. § 4.124a, Diagnostic Code 8521 (2012). The term "incomplete paralysis" with this and other peripheral nerve injuries indicates a degree of lost or impaired function substantially less than the type pictured for complete paralysis given with each nerve, whether due to varied level of the nerve lesion or to partial regeneration. When the involvement is wholly sensory, the rating should be for the mild, or at most, the moderate degree. The ratings for the peripheral nerves are for unilateral involvement; when there is bilateral involvement, the VA adjudicator is to combine the ratings for the peripheral nerves, with application of the bilateral factor. 38 C.F.R. § 4.124a. The Board also observes that the words "mild," "moderate" and "severe" as used in the various Diagnostic Codes are not defined in the VA Schedule for Rating Disabilities. Rather than applying a mechanical formula, the Board must evaluate all of the evidence, to the end that its decisions are "equitable and just." 38 C.F.R. § 4.6 (2012). The Veteran was afforded a VA peripheral nerves examination in February 2008, at which time he was diagnosed as having mild neuropathy of the bilateral lower extremities. Upon physical examination, his bilateral feet exhibited decreased light tough and vibration sense, but normal position sense. His sensory nerves were stated to be affected. Although his bilateral knee reflexes were normal and his bilateral plantar flexion was normal, his bilateral ankle reflexes were hypoactive. There was no evidence of muscle atrophy, abnormal muscle tone or bulk, or abnormal movements. Gait and balance were normal, and joint function was not affected by the nerve disorder. The Veteran was next afforded a VA peripheral nerves examination in March 2012, at which time he was diagnosed as having bilateral lumbar radiculopathy. The Veteran subjectively described constant moderate pain and moderate paresthesias and numbness in the bilateral lower extremities, with intermittent episodes of severe pain. Physical examination revealed normal knee and ankle reflexes, bilaterally. The Veteran's gait was normal, and there was no evidence of muscle atrophy. The Veteran was noted to have incomplete paralysis of the sciatic nerve, bilaterally. Electromyography (EMG) revealed abnormalities in the bilateral lower extremities, and the examiner opined that the Veteran's bilateral lumbar radiculopathy posed merely mild limitations on moderate-to-heavy physical activity such as bending, lifting, and prolonged walking. Based on the above, the Board concludes that ratings greater than 10 percent for neuropathy and sciatica of the left and right lower extremities are not warranted as the Veteran's symptomatology has always been characterized as "mild" in nature. The Veteran's deficits are mostly sensory; and although he exhibited hypoactive bilateral ankle reflexes in February 2008, these reflexes were found to be normal in March 2012. In addition, the Veteran had no evidence of muscle atrophy, which indicates that the Veteran had normal use of his lower extremities and that he did in fact use his lower extremities in a close to normal fashion. GERD The Veteran seeks a higher initial rating for his GERD, which has been assigned a 10 percent rating under Diagnostic Code 7346. Under Diagnostic Code 7346, a 10 percent rating is warranted for a hiatal hernia with two or more of the symptoms for the 30 percent evaluation of less severity. A 30 percent rating is warranted for persistently recurrent epigastric distress with dysphagia, pyrosis, and regurgitation, accompanied by substernal or arm or shoulder pain, productive of considerable impairment of health. Lastly, a 60 percent rating is warranted for symptoms of pain, vomiting, material weight loss and hematemesis or melena with moderate anemia; or other symptom combinations productive of severe impairment of health. 38 C.F.R. § 4.114, Diagnostic Code 7346. The Board finds that an increased rating is not warranted for GERD. The Board finds the service-connected disability is manifested by, at most, intermittent epigastric distress that is mild in nature. The Veteran was afforded a VA esophagus and hiatal hernia examination in February 2008, at which time he was diagnosed as having mild, stable GERD with reflux esophagitis. Subjectively, the Veteran reported nausea, heartburn/pyrosis, regurgitation, and esophageal distress accompanied by mild pain several times per week. Upon physical examination, the Veteran exhibited a very obese abdomen with minimal, non-specific tenderness in the upper epigastrium. There were no peritoneal signs, no hepatoslenomegaly, and no ascites. Cardiopulmonary examination was normal. Upper gastrointestinal (UGI) series revealed no reflux or hiatal hernia, with questionable mild duodenitis. The examiner found that the Veteran's mild, stable GERD only had a mild effect on exercise and sports, and no effect on chores, shopping, recreation, traveling, feeding, bathing, dressing, toileting, and grooming. The Veteran was afforded his most recent VA esophageal conditions examination in March 2012, at which time the Veteran was diagnosed as having GERD. The examiner noted that the Veteran was prescribed capsules of omeprazole once daily prior to a meal for treatment of his GERD. Subjectively, the Veteran described dysphagia, pyrosis, reflux, regurgitation, and sleep disturbance caused by esophageal reflux. Although these symptoms occurred 4 or more times per year, they lasted less than one day. The Veteran further reported mild nausea, vomiting, hematemesis, and melena. There was no evidence of esophageal stricture, spasm of the esophagus, or an acquired diverticulum of the esophagus. The Board finds the pertinent evidence of record set out above documents that the symptomatology associated with the service-connected GERD is productive of intermittent epigastric distress. Significantly, the reports of VA examinations and the Veteran's own self-reported symptomatology do not indicate that the Veteran experiences substernal or arm or shoulder pain or considerable impairment of health due to the service-connected GERD. The Veteran's symptomatology was described as "mild" in nature. The Board finds it reasonable to believe that, if the service-connected disability were productive of significant impairment in health, the Veteran would have informed a health care professional of this fact and this would have been recorded somewhere in the clinical records. The lack of any such annotation anywhere in the medical records supports the Board's finding that the service-connected disability is not productive of considerable or severe impairment in the Veteran's health. Furthermore, this finding is also supported by the examiner's characterization in February 2008 that the service-connected disability had only a mild effect on exercise and sports. Based on the above, the Board finds the symptomatology associated with the service-connected GERD more nearly approximates a 10 percent rating under Diagnostic Code 7346. Residuals of a Tendon Tear of the Left Fourth Digit The Veteran seeks a higher initial rating for his residuals of a tendon tear of the left fourth digit, which has been assigned a noncompensable rating under Diagnostic Code 5230. The diagnostic codes pertaining to impairment of the elbow, forearm, wrist, hand, and fingers apply different disability ratings based upon whether the major or minor arm is affected. 38 C.F.R. § 4.71a; Diagnostic Code 5230. In this case, the evidence shows that the Veteran is left-hand dominant and thus the ratings for the major hand apply to his left fourth digit. 38 C.F.R. § 4.69. Limitation of motion of the fourth fingers is rated under Diagnostic Code 5230, which only provides for a noncompensable rating for the major and minor hands. 38 C.F.R. § 4.71a, Diagnostic Code 5230 (2012). The Veteran was afforded a VA hand, thumb, and fingers examination in February 2008, at which time he was diagnosed as having minimal residuals of a tendon tear of the left fourth digit. The examiner noted that the Veteran experienced a tendon rupture of the left fourth finger in a conveyer belt accident in 2003. The Veteran subjectively reported an overall decrease in left hand strength and dexterity. He additionally described pain in his left fourth finger. Objectively, there was no evidence of amputation, ankylosis, or deformity. There was no gap between the finger and the proximal transverse crease of the hand upon maximal flexion of the finger, nor was there decreased strength for pushing, pulling, and twisting, nor decreased dexterity for twisting, probing, writing, touching, and expression. The affected finger was visibly normal and without deformity or inflammation. There was normal range of motion and muscle strength in all fingers of both hands. Metacarpophalangeal (MP) joints, proximal interphalangeal (PIP) joints, and distal interphalangeal (DIP) joints for all fingers exhibited normal flexion and extension. His handgrip was also normal. Based on the evidence of record, the Board finds that the Veteran is not entitled to a compensable evaluation for his service-connected left fourth digit disability. Diagnostic Code 5230 does not provide for a compensable evaluation for limitation of motion. The Board has considered the Veteran's complaints of pain; however, increased limitation of motion due to pain is not shown. There was no increased limitation of motion due to weakness, fatigability or coordination, or repetitive use in the examinations. See 38 C.F.R. §§ 4.10, 4.40 and 4.45; DeLuca v. Brown, 8 Vet. App. 202 (1995). In light of the foregoing, the Board finds that the preponderance of the evidence is against a finding that the Veteran is entitled to a compensable evaluation for his left fourth digit disability at any point during the period on appeal, and therefore the claim must be denied. While the Veteran is competent to report the symptoms he experiences, and the Board finds him credible in this regard, except where in contrast to objective clinical findings, the reported symptoms are consistent with the assigned schedular evaluation. Ulnar Neuritis of the Right Hand The Veteran was initially granted entitlement to service connection for ulnar neuritis of the right hand and assigned a noncompensable rating effective July 31, 2007, under Diagnostic Code 8516. An April 2013 rating decision granted a 10 percent rating for ulnar neuritis of the right hand effective April 4, 2012, also under Diagnostic Code 8516. As such, the Board will first assess the propriety of the noncompensable rating assigned prior to April 4, 2012, and then assess the propriety of the 10 percent rating assigned since April 4, 2012. Under Diagnostic Code 8516, complete paralysis of the ulnar nerve is defined as where there is a "griffin claw" deformity due to flexor contraction of the ring and little fingers, atrophy is very marked in dorsal interspace and thenar and hypothenar eminences; there is loss of extension of the ring and little fingers, cannot spread the fingers (or reverse), cannot adduct the thumb; and flexion of the wrist is weakened. Complete paralysis warrants a 50 percent rating if affecting the minor extremity, and a 60 percent rating if the major extremity is involved. Where there is severe incomplete paralysis, this warrants a 30 percent rating for a minor extremity, and 40 percent for a major extremity. Moderate incomplete paralysis corresponds to a 20 percent rating for a minor extremity, and 30 percent for a major extremity. Mild incomplete paralysis warrants a 10 percent rating for both a minor and major extremity. Generally, neurological disorders are ordinarily to be rated in proportion to the impairment of motor, sensory or mental function. In rating peripheral nerve injuries and their residuals, attention should be given to the site and character of the injury, the relative impairment in motor function, trophic changes, or sensory disturbances. 38 C.F.R. § 4.120, Diagnostic Code 8515 (2012). A note to 38 C.F.R. § 4.124a states that the term "incomplete paralysis" where involving peripheral nerve injuries, indicates a degree of lost or impaired function substantially less than the type picture for complete paralysis given with each nerve, whether due to varied level of the nerve lesion or to partial regeneration. Also, when peripheral nerve involvement is wholly sensory, the rating should be for the mild or, at most, the moderate degree. The ratings for the peripheral nerves are for unilateral involvement; when bilateral, combine with application of the bilateral factor. Id. The words "mild," "moderate," and "severe" are not defined in the above rating criteria. Rather than applying a mechanical formula, the Board must evaluate all of the evidence to the end that its decisions are "equitable and just." 38 C.F.R. § 4.6 (2012). Neuritis, cranial or peripheral, characterized by loss of reflexes, muscle atrophy, sensory disturbances, and constant pain, at times excruciating, is to be rated on the scale provided for injury of the nerve involved, with a maximum equal to severe, incomplete, paralysis. 38 C.F.R. § 4.123 (2012). Similarly, neuralgia, cranial or peripheral, characterized usually by a dull and intermittent pain, of typical distribution so as to identify the nerve, is to be rated on the same scale, with a maximum equal to moderate incomplete paralysis. 38 C.F.R. § 4.124 (2012). As mentioned above, the record reflects that the Veteran is left-hand dominant. The Veteran was afforded a VA peripheral nerves examination in February 2008, at which time he was diagnosed as having mild, posttraumatic right ulnar neuritis. Subjectively, the Veteran described intermittent weakness, numbness, paresthesias, and pain from the elbow down into the fingers several times per week, which lasted minutes at a time. Upon physical examination, there was no motor function impairment. Sensory testing revealed normal vibration, light touch, and position sense. Reflexes of the right bicep, triceps, and brachioradialis were normal. There was no muscle atrophy or abnormal muscle tone or bulk. Furthermore, joint function was not affected by the nerve disorder. X-rays revealed a small bone fragment near the right elbow. The Veteran was afforded his most recent VA peripheral nerves examination in March 2012, at which time he was diagnosed as having right ulnar neuropathy. Subjectively, the Veteran reported right hand numbness, weakness, and poor grip strength. Furthermore, he described constant, moderate pain, with intermittent severe pain, in his right upper extremity. Objectively, muscle strength testing revealed normal right elbow extension, but only active movement against some resistance with respect to right elbow flexion, wrist flexion, wrist extension, grip, and pinch. There was no evidence of muscle atrophy and reflexes of the right bicep, triceps, and brachioradialis were normal. Sensory examination revealed normal sensation to light touch in the right shoulder area and forearm, but decreased sensation in the hand and fingers. The examiner found there to be moderate, incomplete paralysis of the right ulnar nerve. As the Veteran's right upper extremity is his non-dominant extremity, the Board finds that he is entitled to a 10 percent rating prior to April 4, 2012, for mild incomplete paralysis of the minor extremity, and a 20 percent rating since April 4, 2012, for moderate incomplete paralysis of the minor extremity. However, the Board does not find evidence indicative of more than mild incomplete paralysis of the right upper extremity prior to April 4, 2012. Significantly, the Veteran's right ulnar neuritis was described as "mild" during this period. Moreover, there was no motor function impairment; sensory testing revealed normal vibration, light touch, and position sense; and reflexes of the right bicep, triceps, and brachioradialis were normal. Similarly, the Board does not find evidence indicative of more than moderate incomplete paralysis of the right upper extremity prior to April 4, 2012. During this period, the Veteran's incomplete paralysis of the right ulnar nerve was explicitly described as "moderate" in nature. Muscle strength testing revealed only active movement against some resistance with respect to right elbow flexion, wrist flexion, wrist extension, grip, and pinch, while sensory examination revealed decreased sensation only in the hand and fingers. The Veteran is competent to report his symptoms involving right ulnar neuritis, such as pain and numbness. His complaints are credible to the extent that they reflect pain. The Veteran's complaints have been considered in the above decision. As discussed above, the evidence does not show the severity required for a rating in excess of 10 percent prior to April 4, 2012, or in excess of 20 percent since April 4, 2012, based on the relevant symptomatology under the applicable rating codes. Left Ear Hearing Loss The Veteran contends, in effect, that his left ear hearing loss is impairing and hence should be afforded a higher rating than the initial noncompensable rating currently assigned effective from the date of service connection. 38 C.F.R. § 3.400 (2012). Bilateral hearing loss is evaluated under the provisions of 38 C.F.R. § 4.85, Diagnostic Code 6100. Under that code, evaluations of bilateral defective hearing range from noncompensable to 100 percent based on organic impairment of hearing acuity as measured by the results of speech discrimination tests together with the average hearing threshold level as measured by pure tone audiometric tests in the frequencies of 1000, 2000, 3000, and 4000 hertz (Hz). To evaluate the degree of disability for bilateral defective hearing, the Rating Schedule establishes 11 auditory acuity levels, designated from Level I for essential normal acuity through Level XI for profound deafness. See 38 C.F.R. § 4.85, Tables VI and VIA. Evaluation of hearing impairment is dependent upon mechanical application of specific tables delineated in the rating criteria under 38 C.F.R. §§ 4.85, 4.86. Under 38 C.F.R. § 4.85 , Table VI (Numeric Designation of Hearing Impairment Based on Pure tone Threshold Average and Speech Discrimination) is used to determine a Roman numeral designation (I through XI) for hearing impairment based on a combination of the percent of speech discrimination (horizontal rows) and the pure tone threshold average (vertical columns). The Roman numeral designation is located at the point where the percentage of speech discrimination and pure tone average intersect. 38 C.F.R. § 4.85(b). The pure tone threshold average is the sum of the pure tone thresholds at 1000, 2000, 3000 and 4000 Hz, divided by 4. This average is used in all cases to determine the Roman numeral designation for hearing impairment. 38 C.F.R. § 4.85(d). Alternatively, VA regulations provide that in cases of exceptional hearing loss, when the pure tone thresholds at each of the four specified frequencies (1000, 2000, 3000 and 4000 Hz) is 55 decibels or more, the rating specialist will determine the Roman numeral designation for hearing impairment from either Table VI or Table VIA, whichever results in the higher numeral. Each ear will be evaluated separately. 38 C.F.R. § 4.86(a). The findings for each ear from either Table VI or Table VIA, are then applied to Table VII (Percentage Evaluations for Hearing Impairment) to determine the percentage evaluation by combining the Roman numeral designations for hearing impairment of each ear. The horizontal rows represent the ear having the better hearing and the vertical columns the ear having the poorer hearing. The percentage evaluation is located at the point where the row and column intersect. 38 C.F.R. § 4.85(e). The Veteran was afforded a VA audiological examination in February 2008, at which time he was diagnosed as having abnormal left ear hearing. The Veteran indicated that his situations of greatest hearing difficulty were hearing the telephone and television. Hearing pure tone thresholds, in decibels, were as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 5 10 10 25 30 LEFT 10 10 15 20 30 Using the Maryland CNC word list, speech audiometry revealed speech recognition ability of 84 percent in the right ear and of 88 percent in the left ear. Although the examiner indicated that the Veteran's left ear thresholds would typically be considered normal, hearing was nonetheless judged to be abnormal due to his word recognition ability falling below 94 percent. The Veteran was most recently afforded a VA audiology examination in March 2012, at which time the examiner concluded that the Veteran had hearing loss that was not disabling, bilaterally. The examiner noted that the hearing loss had no significant effects on the Veteran's occupation or daily activities. Hearing pure tone thresholds, in decibels, were as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 15 10 10 30 30 LEFT 15 15 15 25 35 Using the Maryland CNC word list, speech audiometry revealed speech recognition ability of 94 percent in the right ear and of 94 percent in the left ear. Tympanograms suggested normal middle ear function. Although the examiner indicated normal left ear hearing from 250 Hz to 3000 Hz decreasing to a mild high frequency notched sensorineural hearing loss from 4000 Hz to 6000 Hz, she concluded that the Veteran did not have disabling hearing loss pursuant to VA regulation. The Board finds that the VA examiners adequately considered the impact of the Veteran's bilateral hearing on his functioning, as reflected in the noted effects on occupational functioning and daily activities, in compliance with Martinak v. Nicholson, 21 Vet. App. 447, 455-56 (2007). The Board further concludes that these indicated impacts do not in this case render inapplicable the regular schedular standards for rating hearing loss. As discussed below, criteria for an extraschedular evaluation are not met. See 38 C.F.R. § 3.321(b) (2012). Applying the rating criteria under 38 C.F.R. § 4.85, using Table VI, the Veteran had level II hearing loss in the left ear in February 2008 and level I hearing loss in the left ear in March 2012. Then using Table VII, these levels of hearing loss correspond to a zero percent, or noncompensable hearing loss disability rating. Because the Veteran does not have 65 decibel or worse hearing at each of the frequencies 1000, 2000, 3000, and 4000 hertz in either ear, use of Table VIA is not warranted for either ear on that basis. 38 C.F.R. § 4.86(a). Because the Veteran does not have for either ear both a 30 decibels or less hearing loss at 1000 hertz and a 70 decibels or greater hearing loss at 2000 hertz, application of Table VIA is also not warranted on that basis for either ear. 38 C.F.R. § 4.86(b). While the Board has duly considered the competent statements of the Veteran that he has difficulties with hearing telephones and television due to his hearing loss, and while the Board finds these statements entirely credible, the Board nonetheless finds that they ultimately hold little weight in the present adjudication, because of the dictates of the rating criteria for hearing loss which prescribe ratings based on testing findings, not subjective assertions of impairment or of difficulties in communication. The Board also finds that the VA examiners adequately noted and considered the Veteran's subjective assertions of impairment associated with his hearing loss, meeting the requirements of Martinak v. Nicholson. Hypertension The Veteran also seeks a higher initial rating for his service-connected hypertension, which is currently assigned a 10 percent rating under Diagnostic Code 7101. Under Diagnostic Code 7101, a 60 percent rating is warranted for diastolic pressure predominantly 130 or more; a 40 percent disability rating is warranted for diastolic pressure predominantly 120 or more; a 20 percent disability rating is warranted for diastolic pressure predominantly 110 or more or systolic pressure predominantly 200 or more; and a 10 percent disability rating is warranted for diastolic pressure predominantly 100 or more or systolic pressure predominantly 160 or more; or minimum evaluation for an individual with a history of diastolic pressure predominantly 100 or more who requires continuous medication for control. See 38 C.F.R. § 4.104, Diagnostic Code 7101 (2012). As explained above, in order to obtain the higher 10 percent disability rating, medical evidence must demonstrate diastolic pressure predominantly 100 or more or systolic pressure predominantly 160 or more. See 38 C.F.R. § 4.104, Diagnostic Code 7101 (2009). These criteria are disjunctive. See Johnson v. Brown, 7 Vet. App. 95 (1994) (only one disjunctive "or" requirement must be met in order for an increased rating to be assigned); Cf. Melson v. Derwinski, 1 Vet. App. 334 (1991) (use of the conjunctive "and" in a statutory provision meant that all of the conditions listed in the provision must be met). The medical evidence of record demonstrates several blood pressure readings in recent years, which predominantly fall short of the measurements required for a 10 percent rating. Specifically, at the Veteran's February 2008 VA hypertension examination, his blood pressure was 126/78 mmHg. At the time of his most recent March 2012 VA hypertension examination, his blood pressure readings were 119/70, 115/ 64, and 105/68 mmHg. The examiner noted that the Veteran's hypertension or isolated systolic hypertension did not impact his ability to work. The Board recognizes that to control his hypertension, the Veteran must use various daily medications on a continuous basis, to include Lisinopril. However, control of hypertension through the use of continuous medication is a factor already contemplated in the assignment of the Veteran's noncompensable rating. In short, the medical evidence of record does not demonstrate that the schedular criteria for an award of a 10 percent or higher disability rating have been met. Actinic Keratosis The Veteran was initially granted entitlement to service connection for actinic keratosis and assigned a noncompensable rating effective July 31, 2007, under Diagnostic Code 7820. An April 2013 rating decision granted a 20 percent rating for actinic keratosis effective April 4, 2012, also under Diagnostic Code 7820. As such, the Board will first assess the propriety of the noncompensable rating assigned prior to April 4, 2012, and then assess the propriety of the 20 percent rating assigned since April 4, 2012. The Veteran's skin disability is rated under Diagnostic Code 7820. Under Diagnostic Code 7820, infections of the skin not listed elsewhere, including bacterial, fungal, viral, treponemal and parasitic diseases, are to be rated under Diagnostic Code 7800 for disfigurement of the head, face, or neck; Diagnostic Codes 7801 through 7805 for scars; or Diagnostic Code 7806 for dermatitis depending upon the predominant disability. See 38 C.F.R. § 4.118, Diagnostic Code 7820 (2012). Under Diagnostic Code 7806, a 10 percent evaluation is assigned when dermatitis or eczema is at least 5 percent, but less than 20 percent, of the entire body, or at least 5 percent, but less than 20 percent, of exposed areas affected, or intermittent systemic therapy such as corticosteroids or other immunosuppressive drugs required for a total duration of less than six weeks during the past 12- month period. 38 C.F.R. § 4.118, Diagnostic Code 7806. A 30 percent evaluation is assigned for when 20 to 40 percent of the entire body or 20 to 40 percent of exposed areas affected, or systemic therapy such as corticosteroids or other immunosuppressive drugs required for a total duration of six weeks or more, but not constantly, during the past 12-month period. Id. Effective October 23, 2008, the portion of the Rating Schedule pertaining to the rating of skin disorders was revised. Compare 38 C.F.R. § 4118 (2007) with 38 C.F.R. § 4118 (2012). The amendments only apply, however, to applications for benefits received on or after October 23, 2008. 73 Fed. Reg. 54, 708 (Sept. 23, 2008). While the Veteran can request a review under these new criteria, the Veteran has not requested such a review. Nevertheless, the schedular criteria for rating the Veteran's skin disorder was not affected by the revision of rating skin disorders in 2008. Compare 38 C.F.R. § 4118, Diagnostic Code 7806 (2007), with 38 C.F.R. § 4118, Diagnostic Code 7806 (2012). The Veteran was afforded a VA skin diseases examination in February 2008, at which time he was diagnosed as having small actinic keratosis of the scalp. Subjectively, he described mild, intermittent itching on his scalp. Upon objective examination, the vertex of his scalp exhibited a tiny lesion measuring 2 to 3 millimeters with tiny hyperkeratotic scale consistent with small actinic keratosis. Based on the above, the evidence of record does not show that the Veteran's actinic keratosis involved at least 5 percent of the entire body or at least 5 percent of exposed areas affected prior to April 4, 2012. The VA examiner noted that the Veteran's "small" actinic keratosis of the scalp measured only 2 to 3 millimeters. In addition, there is no indication that the Veteran's actinic keratosis required any systemic therapy such as corticosteroids or other immunosuppressive drugs. Thus, an initial compensable evaluation is not warranted prior to April 4, 2012. The Veteran was afforded his most recent VA skin diseases examination in March 2012, at which time he was again diagnosed as having actinic keratosis. The Veteran indicated that he was treated by a dermatologist and had lesions removed from his scalp with liquid nitrogen. However, the examiner noted that the Veteran did not have any scarring or disfigurement caused by the skin condition, did not have any benign or malignant skin neoplasms, and did not have any systemic manifestations due to skin diseases. The Veteran was treated with topical medications for less than 6 weeks during the previous 12 months. Upon objective examination, the Veteran's actinic keratosis was noted to cover 20 to 40 percent of his total body area, but less than 5 percent of the exposed area. The examiner further noted that the Veteran had a malignant neoplasm related to the actinic keratosis, and that he had liposarcoma excised from his right thigh in May 2009 as well as radiating therapy. Finally, the examiner noted that the Veteran had brown keratotic papules on his trunk and upper thighs. However, the examiner opined that none of the Veteran's skin conditions impacted his ability to work. After carefully reviewing the evidence of record, the Board notes that, although the RO purported to increase the Veteran's rating for actinic keratosis under the provisions of Diagnostic Code 7820 (and Diagnostic Code 7806 for dermatitis, by analogy), the RO seems to have erroneously assigned a 20 percent rating due to the fact that Diagnostic Code 7806 specifically calls for a 30 percent rating to be assigned in situations such as the Veteran's. Indeed, the Board emphasizes that while one section of the RO's April 2013 rating decision indicated that it was assigning a 20 percent rating for actinic keratosis, another section purported that the RO was assigning a 30 percent rating for actinic keratosis. However, only the 20 percent rating was assigned. The Board notes that the evidence shows that the Veteran's actinic keratosis covers 20 to 40 percent of his total body area, although less than 5 percent of the exposed area. As such, the Veteran is entitled to a 30 percent evaluation pursuant to Diagnostic Code 7820 (using Diagnostic Code 7806 for dermatitis, by analogy). However, a rating in excess of 30 percent is not warranted. The VA examination did not demonstrate that the Veteran's actinic keratosis affected more than 40 percent of exposed areas or of the total body area. Furthermore, while the Veteran reported treating his skin condition with topical therapy, there is no indication that his skin condition required systemic therapy such as corticosteroids or other immunosuppressive drugs for a total duration of six weeks or more during any 12 month period. Accordingly, an increased evaluation greater than 30 percent for actinic keratosis is not warranted. 38 C.F.R. § 4.118, Diagnostic Code 7806. Furthermore, there is no evidence of permanent scarring or facial disfigurement and the Board finds no basis for evaluating the condition as disfigurement of the head, face, or neck, or as scars, during the entire period on appeal. 38 C.F.R. §§ 4.118, Diagnostic Codes 7800 through 7805. Carpal Tunnel Syndrome of the Left Hand The Veteran also seeks entitlement to a higher initial rating for his carpal tunnel syndrome of the left hand, which has been evaluated as 10 percent disabling under Diagnostic Code 8515, paralysis of the median nerve. Under Diagnostic Code 8515, pertaining to paralysis of the median nerve, a 70 percent evaluation may be assigned for complete paralysis of the median nerve of the major extremity, with the hand inclined to the ulnar side, the index and middle fingers more extended than normally, considerable atrophy of the muscles of the thenar eminence, the thumb in the plane of the hand (ape hand); pronation incomplete and defective, absence of flexion of index finger and feeble flexion of middle finger, cannot make a fist, index and middle fingers remain extended; cannot flex distal phalanx of thumb, defective opposition and abduction of the thumb, at right angles to palm; flexion of wrist weakened; pain with trophic disturbances. A 50 percent evaluation is assigned for incomplete paralysis of the median nerve of the major extremity that is severe. When moderate, a 30 percent evaluation may be assigned, and when mild, a 10 percent evaluation may be assigned. 38 C.F.R. § 4.124a, Diagnostic Code 8515. The term "incomplete paralysis" indicates a degree of lost or impaired function substantially less than the type pictured for complete paralysis given with each nerve, whether due to varied level of the nerve lesion or due to partial regeneration. Moreover, when the involvement is wholly sensory, the rating should be for the mild, or at most, the moderate degree. 38 C.F.R. § 4.124a and Part 4, Code 8515. The Board finds that an increased rating is not warranted for the service-connected left carpal-tunnel syndrome as the symptomatology associated with the disability more nearly approximates mild paralysis of the median nerve. The Veteran was afforded VA peripheral nerves examination in February 2008, at which time he was diagnosed as having carpal tunnel syndrome status post surgery with minimal residuals. The examiner noted that he underwent bilateral carpal tunnel surgery in 1997 due to symptoms of numbness, tingling, and weakness in both hands, with partial relief of symptoms thereafter. Motor examination revealed no evidence of motor function impairment in the left upper extremity. Sensory function testing revealed vibration, light touch, and position sense to be normal. Left bicep, triceps, and brachioradialis testing revealed that reflexes were normal. There was no evidence of muscle atrophy, abnormal muscle tone or bulk, or abnormal movements. The Veteran was most recently afforded a VA peripheral nerves examination in March 2012, at which time he was diagnosed as having left median nerve neuropathy. Subjectively, the Veteran described constant moderate pain in the left upper extremity, with intermittent mild pain. He additionally described moderate paresthesias and numbness in the left upper extremity. Muscle strength testing revealed normal strength in left elbow flexion and extension, but active movement against some resistance in left wrist flexion, wrist extension, gripping, and pinching. Reflexes were normal in the left bicep, triceps, and brachioradialis. Sensation testing for light touch was normal in the left shoulder and forearm, but decreased in the left hand and fingers. Testing for Phalen's sign and Tinel's sign was negative. However, the examiner found that there was mild, incomplete paralysis of the left median nerve. The Board finds the symptomatology associated with the service-connected left carpal-tunnel syndrome more nearly approximates, at most, the ten percent evaluation under Diagnostic Code 8515 currently assigned. The disability is manifested by decreased muscle strength in his left wrist and hand, as well as decreased sensation testing for light touch in the left hand and fingers. Significantly, the March 2012 VA examiner characterized the severity of the Veteran's left carpal tunnel syndrome as "mild." In short, the medical evidence of record does not demonstrate that the schedular criteria for an award of a 10 percent or higher disability rating have been met. Extraschedular Consideration In arriving at the foregoing decisions, the Board has also considered the possibility of referring this case to the Director of the VA Compensation and Pension Service for possible approval of an extraschedular rating for the Veteran's service-connected right shoulder disorder and separately evaluated right shoulder scars. Ordinarily, the VA Rating Schedule will apply unless there are exceptional or unusual factors which would render application of the schedule impractical. See Fisher v. Principi, 4 Vet. App. 57, 60 (1993). An extraschedular disability rating is warranted upon a finding that the case presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization that would render impractical the application of the regular schedular standards. 38 C.F.R. § 3.321(b)(1) (2009), Fanning v. Brown, 4 Vet. App. 225, 229 (1993). There is a three-step inquiry for determining whether a claimant is entitled to an extraschedular rating. Thun v. Peake, 22 Vet. App. 111, 115 (2008). First, the Board must determine whether the evidence presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. Second, if the schedular evaluation is found to be inadequate, the Board must determine whether the Veteran's disability picture exhibits other related factors, such as those provided by the regulation as "governing norms." Third, if the rating schedule is inadequate to evaluate a claimant's disability picture with such related factors as marked interference with employment or frequent periods of hospitalization, then the case must be referred to the VA Under Secretary for Benefits or the Director of the Compensation and Pension Service to determine whether, to accord justice, the claimant's disability picture requires the assignment of an extraschedular rating. In this case, neither the Veteran nor his representative have expressly raised the matter of entitlement to an extraschedular rating. The Veteran's contentions have been limited to those discussed above, i.e., that his disabilities are more severe than reflected by the currently assigned ratings. See Brannon v. West, 12 Vet. App. 32 (1998) (while the Board must interpret a claimant's submissions broadly, the Board is not required to conjure up issues that were not raised by the claimant). Moreover, the Veteran and his representative have not identified, and the Board has not found, any factors which may be considered to be exceptional or unusual with respect to the service-connected disabilities. In this regard, the record does not show that the Veteran has required frequent hospitalizations any service-connected disability. There is no unusual clinical picture presented, nor is there any other factor which takes the disability outside the usual rating criteria. In short, the evidence does not support the proposition that the Veteran's service-connected disabilities present such an exceptional or unusual disability picture as to render impractical the application of the regular schedular standards. Accordingly, further action is not warranted under 38 C.F.R. § 3.321 (b)(1). ORDER An initial evaluation in excess of 10 percent for neuropathy and sciatica of the left lower extremity is denied. An initial evaluation in excess of 10 percent for neuropathy and sciatica of the right lower extremity is denied. An initial evaluation in excess of 10 percent for GERD is denied. An initial compensable evaluation for residuals of a tendon tear of the left fourth digit is denied. A 10-percent evaluation, but no more, for ulnar neuritis of the right hand prior to April 4, 2012, is granted. A 20-percent evaluation, but no more, for ulnar neuritis of the right hand since April 4, 2012, is granted. An initial compensable evaluation for hearing loss in the left ear is denied. An initial compensable evaluation for hypertension is denied. An initial compensable evaluation for actinic keratosis prior to April 4, 2012. A 30-percent evaluation, but no more, for actinic keratosis since April 4, 2012, is granted. An initial evaluation in excess of 10 percent for carpal tunnel syndrome of the left hand is denied. REMAND The Veteran also seeks entitlement to service connection for tooth number 19, diabetes mellitus, and reactive airway disease, as well as increased initial ratings for degenerative disc disease of the lumbar spine, residuals of a right wrist sprain, degenerative disc disease of the cervical spine, chondromalacia of the right knee, and chondromalacia of the left knee. With respect to the service connection issues, the Board recognizes that the first claims file contains many of the Veteran's treatment and personnel records spanning his various periods of active duty from April 1979 to June 2005. The Board also notes that its March 2012 remand instructions directed the RO to contact the National Personnel Records Center and attempt to obtain all service treatment records and the service dental records, to include a specific request to obtain the report of the Veteran's hospitalization at Fort Eustis in 1991. However, in correspondence dated in November 2012, the Veteran submitted photographs of the voluminous service records in his possession, suggesting that there are many records still not in VA's possession. The Veteran explained that he had attempted to deliver his complete collection of original treatment records on every occasion he had met with a VA representative since 2007, and that on each occasion VA had refused delivery of these records. Where VA has constructive and actual knowledge of the existence of potentially pertinent reports in the possession of a Federal agency, an attempt to obtain those reports must be made. See Hyatt v. Nicholson, 21 Vet. App. 390, 394 (2007) (holding that the relevance of documents cannot be known with certainty before they are obtained). The United States Court of Veterans Appeals ("Court") has held that the VA has a statutory duty to assist the Veteran in obtaining military records. See 38 U.S.C.A. § 5103A(b); 38 C.F.R. § 3.159(c)(2); see also Jolley v. Derwinski, 1 Vet.App. 37, 39-40 (1990). Moreover, in Cuevas v. Principi, 3 Vet.App. 542, 548 (1992), the Court held that the duty to assist is heightened when the service medical records are unavailable and includes an obligation to search alternative forms of medical records which support the Veteran's case. As such, the RO must obtain copies of any service treatment records and/or service personnel records in the Veteran's possession before a decision can be rendered with respect to the Veteran's service connection claims. With respect to the remaining increased rating claims, the Board's March 2012 remand instructions directed the RO to schedule appropriate VA examinations, including orthopedic examinations, to determine the nature and severity of the Veteran's service-connected disabilities. Although the Veteran was afforded several other examinations at the James A. Haley Veterans' Hospital in Tampa, Florida, in March 2012, a document dated in February 2012 indicated that the Veteran refused examinations scheduled for February 20, 2012, with respect to his back, knees, neck, and wrist at the James A. Haley Veterans' Hospital. As such, these examination were cancelled. However, in correspondence dated in May 2013, the Veteran's representative indicated that the Veteran had called the phone number provided on the appointment notice and indicated that he would be unable to attend the examinations scheduled for February 20, 2012, due to "urgent family matters" and would need the examinations to be rescheduled. Generally, if a Veteran cancels a scheduled VA examination, the claim would be adjudicated based on the existing evidence of record. See Turk v. Peake, 21 Vet. App. 565 (2008) (in an initial-rating claim, when the Veteran fails to report for an examination, the claim shall be rated on the evidence of record rather than summarily denied because an initial-rating claim is an original compensation claim under 38 C.F.R. § 3.655(b)). There is an exception to this general rule, however, if the Veteran shows good cause for his absence. Examples of good cause include, but are not limited to, the illness or hospitalization of the claimant or death of an immediate family member. 38 C.F.R. § 3.655(a). The Veteran's explanation for his failure to appear for the examinations initially scheduled on remand was he was unable to attend due to urgent family matters. He called prior to the scheduled date of the examination to inform VA of his inability to attend. The Board is therefore giving him another opportunity to report for these necessary VA examinations. Accordingly, the case is REMANDED for the following action: 1. The RO should request through appropriate channels treatment and personnel records, or copies thereof, for the Veteran's periods of active duty from April 1979 to July 1979, from November 1990 to November 1991, from January 2003 to March 2004, and from September 2004 to March 2005, to include the report of the Veteran's hospitalization at Fort Eustis in 1991. These records are purportedly in the Veteran's possession. The medical and personnel records obtained, if any, should be associated with the claims file. All efforts made to obtain these records must be documented, in writing, for inclusion in the claims folder. If the records are not available or cannot be located, an official memorandum of unavailability must be prepared and included in the claims file and disseminated to the Veteran. 2. Reschedule the Veteran for appropriate VA examinations, to determine the current nature and severity of his disabilities of the back, neck, knees, and wrist. The orthopedic examiner should comment on any functional impairment due to pain and the pathology associated with pain should be described. With respect to the subjective complaints of pain, the orthopedic examiner should be requested to specifically comment on whether pain is visibly manifested on movement of the joints, the presence and degree of, or absence of, muscle atrophy attributable to the service-connected disability and the presence or absence of any other objective manifestation that would demonstrate disuse or functional impairment due to pain attributable to the service-connected disability. Complete rationales for any opinions rendered must be provided. The claims file must be reviewed in conjunction with all examinations conducted, and the examination report must reflect that such a review was performed. 3. The Veteran is hereby again advised that his failure to report for these rescheduled examinations, without good cause, may have adverse consequences on his pending claims. 4. Following completion of the above, the RO should review the evidence and determine whether the Veteran's claims may be granted. If not, he and his representative should be furnished an appropriate supplemental statement of the case and be provided an opportunity to respond. The case should then be returned to the Board for further appellate consideration. 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). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2012). ______________________________________________ L. M. BARNARD Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs