Citation Nr: 1324383 Decision Date: 07/31/13 Archive Date: 08/07/13 DOCKET NO. 05-26 408 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Atlanta, Georgia THE ISSUES 1. Entitlement to service connection for a disability characterized by blackouts and dizziness, to include as secondary to service-connected disability. 2. Entitlement to service connection for residuals of a fracture of the right arm, to include as secondary to service-connected disability. 3. Entitlement to service connection for residuals of a fracture of the right ankle, to include as secondary to service-connected disability. 4. Entitlement to a rating higher than 10 percent before January 25, 2011, and a rating higher than 30 percent from January 25, 2011, for a cervical spine disability. 5. Entitlement to a total disability compensation rating based on individual unemployability due to service-connected disability. REPRESENTATION Veteran represented by: Georgia Department of Veterans Services WITNESSES AT HEARING ON APPEAL The Veteran and his spouse ATTORNEY FOR THE BOARD Debbie A. Breitbeil, Counsel INTRODUCTION The Veteran, who is the appellant, served on active duty from November 1990 to April 1991 and from March 2001 to September 2001. This matter is before the Board of Veterans' Appeals (Board) on appeal of a rating decision in November 2006 of the Department of Veterans Affairs (VA) Regional Office (RO) in Atlanta, Georgia, which denied service connection for blackouts and residuals of fractures of the right arm and right ankle; which granted a separate 10 percent rating for cervical spondylosis (residuals of an injury), effective October 28, 2005; and which granted service connection for radiculopathy of the right arm and radiculopathy of the left arm, both associated with cervical spondylosis and assigned a 10 percent rating each, effective October 28, 2005. In November 2007, the Veteran appeared at the RO and testified before a Veterans Law Judge. A transcript of the hearing is of record. In May 2008 and September 2010, the Board remanded the case to the RO for additional development. Then, in a May 2012 rating decision, the RO granted a 30 percent rating for cervical spondylosis, effective January 25, 2011, and the Veteran continued his appeal for a higher rating. AB v. Brown, 6 Vet. App. 35, 38 (1993). In July 2012, the Board remanded the case to the RO in order to afford the Veteran another hearing before a Veterans Law Judge. The previous Veterans Law Judge, before whom the Veteran had testified in November 2007, was no longer employed at the Board, and by law the Veterans Law Judge who conducts a hearing on an appeal must participate in any decision made on that appeal. The Veteran desired another hearing, and in September 2012 he appeared at a hearing before the undersigned Veterans Law Judge. A transcript of that hearing is of record. In February 2013, the Board remanded the case to the RO for additional development. The claims file has now been returned to the Board for further consideration. Regarding the issue of service connection for a disability characterized by blackouts, the Board notes that the Veteran has asserted a history of problems with both blackouts and dizziness (at a 2007 hearing he testified that he became dizzy if he worked with his hands above his head, which over time turned into blackouts). Allegations of blackouts and dizziness are reflected throughout the record in the Veteran's statements and in medical reports. Diagnoses of syncopal episode and vertigo have been made. Most recently, a VA examiner in March 2013addressed complaints of both blackouts and dizziness, in order to provide clarification on the unexplained disability from which the Veteran suffers. Given the intertwined nature of the Veteran's complaints, the issue on appeal has been recast as one for a disability characterized by blackouts and dizziness. The issues of service connection for a disability characterized by blackouts and dizziness, residuals of fractures of the right arm and right ankle, and the issue of a total disability compensation rating based on individual unemployability are addressed in the REMAND portion of the decision below and are REMANDED to the RO via the Appeals Management Center in Washington, DC. FINDINGS OF FACT 1. Before January 25, 2011, the cervical spine was manifested by pain, limitation of motion (forward flexion to 45 degrees, extension to 40 degrees, lateral flexion (left and right) to 45 degrees each, and rotation (left and right) to 60 degrees each), and imaging study findings that were essentially negative; there was no objective evidence of muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour; and there was no objective evidence of incapacitating episodes. 2. From January 25, 2011, the cervical spine is manifested by pain and limitation of motion of range of motion (forward flexion to 15 degrees, extension to 20 degrees, lateral flexion (left and right) to 20 degrees each, and rotation (left and right) to 30 degrees each); there is no objective evidence of ankylosis; and there is no objective evidence of incapacitating episodes. CONCLUSION OF LAW The criteria for a rating higher than 10 percent before January 25, 2011, and a 30 percent rating from January 25, 2011, for a cervical spine disability, have not been met. 38 U.S.C.A. §§ 1155 , 5107(b) (West 2002); 38 C.F.R. §§ 4.7, 4.71a, Diagnostic Codes 5242, 5243 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSION I. The Veterans Claims Assistance Act of 2000 (VCAA) The VCAA, codified in part at 38 U.S.C.A. §§ 5103, 5103A, and implemented in part at 38 C.F.R § 3.159, amended VA's duties to notify and to assist a claimant in developing information and evidence necessary to substantiate a claim. Duty to Notify Under 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b), when VA receives a complete or substantially complete application for benefits, it will notify the claimant of the following: (1) any information and medical or lay evidence that is necessary to substantiate the claim, (2) what portion of the information and evidence VA will obtain, and (3) what portion of the information and evidence the claimant is to provide. Also, the VCAA notice requirements apply to all five elements of a service connection claim. The five elements are: 1) veteran status; 2) existence of a disability; (3) a connection between the veteran's service and the disability; 4) degree of disability; and 5) effective date of the disability. Dingess v. Nicholson, 19 Vet. App. 473 (2006). In a claim for increase, the VCAA requirement is generic notice, that is, the type of evidence needed to substantiate the claim, namely, evidence demonstrating a worsening or increase in severity of the disability and the effect that worsening has on employment. Vazquez-Flores v. Shinseki, 580 F.3d 1270 (Fed. Cir. 2009) (interpreting 38 U.S.C.A. § 5103(a) as requiring generic claim-specific notice and rejecting veteran-specific notice as to the effect on daily life and as to the assigned or a cross-referenced Diagnostic Code under which the disability is rated). The VCAA notice, as required by 38 U.S.C.A. § 5103(a), must be provided to a claimant before the initial unfavorable adjudication by the RO. Pelegrini v. Principi, 18 Vet. App. 112 (2004). The RO provided pre- and post-adjudication VCAA notice by letters, dated in January 2006 and May 2008. The notice included the type of evidence needed to substantiate the claim for a higher rating, namely, evidence to show that the disability was worse and the effect the disability had on employment. The Veteran was notified that VA would obtain service records, VA records, and records of other Federal agencies and that he could submit other records not in the custody of a Federal agency, such as private medical records or with his authorization VA would obtain any such records on his behalf. The May 2008 notice included the elements of a service connection claim, including the effective date of a claim and the degree of disability assignable. As for content of the VCAA notice, the documents complied with the specificity requirements of Quartuccio v. Principi, 16 Vet. App. 183 (2002) (identifying evidence to substantiate a claim and the relative duties of VA and the claimant to obtain evidence); of Charles v. Principi, 16 Vet. App. 370 (2002) (identifying the document that satisfies VCAA notice); of Dingess v. Nicholson, 19 Vet. App. 473 (notice of the elements of the claim); and of Vazquez-Flores v. Shinseki, 580 F.3d 1270 (Fed. Cir. 2009) (claim-specific notice, namely, a worsening or increase in severity of the disability and the effect that worsening has on employment). To the extent that the VCAA notice in May 2008 came after the initial adjudication, the timing of such notice did not comply with the requirement that the notice must precede the adjudication. The procedural defect was cured as after the RO provided content-complying VCAA notice, the claim was readjudicated as evidenced by the supplemental statements of the case dated in June 2010, May 2012, and May 2013. Mayfield v. Nicholson, 499 F.3d 1317 (Fed. Cir. 2007) (Timing error cured by adequate VCAA notice and subsequent readjudication without resorting to prejudicial error analysis.). Duty to Assist Under 38 U.S.C.A. § 5103A, VA must make reasonable efforts to assist the claimant in obtaining evidence necessary to substantiate a claim. The Veteran was given the opportunity to testify at hearings in November 2007 and September 2012, the latter of which he appeared before the undersigned. The RO has also obtained the Veteran's voluminous VA records. The Veteran has not identified any other pertinent records for the RO to obtain on his behalf. Further, VA has conducted necessary medical inquiry in an effort to substantiate the claim for a higher rating for a cervical spine disability. 38 U.S.C.A. § 5103A(d). The Veteran was afforded VA examinations in March 2006, January 2011, and March 2013. As the examination reports and medical opinions contain the Veteran's medical history and pertinent clinical findings by which to evaluate the cervical spine disability according to given rating criteria, the Board finds that the reports are adequate to decide the claim. See Stefl v. Nicholson, 21 Vet. App. 120, 123 (2007) (a medical opinion must be based on consideration of the veteran's prior medical history and examinations and also describe the disability, if any, in sufficient detail so that the Board's evaluation of the claimed disability will be a fully informed one). As there is no indication of the existence of additional evidence to substantiate the claim, the Board concludes that no further assistance to the Veteran in developing the facts pertinent to the claim is required to comply with the duty to assist. II. Principles for Rating Disabilities A disability rating is determined by the application of VA's Schedule for Rating Disabilities (Rating Schedule). The percentage ratings contained in the Rating Schedule represent, as far as can be practicably determined, the average impairment in earning capacity resulting from diseases and injuries incurred or aggravated during military service and their residual conditions in civil occupations. Separate Diagnostic Codes identify the various disabilities. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. The Board will consider whether separate ratings may be assigned for separate periods of time based on facts found, a practice known as "staged ratings," whether it is an initial rating case or not. Fenderson v. West, 12 Vet. App. 119, 126-27 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). III. Rating Criteria, Facts, and Analysis In October 2005, the Veteran filed a claim for a higher rating for his service-connected residuals of a neck and right shoulder injury with musculofascial pain. In a November 2006 rating decision, the RO granted a separate 10 percent rating for cervical spondylosis (residuals of an injury), and granted service connection for radiculopathy of the right arm and radiculopathy of the left arm, both associated with cervical spondylosis, assigning a 10 percent rating for each arm. The effective date for the awards was October 28, 2005. In a statement received in January 2007, the Veteran disagreed with the 10 percent rating for the cervical spine disability. In an October 2007 substantive appeal statement, he asserted that his cervical spine disability had worsened, with increased pain on a daily basis, soreness in the neck when he turned his head, and popping and grinding noises. More recently, at a hearing in September 2012, there was testimony to the effect that the neck condition was deteriorating at a face pace, and that there was tingling and numbness of the hands/feet/arms along with weakness and limitation of motion of the arms. The Veteran's cervical spine disability, characterized as cervical spondylosis, residuals of injury (previously evaluated with the right shoulder but now evaluated separate from it), has been rated as 10 percent disabling for the period before January 25, 2011, and 30 percent for the period from January 25, 2011, under 38 C.F.R. § 4.71a , Diagnostic Code 5242. In evaluating disabilities of the spine, the criteria is for application with or without symptoms such as pain (whether or not it radiates), stiffness, or aching in the area of the spine affected by residuals of injury or disease. 38 C.F.R. § 4.71a, the General Rating Formula for Diseases and Injuries of the Spine. The criteria for a 10 percent rating are forward flexion of the cervical spine greater than 30 degrees but not greater than 40 degrees; the combined range of motion of the cervical spine greater than 170 degrees but not greater than 335 degrees; or muscle spasm, guarding, or localized tenderness not resulting in abnormal gait or abnormal spinal contour. The criteria for a 20 percent rating are forward flexion of the cervical spine greater than 15 degrees but not greater than 30 degrees; the combined range of motion of the cervical spine not greater than 170 degrees; or muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. The criteria for a 30 percent rating are forward flexion 15 degrees or less, or favorable ankylosis of the entire cervical spine. The criterion for a 40 percent rating is unfavorable ankylosis of the entire cervical spine. A 100 percent rating requires unfavorable ankylosis of the entire spine. 38 C.F.R. § 4.71a , Diagnostic Code 5242 (degenerative arthritis of the spine). The criteria under the General Rating Formula for Diseases and Injuries of the Spine provide that normal forward flexion of the cervical spine is zero to 45 degrees, extension is zero to 45 degrees, left and right lateral flexion are zero to 45 degrees, and left and right lateral rotation are zero to 80 degrees. The combined range of motion refers to the sum of the range of forward flexion, extension, left and right lateral flexion, and left and right rotation. The normal combined range of motion of the cervical spine is 340 degrees. Unfavorable ankylosis is a condition in which the entire cervical spine is fixed in flexion or extension and the ankylosis results in one of more of the following: difficulty walking because of a limited line of vision; restricted opening of the mouth and chewing; breathing limited to diaphragmatic respiration; gastrointestinal symptoms due to pressure of the costal margin on the abdomen; dyspnea or dysphagia; atlantoaxial or cervical subluxation or dislocation; or neurologic symptoms due to nerve root stretching. Fixation of a spinal segment in neutral position (zero degrees) always represents favorable ankylosis. Rating factors for a disability of the musculoskeletal system included functional loss. A disability of the musculoskeletal system is primarily the inability, due to damage or infection in parts of the system, to perform the normal working movements of the body with normal excursion, strength, speed, coordination and endurance. The functional loss may be due to pain, supported by adequate pathology and evidenced by the visible behavior of the claimant undertaking the motion, weakness, or atrophy. 38 C.F.R. § 4.40; DeLuca v. Brown, 8 Vet. App. 202, 206-07 (1995). The cervical vertebrae are considered groups of joints. As regards the joints, the factors of disability reside in reductions of the joints normal excursion of movements in different planes. Factors for considerations include excess fatigability, pain on movement, swelling, atrophy of disuse, instability of station, disturbance of locomotion, interference with sitting and standing, and weight-bearing. 38 C.F.R. § 4.45; DeLuca v. Brown, 8 Vet. App. 202, 206-07 (1995). Also, with periarticular pathology, painful motion is factor to be considered. The intent of the Rating Schedule is to recognize actually painful, unstable or malaligned joints, due to healed injury, as entitled to at least the minimum compensable rating for the joint. 38 C.F.R. § 4.59. The record consists in relevant part of VA examinations in March 2006, on January 25, 2011, and in March 2013, and VA outpatient records for the period considered in the appeal. For the period before January 25, 2011, the objective evidence from the March 2006 VA examination shows that the examiner observed that there was no evidence of ankylosis of the cervical spine. Range of motion findings consisted of 45 degrees of forward flexion with pain, with a combined range of motion of 295 degrees (forward flexion of 45 degrees, extension of 40 degrees, rotation to the left and right of 60 degrees each, and lateral flexion to the left and right of 45 degrees each). The range of motion findings were calculated with consideration of pain on movement; and the examiner specifically noted that repetitive action of flexion and extension of the cervical spine against strong resistance and against gravity was met with increased pain, fatigue, weakness, and lack of endurance but that there was no decrease in the limited range of motion as previously reported. 38 C.F.R. §§ 4.40, 4.45, 4.59; DeLuca v. Brown, 8 Vet. App. 202 (1995). There are no other records prior to January 25, 2011, to include outpatient records, that reflect findings to show that the Veteran's cervical spine is more severely limited in motion than at the time of his VA examination in March 2006. Moreover, although the VA examiner noted crepitus and mild spasticity of the muscles affecting the paravertebral muscles at the base of the cervical spine, such spasm was not associated with abnormal gait or abnormal spinal contour because the examiner also noted that the Veteran had no difficulties in walking and his cervical spine had a normal appearance with no evidence of an antalgic posture. VA outpatient records also do not reflect any muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. Therefore, a rating higher than 10 percent is not warranted under Diagnostic Code 5242 for the period before January 25, 2011. Likewise, for the period from January 25, 2011, a rating higher than 30 percent is not warranted under Diagnostic Code 5242. To satisfy the criterion for a higher rating, there would have to be evidence of unfavorable ankylosis of the entire cervical spine. While the Veteran's range of motion of the cervical spine was shown to have become more severe at the time of the VA examinations in January 2011 and March 2013, there was no finding of ankylosis of the cervical spine. The January 2011 VA examination specifically indicated that there was no ankylosis. At that time, range of motion testing showed forward flexion of 15 degrees, extension of 20 degrees, rotation to the left and right of 30 degrees each, and lateral flexion to the left and right of 20 degrees each, and these range of motion findings evidently reflect consideration of pain, but there were no additional limitations after repetitions of range of motion. 38 C.F.R. §§ 4.40, 4.45, 4.59; DeLuca v. Brown, 8 Vet. App. 202 (1995). Thus, even with a more restricted combined range of motion of 135 degrees, the Veteran's cervical spine disability is shown to approximate the criteria for a 30 percent rating and no higher. The findings at the time of the March 2013 VA examination show that the Veteran's range of motion had improved. In reviewing the VA outpatient records, there is no documentation of cervical spine ankylosis. An outpatient record in October 2012 notes that the Veteran's cervical spine was limited in extension by 30 percent, but this does not show that the cervical spine was fixed in neutral position. On account of the absence of evidence of ankylosis, the criterion for the next higher rating, or 40 percent, is not met under Code 5242 for the period from January 25, 2011. The General Rating Formula for Diseases and Injuries of the Spine also provides that any associated objective neurologic abnormalities are evaluated separately under an appropriate diagnostic code. In rating peripheral nerves in the upper extremities, the rating schedule provides up to a 20 percent rating for mild incomplete paralysis and up to 40 percent rating for moderate incomplete paralysis, all depending on the particular nerve or nerve group of the upper extremity that is affected. 38 C.F.R. § 4.124a, Diagnostic Codes 8510-8719. The Veteran is evaluated separately for radiculopathy of the right arm and radiculopathy of the left arm, both 10 percent disabling under 38 C.F.R. § 4.124a, Diagnostic Code 8615, for neuritis of the median nerve. Although the Veteran in January 2007 did not specifically express his disagreement with the ratings assigned for radiculopathy of the upper extremities, the Board will nevertheless address the upper extremity neurologic abnormalities to the extent they may be associated with the cervical spine disability. At the time of the VA examinations cited above, the Veteran had complaints with regard to neurologic abnormality in the upper extremities associated with the cervical spine disease. At the time of the March 2006 VA examination, sensation was decreased on the dermatomal distribution of C3 to C6, affecting the right upper extremity, where motor strength was 3/5 in comparison to the left side (which was 4/5), and deep tendon reflexes were severely decreased in both upper extremities. The examiner diagnosed cervical spondylosis with radiculopathy, as well as right shoulder impingement syndrome. Imaging study results of the cervical spine in February 2008 was essentially negative, with no fracture, alignment and interspaces preserved, a few soft tissue calcifications in the nuchal ligament, and no foraminal encroachment. At the time of the January 2011 VA examination, the Veteran complained of pain radiating into the right shoulder. Reflex testing was normal (2+) in the upper extremities. Sensory examination was normal except for decreased pinprick and light touch, only in the C5 to C6 dermatomal distribution. Motor testing was normal (5/5) in the upper extremities. The examiner diagnosed cervical spine strain with bilateral C5-6 sensory radiculopathies. In terms of the effect of the condition on his occupation and daily activities, the examiner remarked that there would be pain and decreased strength in the upper extremity and that the Veteran might drops things due to numbness of both hands from his neck. At the time of the March 2013 VA examination, muscle strength testing was normal (5/5) in the upper extremities and there was no muscle atrophy. Reflex testing was 1+ (hypoactive). Sensory examination was normal in the C5 and C6/T1 dermatomal distribution (shoulder area and inner/outer forearm, respectively) but decreased in the C6-8 dermatomal distribution (hand/fingers) upon light touch and vibratory sensation. When specifically asked whether the Veteran had radicular pain or any other signs or symptoms of radiculopathy, the examiner indicated that the Veteran did not. The examiner also indicated that the Veteran did not have any other neurologic abnormalities related to a cervical spine condition. In an explanation of rationale for her conclusion, the examiner indicated in the diagnoses that the Veteran had chronic cervical strain but no evidence for cervical radiculopathy on the examination. She stated that the symmetric mildly decreased sensation (monofilament and vibration) of the distal fingers (and toes) on the examination was of unknown etiology but that the Veteran notably had diabetes mellitus, type 2. VA outpatient records are silent for objective findings pertaining to neurologic abnormality from the cervical spine disability. Thus, as reported above, there is some discrepancy in determining the neurologic abnormality, if any, from the Veteran's cervical spine disability. The 2006 VA examiner stated there was radiculopathy manifested by sensation, motor, and reflex deficits. The 2011 VA examiner detected only sensory radiculopathies. The 2013 VA examiner indicated that there were positive neurologic findings, particularly sensory in nature, but determined that the symptoms were not manifestations of radiculopathy from the cervical spine disability but were of other origins probably diabetes mellitus. Given that the 2006 VA examiner did not have the benefit of review of the claims file at the time of the examination, that a cervical spine imaging study in 2008 found preserved interspaces and no foraminal encroachment, and that the 2011 and 2013 examiners essentially had similar findings but the 2013 examiner evidently undertook a more exhaustive review of the claims file (citing to previous VA examinations and outpatient clinic visits) and considered other causes for the neurologic deficits found on examination, the Board accords more probative weight to the 2013 VA examination findings of no radiculopathy. Thus, no additional ratings are warranted for associated objective neurologic abnormalities under the General Rating Formula for Diseases and Injuries of the Spine. The common finding of note on all of the examinations was sensory deficit, particularly in the fingers/hand, and the 2013 VA examiner characterized this deficit as mild. If such deficit was evaluated separately under an appropriate rating criteria for peripheral nerves (see 38 C.F.R. § 4.124a, Diagnostic Code 8615, relative to incomplete paralysis of the muscles of the fingers), a 10 percent rating for each extremity would be in order, and as already noted the Veteran is currently rated for this deficit. Intervertebral disc syndrome is rated under either the General Rating Formula for Diseases and Injuries of the Spine, as discussed above, or the Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes, whichever results in the higher rating when all disabilities are combined under 38 C.F.R. § 4.25. The criteria for a 10 percent rating are intervertebral disc syndrome with incapacitating episodes having a total duration of at least one week but less than 2 weeks during the past 12 months. The criteria for a 20 percent rating are intervertebral disc syndrome with incapacitating episodes having a total duration of at least 2 weeks but less than 4 weeks during the past 12 months. The criteria for a 40 percent rating are intervertebral disc syndrome with incapacitating episodes having a total duration of at least 4 weeks but less than 6 weeks during the past 12 months. The criteria for a 60 percent rating are intervertebral disability syndrome with incapacitating episodes having a total duration of at least 6 weeks during the past 12 months. 38 C.F.R. § 4.71a, Diagnostic Code 5243. The accompanying notes to Diagnostic Code 5243 provide that an incapacitating episode is a period of acute signs and symptoms due to intervertebral disc syndrome that requires bed rest prescribed by a physician and treatment by a physician. A review of the record (both VA examination reports and VA outpatient treatment records) shows that there is no medical evidence to reflect objective findings of incapacitating episodes having a total duration of at least a week during the past twelve months. In fact, there is no evidence of incapacitating episodes whatsoever. The VA examiners in March 2006 and January 2011 stated that the Veteran reported no episodes of incapacitation within the past 12 months. The VA examiner in March 2013 indicated that there was no intervertebral disc syndrome or incapacitating episodes. Therefore, a higher rating is not warranted under Diagnostic Code 5243, for any period considered in this appeal, as it pertains to incapacitating episodes. In conclusion, the Board has considered whether staged ratings may be assigned for separate periods of time based on the facts found, but the evidence shows that the Veteran's cervical spine disability is no more than 10 percent disabling for the period before January 25, 2011 and is no more than 30 percent disabling for the period from January 25, 2011. While the Board acknowledges the Veteran's competence to report neck pain and limitation of motion, he is not competent to identify a specific level of disability according to the appropriate diagnostic codes. Such competent evidence concerning the nature and extent of the Veteran's cervical spine disability has been provided by the medical personnel who have examined him during the current appeal and who have rendered pertinent opinions in conjunction with the evaluations. The medical findings as provided in the examination reports and the clinical records address the applicable criteria under which the Veteran's disability is rated. As such, the Board finds these records to be more probative than the Veteran's subjective reports of increased symptomatology to warrant a higher rating. The Board observes further that the Veteran's opinions and observations alone cannot meet the burden imposed by the rating criteria under 38 C.F.R. § 4.71a, with respect to determining the severity of his service-connected disability. See Moray v. Brown, 2 Vet. App. 211, 214 (1993); see also 38 C.F.R. § 3.159(a)(1) and (2). Determining the severity of the Veteran's disability must be accomplished by a medical professional. See Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007); Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006). As discussed above, the competent medical evidence of record does not support a higher rating than is currently assigned. As the preponderance of the evidence is against the claim for a higher rating, the benefit-of-the-doubt standard of proof does not apply. 38 U.S.C.A. § 5107(b). Extraschedular Consideration Although the Board is precluded by regulation from assigning an extraschedular rating under 38 C.F.R. § 3.321(b)(1) in the first instance, the Board is not precluded from considering whether the case should be referred to the Director of VA's Compensation and Pension Service for a rating. The threshold factor for extraschedular consideration is a finding that the evidence presents such an exceptional disability picture that the available schedular ratings are inadequate. This is accomplished by comparing the level of severity and symptomatology of the service-connected disability with the established criteria. If the criteria reasonably describe the disability level and symptomatology, then the disability picture is contemplated by the Rating Schedule, and the assigned schedular rating is, therefore, adequate and referral for an extraschedular rating is not required. Thun v. Peake, 22 Vet. App. 111, 115 (2008), aff'd sub nom. Thun v. Shinseki, 572 F.3d 1366 (Fed. Cir. 2009). In this case, the Board finds that the rating criteria reasonably describe the level and symptomatology of the Veteran's service-connected cervical spine disability, and provide for higher ratings for more severe symptoms for those symptoms that are related to the service-connected disability. For example, the manifestations of the cervical spine disability, including chronic pain, limitation of motion, and degenerative changes, are all incorporated in the schedular criteria for evaluating impairments of the cervical spine. As articulated above, the Veteran does not experience any symptomatology not already encompassed in the Rating Schedule. As the disability picture is encompassed by the Rating Schedule, referral for extraschedular consideration is not required under 38 C.F.R. § 3.321(b)(1). ORDER A rating higher than 10 percent before January 25, 2011, and a rating higher than 30 percent from January 25, 2011, for a cervical spine disability is denied. REMAND As for the issue of service connection for a disability characterized by blackouts and dizziness, the Veteran underwent a VA examination in March 2013 to determine the etiology of any current disability. The VA examiner undertook an exhaustive review of the Veteran's complaints and medical records, and concluded that there was no objective data to support a more definitive diagnosis than that of a history of reported syncope of unknown etiology (the examiner found no evidence for a current condition characterized by blackouts). Additionally, the VA examiner diagnosed chronic intermittent positional dizziness consistent with benign paroxysmal positional vertigo (BPPV), which she noted is a condition not characterized by blackouts. While the examiner appeared to consider all the significant facts in the case, including any relationship between the Veteran's service-connected hypertension and cervical spine disabilities and his claimed blackouts/dizziness, there did not appear to be any discussion as to whether the diagnosed BPPV had any association with the Veteran's service-connected hearing loss, tinnitus, and/or chronic otitis media with tubes [myringotomy]. As such, the case should be returned for an addendum opinion to determine the origin of the BPPV, to include whether it can be attributable to a service-connected disability or to a closed head injury during service in February 1991 (a VA examiner in March 2009 opined that a tank hatch injury in 1991 was without any neurological residuals but did not consider BPPV). As for the issues of service connection for residuals of fractures of the right arm and right ankle, they are dependent upon the outcome of the appeal for service connection for a disability characterized by blackouts and dizziness. Thus, further development and consideration of such issues is deferred pending the development on the claim for service connection for a disability marked by blackouts and dizziness. As for the issue of a total disability compensation rating based on individual unemployability, the Veteran claims that recent increases in the severity of his disabilities have impaired him in carrying out his occupational duties. Notably, as a result of a May 2012 rating decision, the Veteran's combined disability rating is 80 percent effective from January 25, 2011, and prior to that period he had a combined rating of 70 percent from October 28, 2005. Although the record as it now stands indicates the Veteran does not meet the minimum schedular percentage standards for a total disability rating for compensation based on individual unemployability (he does not have at least one disability rated at 40 percent or more), entitlement to the benefits on an extraschedular basis may be considered if it is shown he is unable to secure and follow a substantially gainful occupation by reason of service-connected disabilities. See 38 C.F.R. § 4.16(b). Therefore, a VA examination is warranted to determine that particular question. Accordingly, the case is REMANDED for the following action: 1. Return the claims file to the VA examiner who examined the Veteran in March 2013 and furnished an opinion concerning the etiology of the disability characterized by blackouts. After a review of the medical and scientific literature, the examiner should provide an addendum opinion on whether it is at least as likely as not (probability of 50 percent or greater) that the Veteran's currently diagnosed BPPV is related to (a) his service-connected tinnitus, hearing loss, and/or chronic otitis media with tubes, or (b) his period of service from November 1990 to April 1991, wherein he sustained a closed head injury in February 1991. The examiner should consider the significant facts of the case, to include the opinion of a VA examiner in March 2009, who concluded that the Veteran's tank hatch injury in 1991 was without any neurological residuals (but there was no consideration of BPPV). If the examiner who conducted the March 2013 VA examination is not available, or if it is determined that another VA examination is necessary, schedule the Veteran for examination by an appropriate medical professional to determine the etiology of the Veteran's BPPV. All indicated tests and studies should be performed. The claim folder, including all newly obtained evidence and a copy of this remand, must be sent to the examiner for review in conjunction with the examination. All opinions expressed must be supported by complete rationale. 2. After completion of the foregoing, schedule the Veteran for a medical examination for the purpose of developing the claim for a total disability rating for compensation based on individual unemployability. The examiner should furnish an opinion as to whether the Veteran is unemployable due to his service-connected disabilities, which include major depressive disorder; cervical spondylosis; residuals of a right shoulder injury with adhesive capsulitis, impingement syndrome, and biceps tendonitis; tinnitus; radiculopathy of the right arm; radiculopathy of the left arm; hearing loss; hypertension; and chronic otitis media with tubes. The Veteran's file should be made available to the examiner for review. 3. After the development has been completed, adjudicate the claims. If the benefits sought are denied, furnish the Veteran and his representative a supplemental statement of the case and return the case to the Board. The Veteran has the right to submit additional evidence and argument on the 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 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). ______________________________________________ ROBERT E. SULLIVAN Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs