Citation Nr: 1324668 Decision Date: 08/02/13 Archive Date: 08/13/13 DOCKET NO. 08-10 145 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Reno, Nevada THE ISSUE Entitlement to a compensable rating for allergic rhinitis. REPRESENTATION Appellant represented by: Veterans of Foreign Wars of the United States WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD D.J. Drucker, Counsel INTRODUCTION The Veteran had active military service from January 1970 to September 1971 and from February 1972 to July 1990. This matter initially came to the Board of Veterans' Appeals (Board) on appeal from an August 2007 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Reno, Nevada, that, in pertinent part, denied the Veteran's claim for a compensable rating for his service-connected allergic rhinitis. In September 2010, the Board remanded the Veteran's case to the RO to comply with his request to testify during a hearing before a Veterans Law Judge. In May 2012, the Veteran testified during a hearing at the RO before the undersigned. A transcript of the hearing is of record. Then, in July 2012, the Board remanded the Veteran's case to the RO via the Appeals Management Center (AMC) in Washington, D.C., for further evidentiary development. The Board observes that service connection is also in effect for chronic sinusitis, currently evaluated as 10 percent disabling under 38 C.F.R. § 4.97, Diagnostic Code 6510 (2012). Findings regarding the sinus disability were reported by an August 2012 VA examiner. In a June 2013 written statement, the Veteran's representative noted that the Veteran's "headaches are of an utmost concern due to the disabling nature." Headaches are a component of the rating criteria for sinusitis and it may be that, by this statement, the Veteran through his representative, seeks to raise a claim for an increased rating for his chronic sinusitis. The matter of entitlement to a rating in excess of 10 percent for chronic sinusitis has thus been raised by the record, but has not been adjudicated by the Agency of Original Jurisdiction (AOJ). Therefore, the Board does not have jurisdiction over it, and it is referred to the AOJ for appropriate action. The record also shows that, in the August 2007 rating decision, the RO granted service connection for peripheral neuropathy of the left and right lower extremities and assigned initial noncompensable ratings. In a written statement with his March 2008 substantive appeal, the Veteran stated that he needed "documentation, evaluation, and increased rating for my discoloration of my ankles and forelegs...and feet" that he believed were due to his service-connected heart disability and exposure to Agent Orange. It is unclear if, by this statement, he sought to file a notice of disagreement with the initial ratings assigned for his lower extremity peripheral neuropathy and raise a claim for increased ratings for his service-connected Achilles tendonitis/plantar fasciitis of the left and right feet. If so, the Veteran or his representative should contact the RO and set forth the specific nature of his claim(s). FINDING OF FACT Since he filed his increased rating claim in July 2006, the Veteran's service-connected allergic rhinitis has not been manifested by polyps, greater than 50 percent obstruction of nasal passages on both sides, or complete obstruction on one side, or by impairment approximating such a level of severity. CONCLUSION OF LAW The criteria for a compensable evaluation for allergic rhinitis have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 4.3, 4.7, 4.97, Diagnostic Code 6522 (2012). REASONS AND BASES FOR FINDING AND CONCLUSION I. Duty to Notify and Assist. As provided for by the Veterans Claims Assistance Act (VCAA), VA has a duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a) (2012). 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) (2009) requires that the Veterans Law Judge who chairs a hearing fulfill two duties to comply with the above the regulation. These duties consist of (1) the duty to fully explain the issues and (2) the duty to suggest the submission of evidence that may have been overlooked. Here, during the hearing, this Veterans Law Judge outlined the issue on appeal and suggested that any evidence tending to show that pertinent disability had worsened in severity would be helpful in establishing the claim. Moreover, neither the Veteran nor his representative has asserted that VA failed to comply with 38 C.F.R. 3.103(c)(2); they have not identified any prejudice in the conduct of the Board hearing. Proper notice from VA must inform the claimant of any information and medical or lay 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 C.F.R. § 3.159(b)(1); Quartuccio v. Principi, 16 Vet. App. 183 (2002). VCAA notice must be provided prior to an initial unfavorable 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). Where complete notice is not timely accomplished, such error may be cured by issuance of a fully compliant notice, followed by readjudication of the claim. See Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); see also Prickett v. Nicholson, 20 Vet. App. 370, 376 (2006). In addition, the notice requirements of the VCAA apply to all elements of a service-connection claim, including the degree of disability and the effective date of the disability. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). Further, this notice must include information that a disability rating and an effective date for the award of benefits will be assigned if service connection is awarded. Id. at 486. Here, the Veteran was sent letters in November 2006 and June 2011 that provided information as to what evidence was required to substantiate the claim and of the division of responsibilities between VA and a claimant in developing an appeal. The November 2006 letter provided notice as to how VA assigns an appropriate disability rating or effective date, curing any timing defect. Accordingly, no further development is required with respect to the duty to notify. Next, VA has a duty to assist the Veteran in the development of his claim. This duty includes assisting him in the procurement of service treatment records and pertinent treatment records and providing an examination when necessary. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. All reasonably identified and available VA and non-VA medical records were obtained. A review of the Veteran's Virtual VA electronic file does not reveal any additional evidence regarding the claim for an increased rating for allergic rhinitis on appeal. The Veteran was afforded VA examinations in March 2007 and July 2009 and the examination reports are of record. In September 2010, the Board remanded the Veteran's case to afford him the opportunity to testify during a hearing before Veterans Law Judge. There was substantial compliance with this remand, as the Veteran testified during a hearing at the RO before the undersigned in May 2012. The Board's July 2012 remand was for the purpose of providing the Veteran with a new VA examination. There has been substantial compliance with the remand as the Veteran was scheduled for a VA examination in August 2012. In the June 2013 written statement, the Veteran's service representative argued that the August 2012 VA examination was inadequate due to it not being conducted during a period of exacerbation, and cited to Ardison v. Brown, 6 Vet. App. 405, 407 (1994). The representative requested that the case be remanded again for an adequate examination that "captures the true identity of [the Veteran's] suffering." In response to the above argument, the Board notes that when a claimant's medical history indicates that his condition undergoes periods of remission and recurrence, VA may be required to provide a medical examination during the period of recurrence in order to provide a proper disability rating. Ardison v. Brown, 6 Vet. App. at 407. In Ardison, the court found that an examination during the remission phase of the condition did not "accurately reflect the elements of the present disability." Id. In this case, the Veteran has reported that the symptoms of his claimed allergic rhinitis undergo periods of exacerbation in November and March. For example, during the July 2009 VA examination, he reported having flare-ups in the late fall and early spring and, during the August 2012 VA examination, he reported that every March and November, he had a sinus, ear, nose, and throat infection that was treated with three weeks of antibiotics. His VA and non VA treatment records show treatment during April 2006 for allergic rhinitis and, as noted, he underwent VA examination during March 2007- during a period that he has identified as one in which flare-ups occur. Moreover, in August 2012, the Veteran reported that his condition was unchanged since his 2007 VA examination. Given this history, the Board finds no duty to schedule another examination. Although the most recent VA examination for the Veteran's service-connected allergic rhinitis disability took place in 2012, he has not reported any change in his allergic rhinitis disability since then, and the record does not otherwise show any changes. Palczewski v. Nicholson, 21 Vet. App. 17 (2007) (mere passage of time does not trigger need for a new VA examination, absent evidence of a change in the disability). An examination or medical opinion is adequate "where it is based upon consideration of the veteran's prior medical history and examinations and also describes the disability, if any, in sufficient detail so that the Board's evaluation of the claimed disability will be a fully informed one." Stefl v. Nicholson, 21 Vet. App. 120, 123 (quoting Ardison v. Brown, 6 Vet. App. at 407). It is a medical examiner's responsibility to provide a well-supported opinion so that the Board may carry out its duty to weigh the evidence of record. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008) (concluding that medical opinion is not entitled to any weight "if it contains only data and conclusions"); Stefl, 21 Vet. App. at 124 (stating that VA medical opinion "must support its conclusion with an analysis that the Board can consider and weigh against contrary opinions"). The court has also held that an examination is inadequate if the examiner ignores a veteran's assertions of continuity of symptomatology. Barr v. Nicholson, 21 Vet. App. 303, 311 (207) (finding error where "the VA examiner did not indicate whether he considered a veteran's assertions of continuity of symptomatology"). The August 2012 VA examination report is adequate. The physician considered an accurate history, including the Veteran's reports, and is well supported by detailed reasons. The Board finds that a remand for a new VA examination is not warranted in the Veteran's case. The Board finds that all necessary development has been accomplished, and therefore appellate review may proceed without prejudice to the appellant. See Bernard v. Brown, 4 Vet. App. 384 (1993). The claims file contains the Veteran's service treatment records, as well as post-service reports of VA and non-VA treatment and examinations. The Board has carefully reviewed such statements and concludes that no available outstanding evidence has been identified. The Board has also perused the medical records for references to additional treatment reports not of record, but has found nothing to suggest that there is any outstanding evidence with respect to the Veteran's claim. For the above reasons, 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 v. Principi, 16 Vet. App. 183 (2002). II. Factual Background and Legal Analysis The Board has thoroughly reviewed the record in conjunction with this case that includes VA and non VA medical records and examination reports, dated from 2005 to 2012, and the Veteran's written statements and oral testimony in support of his claim. Although there is an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, the extensive evidence submitted by the appellant or on his behalf. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (the Board must review the entire record, but does not have to discuss each piece of evidence). Rather, the analysis below will focus specifically on what the evidence shows, or fails to show, on the claim. See Timberlake v. Gober, 14 Vet. App. 122, 129 (2000) (noting that the Board must analyze the credibility and probative value of the evidence, account for the evidence which it finds to be persuasive or unpersuasive, and provide the reasons for its rejection of any material evidence favorable to the claimant). Disability evaluations are determined by the application of a schedule of ratings which is based, as far as can practically be determined, on the average impairment of earning capacity. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1 (2012). Each service-connected disability is rated on the basis of specific criteria identified by Diagnostic Codes. 38 C.F.R. § 4.27 (2012). 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). In the case of an increased rating, 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. Hart v. Mansfield, 21 Vet. App. 505 (2007). The analysis in the following decision is therefore undertaken with consideration of the possibility that different ratings may be warranted for different time periods. 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). Where there is a question as to which of two evaluations is to 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 (2012). In view of the number of atypical instances it is not expected, especially with the more fully described grades of disabilities, that all cases will show all the findings specified. Findings sufficiently characteristic to identify the disease and the disability therefrom, and above all, coordination of rating with impairment of function will, however, be expected in all instances. 38 C.F.R. § 4.21 (2012). Competent medical evidence means evidence provided by a person who is qualified through education, training, or experience to offer medical diagnoses, statements, or opinions. Competent medical evidence may also mean statements conveying sound medical principles found in medical treatises. It also includes statements contained in authoritative writings, such as medical and scientific articles and research reports or analyses. 38 C.F.R. § 3.159(a)(1). Competent lay evidence means any evidence not requiring that the proponent have specialized education, training, or experience. Lay evidence is competent if it is provided by a person who has knowledge of the facts or circumstances and conveys matters that can be observed and described by a lay person. 38 C.F.R. § 3.159(a)(2). The Veteran's statements describing the symptoms of his service-connected allergic rhinitis are deemed competent. These statements must be considered with the clinical evidence of record and in conjunction with the pertinent rating criteria. In July 2006, the RO received the Veteran's current claim for a compensable rating for his service-connected allergic rhinitis disability. In his December 2007 notice of disagreement, the Veteran argued that his nasal passages were blocked and he had to irrigate his nasal passages twice a day. He indicated that a recent 2007 computed axial tomography (CAT) scan showed the blockage. During his May 2012 Board hearing, the Veteran testified that he experienced flare ups in November that typically started as a strep throat, as his allergies affected his sinuses that caused the strep and right-sided headache. See Board hearing transcript at page 4. He had small flare ups with fresh cut grass that were treated with steroids once every three months to reduce swelling in the sinus cavities. Id. He irrigated his nose daily. Id. at 5. The Veteran experienced congestion, blockage headaches, strep, and infection. Id. at 6. Thus, the Veteran contends that a compensable rating is warranted for his service-connected allergic rhinitis. The Veteran's allergic rhinitis is evaluated under Diagnostic Code 6522 that addresses both allergic and vasomotor rhinitis. 38 C.F.R. § 4.97. Under Diagnostic Code 6522, a 10 percent evaluation is assigned when there are no polyps, but with greater than 50 percent obstruction of the nasal passage on both sides or complete obstruction on one side. A 30 percent evaluation is assigned when there are polyps as well. Id. Facts Private medical records, dated from December 2005 to August 2008, and VA medical records, dated from April 2006 to June 2009, reflect the Veteran's treatment for recurring sinus infections and allergic rhinitis. A March 2006 private medical record indicates that the Veteran was seen for treatment of a recurrent sinus infection and reported his last ear, nose, and throat (ENT) evaluation was ten years earlier. On examination, his sinuses were tender on the right. April 2006 private medical records show that the Veteran was treated for allergic rhinitis. Examination of his nose revealed turbinate hypertrophy, bilaterally. An October 3, 2006 private ENT medical record indicates that the Veteran reported right side nasal passage blockage for which antihistamines did not always work. An anterior rhinoscopy revealed boggy mucosa and evidence of "NSD" (nasal septal deviation? no significant defect/deviation?). There were no masses, polyps, or purulence identified. The assessment included chronic sinusitis and it was noted that a nasal endoscopy did not reveal polyps but there was a narrow nasal vault; a deviated nasal septum (acquired); and a hypertrophied nasal turbinate. Private medical records show that, in December 2006, the Veteran underwent endoscopic sinus surgery to include bilateral anterior ethmoidectomies, bilateral maxillary antrostomies, stitch removal, septoplasty, and bilateral inferior turbinate resection. A February 2007 statement from J.L.K., M.D., an allergist and immunologist, notes that the Veteran had to stop immunotherapy due to cardiac-related problems. Since he was off immunotherapy, he had significant problems in the spring. Examination revealed no evidence of polyps. The impression included allergic rhinitis, seasonal and perennial. The Veteran underwent VA examination in March 2007. He took Allegra daily for rhinitis, and Flonase. Recently, he used Astelin nasal spray that seemed to work the best as compared to his other two medications. He had sinus surgery in December 2006 because of chronic sinusitis. His breathing improved but he still had rhinorrhea. The Veteran complained of interference with breathing through his nose, purulent discharge, dyspnea, year-round allergy attacks, and a cough from his postnasal drip, and sinus infections yearly. He felt incapacitated at least once a year. On examination, there was partial obstruction at 40 percent in the bilateral nostrils and no polyps were seen. The diagnosis was chronic allergic rhinitis and chronic sinusitis. According to an April 10, 2007 private ENT record, the Veteran had sinusitis in March 2007 that was treated with antibiotic medication. He had left-sided pressure/fullness. An anterior rhinoscopy revealed normal mucosa and no evidence of NSD. There were no masses, polyps, or purulence identified. Results of a nasal endoscopy showed that the Veteran's middle and inferior turbinates appeared normal. His septum was not deviated. The right middle meatus was blocked with crusts and debrided. The left middle meatus appeared to have scarred shut. The sphenoid and posterior ethmoid outflow tracts appeared normal. The nasopharynx was clear of masses and lesions. There was no purulent drainage, polyps, or masses noted in either nasal cavity. The assessment was sinusitis. A May 2007 letter from S.N., M.D., an ENT specialist, shows that the Veteran complained of nasal congestion obstruction and recurrent episodes of sinusitis that required many courses of antibiotics. It was noted that, on examination, there was moderate deviation of the nasal septum to the right side and some yellow peel and discharge was present in the middle turbinate on the right side. The clinical impression included chronic sinusitis, septal deviation, and bilateral turbinate hypertrophy. When examined by Dr. J.K., the allergist, in June 2007, the Veteran's turbinates were normal. In April 2008, Dr. S.N., the ENT specialist, treated the Veteran for recurrent sinusitis. Dr. S.N. found no evidence of polyps. An 80 percent obstruction of the right nasal passage and a 40 percent obstruction of the left nasal passage were reported. The Veteran's presenting medical problems included chronic sinusitis, septal deviation, and bilateral turbinate hypertrophy. In July 2009, the Veteran underwent another VA examination. He reported having flare-ups of allergy and sinus problems every year in the late spring and early fall and continuous symtoms otherwise. His allergic rhinitis flared-up prior to developing a flare of acute sinusitis. The Veteran irrigated his noise daily with saline that helped relieve some of his problems. He had other health problems, including cardiac problems, and his cardiologist did not wish him to be on desensitizing injections, antihistamines, or nasal sprays. The Veteran had multiple allergies to pollens, molds, dust, mites, and also to chicken. The pollens included many flowers, trees, and farm products such as corn pollen. The examiner stated that the Veteran's allergy situation was quite severe. The VA examiner reported that the Veteran had severe allergic rhinitis that contributed to the development of severe recurring episodes of sinusitis that was treated only with nasal irrigations. The Veteran subjectively complained of constant interference with nose breathing, purulent discharge, and daily crusting. He had a flare of his allergies every fall from September to December and another flare in the spring and early summer, from March to May or June. He had not had to use prolonged antibiotic treatment at present. His symtoms were severe enough that he was unable to go to work from six to nine days every year, usually in the spring and fall. The Veteran reported that his symtoms had a moderate impact on his occupational functioning and daily activities and, with a flare, had a major impact that kept him from going to work. On examination, the Veteran's nasal passageways were patent, and he had irrigated his nose that morning and cleaned his nasal passageways before the examination. There was no hypertrophy of either turbinate and no nasal polyps visible. There was erythema of the mucosal lining of his nose. The orophyarynx was unremarkable. The VA examiner noted that the Veteran, definitely by history, had rather significant allergic rhinitis. It was further noted that the Veteran had periodic episodes of bacterial rhinitis that extended and progressed into bacterial sinusitis. There was no occlusion of either nasal passageway. There was mild septal deviation to the right of the inferior nasal septum. There was some scarring and loss of integrity of the nasal mucosa on inspection. Diagnoses included chronic sinusitis and chronic allergic rhinitis. The VA examiner further stated that the Veteran's nasal and sinus problems primarily had their origin with the development of his severe allergic rhinitis. The allergic rhinitis over the years was a major contributory factor to the development of chronic sinusitis. Currently, the Veteran suffered from significant allergic rhinitis on a daily basis with flares every spring and fall. The Veteran also had "smouldering" underlying bacterial sinusitis that he was never able to get rid of and never will in the future, according to the examiner. The nexus for all these problems, in the VA examiner's opinion, was the unrelenting and severe allergic rhinitis that caused the cascade of events leading to the chronic sinus problems. In August 2012, the Veteran again underwent VA examination. According to the examination report, his diagnosed conditions included chronic sinusitis and allergic rhinitis. The Veteran reported that his rhino sinusitis started in service. Every March and November, he had a sinus ear, nose, and throat infection and was treated with three weeks of antibiotics. He had radical sinus surgery in 2005 to open and drain his sinuses. The VA examiner noted that the Veteran had pan sinusitis. Symtoms associated with the Veteran's chronic sinusitis included chronic sinusitis detected only by imaging studies, episodes of sinusitis, near constant sinusitis ( two to four times a year), headaches, pain and tenderness of affected sinus, and purulent discharge or crusting. The Veteran had two non-incapacitating episodes of sinusitis in the past year that were characterized by headaches, pain, and purulent discharge or crusting and no incapacitating episodes of sinusitis requiring prolonged antibiotic treatment in the past year. With respect to the Veteran's rhinitis, there was not greater than 50 percent obstruction of his nasal passage on both sides due to rhinitis and not complete obstruction on one side due to rhinitis. There was no permanent hypertrophy of the nasal turbinates, no nasal polyps, and no granulomatous conditions. The Veteran did not have a 50 percent obstruction of the nasal passage on both sides, or complete obstruction on one side, due to traumatic septal deviation. The VA examiner reported that it was less likely as not that the Veteran's allergic rhinitis worsened since his VA examination in 2007, as there was no obstruction (greater than 50 percent) of either nasal passages. It was further noted that the Veteran "also states that there was been no change in his allergic rhinitis since the exam of 2007." Analysis The Veteran's service-connected chronic sinusitis is presently assigned a 10 evaluation under Diagnostic Code 6510. However, the matter of entitlement to a rating in excess of 10 percent for chronic sinusitis was not raised by the Veteran, adjudicated by the AOJ, and not certified for appellate consideration by the Board at this time. VA's Schedule for Rating Disabilities considers allergic rhinitis and sinusitis as separate disabilities for rating purposes. See 38 C.F.R. § 4.97, Diagnostic Code 6510-14 (sinusitis) and Diagnostic Code 6522 (allergic or vasomotor rhinitis) (2012). If co-existing, separate disability ratings may be assigned for both disorders. 38 C.F.R. § 4.96(a) (2012). In light of the above, the Board will specifically limit this analysis to the matter of entitlement to an increased (compensable) rating for service-connected allergic rhinitis that is in appellate status. In this regard, the Board also observes that, given the nature of the Veteran's disability, the rating criteria under Diagnostic Code 6522 used to evaluate allergic rhinitis is the most appropriate provisions for application in this case. See Pernorio v. Derwinski, 2 Vet. App. 625 (1992); 38 C.F.R. §§ 4.20, 4.21 (2012). Upon review of the probative medical evidence of record, the clinical evidence in this case clearly reflects that, since his filed his increased rating claim in July 2006, polyps were not present and a greater than 50 percent obstruction of nasal passage on both sides or complete obstruction on one side has not been shown. The 2006 and 2007 private medical records do not discuss findings regarding polyps. When evaluated by VA in March 2007, there was no indication of polyps, although a partial obstruction at 40 percent was noted, bilaterally. While, in April 2008, Dr. S.N. reported an 80 percent obstruction on the right and a 40 percent obstruction on the left, in July 2009, the VA examiner reported that the Veteran's nasal passages were patent and found no occlusion of either nasal passageway and no nasal polyps, but noted severe rhinitis. The August 2012 VA examiner noted no nasal obstruction and no polyps and that clinical findings were unchanged since the 2007 VA examination. No other evidence of record during the appeal period reveals the presence of either of the aforementioned manifestations required to support the assignment of a compensable 10 percent evaluation under Diagnostic Code 6522. Accordingly, the criteria for a compensable evaluation for rhinitis are not met. The Board has also considered whether any other diagnostic codes would allow for a higher disability rating for any period on appeal. Diagnostic Code 6523 addresses bacterial rhinitis, and provides for a 10 percent evaluation when there is permanent hypertrophy of the turbinates with greater than 50 percent obstruction of the nasal passages on both sides or complete obstruction on one side. 38 C.F.R. § 4.97, Diagnostic Code 6523 (2012). The April 2006 private medical record indicates that the Veteran had hypertrophy of the bilateral turbinates, and the October 2006 private record notes hypertrophied nasal turbinate. Although, the April 2007 private record shows normal turbinates, in May 2007 Dr. S.N. noted bilateral turbinate hypertrophy, but the June 2007 private record from Dr. J.K. reflects that the Veteran's turbinates were normal. The July 2009 and August 2012 VA examiners found no evidence of hypertrophy and the August 2012 VA examiner reported that there was no permanent hypertrophy of the nasal turbinates. As such, there is no evidence of permanent hypertrophy of the turbinates with greater than 50 percent obstruction of the nasal passages on both sides or complete obstruction on side such as to warrant a 10 percent rating. Thus, the criteria for a 10 percent rating under Diagnostic Code 6523 are not met. Id. Diagnostic Code 6524 does not apply, as there is no evidence of granulomatosis or granulomatous infection at any point during the Veteran's appeal. 38 C.F.R. § 4.97, Diagnostic Code 6524 (2012). Moreover, there is no evidence of injury to or residuals of injuries to the larynx and pharynx, so Diagnostic Codes 6520 and 6521 do not apply. 38 C.F.R. § 4.97, Diagnostic Code 6520, 6521 (2012). Accordingly, the preponderance of the credible and objective evidence of record is against a compensable rating for the Veteran's service-connected chronic allergic rhinitis and the benefit-of-the-doubt rule does not apply. 38 U.S.C.A. § 5107(b). The Board has also considered whether the Veteran's allergic rhinitis disability presents an exceptional or unusual disability picture as to render impractical the application of the regular schedular standards such that referral to the appropriate officials for consideration of an extra-schedular rating is warranted. See 38 C.F.R. § 3.321(b)(1) (2012); Bagwell v. Brown, 9 Vet. App. 337, 338-39 (1996). Pursuant to § 3.321(b)(1), the Under Secretary for Benefits or the Director, Compensation and Pension Service, is authorized to approve an extraschedular evaluation if the case "presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization as to render impractical the application of the regular schedular standards." 38 C.F.R. § 3.321(b)(1) (2012). The question of an extraschedular rating is a component of a claim for an increased rating. See Bagwell v. Brown, 9 Vet. App. 337, 339 (1996). Although the Board may not assign an extraschedular rating in the first instance, it must specifically adjudicate whether to refer a case for extraschedular evaluation when the issue either is raised by the claimant or is reasonably raised by the evidence of record. Barringer v. Peake, 22 Vet. App. 242 (2008). When it is not possible to separate the effects of a non-service-connected condition from those of a service-connected disorder, reasonable doubt should be resolved in the claimant's favor with regard to the question of whether certain signs and symptoms can be attributed to the service-connected disability. See Mittleider v. West, 11 Vet. App. 181, 182 (1998). Here the Board has considered Mittleider and attributed all potentially service-connected symtoms to his service-connected rhinitis disability before considering if the Veteran is entitled to an extra-schedular rating. If the evidence raises the question of entitlement to an extraschedular rating, the threshold factor for extraschedular consideration is a finding that the evidence before VA presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. Therefore, initially, there must be a comparison between the level of severity and symptomatology of the claimant's service-connected disability with the established criteria found in the rating schedule for that disability. Thun v. Peake, 22 Vet. App. 111 (2008). Under the approach prescribed by VA, if the criteria reasonably describe the claimant's disability level and symptomatology, then the claimant's disability picture is contemplated by the rating schedule, the assigned schedular evaluation is, therefore, adequate, and no referral is required. In the second step of the inquiry, however, if the schedular evaluation does not contemplate the claimant's level of disability and symptomatology and is found inadequate, the RO or Board must determine whether the claimant's exceptional disability picture exhibits other related factors such as those provided by the regulation as "governing norms." 38 C.F.R. 3.321(b)(1) (related factors include "marked interference with employment" and "frequent periods of hospitalization"). The manifestations of the Veteran's disability include nasal congestion, infection, and blockage. The rating schedule contemplates these symptoms. Diagnostic Code 6522. The rating schedule is meant to compensate for average impairment in earning capacity and for considerable time lost from work commensurate with the percentage evaluations. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. Thus, the Board finds that the threshold test is not met for referral for extraschedular consideration. Id.; see also Thun v. Peake, 22 Vet. App. at 111. In addition, the Board notes that if the claimant or the record reasonably raises the question of whether the Veteran is unemployable due to the disability for which an increased rating is sought, then part and parcel to that claim for a higher rating is whether a TDIU as a result of that disability is warranted. See Rice v. Shinseki, 22 Vet. App. 447 (2009). To the extent that the Veteran's allergic rhinitis affects his ability to work, the RO's April 2008 rating decision, that granted entitlement to a TDIU from December 21, 2007, recognized the effect of all the Veteran's service-connected disabilities, including the rhinitis disability, on his employability. Thus, any further consideration of the Veteran's claim under Rice is not warranted at this time. Further, in view of the holding in Hart and, based upon the record, the Board finds that at no time since the Veteran filed his most recent claim for an increased rating has the disability on appeal been more disabling than as currently rated under the present decision of the Board. ORDER A compensable rating for allergic rhinitis is denied. ____________________________________________ ERIC S. LEBOFF Veterans Law Judge, Board of Veterans' Appeals