Citation Nr: 1325242 Decision Date: 08/09/13 Archive Date: 08/13/13 DOCKET NO. 09-03 618 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Roanoke, Virginia THE ISSUES 1. Entitlement to service connection for hypertension. 2. Entitlement to an initial rating in excess of 10 percent for pseudofolliculitis barbae. REPRESENTATION Appellant represented by: Virginia Department of Veterans Services ATTORNEY FOR THE BOARD Amanda Christensen, Associate Counsel INTRODUCTION The Veteran had active military service from June 2000 to June 2004. This appeal comes to the Board of Veterans' Appeals (Board) from an April 2008 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Decatur, Georgia. The Board has not only reviewed the Veteran's physical claims file but also the Veteran's file on the "Virtual VA" system to insure a total review of the evidence. FINDINGS OF FACT 1. Hypertension was not present during active service or within the first year after discharge and is not otherwise related to service. 2. The Veteran's pseudofolliculitis barbae manifests as erthrmatous papules containing ingrown hairs only after shaving and does not affect more than 20 percent of his body or require systemic therapy of corticosteroids and immunosuppressants for a total duration of six weeks or more. CONCLUSIONS OF LAW 1. The criteria for service connection for hypertension have not been met. 38 U.S.C.A. §§ 1110, 5107 (West 2002); 38 C.F.R. §§ 3.303, 3.304, 3.307, 3.309 (2012). 2. The criteria are not met for a disability rating higher than 10 percent for pseudofolliculitis barbae. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.20, 4.118, Diagnostic Codes 7800, 7813, 7806 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Hypertension Service connection will be granted if it is shown that the veteran suffers from a disability resulting from personal injury suffered or disease contracted in the line of duty, or for aggravation of a preexisting injury suffered or disease contracted in the line of duty, during active military service. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303. Disorders diagnosed after discharge will still be service connected if all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d); see also Combee v. Brown, 34 F.3d 1039, 1043 (Fed. Cir. 1994). Service connection may also be awarded where the evidence shows that a Veteran had a chronic condition in service or during an applicable presumptive period and still has the condition. 38 C.F.R. §§ 3.303(b), 3.307, 3.309. Certain disorders, including hypertension, will be presumed to have been incurred in service if manifested to a compensable degree within one year after service. 38 U.S.C.A. §§ 1101, 1112, 1113; 38 C.F.R. §§ 3.307, 3.309. To establish service connection, there must be a competent diagnosis of a current disability; medical or, in certain cases, lay evidence of in-service occurrence or aggravation of a disease or injury; and competent evidence of a nexus between an in-service injury or disease and the current disability. Hickson v. West, 12 Vet. App. 247, 252 (1999); see Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). Competent medical evidence is 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 include 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 is 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 facts or circumstances and conveys matters that can be observed and described by a lay person. 38 C.F.R. § 3.159(a)(2). This may include some medical matters, such as describing symptoms or relating a contemporaneous medical diagnosis. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). In determining whether service connection is warranted for a disability, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the veteran prevailing in either event, or whether a preponderance of the evidence is against the claim, in which case the claim is denied. 38 U.S.C.A. § 5107; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination, the benefit of the doubt is afforded the claimant. At his entrance examination in October 1999, the Veteran was found to have a blood pressure of 140/83. His service treatment records contain a sampling of blood pressure readings done when the Veteran was seeking treatment for other conditions, but do not clearly document a history of hypertension. Readings from 2001 include 135/75, 147/83, and 137/73. In 2003 he had the following readings: 122/86, 120/78, 130/90, 128/96, 128/86, 126/84, 120/82, 138/88. In January 2004 he had a reading of 110/83. On his April 2004 discharge report of medical history the Veteran checked that he had a history of "high or low blood pressure" and a note states "hx of HTN- no meds." No blood pressure readings were taken at his discharge examination, although his vascular system is noted as normal. Although the Veteran reported a history of hypertension on discharge, service treatment records contain no complaints of or treatment for hypertension and blood pressure readings taken in service do not clearly document hypertension. As noted above, the Veteran had active military service from June 2000 to June 2004. After service, a December 2004 blood pressure reading taken at the VA was 132/71, providing evidence against this claim. An April 2007 VA treatment record first mentions hypertension, stating that the Veteran reported he was told he had hypertension several weeks ago and several other times in the last three years but that he is on no blood pressure medication. His blood pressure was 135/89, providing evidence against this claim. A July 2007 note reflects that the Veteran went to the VA for a blood pressure check for "elevated blood pressure without a diagnosis of hypertension." His blood pressure at that time was 128/71, providing evidence against this claim. VA records first list a diagnosis of hypertension in March 2011. In April 2012 the Veteran was noted to have not taken his blood pressure medication for two days because he was worried about side effects and had readings of 144/103 and 154/95. For a compensable rating for hypertension, diastolic pressure must be predominantly 100 or more, or systolic pressure must be predominantly 160 or more, or the veteran must have a history of diastolic pressure predominantly 100 or more and require continuous medication for control. The evidence does not show that hypertension was diagnosed or manifest within one year of the Veteran's separation from service, much less manifest to a compensable degree. VA records reflect that the Veteran was not diagnosed with hypertension until seven years after service. Although in 2007 the Veteran reported he had been told he had hypertension over the past three years, VA medical records specifically state that the Veteran was not given a diagnosis of hypertension in 2007. To the extent that the Veteran may have diagnosed himself with hypertension based on some observable symptoms, the Board finds he is not competent to do so. Therefore, the Veteran's hypertension may not be presumed to have been incurred in service. See 38 C.F.R. § 3.307. While records suggest the Veteran may have had some isolated higher than normal blood pressure readings both in service and since service, the evidence also does not show continuous hypertension since service. See 38 C.F.R. § 3.303(b). The length of time between the Veteran's discharge from service and his diagnosis of hypertension and the Veteran's only intermittently raised blood pressure readings in the intervening years as well as in service all weigh against a finding of service connection in this case. Further, no medical opinion evidence from a medical professional is in evidence supporting a connection between the Veteran's hypertension diagnosed in 2011 and his service seven years prior. As it relates to the statements from the Veteran asserting a nexus between his hypertension and service, the Board acknowledges Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007), in which it was held a lay person may speak as to etiology in some limited circumstances in which nexus is obvious merely through lay observation. Here, however, the question of causation extends beyond an immediately observable cause-and-effect relationship and, as such, the Veteran is not competent to address etiology in the present case. Therefore, to the extent that he has opined that his hypertension is related to his service, the Board gives his opinion little weight. The Veteran simply does not have the medical expertise associate his service with hypertension. The readings both during service and following service do not support a finding that would support the Veteran's claim and actually provide highly probative evidence against the claim that this problem began during service. In sum, the preponderance of the evidence weighs against a finding that the Veteran's hypertension developed in service or within the one year following service or is due to any event or injury in service. As the preponderance of the evidence is against the claims of service connection for hypertension, the benefit of the doubt rule is not applicable. See 38 U.S.C.A. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49, 54-56 (1990). Pseudofolliculitis Barbae Disability evaluations are determined by evaluating the extent to which a Veteran's service-connected disability adversely affects his or her ability to function under the ordinary conditions of daily life, including employment, by comparing his or her symptomatology with the criteria set forth in the Schedule for Rating Disabilities. The percentage ratings represent as far as can practicably be determined the average impairment in earning capacity resulting from such diseases and injuries and the residual conditions in civilian occupations. Generally, the degree of disabilities specified are considered adequate to compensate for considerable loss of working time from exacerbation or illness proportionate to the severity of the several grades of disability. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. § 4.1 (2012). Separate diagnostic codes identify the various disabilities and the criteria for specific ratings. If two disability evaluations are potentially applicable, the higher evaluation will be assigned to the disability picture that more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7 (2012). Any reasonable doubt regarding the degree of disability will be resolved in favor of the Veteran. 38 C.F.R. § 4.3 (2012). However, the evaluation of the same disability under various diagnoses, known as pyramiding, is to be avoided. 38 C.F.R. § 4.14 (2012). If there is disagreement with the initial rating assigned following a grant of service connection, separate ratings can be assigned for separate periods of time, based on the facts found. Fenderson v. West, 12 Vet. App. 119, 126 (1999). See AB v. Brown, 6 Vet. App. 35 (1993) (a claim for an original or an increased rating remains in controversy when less than the maximum available benefit is awarded). The RO has rated the Veteran's pseudofolliculitis barbae as 10 percent disabling since April 2011 under Diagnostic Code 7813. Pursuant to Diagnostic Code 7813, dermatophytosis is to be rated as disfigurement of the head, face, or neck (DC 7800), scars (DCs 7801, 7802, 7803, 7804, or 7805) or dermatitis (DC 7806), depending on the predominant disability. Under Diagnostic Code 7806 a 10 percent evaluation is assigned when 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 are affected, or; intermittent systemic therapy such as corticosteroids or other immunosuppressive drugs were required for a total duration of less than six weeks during the past 12-month period. 38 C.F.R. § 4.118. A 30 percent evaluation is assigned when 20 to 40 percent of the entire body or 20 to 40 percent of exposed areas are affected, or; systemic therapy such as corticosteroids or other immunosuppressive drugs were required for a total duration of six weeks or more, but not constantly, during the past 12-month period. Id. A 60 percent evaluation is assigned when more than 40 percent of the entire body or more than 40 percent of exposed areas are affected, or; constant or near-constant systemic therapy such as corticosteroids or other immunosuppressive drugs were required during the past 12-month period. Id. Diagnostic Code 7800, relating to disfigurement of the head, face, or neck, provides for a 10 percent evaluation for a scar of the head, face, or neck with one characteristic of disfigurement. A 30 percent evaluation is assigned for visible or palpable tissue loss and either gross distortion or asymmetry of one feature or paired set of features (nose, chin, forehead, eyes (including eyelids), ears (auricles), cheeks, lips); or with two or three characteristics of disfigurement. A 50 percent evaluation is assigned for visible or palpable tissue loss and either gross distortion or asymmetry of two features or paired sets of features (nose, chin, forehead, eyes (including eyelids), ears (auricles), cheeks, lips); or with four or five characteristics of disfigurement. An 80 percent evaluation is assigned for visible or palpable tissue loss and either gross distortion or asymmetry of three or more features or paired sets of features (nose, chin, forehead, eyes (including eyelids), ears (auricles), cheeks, lips), or; with six or more characteristics of disfigurement. The eight characteristics of disfigurement include: (1) Scar 5 or more inches (13 or more cm.) in length; (2) Scar at least one-quarter inch (0.6 cm.) wide at its widest part; (3) Surface contour of scar elevated or depressed on palpation; (4) Scar adherent to underlying tissue; (5) Skin hypo- or hyperpigmented in an area exceeding six square inches (39 sq. cm.); (6) Skin texture abnormal (irregular, atrophic, shiny, scaly, etc.) in an area exceeding six square inches (39 sq. cm.); (7) Underlying soft tissue missing in an area exceeding six square inches (39 sq. cm.); and (8) Skin indurated and inflexible in an area exceeding six square inches (39 sq. cm.). In 2008, VA clarified its regulations for rating skin disorders, specifically scars. See Schedule for Rating Disabilities; Evaluation of Scars, 73 Fed. Reg. 54, 708 (2008) (codified as revised at 38 C.F.R. § 4.118, Diagnostic Codes 7801-7805 (2012)). Those revisions are applicable only for claims for benefits received by VA on or after October 23, 2008. Those revisions are not applicable to the current appeal and will not be discussed below because the Veteran's claim was received prior to October 23, 2008. VA treatment records show the Veteran has regularly been treated for pseudofolliculitis barbae and was put on shaving profile in December 2004. The Veteran was afforded a VA examination for his pseudofolliculitis barbae in April 2011. The examiner found the Veteran had pseudofolliculitis barbae on his face, chest, and back. The condition manifests with exudation, itching, shedding, and crusting. The examiner listed the following characteristics: exfoliation, crusting, disfigurement, induration of more than six square centimeters, inflexibility of more than six square centimeters, hyperpigmentation of more than six square centimeters, and abnormal texture of more than six square centimeters. The examiner noted no ulceration, tissue loss, hypopigmentation, or limitation of motion. He found that the condition covers 15% of the exposed area and 4.5% of the whole body. In a June 2012 addendum the examiner clarified that the Veteran has 390 square centimeters of disfigurement on his head, 96 square centimeters of disfigurement on his face, and 42 square centimeters of disfigurement on his neck for a total area of 528 square centimeters. The examiner found the Veteran had no acne, chloracne, scarring alopecia, alopecia areata, hyperhidrosis, or scars. The Veteran reported the symptoms occur when he shaves. He reported 360 attacks over the past year with each occurrence lasting one to two weeks. The Veteran reported his face is sensitive to touch during a flare-up and it is embarrassing and causes low self esteem. He stated that it could be hindering him from getting promoted at work. The Veteran reported he has treated the condition with a topical antibiotic three times a day. In April 2012 at a VA dermatology visit it was noted that the Veteran's pseudofolliculitis barbae had resolved with beard growth and simple trimming. The examiner found no abnormalities on the Veteran's face, scalp, or neck. To be eligible for the next higher rating, 30 percent, under Diagnostic Code 7806 the Veteran's skin condition must affect 20 to 40 percent of the entire body or 20 to 40 percent of exposed areas, or; systemic therapy such as corticosteroids or other immunosuppressive drugs must have been required for a total duration of six weeks or more, but not constantly, during the past 12-month period. The April 2011 examiner found the Veteran's pseudofolliculitis barbae covered 15% of the exposed area of his body and 4.5% of the whole body, and a year later the condition was found to have resolved with no skin abnormalities present. Therefore, the Veteran is not entitled to a higher rating under Diagnostic Code 7806 as the Veteran's skin condition at no time affected at least 20 percent of his body or required systemic therapy. Under Diagnostic Code 7800 the next higher rating, 30 percent, is assigned for visible or palpable tissue loss and either gross distortion or asymmetry of one feature or paired set of features; or with two or three characteristics of disfigurement. The Veteran does not have tissue loss or gross distortion or asymmetry of his features. He does also not have any reported scars. The April 2011 examiner did report seeing hyperpigmentation, abnormal skin texture, and inflexible skin on the Veteran's body and noted erthrmatous papules containing ingrown hairs across 528 square centimeters of the Veteran's head, face, and neck. However, the Veteran reported having symptoms only intermittently after shaving. In April 2012 the Veteran's pseudofolliculitis barbae was determined to have resolved with beard growth and simple trimming and no abnormalities were noted on the Veteran's face, scalp, or neck. Thus, while the record reflects the Veteran has experienced flare-ups of his condition, including apparently during his April 2011 examination, his symptoms have never been constant and have since resolved. Therefore, although the April 2011 examiner's report suggests the Veteran could have at times experienced two or three characteristics of disfigurement, the record suggests the condition was intermittent brought on only by shaving. Notably, VA records reflect the Veteran was given a shaving profile in July 2004. In this regard, the Board must note that it does not believe that this condition has "resolved" and has taken seriously the Veteran's statements, however, the fact that the Veteran is still having problems is the basis for the current 10 percent evaluation, without which there would be no basis to award the Veteran compensation for this problem. Based on the forgoing, the Board finds the Veteran's condition does not more closely approximate the criteria for a 30 percent rating under Diagnostic Code 7800. As the preponderance of the evidence is against this claim, the benefit of the doubt doctrine does not apply, and the claim for an increased disability rating in excess of 10 percent for pseudofolliculitis barbae must be denied. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). The Board has also considered whether referral for consideration of an extraschedular rating is warranted, noting that if an exceptional case arises where ratings based on the statutory schedules are found to be inadequate, consideration of an "extra-schedular" evaluation commensurate with the average earning capacity impairment due exclusively to the service-connected disability or disabilities will be made. 38 C.F.R. § 3.321(b)(1). The Court has held that the determination of whether a claimant is entitled to an extraschedular rating under § 3.321(b) is a three-step inquiry, the responsibility for which may be shared among the RO, the Board, and the Under Secretary for Benefits or the Director, Compensation and Pension Service. Thun v. Peake, 22 Vet. App. 111 (2008). 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. This means that 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. 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 adequate, and no referral is required. If the criteria do not reasonably describe the claimant's disability level and symptomatology, a determination must be made 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"). See id. However, in this case, the medical evidence fails to show anything unique or unusual about the Veteran's service connected pseudofolliculitis barbae that would render the schedular criteria inadequate. The Veteran's skin condition symptoms, including erthrmatous papules containing ingrown hairs, are contemplated in the rating assigned. As such, it would not be found that his disability met the "governing norms" of an extraschedular rating. Accordingly, referral for consideration of an extraschedular rating is not warranted. Moreover, even if it were argued that the schedular rating criteria were inadequate, the Board finds no reason to refer the case to the Compensation and Pension Service to consider whether an extra-schedular rating is warranted. In this case, there is no evidence of any hospitalization associated with the Veteran's pseudofolliculitis barbae. In addition, the Board finds the record does not reflect that the Veteran's pseudofolliculitis barbae markedly interferes with his ability to work. See 38 C.F.R. § 4.1 (indicating that generally, the degrees of disability specified in the Rating Schedule are considered adequate to compensate for considerable loss of working time from exacerbations or illnesses proportionate to the severity of the several grades of disability). The manifestations of the Veteran's disability are considered by the schedular rating. Based on the foregoing, the Board finds the schedular evaluation is adequate, and referral is not required. 38 C.F.R. § 3.321; Thun v. Peake, 22 Vet. App. 111 (2008). Duties to Notify and Assist As provided for by the Veterans Claims Assistance Act of 2000 (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, 3.326(a) (2012). Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant and his or her representative, if any, of any information, and any medical or lay evidence, that is necessary to substantiate the claim. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b); Quartuccio v. Principi, 16 Vet. App. 183 (2002). 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 C.F.R. § 3.159(b)(1). Such notice should also address VA's practices in assigning disability evaluations and effective dates for those evaluations. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). While the required notice should be furnished prior to the issuance of the appealed rating decision, any initial errors of notice will not be prejudicial if: 1) corrective actions (e.g., issuance of a post-adjudication notice letter containing the required information) are taken, and 2) the appeal is readjudicated (e.g., in a Supplemental Statement of the Case). See Mayfield v. Nicholson, 499 F.3d 1317 (Fed. Cir. 2007). Here, the VCAA duty to notify was satisfied by way of a letters sent to the Veteran in January 2008 and June 2008. In the January 2008 letter, the RO informed the Veteran of what evidence was required to substantiate the claim for service connection for hypertension and in the June 2008 letter, the RO informed the Veteran of what evidence was required to substantiate the claim for an increased rating for pseudofolliculitis barbae. Both letters provided information on the Veteran's and VA's respective duties for obtaining evidence. In the letters the RO also provided notice with regard to how VA assigns disability ratings and effective dates. Thus, the duty to notify has been satisfied. VA also has a duty to assist the Veteran with the development of facts pertinent to the appeal. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159(c). This duty includes the obtaining of "relevant" records in the custody of a federal department or agency under 38 C.F.R. § 3.159(c)(2), as well as records not in federal custody (e.g., private medical records) under 38 C.F.R. § 3.159(c)(1). VA will also provide a medical examination if such examination is determined to be "necessary" to decide the claim. 38 C.F.R. § 3.159(c)(4). The Board finds that all necessary development has been accomplished. The RO has obtained the Veteran's service treatment records and VA treatment records. Neither the Veteran nor his representative has identified, and the record does not otherwise indicate, any additional existing evidence that is necessary for a fair adjudication of the claim that has not been obtained. The Veteran was afforded a VA medical examination with regard to his pseudofolliculitis barbae in April 2011. An addendum was provided in March 2012. The examiner, a medical professional, obtained an accurate history, listened to the Veteran's assertions, and provided the Board with sufficient information to rate the Veteran's disability. Therefore, the Board finds that the examination is adequate and contains sufficient information to decide the issue on appeal. Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). The Veteran was not afforded a VA examination for his hypertension claim, but none is required. In determining whether the duty to assist requires that a VA medical examination be provided or medical opinion obtained with respect to a veteran's claim for benefits, there are four factors for consideration. These four factors are: (1) whether there is competent evidence of a current disability or persistent or recurrent symptoms of a disability; (2) whether there is evidence establishing that an event, injury, or disease occurred in service, or evidence establishing certain diseases manifesting during an applicable presumption period; (3) whether there is an indication that the disability or symptoms may be associated with the veteran's service or with another service-connected disability; and (4) whether there otherwise is sufficient competent medical evidence of record to make a decision on the claim. 38 U.S.C. § 5103A(d) and 38 C.F.R. § 3.159(c)(4). With respect to the third factor above, the Court of Appeals for Veterans Claims has stated that this element establishes a low threshold and requires only that the evidence "indicates" that there "may" be a nexus between the current disability or symptoms and the veteran's service. The types of evidence that "indicate" that a current disability "may be associated" with military service include, but are not limited to, medical evidence that suggests a nexus but is too equivocal or lacking in specificity to support a decision on the merits, or credible evidence of continuity of symptomatology such as pain or other symptoms capable of lay observation. McLendon v. Nicholson, 20 Vet. App. 79 (2006). The Federal Circuit has addressed the appropriate standard to be applied in determining whether an examination is warranted. In Waters v. Shinseki, 601 F.3d 1274 (Fed. Cir. 2010) and Colantonio v. Shinseki, 606 F.3d 1378 (Fed. Cir. 2010), the Federal Circuit held that while there must be "medically competent" evidence of a current disability, "medically competent" evidence is not required to indicate that the current disability may be associated with service. Colantonio, 606 F.3d at 1382; Waters, 601 F.3d at 1277. On the other hand, a conclusory generalized lay statement suggesting a nexus between a current disability and service would not suffice to meet the standard of subsection (B), as this would, contrary to the intent of Congress, result in medical examinations being "routinely and virtually automatically" provided to all veterans claiming service connection. Waters, 601 F.3d at 1278-1279. Here, as the only evidence that the Veteran's claimed hypertension is related to his military service is his own conclusory generalized lay statements, which are unsupported by even speculative medical evidence and is, in fact, unsupported by the blood pressure reading cited above. Accordingly, the Board finds that referral for a VA medical examination for hypertension is not warranted. Significantly, neither the appellant nor his or representative has identified, and the record does not otherwise indicate, any additional existing evidence that is necessary for a fair adjudication of the claim that has not been obtained. Hence, no further notice or assistance to the appellant is required to fulfill VA's duty to assist the appellant in the development of the 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). ORDER Service connection for hypertension is denied. A rating in excess of 10 percent for pseudofolliculitis barbae is denied. ____________________________________________ JOHN J. CROWLEY Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs