Citation Nr: 1327158 Decision Date: 08/26/13 Archive Date: 08/29/13 DOCKET NO. 10-06 030 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Milwaukee, Wisconsin THE ISSUES 1. Entitlement to a higher disability rating higher for right hand superficial radial sensory neuropathy, currently rated as 20 percent disabling. 2. Entitlement to the assignment of separate disability ratings for vocal cord dysfunction and laryngopharyngeal reflux (LPR), which are currently rated as one disability described as vocal cord dysfunction due to LPR. 3. Entitlement to a disability rating or ratings higher than the existing single 10 percent rating for vocal cord dysfunction and LPR. REPRESENTATION Appellant represented by: Wisconsin Department of Veterans Affairs WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD K. J. Kunz, Counsel INTRODUCTION The Veteran served on active duty from October 1985 to October 1989 and from October 2001 to October 2002. He also had reserve service. This appeal comes before the Board of Veterans' Appeals (Board) from rating decisions by the Milwaukee, Wisconsin Regional Office (RO) of the United States Department of Veterans Affairs (VA). In a July 2008 rating decision the RO continued a 20 percent disability rating for right hand superficial radial sensory neuropathy. In a May 2010 rating decision the RO changed the description of a service-connected disability from "vocal cord dysfunction," to "vocal cord dysfunction due to laryngopharyngeal reflux." At that time a 0 percent disability rating was in effect for that disability, and the RO continued a 0 percent rating. In a February 2012 rating decision the RO increased, effective February 27, 2009, the rating for vocal cord dysfunction due to LPR from 0 percent to 10 percent. The Veteran initiated but did not perfect an appeal of the ratings assigned for left knee patellofemoral pain syndrome and right knee patellofemoral pain syndrome. In the July 2008 rating decision the RO continued ratings of 10 percent each for those knee disabilities. In February 2009 the Veteran submitted a notice of disagreement (NOD) with decisions in the July 2008 rating decision including the ratings for the knee disabilities. In January 2010 the RO issued a statement of the case (SOC) regarding appealed issues including the knee disability ratings. In a February 2010 substantive appeal the Veteran perfected his appeal on other issues (the ratings for right hand neuropathy, vocal cord dysfunction, and LPR) but did not address the issue of ratings for knee disabilities. Appellate review of a VA decision on benefits will be initiated by an NOD and completed by substantive appeal after an SOC is furnished. 38 U.S.C.A. § 7105(a) (West 2002). In the substantive or formal appeal the benefits sought on appeal must be clearly identified. See 38 U.S.C.A. § 7105(d)(3) (West 2002). As the Veteran did not perfect, or complete the filing of, an appeal of the knee disability ratings by addressing those issues in a substantive appeal, the ratings for the knee disabilities are not before the Board on appeal. In March 2013 the Veteran had a videoconference hearing before the undersigned Acting Veterans Law Judge. A transcript of that hearing is associated with the record. The Board has reviewed both the Veteran's paper claims file and the Veteran's file on the Virtual VA electronic file system, to ensure a total review of the evidence. In this decision the Board grants entitlement to separate disability ratings for vocal cord dysfunction and for LPR. The matter of the assignment of specific separate ratings for vocal cord dysfunction and for LPR is addressed in the REMAND portion of the decision below and is REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. FINDINGS OF FACT 1. The Veteran's right hand superficial radial sensory neuropathy is manifested by pain, numbness, hypersensitivity, and an uncomfortable tingling sensation with any contact with a particular area of the hand; but does not produce any weakness or limitation of motion of any part of the wrist, hand, or fingers. 2. The Veteran's vocal cord dysfunction is manifested by hoarseness and vocal changes. Those manifestations are separate and distinguishable from, and affect areas and functions different from, his LPR symptoms of reflux, burning, and discomfort of the stomach, hiatus, esophagus, and throat. CONCLUSIONS OF LAW 1. The Veteran's right hand superficial radial sensory neuropathy meets the criteria for a 30 percent disability rating. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. Part 4, including §§ 4.1, 4.2, 4.7, 4.10, 4.123, 4.124, 4.124a, Diagnostic Codes 8514, 8614, 8714 (2012). 2. Vocal cord dysfunction symptoms affecting speech should be rated separately from gastrointestinal and esophageal symptoms of LPR. 38 U.S.C.A. §§ 1155, 5107); 38 C.F.R. §§ 4.1, 4.14 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA), Pub. L. No. 106-475, 114 Stat. 2096 (Nov. 9, 2000) (codified at 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, and 5126 (West 2002 & Supp. 2011)) redefined VA's duty to assist a claimant in the development of a claim for VA benefits. VA regulations for the implementation of the VCAA were codified as amended at 38 C.F.R. §§ 3.102, 3.156(a), 3.159, and 3.326(a) (2012). The notice requirements of the VCAA require VA to notify the Veteran of what information or evidence is necessary to substantiate the claim; what subset of the necessary information or evidence, if any, the claimant is to provide; and what subset of the necessary information or evidence, if any, VA will attempt to obtain. 38 C.F.R. § 3.159(b). The United States Court of Appeals for Veterans Claims (Court) has stated that the requirements apply to all five elements of a service connection claim: veteran status, existence of a disability, a connection between the veteran's service and the disability, degree of disability, and effective date of the disability. Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). VCAA notice must be provided to a claimant before the initial unfavorable decision on a claim for VA benefits by the agency of original jurisdiction (in this case, the RO). Id.; see also Pelegrini v. Principi, 18 Vet. App. 112 (2004). Insufficiency in the timing or content of VCAA notice is harmless, however, if the errors are not prejudicial to the claimant. Conway v. Principi, 353 F.3d 1369, 1374 (Fed. Cir. 2004) (VCAA notice errors are reviewed under a prejudicial error rule). Also, in Bryant v. Shinseki, 23 Vet. App. 488, 493-94 (2010), the Court held that 38 C.F.R. § 3.103(c)(2) requires that that the Veterans Law Judge (VLJ) who conducts a Board hearing fulfill duties to (1) fully explain the issues and (2) suggest the submission of evidence that may have been overlooked. The RO provided the Veteran with VCAA notice in letters issued in December 2002, March 2003, January 2004, January 2006, March 2006, March 2008, January 2010, and February 2012. In those letters the RO addressed the information and evidence necessary to substantiate claims for service connection and increased ratings. The RO informed the Veteran how VA assigns effective dates. The letters also addressed who was to provide the evidence. In the March 2013 videoconference hearing the Veteran was assisted by an accredited representative from the Wisconsin Department of Veterans Affairs. The undersigned Acting VLJ fully explained the issues and suggested the submission of evidence that may have been overlooked. Neither the Veteran nor his representative has asserted that VA failed to comply with 38 C.F.R. § 3.103(c)(2) or identified any prejudice in the conduct of the Board hearing. The Board therefore finds that, consistent with Bryant, the Acting VLJ who conducted the hearing complied with the duties set forth in 38 C.F.R. § 3.103(c)(2), and that any error provided in notice during the Veteran's hearing constitutes harmless error. The Veteran's claim file (including information on paper and in electronic form) contains service treatment records, records of post-service treatment and examinations, statements from the Veteran, and a transcript of the March 2013 hearing. The Veteran has had medical examinations performed by qualified clinicians who reviewed the Veteran's claim file. The examiners explained their findings and conclusions. The examinations and examination reports are adequate for the purpose of addressing the claims that the Board is deciding at this time. The Board finds that the Veteran was notified and aware of the evidence needed to substantiate his claims, as well as the avenues through which he might obtain such evidence, and the allocation of responsibilities between the Veteran and VA in obtaining such evidence. The Veteran has actively participated in the claims process by providing evidence and argument. Thus, he was provided with a meaningful opportunity to participate in the claims process, and he has done so. Any error in the sequence of events or content of the notice is not shown to have affected the essential fairness of the adjudication nor to have caused injury to the Veteran's interests. See Pelegrini, 18 Vet. App. at 121. Therefore, any such error is harmless, and does not prohibit consideration on the merits of the claims that the Board is deciding at this time. See Conway, 353 F.3d at 1374, Dingess, 19 Vet. App. 473; see also ATD Corp. v. Lydall, Inc., 159 F.3d 534, 549 (Fed. Cir. 1998). Right Hand Superficial Radial Sensory Neuropathy The Veteran contends that his service connected right hand superficial radial sensory neuropathy warrants a disability rating higher than the existing 20 percent rating. VA assigns disability ratings by evaluating the extent to which a veteran's service-connected disability adversely affects his ability to function under the ordinary conditions of daily life, including employment, by comparing his symptomatology with the criteria set forth in the VA Schedule for Rating Disabilities (rating schedule). 38 U.S.C.A. § 1155; 38 C.F.R. Part 4, including §§ 4.1, 4.2, 4.10. If two ratings are potentially applicable, the higher rating 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. When evaluation of a musculoskeletal disability is based on limitation of motion, VA regulations provide, and the Court has emphasized, that evaluation must include consideration of impairment of function due to such factors as pain on motion, weakened movement, excess fatigability, diminished endurance, or incoordination. 38 C.F.R. §§ 4.40, 4.45, 4.59 (2012); see DeLuca v. Brown, 8 Vet. App. 202 (1995). In determining the current level of impairment, the disability must be considered in the context of the whole recorded history, including service medical records. 38 C.F.R. § 4.2. The Board acknowledges that a claimant may experience multiple distinct degrees of disability that might result in different levels of compensation from the time the increased rating claim was filed until a final decision is made. See Hart v. Mansfield, 21 Vet. App. 505 (2007). The Board will consider the evidence for the entire period from the year preceding the Veteran's January 2008 claim for an increased rating and will consider whether higher ratings are warranted for any periods. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a claim, VA shall give the benefit of the doubt to the claimant. 38 U.S.C.A. § 5107. The Veteran is right handed. The RO evaluates the Veteran's right hand superficial radial sensory neuropathy under 38 C.F.R. §§ 4.123, 4.124, and 4.124a, Diagnostic Codes 8514, 8614, and 8714. That part of the rating schedule provides for evaluating complete and incomplete paralysis and neuritis and neuralgia of the radial (or musculospiral) nerve of the major or dominant upper extremity as follows: Complete paralysis of the nerve; drop of hand and fingers, wrist and fingers perpetually flexed, the thumb adducted falling within the line of the outer border of the index finger; can not extend hand at wrist, extend proximal phalanges of fingers, extend thumb, or make lateral movement of wrist; supination of hand, extension and flexion of elbow weakened, the loss of synergic motion of extensors impairs the hand grip seriously; total paralysis of the triceps occurs only as the greatest rarity ........................................... 70 percent Incomplete paralysis of the nerve: Severe ................................................ 50 percent Moderate ............................................. 30 percent Mild ................................................... 20 percent Note: Lesions involving only "dissociation of extensor communis digitorum" and "paralysis below the extensor communis digitorum" will not exceed the moderate code under code 8514. Peripheral neuritis is characterized by loss of reflexes, muscle atrophy, sensory disturbances, and constant pain, at times excruciating, and is to be rated on the scale provided for injury of the nerve involved, with a maximum equal to severe, incomplete, paralysis. The maximum rating which may be assigned for neuritis not characterized by organic changes referred to in this section will be that for moderate severe, incomplete paralysis. 38 C.F.R. § 4.123. Peripheral neuralgia is characterized usually by a dull and intermittent pain, of typical distribution so as to identify the nerve, and is to be rated on the same scale, with a maximum equal to moderate incomplete paralysis. 38 C.F.R. § 4.124. Service treatment records reflect that during service in 2002 the Veteran sustained injury that was followed by pain and neuropathy in her right upper extremity. Symptoms then included numbness over the dorsum of the thumb and the first and second digits, and paresthesias with pressing over the distal radius. An electromyography (EMG) study in July 2002 suggested right superficial radial nerve neuropathy. In a May 2003 VA medical examination the Veteran reported ongoing numbness in his right hand. He related discomfort in his right hand located at the first web. He stated that discomfort increased when a pen or eating utensil touched the first web. He indicated that pushing a lawnmower or holding a show shovel bothered his right hand. He reported that he did not have a problem with vacuuming, cleaning, dishwashing, or laundry. The examiner found that the Veteran had dysesthesia and paresthesia in the right radial territory, and slightly decreased pain and pin prick sensation in the right median nerve. The muscles enervated by the right median, radial, and ulnar nerves had no muscle weakness. Ranges of motion of the right wrist and fingers were fine. There was no pain on motion of the right hand. There was no excessive fatigability, weakness, or incoordination of the right wrist, hand, or fingers. A May 2003 EMG study showed mild superficial radial sensory neuropathy at the right wrist and hand. In January 2008 the Veteran requested a rating higher than the existing 20 percent rating for his right hand neuropathy. He stated that the hand sensitivity was such that it hurt when he held anything, like a pen, for an extended period. He reported that the problems with his dominant right hand made it difficult to do regular activities. On VA examination in May 2008 the Veteran reported ongoing pain and a numb area on his right hand. He indicated that the webspace of his right hand had tingling pain and was hypersensitive. He stated that the pain and tingling were worse with holding a writing implement or eating utensil, and that the symptoms made him unable to hold a cup for a prolonged period. He reported that any touching of the affected area caused pain. He stated that the pain and other symptoms had worsened since the previous VA examination. He explained that the dysesthesias had become more acute or intense. The Veteran indicated that he worked in an office job. He stated that he was able to use a keyboard. He indicated that he adapted to the symptoms of the hand neuropathy by substituting activities as needed. He stated that with frequent substitution of activities he was able to complete his work without difficulty. He indicated that he was able to perform self care and activities of daily living and to take care of his child. He stated that he was able to shower, but that water touching his right webspace made that area very uncomfortable. He stated that the right hand symptoms were very superficial but that the discomfort became very intense with any stimulation. The examiner found normal strength, reflexes, and ranges of motion in the joints and muscles of the right elbow, wrist, and fingers. Protective sensation measured with 5.07 monofilament was present. There was decreased light touch sensation in the right superficial radial nerve territory. The examiner asked the Veteran to write. While writing the Veteran made a transition to shift the pen to not touch the webspace. The Veteran reported dysesthesias between 15 and 30 seconds while writing. The examiner concluded that tenderness and sensory changes caused the Veteran to change his positioning. The examiner found that the Veteran was able to continue writing, and that his right hand neuropathy did not cause problems dressing and undressing, pushing off from a chair, or grabbing objects. The examiner wrote: The findings do not suggest any increased functional problems; however, it is clearly bothering him more, as he is requiring more and more substitution patterns, with more intense dysesthesias in the right hand. In a July 2008 statement, the Veteran contended that his right hand symptoms were moderate as opposed to mild. He stated that the symptoms in his dominant right hand made him take longer and alter the way he did things like writing and eating. In a February 2009 statement he asserted that EMG and examination findings supported his contention that his symptoms were moderate rather than mild. In May 2009 the Veteran had a VA surgery consultation regarding a slow growing mass in the second webspace of his right hand, with associated fingertip paresthesia. The consulting clinician found that the 2 x 3 x 4 centimeter mass was tender to palpation. It was also noted that the Veteran had radial nerve parasthesia involving his right hand and distal forearm. Right hand x-rays were negative for fracture or other bony abnormality. In July 2009 the Veteran had surgery to excise the mass in the second webspace. On follow-up in August 2009 the Veteran reported minimal pain and a little sensitivity in his right hand. In late August 2009 the Veteran had no real complaints of pain in his right hand. A clinician found that sensation to light touch was intact in the entire right hand. In a February 2010 statement the Veteran noted that his right hand neuropathy produced sensory dysfunction without impairment of movement of the hand. He indicated that he found it unclear from the rating criteria what constitutes mild versus moderate impairment. He asserted that his right hand disability had worsened since the 2002 effective date of service connection and the 20 percent rating. He contended that the disability thus had increased from mild to moderate, and warranted a 30 percent rating. On VA hand and nerves examinations in September 2012 the examiner reported having reviewed the claims file. The examiner noted that May 2003 EMG studies showed abnormal results in the right upper extremity. She indicated that the Veteran had been diagnosed with mild sensory radial neuropathy of the right hand. The Veteran stated that his right hand neuropathy had not improved. He reported having numbness in the right first through third fingers, most prominent in the radial aspect of the index finger. He stated that he got pain in the area if he used a pen with a clip, but not if he used a straight pen. He indicated that contact of the area by utensils or other objects caused irritation in the form of prickly, superficial pain. He stated that typing did not bother him. He related that he worked in an office. The examination report indicated that the Veteran had in his right upper extremity numbness, paresthesias and/or dysesthesias, and intermittent pain. On the examination report for each of those symptoms mild was checked. The other choices were none, moderate, and severe. The examiner found that the Veteran had full muscle strength in movement of his right elbow and wrist, in grip of the hand, and in pinch of the thumb to the index finger. There was no evidence of muscle atrophy. Right and left upper extremity deep tendon reflexes were hypoactive. There was no evidence of limitation of motion, pain on motion, or weakness of the finger joints. Sensation to light touch was normal in the right forearm, hand, and fingers. The examiner found that the right radial nerve had normal function. The examiner stated that the Veteran's peripheral neuropathy did not impact his ability to work. In the March 2013 Board videoconference hearing the Veteran noted that on the 2012 VA examination report the examiner checked mild to describe his right hand neuropathy symptoms, but that the examiner did not ask the Veteran to characterize the severity of the symptoms. The Veteran stated that he got a pins and needles sensation if any object or even water touched the web space between his right thumb and index finger. He reported that he had pain in that area, and recently also had itching. He related that he avoided activities that affected his hand. He indicated that the symptoms did not affect his work. He contended that earlier his symptoms and impairment were mild, but that they worsened and progressed to moderate. The evidence indicates that the Veteran's right hand neuropathy is manifested by pain, numbness, hypersensitivity, and an uncomfortable tingling sensation with any contact with a particular area of the hand; without weakness or limitation of motion. Those manifestations most closely resemble peripheral neuralgia as described under 38 C.F.R. § 4.124, and do not show any of the types of impairment described under paralysis of the radial nerve under Diagnostic Code 8514. For peripheral neuralgia the maximum rating is equal to the rating for moderate incomplete paralysis. 38 C.F.R. § 4.124. Examination reports and statements from the Veteran show a reasonably consistent picture of the Veteran's right hand neuropathy necessitating frequent adjustments in work and daily activities. Considering the impact of the disorder on the Veteran, the neuropathy reasonably warrants the maximum rating for peripheral neuralgia, consistent with moderate incomplete paralysis of the major radial nerve, that is, a 30 percent rating. The right hand neuropathy has not at any time warranted a rating than 30 percent. The Board acknowledges the Veteran's account of the worsening of the effects of the neuropathy. The manifestations have remained limited, however, to hypersensitivity and discomfort, without any type of hand or finger motion being precluded or even weakened. The Board has considered whether the record raises the issue of unemployability, such that unemployability must be considered. See Rice v. Shinseki, 22 Vet. App. 447 (2009). The Veteran and clinicians who have examined him have repeatedly and consistently indicated that his right hand neuropathy necessitates adjustments at work but does not keep him from completing his work tasks and maintaining his full time employment. Thus, the record with respect to his right hand neuropathy does not raise the issue of unemployability. When there is an exceptional disability picture, such that the rating schedule criteria do not reasonably describe a claimant's disability level and symptomatology, an RO may refer a case to the VA Under Secretary for Benefits or to the Director of the VA Compensation and Pension Service for consideration of an extraschedular rating. See 38 C.F.R. § 3.321(b)(1) (2012); see also Thun v. Peake, 22 Vet. App. 111, 115 (2008). Extraschedular ratings are limited to cases in which it is impractical to apply the regular standards of the rating schedule because there is an exceptional or unusual disability picture, with such related factors as frequent hospitalizations or marked interference with employment. 38 C.F.R. § 3.321(b)(1). The Veteran's right hand neuropathy has not required frequent hospitalizations. As noted above, the right hand neuropathy necessitates adjustments at work, but the impact of the condition does not even begin to approach marked interference with employment. The rating criteria take into account the discomfort the Veteran experiences, and provide for higher ratings for greater impairment of hand function than is present in this case. Therefore the regular rating criteria are sufficient to the circumstances of this case. It is not necessary to refer the rating of the Veteran's right hand neuropathy for consideration of extraschedular ratings. Vocal Cord Dysfunction and Laryngopharyngeal Reflux The Veteran is seeking two separate ratings for dysfunction and symptoms that the RO has addressed and evaluated as a single disability. Specifically, he requests separate service connection and separate ratings for vocal cord dysfunction and LPR. He essentially contends that each of those disorders has symptoms distinct from the symptoms of the other. Whether vocal cord dysfunction and LPR are evaluated as one condition or two, he is seeking a rating or ratings higher than the single 10 percent rating that is currently assigned. From 2002 forward the Veteran has submitted and the RO has addressed claims regarding his throat. During his 2001 to 2002 period of active service the Veteran received treatment for symptoms including sore throat. In December 2002 he submitted a claim for service connection for chronic obstructive pulmonary disease (COPD). In January 2003 laryngoscopy showed upper airway obstruction in the throat with lingular and tonsillar hypertrophy. Vocal cord dysfunction was diagnosed. On VA respiratory examination in May 2003 the Veteran reported a history of sore throat, breathing problems, and voice changes since service. In May 2003 videostroboscopy showed posterior glottis erythema and edema consistent with LPR. In July 2003 a clinician found that the Veteran had LPR and dyspnea associated with epiglottic/tongue base retroversion. In August 2003 the Veteran reported that his vocal cord changes had earlier been attributed to COPD and emphysema, but later were attributed to acid reflux. On VA respiratory examination in September 2003 the Veteran was noted to have vocal cord dysfunction. In an October 2003 rating decision, the RO granted service connection for vocal cord dysfunction. The RO assigned for that disability ratings of 0 percent from October 29, 2002, 10 percent from January 24, 2002, and 0 percent from June 1, 2003. The RO evaluated the vocal cord dysfunction under Diagnostic Code 6599, meaning evaluated as analogous to nose and throat respiratory disorders under 38 C.F.R. § 4.97 and diagnostic codes in the 6500 range, and under Diagnostic Code 6516, for chronic laryngitis. Diagnostic Code 6516 provides for a 30 percent rating for hoarseness, with thickening or nodules of cords, polyps, submucous infiltration, or pre-malignant changes on biopsy; and provides for a 10 percent rating for hoarseness, with inflammation of cords or mucous membrane. VA treatment records from 2004 forward reflect that the Veteran was on medication to address reflux. In November 2005 the Veteran requested an increased rating for vocal cord dysfunction. In VA treatment notes from January 2006 a clinician indicated that the Veteran had sleep problems possibly from obstructed airway. On VA examination in January 2006 the Veteran reported breathing issues from 2002 forward and a diagnosis of vocal cord dysfunction. It was noted that the Veteran was on medication to address reflux. In a June 2006 rating the RO continued the 0 percent rating for vocal cord dysfunction. In January 2008 the Veteran requested service connection for gastroesophageal reflux disease (GERD). In a July 2008 rating decision the RO denied service connection for GERD. In February 2009 the Veteran appealed that decision. He asserted that he had vocal cord dysfunction and reflux, and that they were two separate disorders that should be rated separately. He indicated that he had learned that his reflux was not GERD but was instead LPR. In an April 2010 telephone contact the Veteran clarified that he was not making a new claim for a higher rating for vocal cord dysfunction. In a May 2010 rating decision the RO changed the description of a service-connected disability from "vocal cord dysfunction," to "vocal cord dysfunction due to laryngopharyngeal reflux." The RO continued the 0 percent disability rating had been in effect for vocal cord dysfunction. The RO continued to evaluate the disability under Diagnostic Codes 6599 and 6516. In September 2010 the Veteran appealed the May 2010 rating decision. He reported that he had cough, hoarseness, a lump in the throat, chronic voice clearing, and sore throat. He asserted that his vocal cord dysfunction and LPR were separate conditions that should be evaluated separately. He also contended that the symptoms and affects of those conditions warranted a compensable rating or ratings. In November 2010 the Veteran requested a higher rating for vocal cord dysfunction. On VA examination in June 2011 the Veteran indicated that he was on medication for reflux. He stated that he had a sore throat, a lump in his throat, frequent throat clearing, and some coughing. The examiner's diagnosis was chronic LRP. In a February 2012 rating decision the RO increased, effective February 27, 2009, the rating for vocal cord dysfunction due to LPR from 0 percent to 10 percent. The RO continued to evaluate the disability under Diagnostic Codes 6599 and 6516. In February 2012 the Veteran wrote that his LPR had manifestations that the RO had not considered, and that were not addressed by Diagnostic Code 6516, which the RO used to rate his vocal cord dysfunction with LPR. In the March 2013 Board videoconference hearing, the Veteran reported that his vocal cord dysfunction was manifested by hoarseness. He stated that his LPR was manifested by pain in his throat and nausea. He asserted that these were separate conditions that have separate and different symptoms. He again contended that Diagnostic Code 6516 does not address some of the manifestations of LPR that he experiences. Later in March 2013, the Veteran was examined by a VA physician. The examiner reported having reviewed examination reports and treatment records. He discussed the findings of imaging performed in 2003 and 2011. He stated that the Veteran had hiatal hernia and LPR. He explained: The veteran suffers from chronic laryngopharyngeal reflux or (LPR) and which is manifest[ed] by both vocal cord dysfunction and gastrointestinal (GI) symptoms. The GI symptoms include: epigastric distress; pyrosis; reflux; regurgitation; nausea[.] The Veteran contends that his vocal cord dysfunction has different symptoms than, and is a separate disorder from, his laryngopharyngeal reflux. Disability ratings are intended to represent as far as can practicably be determined the average impairment in earning capacity resulting from service-connected disabilities. 38 C.F.R. § 4.1. Pyramiding, described as the evaluation of the same disability under various diagnoses, is to be avoided. 38 C.F.R. § 4.14. The VA physician who examined the Veteran in March 2013 concluded that the Veteran has LPR that causes vocal cord dysfunction and GI symptoms. The physician attributed the symptoms to one disorder, LPR, but described distinguishable types of symptoms resulting from that disorder. Diagnostic Code 6516 addresses the Veteran's hoarseness and vocal cord dysfunction. However, Diagnostic Code 6516 does not address GI symptoms of LPR such as epigastric distress, pyrosis, reflux, regurgitation, and nausea. Having voice changes and difficulty speaking is a different type of impairment than having burning and pain from reflux from the stomach upward. As hoarseness and altered speech from vocal cord dysfunction, and burning and pain in the stomach, esophagus, and throat from reflux are different types of symptoms affecting different areas and functions, they do not constitute the same disability. Therefore rating the vocal cord and GI symptoms separately would not be pyramiding, and in fact would be the more appropriate way to evaluate the Veteran's disorders. The Board therefore grants entitlement to separate service connection and separate ratings for vocal cord dysfunction (as manifested by hoarseness and any speech changes or impairment) and for LPR (as manifested by symptoms including discomfort affecting the stomach, hiatus, esophagus, and throat). ORDER Entitlement to a 30 percent disability rating for right hand superficial radial sensory neuropathy is granted, subject to the laws and regulations controlling the disbursement of monetary benefits. Entitlement to the assignment of separate disability ratings for vocal cord dysfunction and for LPR is granted, subject to the laws and regulations controlling the disbursement of monetary benefits. REMAND In this decision the Board granted entitlement to separate disability ratings for vocal cord dysfunction with affects on speech and for LPR with GI symptoms. As the agency of original jurisdiction (the RO) has not assigned separate ratings for those separate disabilities in the first instance, the Board will remand the case to the RO to assign such ratings. Accordingly, these matters are REMANDED for the following action: 1. Assign a disability rating or ratings based on the evidence for vocal cord dysfunction including any hoarseness, vocal changes, or speech impairment. Assign a separate disability rating or ratings based on the evidence for laryngopharyngeal reflux (LPR) including any symptoms or disorders affecting the stomach, hiatus, esophagus, and throat. If deemed necessary, develop additional evidence regarding the manifestations and effects of those disorders. 2. Thereafter issue a supplemental statement of the case and afford the Veteran an opportunity to respond. Thereafter, return the case to the Board for appellate review if otherwise in order. The Board intimates no opinion as to the ultimate outcome of the matters that the Board has remanded. The Veteran has the right to submit additional evidence and argument on those matters. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2012). ______________________________________________ MATTHEW D. TENNER Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs