Citation Nr: 1327951 Decision Date: 09/03/13 Archive Date: 09/10/13 DOCKET NO. 09-46 297 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Waco, Texas THE ISSUES 1. Entitlement to an initial compensable rating for allergic rhinitis. 2. Entitlement to an initial compensable rating for gastroesophageal reflux disease prior to January 25, 2010, and in excess of 30 percent thereafter. 3. Entitlement to an initial compensable rating for ganglion cyst of the right wrist prior to January 25, 2010, and in excess of 10 percent thereafter. REPRESENTATION Appellant represented by: Texas Veterans Commission ATTORNEY FOR THE BOARD A. Adamson, Counsel INTRODUCTION The Veteran served on active duty from November 1986 to November 2006. This case comes before the Board of Veterans' Appeals (Board) on appeal of a January 2009 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Waco, Texas. In the January 2009 decision, the RO granted service connection for each of the three disabilities at issue in this appeal and assigned initial noncompensable ratings for each, all effective July 9, 2008. Thereafter, in a May 2010 rating decision, the RO granted a 30 percent rating for gastroesophageal reflux disease (GERD) and a 10 percent rating for right wrist ganglion cyst, effective January 25, 2010. These increases did not satisfy the Veteran's appeal. The Veteran requested a Travel Board hearing on his October 2009 VA Form 9, and again in December 2009, but submitted a statement in November 2011 indicating that he no longer desired a hearing. The Veteran has not alleged unemployability due to his service-connected disabilities, and the matter of entitlement to a total rating based on individual unemployability due to service-connected disabilities is not raised by either the Veteran or the evidence of record. See Rice v. Shinseki, 22 Vet. App. 447 (2009). The record before the Board consists of the Veteran's paper claims files and an electronic file known as Virtual VA. FINDINGS OF FACT 1. At no time during the initial rating period has Veteran's allergic rhinitis been manifested by obstruction of more than 50 percent in each nostril, by 100 percent in one nostril, or by nasal polyps. 2. For the period prior to January 25, 2010, the Veteran's GERD was manifested by the need for ongoing medication, regurgitation of liquid and occasional diarrhea, but not by persistently recurrent epigastric distress with dysphagia, pyrosis, and regurgitation, accompanied by substernal or arm or shoulder pain and productive of considerable impairment of health, or by symptoms of pain, vomiting, material weight loss and hematemesis or melena with moderate anemia, or other symptom combinations productive of impairment of considerable impairment of health. 3. For the period from January 25, 2010, to the present, the Veteran's GERD has been manifested by dysphagia, pyrosis, epigastric pain, substernal pain, reflux, regurgitation, nausea, and vomiting, but not by symptoms of pain, material weight loss and hematemesis or melena with moderate anemia, or other symptom combinations productive of impairment of health that more nearly approximates severe than considerable. 4. For the period prior to January 25, 2010, the Veteran's right wrist ganglion cyst measured 0.5 cm in diameter and was painful and tender to palpation, but was not deep, did not limit the motion of the wrist, and did not leave the wrist ankylosed. 5. For the period from January 25, 2010, to the present, the Veteran's right wrist ganglion cist measured 1.0 cm in diameter, has been painful and tender to palpation, but is not deep, does not limit the motion of the wrist, and does not leave the wrist ankylosed. CONCLUSIONS OF LAW 1. The criteria for a compensable initial rating for allergic rhinitis have not been met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 4.7, 4.31, 4.97, Diagnostic Code 6522 (2012). 2. Prior to January 25, 2010, the criteria for an initial compensable rating for GERD have not been met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 4.7, 4.20, 4.114, Diagnostic Code 7346 (2012). 3. On and after January 25, 2010, the criteria for a rating in excess of 30 percent for GERD have not been met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 4.7, 4.20, 4.114, Diagnostic Code 7346 (2012). 4. Throughout the initial rating period, the criteria for a 10 percent rating, but not higher, for a ganglion cyst of the right wrist have been met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 4.7, 4.20, 4.118, Diagnostic Codes 7804, 7819 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA), codified in pertinent part at 38 U.S.C.A. §§ 5103, 5103A (West 2002 & Supp. 2012), and the pertinent implementing regulation, codified at 38 C.F.R. § 3.159 (2012), provide that VA will assist a claimant in obtaining evidence necessary to substantiate a claim but is not required to provide assistance to a claimant if there is no reasonable possibility that such assistance would aid in substantiating the claim. They also require VA to notify the claimant and the claimant's representative, if any, of any information, and any medical or lay evidence, not previously provided to the Secretary that is necessary to substantiate the claim. As part of the notice, VA is to specifically inform the claimant and the claimant's representative, if any, of which portion, if any, of the evidence is to be provided by the claimant and which part, if any, VA will attempt to obtain on behalf of the claimant. The Board also notes the United States Court of Appeals for Veterans Claims (Court) has held that the plain language of 38 U.S.C.A. § 5103(a) (West 2002), requires that notice to a claimant pursuant to the VCAA be provided 'at the time' that or 'immediately after' VA receives a complete or substantially complete application for VA-administered benefits. Pelegrini v. Principi, 18 Vet. App. 112, 119 (2004). The timing requirement enunciated in Pelegrini applies equally to the initial-disability-rating and effective-date elements of a service-connection claim. Dingess v. Nicholson, 19 Vet. App. 473 (2006). The Veteran was provided adequate VCAA notice in a letter dated in August 2008, prior to the January 2009 rating decision on appeal. The record also reflects that all pertinent available service treatment records (STRs) and all available post-service medical evidence identified by the Veteran have been obtained. The Veteran has been afforded appropriate VA examinations, most recently in May and June 2012. The Veteran has not asserted, and the evidence of record does not show, that his disabilities have increased significantly in severity since those examinations. The Veteran has also been afforded an opportunity for a hearing before a Decision Review Officer or before the Board, but declined to do so. Neither the Veteran nor his representative has identified any outstanding evidence that could be obtained to substantiate the claims; the Board is also unaware of any such evidence. Accordingly, the Board will address the merits of the Veteran's claims. General Legal Criteria: Disability Ratings Disability evaluations are determined by the application of the VA's Schedule for Rating Disabilities (Rating Schedule), 38 C.F.R. Part 4 (2012). The percentage ratings contained in the Rating Schedule represent, as far as can be practicably determined, the average impairment in earning capacity resulting from diseases and injuries incurred or aggravated during military service and their residual conditions in civil occupations. 38 U.S.C.A. § 1155; 38 C.F.R. §§ 3.321(a), 4.1 (2012). Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. 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 are sufficient; and above all, a coordination of rating with impairment of function will be expected in all cases. 38 C.F.R. § 4.21 (2012). The evaluation of the same disability under various diagnoses is to be avoided. 38 C.F.R. § 4.14 (2012). 38 C.F.R. § 4.14 does not preclude the assignment of separate evaluations for separate and distinct symptomatology where none of the symptomatology justifying an evaluation under one diagnostic code is duplicative of or overlapping with the symptomatology justifying an evaluation under another diagnostic code. Esteban v. Brown, 6 Vet. App. 259, 262 (1994). Burden of Proof Except as otherwise provided by law, a claimant has the responsibility to present and support a claim for benefits under laws administered by the Secretary. The Secretary shall consider all information and lay and medical evidence of record in a case before the Secretary with respect to benefits under laws administered by the Secretary. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102; see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). To deny a claim on its merits, the evidence must preponderate against the claim. Alemany v. Brown, 9 Vet. App. 518, 519 (1996), citing Gilbert, 1 Vet. App. at 54. Analysis In accordance with 38 C.F.R. §§ 4.1, 4.2, 4.41, 4.42 (2012) and Schafrath v. Derwinski, 1 Vet. App. 589 (1991), the Board has reviewed all evidence of record pertaining to the history of the service-connected disabilities. The Board has found nothing in the historical record which would lead to the conclusion that the current evidence of record is not adequate for rating purposes. Moreover, the Board is of the opinion that this case presents no evidentiary considerations which would warrant an exposition of remote clinical histories and findings pertaining to the disabilities under review. Allergic Rhinitis Allergic rhinitis is rated under 38 C.F.R. § 4.97, Diagnostic Code 6522; the rating criteria are as follows: a 10 percent rating is warranted for allergic or vasomotor rhinitis without polyps but with greater than 50 percent obstruction of nasal passages on both sides or complete obstruction on one side. A 30 percent rating is warranted for allergic or vasomotor rhinitis with polyps. In every instance where the schedule does not provide a noncompensable evaluation for a diagnostic code, a noncompensable evaluation will be assigned when the requirements for a compensable evaluation are not met. 38 C.F.R. § 4.31. The Veteran seeks a compensable rating for his allergic rhinitis. The RO granted his service connection claim for this disability on the basis that the disability was shown to have preexisted service, but permanently worsened during service. While VA examination was obtained related to other claims in December 2008, this examination did not consider the Veteran's rhinitis. The first and only VA examinations related to the Veteran's rhinitis were conducted in May and June 2012. There are no clinical records of outpatient treatment available for the Board's review. The Veteran has not indicated that any such treatment records exist. Moreover, the Veteran has not provided any statements describing his symptoms during the course of this appeal. Thus, the only evidence available for the analysis of this claim are the May and June 2012 VA examination reports. The symptoms described are identical in both the May 2012 and June 2012 examination reports, which are in the format of a disability benefits questionnaire. At both times, the examiners confirmed the diagnosis of allergic rhinitis and specifically noted that the Veteran does not have chronic sinusitis. Continuous medication was noted as required in order to control the symptoms. The examiners confirmed that there was not an obstruction of greater than 50% of the nasal passage on both sides due to the rhinitis, nor was there complete obstruction of one side. The examiners also confirmed that there were no polyps present. Because the evidence shows that the Veteran does not have a greater than 50 percent obstruction of the nasal passage on either side, or complete obstruction on one side, and because there is also no showing of polyps at any time, the allergic rhinitis disability does not meet the criteria for a compensable rating. The Veteran's appeal as to this issue must be denied. Gastroesophageal Reflux Disease The RO initially granted service connection for GERD and awarded a noncompensable rating. A 30 percent rating, effective January 25, 2010, was assigned by way of a February 2013 rating decision. When an unlisted condition is encountered it will be permissible to rate under a closely related disease or injury in which not only the functions affected, but the anatomical location and symptomatology are closely analogous. 38 C.F.R. § 4.20. In this regard, the RO has rated the Veteran's service-connected GERD under Diagnostic Code 7346, analogous to hiatal hernia. Under Diagnostic Code 7346, a 10 percent rating is warranted when there are two or more of the symptoms for the 30 percent evaluation of less severity. A 30 percent disability evaluation is warranted for persistently recurrent epigastric distress with dysphagia, pyrosis, and regurgitation, accompanied by substernal or arm or shoulder pain and productive of considerable impairment of health. A 60 percent evaluation is warranted where there are symptoms of pain, vomiting, material weight loss and hematemesis or melena with moderate anemia, or other symptom combinations productive of severe impairment of health. Dysphagia is defined as difficulty in swallowing. DORLAND'S ILLUSTRATED MEDICAL DICTIONARY, 587 (31st ed. 2007). Pyrosis is defined as heartburn. Id. at 1587. Hematemesis is defined as the vomiting of blood. Id. at 842. Melena is defined as the passage of dark-colored feces stained with blood pigments or with altered blood. Id. at 1142. Initially, the Board notes that in October 2009, on his VA Form 9, the Veteran reported that he was in receipt of private treatment for his GERD and that he receives his prescription medication from a private provider. The RO did provide the Veteran with a VA Form 21-4142 in August 2008 in order that VA could assist him in developing relevant private treatment evidence; however, the Veteran did not respond. Thus, the Board is proceeding with the adjudication of this claim based upon the evidence of record, which includes a VA examination report and the Veteran's lay statements. In December 2008, the Veteran underwent a VA examination. He reported that he had taken Prilosec since his initial diagnosis of GERD in service. He reported that he had no history of abdominal pain, abdominal cramps, or heartburn. He did report experiencing regurgitation of liquid if he either forgets to take his Prilosec or if he eats after 6:00 p.m. He had no complaints of nausea, vomiting or constipation, but did report occasional diarrhea. He reported no trouble swallowing, as well as no peptic ulcer, rectal bleeding, hematochezia, hematemesis or hemoptysis. The examiner confirmed the appropriate diagnosis as GERD. The only additional evidence of record related to the Veteran's GERD prior to January 25, 2010, is his statement in October 2009 on the VA Form 9. He reported the he had attempted to get a treatment provider for his GERD, but that the facility in his region was not taking new patients. Again, he reported that he was obtaining his current medications from a private provider. He did not otherwise reference any specific symptoms of GERD at that time. In considering the evidence of record under the laws and regulations as set forth above, the Board concludes that the Veteran is not entitled to an initial compensable evaluation for his service-connected GERD for the period prior to January 25, 2010. As noted, in order to warrant a compensable rating, the Veteran must exhibit two or more of the symptoms for the 30 percent evaluation of less severity. A review of the record throughout this period shows only that ongoing medication was required, and that the Veteran experienced regurgitation of liquid and occasional diarrhea. The record is devoid of evidence showing any of the following: persistently recurrent epigastric distress with dysphagia, pyrosis, and regurgitation, accompanied by substernal or arm or shoulder pain and productive of considerable impairment of health. There was also no evidence of symptoms of pain, vomiting, material weight loss and hematemesis or melena with moderate anemia, or other symptom combinations productive of severe impairment of health. Thus, the criteria are not met for a compensable evaluation of GERD prior to January 25, 2010. The Veteran was again evaluated by a VA examiner on January 25, 2010. At this time, he reported that his symptoms had progressively worsened over the years, especially over the prior one year. He continued to deny having dysphagia, hematemesis or melena, but he did describe pyrosis, epigastric pain, including associated substernal pain, but no arm pain. These episodes were reported to occur three to seven times per week, lasting several hours each time. He also reported frequent reflux and regurgitation, at least one time per week. He reported the reflux causes him to cough, giving him the feeling that the acid has aspirated into his lungs which causes him to cough more, lasting for hours. The Veteran also reported nausea and vomiting approximately twice per month. Physical examination revealed bowel sounds present in all quadrants, with epigastric tenderness to palpation. The examiner diagnosed GERD with symptoms of pyrosis, epigastric pain, substernal pain, reflux, regurgitation, nausea, and vomiting. These symptoms clearly meet the criteria for a 30 percent rating. However, while there was noted vomiting approximately twice per month, there was not pain, material weight loss and hematemesis or melena with moderate anemia, or other symptom combinations productive of impairment of health that more nearly approximates severe than considerable. Thus, a 30 percent rating, but no more, was appropriately assigned effective the date of this examination. The question remains whether there is evidence to support a rating in excess of the 30 percent assigned at any time since January 2010. More recently, the Veteran underwent VA examination in June 2012. At this time, he reported dysphagia, reflux, and regurgitation, but no pain, weight loss, anemia, nausea or vomiting, hematemesis or melena. The examiner also noted that the Veteran's GERD does not impact the Veteran's ability to work. There is no indication in this report that the Veteran has symptoms of GERD that are productive of impairment of health that more nearly approximates severe than considerable. Thus, these more recent findings fail to show that a rating in excess of 30 percent is warranted for the Veteran's GERD since January 25, 2010, under Diagnostic Code 7346. Ganglion Cyst, Right Wrist The Veteran's right wrist claim was filed in July 2008, and in the January 2009 rating decision under appeal, the RO granted service connection, effective the date of receipt of the claim. A noncompensable rating was assigned. By way of a May 2010 rating decision, a 10 percent rating was assigned, effective January 25, 2010. The VA rating schedule contains no diagnostic code specifically applicable to rating a ganglion cyst of the wrist; therefore, it is rated by analogy to a closely related disease or injury in which not only the functions affected, but the anatomical localization and symptomatology are closely analogous. 38 C.F.R. § 4.20. In this case, the RO initially rated the disability as synovitis, which is rated on limitation of motion of the affected part, as arthritis, degenerative. 38 C.F.R. § 4.71a, DC 5020. Limitation of motion of the wrist is rated under DC 5215. A 10 percent rating is warranted for the major extremity (the Veteran is right-handed) if palmar flexion is limited in line with the forearm or if dorsiflexion is less than 15 degrees. 38 C.F.R. § 4.71a, DC 5215. This is the maximum schedular rating for limitation of wrist motion available under this diagnostic code. A higher rating is available under DC 5214, which requires evidence of ankylosis. Disabilities evaluated on the basis of limitation of motion require VA to apply the provisions of 38 C.F.R. §§ 4.40 and 4.45, pertaining to functional impairment. The Court has instructed that in applying these regulations VA should obtain examinations in which the examiner determines whether the disability is manifested by weakened movement, excess fatigability, incoordination, pain, or flare ups. Such inquiry is not to be limited to muscles or nerves. These determinations are, if feasible, to be expressed in terms of the degree of additional range-of-motion loss due to any weakened movement, excess fatigability, incoordination, flare ups, or pain. The examiner should also determine the point, if any, at which such factors cause functional impairment. Mitchell v. Shinseki, 25 Vet. App. 32, 43-4 (2011); DeLuca v. Brown, 8 Vet. App. 202 (1995); see also Johnston v. Brown, 10 Vet. App. 80, 84-5 (1997); 38 C.F.R. § 4.59. Effective January 25, 2010, the RO awarded a 10 percent rating for the Veteran's right wrist ganglion cyst under 38 C.F.R. § 4.118, Diagnostic Code 7819, which pertains to benign skin neoplasms. Diagnostic Code 7819 directs that benign skin neoplasms are to be rated as disfigurement of the head, face, or neck (DC 7800), scars (DC's 7801, 7802, 7803, 7804, or 7805), or impairment of function. Because the underlying rating criteria pertain to the skin, the Board notes that the regulations pertaining to rating skin disabilities were revised, effective October 23, 2008. However, those revised provisions are applicable only to claims received on or after October 23, 2008. Because the current claim was received prior to that date and the Veteran has not requested that his claim be considered under the revised criteria, those revisions do not apply in this case. 73 Fed. Reg. 54708 (Sept. 23, 2008). In this case, the RO based the 10 percent rating assigned as of January 25, 2010, on the pain and deemed it impairment of function in the area of the ganglion cyst. Scars (other than those involving the head, face, or neck) that are deep or that cause limited motion warrant a 10 percent rating for an area or areas exceeding 6 square inches (39 sq. cm.) and a 20 percent for area or areas exceeding 12 square inches (77 sq. cm.). A deep scar is one associated with underlying soft tissue damage. 38 C.F.R. § 4.118, DC 7801, Note (2). A 10 percent rating is warranted for scars (other than those on the head, face, or neck) that are superficial and that do not cause limited motion, provided that they cover an area or areas of 144 square inches (929 sq. cm.) or greater. A superficial scar is one not associated with underlying soft tissue damage. 38 C.F.R. § 4.118, Diagnostic Code 7803, Note (2). A 10 percent rating is warranted for scars that are superficial, unstable or painful. 38 C.F.R. § 4.118, DCs 7803, 7804. An unstable scar is one where, for any reason, there is frequent loss of covering of skin over the scar. 38 C.F.R. § 4.118, DC 7803, Note (1). For the period prior to January 25, 2010, for which the Veteran has a noncompensable rating assigned for this right wrist ganglion cyst, the only medical evidence available for the Board's review related to the wrist is a December 2008 VA examination report. At that time, the Veteran reported his history of ganglion cyst, and reported that his current symptoms included constant pain around the cyst area. The pain was noted to increase with movement of the wrist or use of the right arm. Physical examination revealed no anatomical defect of the right wrist, and no swelling, heat, instability, weakness, tenderness or redness. There was normal dorsiflexion (0 to 70 degrees), palmar flexion (0 to 80 degrees) and radial (0 to 20 degrees) and ulnar (0 to 45 degrees) deviation both actively and passively. The examiner also noted that there was no pain with motion at the time of this examination, and that with repetition there was no pain or change in function. The examiner did observe a 0.5 cm wide soft cyst on the medial aspect of the right wrist, with tenderness to palpation. X-ray examination was normal. Thus, the symptoms appear to be related to the actual cyst, rather than to the function of the joint. For this time period, the Veteran's range of motion of the wrist was noted as normal and there was no indication of ankylosis; thus, a compensable rating is not warranted under either DC 5214 or 5215. However, the area of the cyst was clearly noted as constantly painful and tender on palpation. Again, a 10 percent rating is warranted under DC 7804 for superficial scars that are tender or painful on examination. 38 C.F.R. § 4.118. Such a rating, therefore, is appropriate for this initial period under appeal. There is no indication that the ganglion cyst can be likened to a deep scar, and it is noted to be 0.5 cm wide, thus the other rating criteria related to scars do not provide for a higher rating. Assuming, arguendo, that the symptoms of the Veteran's right wrist ganglion cyst did manifest as limited wrist motion, the Board also notes that an initial rating in excess of 10 percent is not warranted in this case under DC 5215 because 10 percent is the maximum schedular rating provided under DC 5215 for limited motion of the wrist. Further, as a 10 percent rating is the highest rating available for limitation of motion of the wrist, a higher rating is also not possible based on any motion restriction under 38 C.F.R. § 4.71a , Diagnostic Code 5215. Given that the pain was described by the Veteran as associated with moving and using the wrist and arm, the Board has considered the guidance of DeLuca v. Brown, 8 Vet. App. 202 (1995) (discussing 38 C.F.R. §§ 4.40, 4.45); however, the analysis in DeLuca does not assist the Veteran, as the 10 percent rating deemed warranted in this case is also the maximum disability evaluation based on any limitation of motion of the wrist. Where a veteran is in receipt of the maximum schedular rating based on limitation of motion of the wrist and a higher rating requires ankylosis, the regulations pertaining to functional impairment (38 C.F.R. §§ 4.40 , 4.45, 4.59) are not for application. See Johnston, 10 Vet. App. at 85. Further, as the rating assigned will be based upon the Veteran's pain, the rating assigned contemplates functional limitations of his wrist, and thus to assign a separate rating under Diagnostic Code 5215 for limitation of motion would constitute pyramiding and is prohibited by 38 C.F.R. § 4.14. Resolving reasonable doubt in favor of the Veteran, the service-connected right wrist ganglion cyst was painful and tender to palpation since the time of the Veteran's initial claim for service connection and can, therefore, be rated as a painful scar under DC 7004, warranting a 10 percent, but no more, disability rating for the entire period prior to January 25, 2010. With respect to the period beginning January 25, 2010, the Board notes that at a VA examination on that date, the Veteran again reported pain over the area of the cyst, with the pain radiating from the site of the cyst to the medial edge of his thumb and up the radial edge of his right forearm. He reported a constant dull ache, which worsens with any type of movement. Physical examination revealed the cyst to be 1 cm in diameter along the radial edge of the right forearm. Range of motion of the right wrist was reported as normal. There was no change in function with repetition of motion. The examiner also noted that because there was no prior surgery for the cyst, there was no scar to examine. Following this examination, the RO assigned a 10 percent rating for the Veteran's pain, deeming it impairment of function under DC 7819. Most recently, the Veteran's right wrist was examined in June 2012. At this time, again, range of motion was normal and no ankylosis was reported. This examiner noted that there was no evidence of pain with motion, but there was no indication in this report of the Veteran's reported history. Examination also revealed that there was no limitation of motion following repetitive movement. No functional loss was noted related to the right wrist, but the examiner did report that the Veteran has radial nerve symptoms when the cyst expands. The 2012 examiner indicated that there was no pain on palpation of the cyst. X-ray examination at this time was also noted as normal. The above evidence reflects that since January 25, 2010, there has been a right wrist disability manifested by pain that is reported by the Veteran as with use, but is not shown on physical examination. Physical examination clearly reveals that the Veteran experienced normal range of motion and no ankylosis in the right wrist. Again, where, as here, a veteran is in receipt of the maximum schedular rating based on limitation of motion of the wrist and a higher rating requires ankylosis, the regulations pertaining to functional impairment (38 C.F.R. §§ 4.40 , 4.45, 4.59) are not for application. See Johnston, 10 Vet. App. at 85. As the evidence does not reflect that there is any ankylosis of the wrist, a rating in excess of 10 percent for a ganglion cyst of the right wrist under either DC 5214, or DC 5215 is not warranted at any time during the claim period. Moreover, there is no indication that the ganglion cyst can be likened to a deep scar, and it is noted during this period of the appeal to be 1.0 cm in diameter, thus there is no basis for a rating in excess of 10 percent under the rating criteria related to scars. Again, to assign separate ratings under the diagnostic code related to scars as well as the diagnostic code related to range of motion would be pyramiding in that the symptom of the right wrist ganglion cyst being compensated is pain, rather than pain and an actual scar. For these reasons, the Board finds that a rating in excess of 10 percent for the service-connected right ganglion cyst is not warranted for the period beginning January 25, 2010. Additional Considerations VA must consider all favorable lay evidence of record. 38 USCA § 5107(b); Caluza v. Brown, 7 Vet. App. 498 (1995). The Board has accordingly considered the lay evidence offered by the Veteran, in the form of correspondence to VA, in addition to the medical evidence cited above. The Veteran is competent to testify in regard to the onset and continuity of symptomatology. Heuer v. Brown, 7 Vet. App. 379, 384 (1995); Falzone v. Brown, 8 Vet. App. 398, 403 (1995); Caldwell v. Derwinski, 1 Vet. App. 466 (1991). However, even affording the Veteran full competence and credibility, the evidence simply does not show entitlement to a higher rating under any applicable diagnostic code. Consideration has been given to assigning a staged rating or further staged rating; however, at no time during the period in question has either disability warranted more than the assigned ratings, to include the increases granted herein. See Fenderson v. West, 12 Vet. App. 119 (1999). The Board has considered whether the case should be referred to the Director of the Compensation and Pension Service for extra-schedular consideration. In determining whether a case should be referred for extra-schedular consideration, the Board must compare the level of severity and the symptomatology of the claimant's disabilities with the established criteria provided in the rating schedule for each disability. If the criteria reasonably describe the claimant's disability level and symptomatology, then the disability picture is contemplated by the rating schedule, the assigned evaluation is therefore adequate, and no referral for extra-schedular consideration is required. Thun v. Peake, 22 Vet. App. 111, 115 (2008). In this case, the manifestations of the service-connected disabilities, as discussed above, are contemplated by the schedular criteria. The Board has therefore determined that referral of this case for extra-schedular consideration under 38 C.F.R. § 3.321(b) is not in order. ORDER An initial compensable rating for allergic rhinitis is denied. An initial compensable rating for gastroesophageal reflux disease prior to January 25, 2010, and in excess of 30 percent thereafter, is denied. The Board having determined that the Veteran's right wrist ganglion cyst warrants a 10 percent rating, but not higher, throughout the initial rating period, the benefit sought on appeal is granted to this extent and subject to the criteria applicable to the payment of monetary benefits. ____________________________________________ Shane A. Durkin Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs