Citation Nr: 1329498 Decision Date: 09/13/13 Archive Date: 09/20/13 DOCKET NO. 03-26 504 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUES 1. Entitlement to an increased disability rating higher than 40 percent for degenerative arthritis, cervical spine, status post neck and right shoulder injury with painful and limited motion, from October 29, 2003, forward, and higher than 10 percent prior to October 29, 2003. 2. Entitlement to an initial disability rating higher than 20 percent for radiculopathy of the left upper extremity from October 29, 2003 forward, and to a compensable rating prior to October 29, 2003. 3. Entitlement to an initial disability rating higher than 10 percent for gastro-esophageal reflux disorder (GERD) and hiatal hernia. 4. Entitlement to an initial disability rating higher than 30 percent for craniotomy scar. 5. Entitlement to an initial compensable disability rating or ratings for manifestations of Arnold-Chiari I Malformation with cervical syringohydromyelia status post suboccipital craniotomy, to include the following: swallowing disorder, speech disorder, hearing loss, back symptoms, and chewing disorder. 6. Entitlement to an effective date earlier than May 30, 2006 for service connection for Arnold-Chiari I Malformation with cervical syringohydromelia status post suboccipital craniotomy. REPRESENTATION Appellant represented by: The American Legion ATTORNEY FOR THE BOARD Amanda Christensen, Associate Counsel INTRODUCTION The Veteran served on active duty from April 1979 to April 1982. This matter comes to the Board of Veterans' Appeals (Board) on appeal from August 2001, May 2006, June 2007, and October 2009 rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in St. Petersburg, Florida. In August 2011, the Board remanded the Veteran's claim for additional development. The claim has since been returned to the Board for further appellate action. 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. In an August 2012 statement, the Veteran raised the issue of entitlement to a temporary 100 percent evaluation from March 30, 2004 to June 16, 2004 for convalescence from a craniotomy related to his service-connected Arnold-Chiari Malformation. This issue has not been adjudicated by the Agency of Original Jurisdiction (AOJ) (it appears). Therefore, the Board does not have jurisdiction over it, and it is referred to the AOJ for appropriate action. The issue of entitlement to a compensable disability rating or ratings for manifestations of Arnold-Chiari I Malformation with cervical syringohydromyelia status post craniotomy 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. Prior to October 29, 2003 the Veteran's degenerative arthritis, cervical spine, status post neck and right shoulder injury with painful and limited motion, was manifested by at least 40 degrees forward flexion and a combined range of motion of at least 265 degrees without incapacitating episodes due to intervertebral disc syndrome. 2. As of October 29, 2003 the Veteran's degenerative arthritis, cervical spine, status post neck and right shoulder injury with painful and limited motion, has been manifest by ankylosis of his cervical spine but not his thoracolumbar spine. 3. Prior to October 29, 2003 the Veteran did not have symptoms of radiculopathy of the left upper extremity. 4. As of October 29, 2003 the Veteran's radiculopathy of the left upper extremity has been manifest by decreased sensation, decreased muscle strength, decreased grip, and hypoactive reflexes, not productive of more than moderate impairment. 5. The Veteran's GERD and hiatal hernia has been manifest by heartburn, reflux, and regurgitation without substernal or arm or shoulder pain and not productive of considerable impairment of health. 6. The Veteran's craniotomy scar is located on his posterior neck, is 16 centimeters by 1 centimeter, and has a surface contour that is depressed on palpation, but otherwise has no other characteristics of disfigurement. 7. The Veteran filed a reopened claim for service connection for manifestations of Arnold-Chiari I Malformation with cervical syringohydromyelia status post suboccipital craniotomy on May 30, 2006. CONCLUSIONS OF LAW 1. The criteria for a rating in excess of 10 percent for degenerative arthritis, cervical spine, status post neck and right shoulder injury with painful and limited motion prior to October 29, 2003 have not been met. 38 U.S.C.A. § 1155, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.321, 4.1, 4.40, 4.45, 4.71a, Diagnostic Code 5242 (2012). 2. The criteria for a rating in excess of 40 percent for degenerative arthritis, cervical spine, status post neck and right shoulder injury with painful and limited motion as of October 29, 2003 have not been met. 38 U.S.C.A. § 1155, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.321, 4.1, 4.40, 4.45, 4.71a, Diagnostic Code 5242 (2012). 3. The criteria for a 30 percent rating, but no higher, for radiculopathy of the left upper extremity have been met as of October 29, 2003, but no earlier. 38 U.S.C.A. § 1155, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.321, 4.1, 4.124a , Diagnostic Code 8513 (2012). 4. The criteria for a rating in excess of 10 percent for GERD and hiatal hernia have not been met. 38 U.S.C.A. § 1155, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.321, 4.1, 4.114, Diagnostic Code 7346 (2012). 5. The criteria for a rating in excess of 30 percent rating for craniotomy scar have not been met. 38 U.S.C.A. § 1155, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.321, 4.1, 4.118, Diagnostic Codes 7800 (2012). 6. The criteria for an effective date earlier than May 30, 2006 for service connection for manifestations of Arnold- Chiari I Malformation with cervical syringohydromyelia status post suboccipital craniotomy have not been met. 38 U.S.C.A. § 5110 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.151, 3.400 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Procedural History In August 2000 the Veteran filed a claim for service connection for GERD and hiatal hernia. In September 200 he filed a claim for an increased rating for cervical spine disability, status post neck and right shoulder injury, currently rated at 10 percent. In an August 2001 the RO issued a rating decision that denied service connection for GERD and hiatal hernia and denied a disability rating higher than 10 percent for degenerative arthritis of the cervical spine, status post neck and right shoulder injury. The Veteran appealed those determinations, and, in February 2005, the Board remanded both issues for additional development. In a May 2006 rating decision, the RO granted service connection for GERD and hiatal hernia and assigned a 10 percent disability rating effective August 24, 2000. This action satisfied the appeal with regard to the issue of entitlement to service connection for GERD and hiatal hernia. In that May 2006 decision, the RO also granted a 40 percent rating for the Veteran's degenerative arthritis, cervical spine, status post neck and right shoulder injury with painful and limited motion, and granted service connection for degenerative arthritis cervical spine with radiculopathy into the left upper extremity, assigning a 10 percent disability rating effective October 29, 2003. As this is not the highest available disability rating for a cervical spine disability the decision did not resolve the appeal. Later that month, the RO received a notice of disagreement with the rating assigned for GERD and hiatal hernia. Also in May 2006, the Veteran filed a claim for VA disability compensation benefits for Chiari Malformation secondary to degenerative arthritis of the cervical spine, and for impaired vision secondary to degenerative arthritis of the cervical spine. In October 2006 he filed a claim of entitlement to service connection for headaches as secondary to his degenerative arthritis of the cervical spine. In December 2006, the RO received a notice of disagreement with the effective date of the award of a 10 percent disability rating for degenerative arthritis, cervical spine with radiculopathy into the left upper extremity and the effective date of the award for the increased (from 10 percent to 40 percent) rating for service-connected degenerative arthritis cervical spine, status post neck and right shoulder injury with painful and limited motion. The Veteran argued that a private physician's medical evaluation of November 2006 provided evidence that his service connected cervical condition had worsened in September 2000. He requested that VA pay him the award increase from that date. In a June 2007 rating decision, the RO granted service connection for muscle tension headaches and assigned a 30 percent disability rating effective May 30, 2007. The RO also granted service connection for Arnold-Chiari I Malformation with cervical syringohydromyelia status post suboccipital craniotomy and assigned a noncompensable (zero percent) rating effective May 30, 2006. Later in June 2007, the RO received a letter from the Veteran in which he disagreed with the effective date assigned for award of service connection for muscle tension headaches and for Arnold-Chiari Malformation I with cervical syringohydromyelia status post suboccipital craniotomy. He contended that the effective date should be one year prior to when VA received his request of May 30, 2006, i.e. May 30, 2005. In that June 2007 letter he also stated that he was not being compensated for disabilities which he stated were directly related to Arnold-Chiari I Malformation with cervical syringohydromyelia status post suboccipital craniotomy and listed the following: (1) swallowing disorder difficulty, (2) speech disorder slurred speech, (3) hearing loss left ear, (4) depression from suboccipital craniotomy, (5) lower back pain that radiates with sharp pain down both legs and feet, (6) frequent loss of balance, (7) cervical neurosis right side that at times disables chewing on the right side of his mouth. In a July 2007 rating decision the RO granted service connection for impaired vision and assigned a noncompensable rating effective May 30, 2006. The RO issued a statement of the case in August 2007 as to the issues of the rating assigned for GERD and hiatal hernia, entitlement to an effective date earlier than May 30, 2006 for service connection for muscle tension headaches, and entitlement to an effective date earlier than May 30, 2006 for service connection for Arnold-Chiari I Malformation with cervical syringohydromyelia status post suboccipital craniotomy. The RO issued a rating decision August 30, 2007 in which it granted an effective date of May 30, 2006 for service connection for muscle tension headaches. This action thus resolved the appeal as to the effective date of grant of service connection for muscle tension headaches because the date requested by the Veteran was assigned. In September 2007, the RO received from the Veteran a notice of disagreement with the disability rating assigned for his vision impairment. That month the RO also received his VA Form 9, substantive appeal perfecting the rating assigned for his GERD and hiatal hernia. In that substantive appeal the Veteran asserted that his GERD and hiatal hernia had increased in severity. In February 2008, the RO received a VA Form 21-8940 claim for a total rating based on individual unemployability due to service connected disability (a TDIU). In a March 2008 rating decision the RO granted a TDIU, effective February 15, 2008. In October 2008, the RO received a notice of disagreement with the effective date assigned for his TDIU. The Veteran contended that the effective date should be May 30, 2006. In a March 2008 rating decision the RO increased the disability rating assigned for radiculopathy of the left upper extremity to 20 percent, effective October 29, 2003. In April 2008, the RO received a letter from the Veteran that was similar to the letter received in June 2007. It differed in that he added an additional alleged manifestation of his Arnold - Chiari Malformation I, and additional explanation. He added that he had frequent middle - back pains with severe back and neck muscle spasms. He also stated that his Chiari Malformation and Syringohydromyelia status suboccipital craniotomy "affects my central nervous system which affects my entire body from head to toe." In April 2008, the RO issued a statement of the case as to the Veteran's disagreement with the disability rating assigned for his impaired vision. In a February 2009 rating decision, the RO granted a TDIU for the period from May 30, 2006 to October 9, 2006 on an extraschedular basis and left unchanged the grant of a TDIU from February 3, 2008 on a schedular basis. This did not resolve the Veteran's disagreement. In February 2009, the RO issued a statement of the case as to the disability rating assigned for Arnold-Chiari I Malformation with cervical syringohydromyelia status post craniotomy. Later in February 2009, the RO received from the Veteran a VA Form 9 substantive appeal perfecting the issue of the rating assigned for the Veteran's Arnold-Chiari I Malformation with cervical syringohydromyelia status post craniotomy. He reiterated in that substantive appeal his contention that he has not been compensated for conditions which he alleges are manifestations of his Arnold-Chiari I Malformation with cervical syringohydromyelia status post craniotomy. The Veteran did not file a substantive appeal with regard to the disability rating assigned for his impaired vision, and thus that issue is not currently before the Board. In an October 2009 rating decision, the RO granted service connection for a scar from the craniotomy and assigned a noncompensable rating effective February 24, 2009. In March 2010, the RO received from the Veteran a notice of disagreement as to the rating assigned for this scar. In April 2011, the RO issued a statement of the case with regard to that disagreement. In June 2011, the RO received from the Veteran a VA Form 9 substantive appeal perfecting the issue of the rating assigned for the scar. In January 2013 the RO issued a statement of the case denying a TDIU for the period from October 9, 2006 to February 3, 2008. In May 2013 the RO received a written statement from the Veteran withdrawing his TDIU appeal, therefore that issue is not before the Board. In June 2013 the RO issued a statement of the case on the six remaining issues. Also in June 2013, the RO issued a rating decision granting a 30 percent rating for the craniotomy scar. As the rating represents a partial grant of benefits, this issue remains on appeal and is before the Board. The RO also granted service connection for a mood disorder as secondary to Arnold-Chiari I Malformation with cervical syringohydromyelia status post craniotomy and assigned a 10 percent rating. The Veteran has not appealed this rating. Neck The Veteran contends he is entitled to a disability rating higher than 40 percent for degenerative arthritis, cervical spine, status post neck and right shoulder injury with painful and limited motion, from October 29, 2003 forward, and higher than 10 percent prior to October 29, 2003. 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). Where entitlement to compensation has already been established and an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). However, staged ratings are appropriate for an increased rating claim if the factual findings show distinct time periods where the service-connected disability exhibited symptoms that would warrant different ratings. See Hart v. Mansfield, 21 Vet. App. 505 (2007). 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). The Veteran's cervical spine disability is rated under Diagnostic Code 5010-5242. Diagnostic Code 5010 contemplates traumatic arthritis and directs that disabilities under this Diagnostic Code be rated as degenerative arthritis under Diagnostic Code 5003. In turn, Diagnostic Code 5003 directs that degenerative arthritis be rated based on limitation of motion of the affected part. Diagnostic Code 5242 rates based on limitation of motion of the spine and is subsumed into the General Rating Formula for Diseases and Injuries of the Spine (General Rating Formula). Under the General Rating Formula, the criteria for a 10 percent rating are forward flexion of the cervical spine greater than 30 degrees but not greater than 40 degrees; or, where the combined range of motion of the cervical spine is greater than 170 degrees but not greater than 335 degrees; or, where there is muscle spasm, guarding, or localized tenderness not resulting in abnormal spinal contour; or, a vertebral body fracture with loss of 50 percent or more of the height. The criteria for a 20 percent rating are forward flexion of the cervical spine greater than 15 degrees but not greater than 30 degrees; or, where the combined range of motion of the cervical spine is not greater than 170 degrees; or, where there is muscle spasm or guarding severe enough to result in abnormal spinal contours. A 30 percent rating is warranted if forward flexion of the cervical spine is limited to 15 degrees or less; or there is favorable ankylosis of the entire cervical spine. A 40 percent disability rating is assigned for unfavorable ankylosis of the entire cervical spine. A 100 percent disability rating is assigned for unfavorable ankylosis of entire spine. 38 C.F.R. § 4.71a, Diagnostic Codes 5235-5242. Normal forward flexion of the cervical segment of the spine is zero to 45 degrees, extension is zero to 45 degrees, left and right lateral flexion are zero to 45 degrees, and left and right lateral rotation are zero to 60 degrees. See 38 C.F.R. § 4.71a, Plate V (2012). Any associated objective neurological abnormalities are to be rated separately, under an appropriate diagnostic code. 38 C.F.R. § 4.71a, General Rating Formula, Note (1). In reaching the following conclusion, the Board has considered whether a higher disability evaluation is warranted on the basis of functional loss due to pain or due to weakness, fatigability, incoordination, or pain on movement of a joint under 38 C.F.R. §§ 4.40 and 4.45. See also DeLuca v. Brown, 8 Vet. App. 202 (1995). Functional loss contemplates the inability of the body to perform the normal working movements of the body with normal excursion, strength, speed, coordination and endurance, and must be manifested by adequate evidence of disabling pathology, especially when it is due to pain. 38 C.F.R. § 4.40. The Veteran's VA treatment records show a complaint of neck and shoulder pain in November 2000 at which time an x-ray showed mild degenerative changes with slightly narrowed C5-6 disc space. The Veteran was afforded a VA examination in January 2001, at which time he reported pain, weakness, and stiffness of his neck. On range of motion testing of his cervical spine, his flexion, extension, and right lateral flexion were measured to 40 degrees; his left lateral flexion was measured to 45 degrees; and his right and left rotation were measured to 50 degrees. The examiner noted no spasm or tenderness. VA treatment records reflect that in May 2001 he was noted to have chronic muscle spasm on the right side of his neck. In June 2001 he was found to have mild limitation of rotation in his neck with some tender spots on palpation. The Veteran's VA records reflect no additional complaint of neck problems until October 29, 2003 when the Veteran sought treatment complaining of left-sided neck pain for the last three to four months. The Veteran has been assigned a 40 percent disability rating as of that date, with a 10 percent rating assigned prior. The Veteran underwent a VA examination in March 2006. On range of motion testing for both active and passive motion, his cervical flexion was measured to 10 degrees, extension to 0 degrees, left lateral flexion to 0 degrees, right lateral flexion to 10 degrees, left lateral rotation to 0 degrees, and right lateral rotation to 20 degrees. He had no active motion versus strong resistance and no range of motion in any direction after repetition due to pain. Part of his cervical spine was noted to be ankylosed in flexion but no ankylosis was found in his thoracolumbar spine. The examiner found the Veteran had more than 12 episodes a year in which it became more painful to move his neck due to movement triggering spasm, resulting in a narrowed visual field, which is incapacitating. At an August 2006 VA initial physical medical and rehabilitation appointment, the Veteran's cervical flexion was measured to 15 degrees, extension to 12 degrees, right lateral flexion to 24 degrees, left lateral flexion to 3 degrees, right rotation to 16 degrees, and left rotation to 3 degrees. His left shoulder abduction and flexion were to 90 degrees and other range of motions within normal limits. In an August 2012 statement the Veteran said his August 2012 neck surgery had lessened the chronic pain on the left side of his neck and body but made his neck stiffer. The Veteran was afforded a VA examination in March 2013. The examiner noted the Veteran has left sided paresthesia, numbness, and left upper extremity weakness. The Veteran also reported constant pain on the left side of his head and neck. The examiner noted the Veteran's head remained tilted toward the right with rotation of his face toward the left side. The Veteran reported he is unable to straighten his head and neck and if he attempts to do so, he experiences numbness on his upper left extremity and increased pain on the left side of his head and neck. The Veteran reported flare-ups that impact the function of his cervical spine. On range of motion testing, the examiner measured forward flexion, right and left lateral flexion, and right and left lateral rotation all to 0 degrees and extension to 10 degrees, all with pain. The examiner found the Veteran was unable to perform repetitive-use testing. He noted the Veteran experiences weakened movement; excess fatigability; pain on movement; and interference with sitting, standing and/or weight bearing. The examiner found the Veteran has localized tenderness or pain to palpation of the joints/soft tissue of the cervical spine, but no guarding or muscle spasm. The examiner stated that the Veteran has intervertebral disc syndrome but has not had any incapacitating episodes over the past 12 months. The examiner noted that the Veteran was unable to lay flat on the gantry and unable to straighten his neck. His gait was found to be normal. At a March 2013 VA physical medicine rehabilitation consultation, the Veteran's active range of motion was decreased in all planes with essentially no extension. He was able to passively straighten his head. The Board finds the evidence does not support a rating above 10 percent for any period prior to October 29, 2003. The January 2001 range of motion testing showed the Veteran's flexion to be greater than 30 degrees and his combined range of motion well above 170 degrees. Further, while the evidence suggests the Veteran experienced muscle spasms in his neck, it does not show that it was severe enough to result in abnormal spinal contours. No additional functional loss is suggested as a result of pain, weakness, fatigability, or incoordination such that the Veteran's condition would more closely approximate the criteria for a higher rating. The Veteran has identified a November 2006 private medical opinion as supporting that his condition had worsened by September 2000, entitling him to a higher rating at that point, however, the Board finds the evidence does not support that contention. The opinion primarily discusses the etiology of the Veteran's syrinx. It does reference a 2000 x-ray that showed degenerative changes with a narrow C5-6 disc. While the Board recognizes the x-ray findings, they do not alone support that the Veteran's condition manifest with severity of symptomatology warranting a rating above 10 percent. Based on the forgoing, the Board finds that the Veteran does not meet the criteria for the next higher rating, 20 percent, under Diagnostic Code 5242 prior to October 29, 2003. The Board further finds he is not entitled to a rating in excess of 40 percent as of October 29, 2003. For the Veteran to be entitled to the next higher rating under Diagnostic Code 5242, 100 percent, he would have to have unfavorable ankylosis of entire spine. The evidence of record does not show that the Veteran has experienced unfavorable ankylosis of his entire spine at any point during the pendency of this appeal. Specifically, the March 2006 VA examiner who found ankylosis of the Veteran's cervical spine found no ankylosis of the Veteran's thoracolumbar spine. No other medical records reflect unfavorable ankylosis of the Veteran's entire spine and the Veteran has not contended his entire spine is ankylosed. While the Board recognizes that the Veteran experiences additional pain and functional loss with repetitive testing, his 40 percent rating already accounts for unfavorable ankylosis of the entire cervical spine. Further, the Board notes that the 40 percent rating is the highest available for disability of only the cervical spine. Based on the forgoing, the Board finds the Veteran is not entitled to a higher rating under Diagnostic Code 5242. The Board also finds the Veteran is not entitled to a higher or additional rating for his neck under any other diagnostic code for any period during the pendency of this appeal. Back disabilities may also be rated under the Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes, which assigns a 20 percent rating when intervertebral disc syndrome causes incapacitating episodes with a total duration of at least 2 weeks, but less than 4 weeks, during the past 12 months; a 40 percent rating when intervertebral disc syndrome causes incapacitating episodes having a total duration of at least 4 weeks, but less than 6 weeks, during the past 12 months; and a 60 percent rating when intervertebral disc syndrome causes incapacitating episodes having a total duration of at least 6 weeks, during the past 12 months. 38 C.F.R. § 4.71a, Diagnostic Code 5243. An incapacitating episode is a period of acute signs and symptoms due to intervertebral disc syndrome that requires bed rest prescribed by a physician and treatment by a physician. Id., Note (1). In this case, the Veteran has been found to have intervertebral disc sydrome, but the evidence does now show he has experienced incapacitating episodes such that would entitle him to a higher rating during any period. The evidence does not show the Veteran experienced any incapacitating episodes due to his neck prior to October 29, 2003 or at least six weeks of incapacitating episodes thereafter. Specifically, the March 2013 VA examiner found the Veteran had had no incapacitating episodes for the past 12 months. Although the March 2006 VA examiner stated that the Veteran had more than 12 incapacitating episodes a year, the examiner indicated those episodes were defined as increased pain and spasms resulting in a more limited visual field due to restricted neck movement, not bed rest prescribed by a physician. Therefore, the Veteran would not be entitled to a higher rating under Diagnostic Code 5243. The regulations also provide that in addition to orthopedic considerations, any associated objective neurologic abnormalities, including, but not limited to, bowel or bladder impairment, should be evaluated separately, under an appropriate diagnostic code. In this case, the evidence shows the Veteran has radiculopathy of the left upper extremity; however, he has already been rated for that disability, which the Board discusses later. The evidence does not show additional neurological disability. Specifically, strength and deep tendon reflexes were normal in the Veteran's right upper extremity on VA examination in March 2013, and the examiner found no signs or symptoms of radiculopathy in the Veteran's right upper extremity and no symptoms attributable to any peripheral nerve conditions in his lower extremities. Although the March 2013 examiner marked that the Veteran had mild radiculopathy on his right side overall, no indications of any neurological abnormalities of the Veteran's right side were noted nor was any impairment of any nerve roots affecting the right side. Therefore, the Board finds the evidence overall does not support a finding of any right-sided neurological disability. Overall, the preponderance of the evidence is against the Veteran's claim for a rating higher than 10 percent prior to October 29, 2003 and a rating higher than 40 percent thereafter for degenerative arthritis, cervical spine, status post neck and right shoulder injury with painful and limited motion. In reaching this determination, the Board acknowledges that VA is statutorily required to resolve the benefit of the doubt in favor of the Veteran when there is an approximate balance of positive and negative evidence regarding the merits of an outstanding issue. That doctrine, however, is not applicable in this case because the preponderance of the evidence is against the Veteran's claim. See Gilbert v. Derwinski, 1 Vet. App. 49, 55; 38 U.S.C.A. § 5107(b); 38 C.F.R. § 4.3. Radiculopathy The Veteran contends he is entitled to a disability rating higher than 20 percent for radiculopathy of the left upper extremity from October 29, 2003 forward, and to a compensable rating prior to October 29, 2003. As indicated above, Note (1) of the General Rating Formula directs that any objective neurologic abnormalities associated with a Veteran's service-connected cervical spine disability should be evaluated separately under an appropriate diagnostic code. The RO has awarded the Veteran a separate 20 percent evaluation for left upper extremity radiculopathy as of October 29, 2003 under Diagnostic Code 5242-8513. The Veteran is right-handed, therefore ratings of his upper left extremity are those of the minor extremity. Diagnostic Code 8513 provides ratings for diseases of the peripheral nerves, paralysis of all radicular groups. A 20 percent rating is afforded for mild, incomplete paralysis; a 30 percent rating for moderate, incomplete paralysis; a 60 percent rating for severe, incomplete paralysis; and an 80 percent rating for complete paralysis. 38 C.F.R. § 4.124a. Peripheral nerve disability ratings are also available for each individual nerve and the upper, middle, and lower radicular groups; however, rating the Veteran under Diagnostic Code 8513 provides for the highest rating. The term "incomplete paralysis" indicates a degree of lost or impaired function substantially less than the type picture for complete paralysis given with each nerve, whether due to varied level of the nerve lesion or to partial regeneration. 38 C.F.R. § 4.124a. When the involvement is wholly sensory, the rating should be for the mild, or at most, the moderate degree. The words "mild," "moderate," and "severe," as used in the various diagnostic codes, are not defined in the Rating Schedule. Rather than applying a mechanical formula, the Board must evaluate all of the evidence to ensure that its decisions are "equitable and just." 38 C.F.R. § 4.6 (2012). In June 2001 the Veteran was evaluated at the VA for physical rehabilitation of a left shoulder ache. He reported he injured his shoulder three years ago and has had off and on pain but no weakness or sensory complaints. The VA doctor noted no clinical signs of impingement or active radiculopathy. On October 29, 2003, the Veteran complained of neck pain radiating to the back of his head and into his left shoulder. He reported decreased sensation in the last two fingers in his left hand and left upper extremity weakness since walking into a mirror in 1997. He was found to have normal muscle strength and was intact to vibration, joint position sensation, stereognosis, and graphesthesia on sensory examination but with a diminished sensation to pin in a C2-T5 dermatomal distribution on the left. In November 2003 he reported numbness in his entire left upper extremity, most pronounced in the last two fingers on the left hand. He had decreased strength of 4+/5+ in the deltoids, triceps, wrist flexors and 4-5+/5+ in the terres major and 3-4+/5+ in the intrinsic muscles of the hand. His deep tendon reflexes were 0+ in the biceps, triceps, and brachioradialis and finger flexors were absent. He had decreased sensation to pin on the entire left upper extremity as well as agraphesthesia on the left, but was intact to joint positions sensation and stereognosis. December 2003 electromyogram and nerve conduction studies were normal. In September 2004 the Veteran reported improvement in the numbness. In August 2005 he was noted to have some decreased strength in the left upper extremity, mild hyperreflexia and a positive Hoffman's sign. In March 2006 the Veteran underwent a VA examination. He reported numbness in the left side of his neck, shoulder, arm, and fourth and fifth fingers that began in 2002. He also reported moderate weakness of the left upper extremity, although the examiner found the Veteran's muscle strength was 5/5. At an August 2007 private neurology consultation the Veteran complained of numbness and discomfort in his left face, arm, and leg as well as chronic pain and spasms over his neck and shoulders. Electrical studies did not reveal any significant focal root abnormalities although the Veteran had a lot of myofascial spasms in his cervical spine. The Veteran underwent a VA examination in January 2008. The examiner found the Veteran's left elbow strength was 50 percent with pain on range of motion from left neck to left hand and pain of the left hand with skin discoloration. Normal muscle tone and normal muscle bulk were noted. The Veteran was found to have decreased light touch on the left hand and fingers, diminished pin prick on the left hand and fingers, and diminished vibratory sense on the left hand and fingers. His deep tendon reflexes were normal except for 1+ on the left triceps. The Veteran's gait was noted to be normal, and no significant focal root impingement was found on electrical studies at a February 2008 private neurology appointment. At a July 2008 private neurology appointment the Veteran was noted to have no new changes overall in his neurological condition. In January 2009 the Veteran returned to the VA for a follow- up. The neurosurgeon noted the Veteran's symptoms had persisted but he had had less gait difficulty and left sided weakness over the past year. He had full strength but diminished pinprick sensation on his left side. As part of his Social Security disability application, in March 2009 the Veteran described weakness and numbness in his left arm and hand that reduces his manual dexterity and fine motor skills. In April 2009 the Veteran's private physician wrote in a Social Security questionnaire that the Veteran is unable to grasp small objects and has a grip strength of 4/5. In May 2009 the Veteran was seen at the VA and was found to have normal muscle mass and tone but a mild weakness of the left upper extremity with decreased rapid alternating movements in the left fingers and a decreased left hand grasp. He had diminished vibratory sensation and sensation to pin in the left upper extremity but had intact joint position, stereognosis, and graphesthesia. Movement on the left was more deliberate due to weakness. Upon evaluation while in rehabilitation for a cervical decompression in June 2011 the Veteran was noted to have 3- 4/5 muscle strength in his upper extremities. In an August 2012 statement, the Veteran reported his thumb and little finger twitch and he has little ability to use from his neck to his hand without pain. He stated that his left hand and arm are weak, painful, and have lost muscle mass compared to the right side. He reported he needs regular assistance to push a shopping cart, drive, carry groceries, clean, and cook. The Veteran was afforded a VA examination in March 2013. The examiner noted the Veteran has left-sided paresthesia, numbness, and left upper extremity weakness. The Veteran also reported constant pain on the left side of his head and neck and persistent tingling and partial numbness of his left upper extremity. The examiner noted the Veteran is taking butalbital, clonazepam, cyclobenzaprine, gabapentin, thiamine, and oxycodone. On strength testing on his left side, the Veteran's elbow and wrist flexion and extension and his finger flexion and abduction were measured to 4/5. His grip and pinch were 3- 4/5. On reflex testing, he had hypoactive reflexes in his biceps and brachioradialis on the left. He had decreased sensation to light touch in his left shoulder, inner/outer forearm, and hand and fingers. The examiner noted the Veteran had mild to moderate constant pain and numbness and mild intermittent pain and paresthesias and/or dysenthesias in his left upper extremity. The examiner found the C5/C6 and C7 nerve roots were involved. The examiner rated the Veteran's left-sided radiculopathy as moderate. The examiner further rated as mild the Veteran's incomplete paralysis of the radial, median, musculocutaneous, circumflex, and long thoracic nerves on the left side. The Board finds that the evidence does not support that the Veteran had any radiculopathy symptoms prior to October 29, 2003. There are no complaints in the record and in June 2001 the Veteran specifically denied weakness and sensory complaints and a VA doctor found no clinical signs of impingement or active radiculopathy, providing highly probative evidence against his own claim. Therefore, the Board finds the Veteran is not entitled to a compensable rating for radiculopathy of the left upper extremity prior to October 29, 2003, the date on which the RO has granted service connection and awarded a 20 percent rating. However, the Board finds that the Veteran is entitled to a 30 percent rating from October 29, 2003 as his condition from that point more closely approximates moderate severity as it is manifest by both sensory impairment and functional limitation. Although the March 2013 VA examiner rated the severity of the Veteran's condition for each of the five nerves affected as mild, the examiner also indicated the severity of the Veteran's left-sided radiculopathy as a whole is moderate. The Board notes that the Veteran's symptoms as described on the examination are not only sensory, including pain, paresthesias/dysesthesias, numbness, and decreased sensation to light touch, but also involve a loss of muscle strength, particularly grip strength, and hypoactive reflexes in the bicep and brachioradialis. Although there has been some fluctuation in the manifestations of the Veteran's condition, the Veteran's January 2008 VA examination and other treatment records reflect symptoms of moderate severity since October 29, 2003, particularly decreased sensation, decreased muscle strength, and hypoactive reflexes in his left upper extremity. The Veteran has reported difficulty carrying, pushing, and otherwise using his left arm, complaints that are supported by medical evidence showing decreased muscle and grip strength, including the April 2009 private physician report noting the Veteran is unable to grasp small objects. The Veteran has also reported twitching in his fingers, which was also noted in a May 2009 VA treatment record. Based on the forgoing, and giving the Veteran the benefit of the doubt, the Board finds that the Veteran's disability more closely approximates moderate severity so as to entitle him to a 30 percent rating under Diagnostic Code 8513. The Board further finds a rating in excess of 30 percent is not warranted. For the next higher rating under Diagnostic Code 8513, 60 percent, to be warranted, the Veteran's disability would have to involve severe, incomplete paralysis. However, the evidence shows that although the Veteran experiences a number of symptoms due to his left upper extremity radiculopathy, he has maintained some muscle strength, deep tendon reflexes, and sensory perception. The evidence does not show significant muscular atrophy or other findings, including severe functional loss, that more nearly approximately severe, incomplete paralysis or complete paralysis. In this regard, the Veteran should understand a rating of 30 percent represents significant impairment due to radiculopathy and encompasses the symptoms the Veteran has described, including weakness, pain, twitching fingers, and gripping difficulties. As the preponderance of the evidence is against a rating higher than 30 percent, the benefit of the doubt doctrine does not apply. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102; Gilbert, 1 Vet. App. 49. GERD/Hiatal Hernia The Veteran contends he is entitled to a disability rating greater than 10 percent for his GERD and hiatal hernia. The Veteran's current 10 percent rating for GERD and hiatal hernia was awarded under Diagnostic Code 7399-7346. 38 C.F.R. §§ 4.20, 4.27 (2012) (when an unlisted disease, injury, or residual condition is encountered, requiring rating by analogy, the diagnostic code number will be "built-up" by using the first two digits of that part of the rating schedule which most closely identifies the part, or system, of the body involved and adding "99" for the unlisted condition). Diagnostic Code 7346 for hiatal hernia assigns a 10 percent evaluation where there are two or more of the symptoms of a 30 percent evaluation with less severity. A 30 percent rating is assigned with persistently recurrent epigastric distress with dysphagia, pyrosis, and regurgitation, accompanied by substernal or arm or shoulder pain, productive of considerable impairment of health. A 60 percent rating is assigned with symptoms of pain, vomiting, material weight loss and hematemesis or melena with moderate anemia; or other symptom combinations productive of severe impairment of health. 38 C.F.R. § 4.114. The Veteran underwent a VA examination in January 2001. He reported feeling bloated and gassy. At a February 2001 VA gastroenterology consultation the Veteran was diagnosed with GERD symptoms mostly controlled with Lansoprazole and a hiatal hernia. The Veteran had another VA examination in August 2001. He reported that since taking medication his symptoms are mostly controlled but occasionally he still has heartburn. He denied nausea, vomiting, indigestion, and dysphagia. After an esophagogastroduodenoscopy the examiner diagnosed chronic gastritis but not GERD or a hernia. A July 2003 CT scan and a November 2003 MRI both showed a small hiatal hernia. The Veteran underwent a VA examination in March 2006. He reported dysphagia most of the time, although always being able to swallow liquid and solid foods; substernal esophageal pain several times a day; heartburn several times a day; and regurgitation several times a week. The examiner stated that the Veteran's symptoms are intermittent and helped with medication. A February 2007 private treatment note relates that the Veteran has had GERD for many years treated with Prilosec and does not have vomiting or dysphagia. After a colonoscopy and esophagogastroduodenoscopy were done he was diagnosed with endoscopic gastritis, GERD that appeared to be uncomplicated reflux, and asymptomatic diverticulosis. He was noted to have dyspepsia in March 2007. At a January 2008 VA neurosurgery outpatient appointment, the Veteran was found to have improvement in his speech and swallowing but was slightly dysarthric. In a swallowing evaluation he was found to have a functional oropharyngeal swallow with no instances of penetration or aspiration, although significant esophageal backflow was observed. At a February 2008 VA appointment the Veteran reported dysphagia and regurgitation and requested a new medication. He stated that he still feels like he has difficulty swallowing at times although he had a normal swallow evaluation. In a March 2009 statement, the Veteran contended that he regurgitates food once or more per week and has pain in his stomach, chest, arms, and shoulders several times per week. On a medical questionnaire completed by his private doctor in connection with his Social Security disability claim in May 2009, the doctor indicated the Veteran had mild dysphagia, providing evidence against this claim of high probative value. In an August 2012 statement, the Veteran contended that his GERD and hiatal hernia have gotten worse since 2006. He noted he has an ulcer in his intestine that aggravates his condition and taking the medication prescribed for his service-connected disabilities often upset his stomach. The Veteran was afforded a VA examination in March 2013 at which the examiner noted the Veteran had been diagnosed with GERD, hiatal hernia, and grade 1 esophageal varix. The examiner found the Veteran's esophageal conditions manifest with persistently recurrent epigastric distress, pyrosis, reflux, regurgitation, and sleep disturbance caused by esophageal reflux four or more times per year lasting less than a day each. No dysphagia or substernal arm or shoulder pain was found. The examiner noted the Veteran has no swallowing difficulty with liquids or solids and is eating nutrisystem foods. He takes pantoprazole. To be entitled to a 30 percent rating, the Veteran would have to have persistently recurrent epigastric distress with dysphagia, pyrosis, and regurgitation, accompanied by substernal or arm or shoulder pain, productive of considerable impairment of health. While the March 2013 VA examiner found he does have persistently recurrent epigastric distress with pyrosis and regurgitation, the other criteria, including dysphagia and substernal or arm or shoulder pain are not met based on the examination. Simply stated, while the condition may have truly become worse, it does not meet the requirements of the next higher rating. A review of all of the Veteran's medical records shows one complaint of substernal esophageal pain at his March 2006 VA examination. In a March 2009 statement, the Veteran stated that he has pain in his stomach, chest, arms, and shoulders several times per week. However, the March 2013 VA examiner specifically found the Veteran does not have substernal, arm, or shoulder pain, and the medical records reflect no other complaints of such pain related to his digestive system. The March 2013 VA examiner also found the Veteran has no swallowing difficulty, although his medical records do show prior complaints of dysphagia, including at his March 2006 VA examination. However, he was found to have a functional swallow on evaluation in 2008. Overall, the Board finds that the evidence does not show that the Veteran's condition has been productive of considerable impairment of health so that it might more closely approximate a 30 percent rating. The August 2001 VA examiner found the Veteran's symptoms were mostly controlled with medication. The March 2006 VA examiner also described the Veteran's symptoms as intermittent and controlled with medication. Records show the Veteran has changed medications over the years, but has consistently been on medication to treat his symptoms. There has been some fluctuation in his symptoms over the years as well, but at no point does the evidence indicate a considerable or severe impairment of health due to GERD or hiatal hernia as is required for a higher rating. Instead, the evidence suggests the Veteran's swallowing difficulties dissipated and he has continued on medication to treat his symptoms, which have included heartburn, reflux, and regurgitation, but have not included anemia, weight loss, nausea, vomiting, or melena. In this regard, it is important for the Veteran to understand that the 10 percent rating assigned encompasses the symptoms described by the Veteran and with no symptoms attributable to the condition he would not be entitled to even a compensable rating. The Board has considered whether a staged rating is warranted but finds that it is not. As the preponderance of the evidence is against an increased rating, the benefit of the doubt doctrine does not apply, and the claim for a higher disability rating for GERD and hiatal hernia must be denied. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102; Gilbert, 1 Vet. App. 49. The Board further finds that the Veteran's GERD and hiatal hernia should not be evaluated separately as the Veteran has requested. The Schedule of Ratings of the Digestive System at 38 C.F.R. § 4.114 provides that ratings under Diagnostic Codes 7301 to 7329, inclusive 7331, 7342, and 7345 to 7348 inclusive will not be combined with each other. Rather, these diseases of the digestive system, while differing in the site of pathology, produce a common disability picture characterized by varying degrees of abdominal distress or pain, anemia and disturbances in nutrition. They are to be assigned a single disability rating based on the predominant disability picture, with elevation to the next higher level where the severity of the overall disability picture warrants. 38 C.F.R. §§ 4.113, 4.114. To do otherwise would amount to impermissible pyramiding, or the assignment of multiple separate ratings for the same symptoms of disability. See 38 C.F.R. § 4.14. The Veteran's GERD and hiatal hernia have a common disability picture. Craniotomy Scar In a June 2013 rating decision, the Veteran was awarded a rating of 30 percent for his craniotomy scar. The increased rating constitutes a partial grant of benefits, such that the issue remains on appeal and is for consideration by the Board. 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 Veteran's scar has been rated under Diagnostic Code 7800 for scars or other disfigurement of the head, face, or neck. As he filed his claim in February 2009, the 2008 revisions to the regulations for rating scars apply. Under Diagnostic Code 7800, a 10 percent rating is assigned for one characteristic of disfigurement. A 30 percent evaluation is assigned in cases of visible or palpable tissue loss and either gross distortion or asymmetry of one feature or a 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 warranted in cases of 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 warranted in cases of 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. 38 C.F.R. § 4.118, Diagnostic Code 7800. According to Note (1), the eight "characteristics of disfigurement" are: (1) a scar of five or more inches (13 or more cm.) in length; (2) a scar of at least one-quarter inch (0.6 cm.) wide at the widest part; (3) surface contour of the scar elevated or depressed on palpation; (4) scar adherent to underlying tissue; (5) skin hypo- or hyper- pigmented 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.). Id. Note (4) directs that disabling effects other than disfigurement that are associated with individual scar(s) of the head, face, or neck, such as pain, instability, and residuals of associated muscle or nerve injury, should be separately evaluated under the appropriate diagnostic code(s) and § 4.25 applied to combine the evaluation(s) with the evaluation assigned under this diagnostic code. The Veteran was afforded a VA examination in August 2009. The examiner measured the Veteran's scar as 10 centimeters by .5 centimeters running from the occipital region of his skull to the base of his neck. In an August 2011 statement the Veteran said that the scar is tender and painful, especially when he lays his head back on his chair. In an August 2012 statement, the Veteran explained that during a June 2011 laminoplasty the existing scar was enlarged. In March 2013, a VA examiner completed a scars disability benefits questionnaire. The Veteran was noted to have a scar at the posterior neck. The scar was found not to be painful or unstable. The examiner measured it as 16 centimeters by 1 centimeter. Its surface contour was depressed on palpation but it was not adherent to underlying tissue nor was the underlying soft tissue missing. There was also no abnormal pigmentation or texture. The Board finds the Veteran is not entitled to a rating greater than 30 percent as his scar has only been found to have three characteristics of disfigurement on examination. Specifically, the March 2013 VA examiner found the scar is 13 or more centimeters in length, at least 0.6 centimeters wide, and the surface contour depressed on palpation. No other characteristics of disfigurement have been found. The evidence also does not show visible or palpable tissue loss or gross distortion or asymmetry of two features or paired sets of features. Therefore, the scar does not meet the criteria for a higher rating. Although the scar was found not to be painful on examination, the Veteran has previously stated that it is painful. However, a single painful scar warrants only a 10 percent rating under Diagnostic Code 7804, therefore the Board notes that it is more beneficial to the Veteran to rate his scar under Diagnostic Code 7800. Based on the forgoing, the Board finds the Veteran is not entitled a rating greater than 30 percent for his craniotomy scar. As the preponderance of the evidence is against a higher rating, the benefit of the doubt doctrine does not apply. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102; Gilbert, 1 Vet. App. 49. Extraschedular The Board has also considered whether referral for consideration of an extraschedular rating is warranted for any of the Veteran's disabilities, 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 disabilities that would render the schedular criteria inadequate. The Veteran's symptoms of cervical spine degenerative arthritis, including loss of range of motion and pain; his symptoms of left upper extremity radiculopathy, including weakness, pain, and sensory impairment; his symptoms of GERD and hiatal hernia, including heartburn, reflux, and regurgitation; and his craniotomy scar characteristics, are all contemplated in the ratings assigned. As such, it would not be found that any of his disabilities meet the "governing norms" of an extraschedular rating. Accordingly, referral for consideration of an extraschedular rating is not warranted, particularly in light of the TDIU finding. However, 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 for any of the Veteran's disabilities. The Board recognizes that the Veteran has had some hospitalization for surgery related to his neck and the Veteran reported his loss of range of motion in his neck contributed to his failing a shooting test required for his continued employment as a security officer and he is currently not working. However, the Board notes that the Veteran has been granted individual unemployability benefits from May 30, 2006 to October 9, 2006 and since February 3, 2008. The manifestations of the Veteran's disabilities are considered by the schedular ratings. Based on the foregoing, the Board finds the schedular evaluations are adequate, and referral is not required. 38 C.F.R. § 3.321; Thun v. Peake, 22 Vet. App. 111 (2008). Effective Date for Arnold-Chiari I Malformation The Veteran contends he is entitled to effective date earlier than May 30, 2006 for service connection for Arnold- Chiari I Malformation with cervical syringohydromelia status post suboccipital craniotomy. The effective date for a reopened claim, after a final disallowance, shall be the date of receipt of the new claim or date entitlement arose, whichever is later. 38 C.F.R. § 3.400(q)(2). See Leonard v. Principi, 405 F.3d 1333 (Fed. Cir. 2005); Nelson v. Principi, 18 Vet. App. 407, 409 (2004); Sears v. Principi, 16 Vet. App. 245, 247 (2002), aff'd, 349 F.3d 1326 (Fed. Cir. 2003); see also, Lapier v. Brown, 5 Vet. App. 215 (1993). In this case, the Veteran did not appeal a September 2004 rating decision denying his claim for service connection for Arnold-Chiari Malformation. In addition, no new service department records were associated with the file and new additional evidence was received prior to the expiration of the appeal period. Therefore, the decision became final. On May 30, 2006 the Veteran filed a request to reopen his claim for service connection for Arnold-Chiari Malformation. The claim was reopened and the RO granted service connection effective May 30, 2006, the date the Veteran's reopened claim was received. Therefore, the Veteran is not entitled to an earlier effective date. 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 letters sent to the Veteran, including most recently in July 2012. In the letters, the RO informed the Veteran of what evidence was required to substantiate his claims for increased ratings and an earlier effective date for service connection for manifestations of Arnold-Chiari I Malformation and of 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, VA treatment records, and private treatment records identified by the Veteran. The Veteran also submitted lay statements. 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 in January 2001 for evaluation of his neck and GERD; in August 2001 for evaluation of his GERD; in March 2006 for evaluation of his neck, radiculopathy, and GERD; in January 2008 for evaluation of his radiculopathy; in August 2009 for evaluation of his scar; and in March 2013 for evaluation of his neck, radiculopathy, GERD, and scar. The examiners, medical professionals, obtained an accurate history, listened to the Veteran's assertions, and performed the necessary tests. The examiners provided the Board with sufficient information to rate the Veteran's disabilities. Therefore, the Board finds that the examinations are adequate and contains sufficient information to decide the issues on appeal. Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). Hence, no further notice or assistance to the Veteran is required to fulfill VA's duty to assist 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, 16 Vet. App. 183. ORDER A rating in excess of 10 percent for degenerative arthritis, cervical spine, status post neck and right shoulder injury with painful and limited motion prior to October 29, 2003 and in excess of 40 percent thereafter is denied. A compensable rating for radiculopathy of the left upper extremity prior to October 29, 2003 is denied. A rating of 30 percent, but no higher, for radiculopathy of the left upper extremity as of October 29, 2003 is granted, subject to the laws and regulations controlling the disbursement of monetary benefits. A rating in excess of 10 percent for GERD and hiatal hernia is denied. A rating in excess of 30 percent rating for craniotomy scar is denied. An effective date earlier than May 30, 2006 for service connection for manifestations of Arnold-Chiari I Malformation with cervical syringohydromyelia status post suboccipital craniotomy is denied. REMAND Unfortunately, remand of the Veteran's claim for a compensable rating for manifestations of Arnold-Chiari I Malformation with cervical syringohydromyelia status post craniotomy is necessary. Although the Board regrets the additional delay, further development of the record is required before the Board may render a decision in the instant case. The RO granted service-connection for manifestations of Arnold-Chiari I Malformation with cervical syringohydromyelia status post craniotomy in June 2007 and assigned a noncompensable rating. The RO noted some of the manifestations being claimed by the Veteran are already being compensated separately, including headaches, neck pain, and left upper extremity radiculopathy. The Board further notes that since that decision, the Veteran has been service-connected for impaired vision and a mood disorder, both secondary to Arnold-Chiari I Malformation. However, the Veteran has claimed he is entitled to a compensable rating or ratings for additional manifestations. In a June 2007 letter the Veteran listed the following manifestations: (1) swallowing disorder difficulty, (2) speech disorder slurred speech, (3) hearing loss left ear, (4) depression from suboccipital craniotomy, (5) lower back pain that radiates with sharp pain down both legs and feet, (6) frequent loss of balance, (7) cervical neurosis right side that at times disables chewing on the right side of his mouth. In an April 2008 letter, the Veteran added that he also has frequent middle - back pains with severe back and neck muscle spasms and that his Chiari Malformation and syringohydromyelia "affects my central nervous system which affects my entire body from head to toe." In April 2007 the Veteran was afforded a VA examination at which the examiner identified the following effects of his Arnold-Chiari Malformation: vision difficulty, lack of stamina, decreased strength in the upper extremity, and pain. The Veteran was afforded another VA examination in January 2008 at which the examiner identified the following symptoms of his syringomyelia: decreased mobility, decreased manual dexterity, problems with lifting and carrying, difficulty reaching, hearing difficulty, vision difficulty, lack of stamina, weakness or fatigue, decreased strength in the upper extremity, and pain. In August 2011 the Board remanded the Veteran's claim for a VA examination to determine all manifestations of the Veteran's Arnold-Chiari I Malformation with cervical syringohydromyelia status post craniotomy. The examiner was specifically requested to address whether the Veteran has impaired vision, swallowing disorder, speech disorder, hearing loss, back and neck symptoms, and chewing disorder, and if so, the nature and severity of each. The Veteran was afforded a VA examination in March 2013. The examiner found he is able to see, hear, smell, taste, eat, and talk, and his chewing and swallowing are good. However, the examination does not indicate whether the Veteran was afforded a hearing examination to evaluate whether he has hearing loss and the examiner did not address the Veteran's contention that he experiences back pain radiating into his legs and loss of balance as a result of his Arnold-Chiari I Malformation. The examiner further did not specifically opine as to what are the manifestations of the Veteran's Arnold-Chiari I Malformation with cervical syringohydromyelia status post craniotomy. In this regard, in light of the TDIU finding, in consultation with the Veteran's representative, the Veteran may wish to withdraw this claim (in writing). In any event, until such time as the claim is withdrawn, this issue must be fully adjudicated by the Board. Accordingly, the case is REMANDED for the following action: 1. Afford the Veteran an examination to determine all manifestations of his Arnold-Chiari I Malformation with cervical syringohydromyelia status post craniotomy (if any). The examiner must specifically address whether the Veteran suffers, as a result of this condition, the following as a result of this condition (and if so the nature and severity of the manifestation): (a) swallowing disorder; (b) speech disorder; (c) hearing loss (a separate audoiolgical examination should be undertaken); (d) back disorder, including pain radiating into his legs; (e) loss of balance; and (f) chewing disorder. Relevant medical records should be made available to the examiner for review in conjunction with the examination, and the examiner should annotate as to whether the claims file was reviewed. 2. This is a complex issue. The RO/AMC should insure that the instructions undertaken above have been compelted. 3. Upon completion of the above, readjudicate the issue on appeal. If any benefit sought on appeal remains denied, the Veteran and his representative should be furnished an appropriate supplemental statement of the case and be provided an opportunity to respond. Thereafter, the case should be returned to the Board for further appellate consideration, as appropriate. The appellant has the right to submit additional evidence and argument on the matter or matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board 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). ______________________________________________ JOHN J. CROWLEY Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs