Citation Nr: 1331137 Decision Date: 09/26/13 Archive Date: 09/30/13 DOCKET NO. 10-29 540 ) DATE ) ) On appeal from the Department of Veterans Affairs (VA) Regional Office in Phoenix, Arizona THE ISSUE Entitlement to a disability rating in excess of 10 percent for a respiratory disorder. REPRESENTATION Appellant represented by: Veterans of Foreign Wars of the United States WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD Suzie S. Gaston, Counsel INTRODUCTION The Veteran had active service from September 1981 to May 1983. This matter comes before the Board of Veterans' Appeals (hereinafter Board) on appeal from a September 2008 rating decision, by the Phoenix, Arizona, Regional Office (RO), which denied the Veteran's claim for a rating in excess of 10 percent for a respiratory disorder claimed as a breathing disorder. He perfected a timely appeal to that decision. On November 19, 2012, the Veteran testified at a hearing before the undersigned Veterans Law Judge sitting at the RO. A transcript of that hearing has been associated with the claims folder. In July 2012, the Board remanded the case for evidentiary development. Following the requested development, a supplemental statement of the case (SSOC) was issued in January 2013. In February 2013, the Board again remanded the case for further evidentiary development. Following the requested development, an SSOC was issued in May 2013. In July 2013, the Board once again remanded the case for still further evidentiary development. The Appeals Management Center (AMC) completed the requested development and issued another SSOC in June 2012. Review of the record reflects substantial compliance with the Board's Remand directives. Stegall v. West, 11 Vet. App. 268, 271 (1998). Please note this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2012). 38 U.S.C.A. § 7107(a) (2) (West 2002). FINDING OF FACT The record shows that the Veteran had a Forced Expiratory Volume at one Second (FEV-1) on pulmonary function testing that was 75 percent of the predicated value prior to March 14, 2013, and a Forced Expiratory Volume at one Second (FEV-1) of 63 percent of the predicted value since March 14, 2013. CONCLUSIONS OF LAW 1. The criteria for a rating in excess of 10 for a respiratory disorder were not met prior to March 14, 2013. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.159, 4.1-4.7, 4.20, 4.96, 4.97, Diagnostic Code 6844 (2013). 2. Since March 14, 2013, the criteria for a 30 percent rating for Veteran's respiratory disorder have been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.159, 4.1-4.7, 4.20, 4.96, 4.97, Diagnostic Code 6844 (2013). REASONS AND BASES FOR FINDING AND CONCLUSIONS I. Duties to Notify and Assist. The Veterans Claims Assistance Act of 2000 (VCAA) enhanced VA's duty to notify and assist claimants in substantiating their claims for VA benefits, as codified in pertinent part at 38 U.S.C.A. §§ 5103, 5103A (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.159, 3.326(a) (2013). Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant of the information and evidence not of record that is necessary to substantiate the claim; and to indicate which information and evidence VA will obtain and which information and evidence the claimant is expected to provide. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b). The United States Court of Appeals for Veterans Claims has held that VCAA notice should be provided to a claimant before the initial RO decision on a claim. Pelegrini v. Principi, 18 Vet. App. 112 (2004). However, if VCAA notice is provided after the initial decision, such a timing error can be cured by subsequent readjudication of the claim, as in a statement of the case (SOC) or supplemental SOC (SSOC). Mayfield v. Nicholson, 20 Vet. App. 537, 543 (2006); Prickett v. Nicholson, 20 Vet. App. 370, 376 (2006). In this case, VA satisfied its duty to notify by means of a letter dated in February 2008 from the RO to the Veteran which was issued prior to the RO decision in September 2008. Additional letters were issued in July 2012, October 2012, and February 2013. Those letters informed the Veteran of what evidence was required to substantiate the claim for a higher rating and of his and VA's respective duties for obtaining evidence. Accordingly, the requirements the Court set out in Pelegrini have been satisfied. The Board finds that the content of the above-noted letters provided to the Veteran complied with the requirements of 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) regarding VA's duty to notify. Regarding the duty to assist, the Veteran was provided an opportunity to submit additional evidence. It also appears that all obtainable evidence identified by the Veteran relative to the claim decided herein has been obtained and associated with the claims file, and that neither he nor his representative has identified any other pertinent evidence not already of record that would need to be obtained for a proper disposition of this claim. It is therefore the Board's conclusion that the Veteran has been provided with every opportunity to submit evidence and argument in support of his claim, and to respond to VA notice. The Veteran has been afforded VA examinations with respect to the issue in question. McLendon v. Nicholson, 20 Vet. App. 79 (2006). The examinations were conducted by medical professionals who reviewed the medical records, solicited history from the Veteran, and provided information necessary to decide the issue addressed in this decision. Nieves-Rodriguez v. Peake, 22 Vet. App 295 (2008). They were also provided in connection with the July 2012, February 2013 and July 2013 Board remands. The Board finds that there was substantial compliance with the Board remands. Accordingly, the Board finds that VA has satisfied its duty to notify and assist the Veteran in apprising him as to the evidence needed, and in obtaining evidence under the duty-to-assist requirements. Therefore, no useful purpose would be served in remanding this matter for yet more development. Such a remand would result in unnecessarily imposing additional burdens on VA, with no additional benefit flowing to the Veteran. The Court has held that such remands are to be avoided. Sabonis v. Brown, 6 Vet. App. 426, 430 (1994). II. Factual background. By a rating action in June 2007, the RO granted service connection for a respiratory condition, claimed as a breathing disorder; a 10 percent disability rating was assigned, effective January 31, 2007. The Veteran's claim for an increased rating for his respiratory disorder was received in January 2008. In conjunction with the claim, the Veteran was afforded a VA examination in March 2008. It was noted that the Veteran was being examined for evaluation of a breathing disorder associated with residuals of a stab wound to the chest; however, this is complicated by other factors, including disseminated coccidioidomycosis including bilateral pulmonary interstitial and nodular involvement noted in 1997 and 1998. The examiner noted that he did not see any mention of asthma during the 1997 to 1998 notes. The earliest clinical outpatient notes that he was able to see were from 2004, at which time the Veteran was being treated for asthma. Nonetheless, the examiner noted that asthma is the condition for which the Veteran was being evaluated and that was his primary clinical diagnosis. His chronic chest tightness and tendency to wheezing and chronic cough were present year round. It was noted that approximately three times a year, and correlated with pollution, the Veteran has to come in for SVN treatments but he has never had to go to the emergency room. He has not been hospitalized for asthma. His usual treatment has been Albuterol 2 puffs twice a day, which has been very effective. It was noted that when his chest is tight, he is short of breath even at rest. He has not had systemic symptoms. His appetite is good and his weight is stable. His energy levels are all right and he does not have unexplained fevers or night sweats. He coughs a lot and he often has a dry cough and an irritating cough at night. He will use a humidifier in the bedroom. He has never had hemoptysis. He has an essentially normal chest x-ray in March 2007. On examination, it was noted that the Veteran was treated for hypertension. The Veteran was described as stocky, muscular and well-developed. He had not used his inhalers prior to the examination and he began to look uncomfortable and even slightly tachypneic and anxious because he felt he needed his inhaler. It was noted that the lungs were being examined before the use of an inhaler, and there was some mild prolongation of expiration. However, there were no wheezes or rales. He became much more comfortable and that prolongation was reduced after he used his inhaler. The chest was normal to percussion. There was no clubbing or edema. The examiner noted that the Veteran's main chronic condition was asthma and his doctors had also used a diagnosis of chronic bronchitis. A pulmonary function test (PFT) was conducted in April 2008, and it revealed that the Veteran's FVC was 70 percent predicted, his FEV-1 was 75 percent predicted, and his FEV-1/FVC was 88 percent predicted. The DLCO was 72 percent. The examiner stated that the residuals indicate only a mild restrictive defect and mild decrease in DLCO. The examiner stated that there was no evidence of any pulmonary condition which is related to a stab wound to the chest or from scars of such stab wound. The examiner also stated that it is not clear from the PFT results that the Veteran has asthma or bronchitis, but it is thought so by his treating doctors; however, neither of those conditions would be related to a stable wound. The examiner stated that it is not known with certainty while the PFT demonstrate a restrictive defect, but it is likely that it is from the 1997-1998 coccidiodomycosis, and it is unlikely that it results from a stab wound. Received in February 2010 were VA progress notes dated in August 2009. The Veteran was seen on August 12, 2009, at which time the examiner noted that he had previously seen the Veteran briefly in urgent care with complaints of right sided chest pain. He has returned with some worsening chest pain, particularly on deep breathing; he stated that it was deep seated and unable to reproduce it by any pressure. On examination, it was noted that chest expansion was satisfactory. Air entry was fair to good bilaterally. There were no wheezing or crackles; fremitus was normal. The assessment was persistent right-sided chest pain with some shortness of breath, not responding to Albuterol and mometasone therapy. On August 14, 2009, the Veteran was seen by the pulmonary home health consultant, at which time it was noted that he was unable to sustain a 5 second hold due to coughing and pain on inspiration. He was approved for svn machine. VA progress notes dated in March 2010 reflect ongoing complaints of right sided chest pain. The Veteran was seen in April 2010 complaining of shortness of breath; he was diagnosed with acute bronchitis and controlled asthma. Received in October 2010 were VA progress notes dated from August 2010 to October 2010. In August 2010, the Veteran was instructed on the use of a TENS unit. In November 2010, the Veteran was seen on an emergency visit with complaints of pain in the right chest. It was noted that he presented with mildly worsened pain noticed after yesterday's workout. He had no shortness of breath or coughs. The assessment was acute exacerbation of chronic right chest and shoulder pain. At his personal hearing in November 2010, the Veteran reported that he used to be a volunteer at his child's school, he used to be a baseball coach and occasionally chaperoned field trips; however, he is no longer able to participate in those activities because he would experience shortness of breath. The Veteran also testified that he used to be very active and do such things as riding his bike and take long walks; but he is unable to do those things because he would have to constantly stop and get some rest or use his inhaler. The Veteran brought in some medication which he noted were a steroid inhaler which is used to prevent lung infection and his nebulizer. Received in June 2012 was a clinic note, dated in May 2012, indicating that the Veteran was seen for shortness of breath symptoms, which were persisting and for which he had undergone a pulmonary function test. The PFT report, dated in June 2012, noted that testing was performed three times, revealed FEV-1 of 46 percent predicted, 39 percent predicted and 38 percent predicted. FEV-1/FVC was noted to be preserved, however, with findings of 119 percent, 116 percent and 116 percent. The test was interpreted to reveal a severe restrictive pattern indicated by the reduction in FVC with preservation of the FEV-1/FVC ration. Received in July 2012 was a VA progress note dated in May 2009, indicating that the Veteran was seen for complaints of rib pain to the right chest from coughing. The Veteran stated that he had had a cough for two weeks; he noted that he was coughing frequently during the day. He reported having a sore throat, some shortness of breath, and chest pain to the right ribs on coughing. No wheezing or crackles were noted. The assessment was acute bronchitis, and chronic asthma. The Veteran was afforded a VA examination in August 2012. The examiner noted that the Veteran's history included undergoing a right thoracotomy to repair damage from a stab wound, which was in the mid-lower right parasternal area. The examiner stated that it is in the thoracotomy operative area, probably at the rib fracture site that the Veteran has since had chest wall type pain. It is not all along the entire scar, and it does not seem to be scar pain. The examiner noted that the pain is increased by truncal movement, twisting, heavy lifting and heavy exertion. The examiner stated that, contrary to what has been said on previous examination, it is not pleuritic; he noted that it does not hurt him to breathe deeply. The examiner noted that this is very important as it would make the likelihood of any restriction in breathing to be secondary to the pain also unlikely. As is known, the Veteran had disseminated cocci in 1997-1998, but there is no evidence of residual lung damage. The examiner reported that records reviewed indicate that it wasn't until 2000 that his complaints suggested asthma with cough and shortness. The complaints of that and productive cough have persisted, with chronic treatment with Albuterol and also inhaled steroid sprays more recently. Yet, he did not find that the Veteran has had physical findings supportive; that is, on no visits did he find that he had had wheezes nor other abnormalities. The examiner noted that the Veteran had marked abdominal obesity, which can cause the restrictive change that has been demonstrated on his pulmonary function studies. The pulmonologist who read a past study suggested his obesity can explain the restriction seen. The examiner noted a diagnosis of asthma. The examiner noted that the Veteran has been diagnosed clinically as having asthma, based on his symptoms; however, in review of the records he did not find that there have been objective findings on physical examination or pulmonary function studies. Nevertheless, the examiner included asthma as a claimed condition because it was and is clinically diagnosed by the Veteran's treating doctors, and it is in his opinion the only respiratory condition that can reasonably be diagnosed. The examiner stated that the question becomes is it related to his stab wound that occurred in service. The examiner stated that the Veteran's respiratory condition does not require the use of oral or parenteral corticosteroid medications. It does not require the use of oral bronchodilators. The examiner noted the Veteran required daily bronchodilator therapy and daily anti-inflammatory medication. It was also noted that the Veteran required infrequent short courses of antibiotics. He does not require outpatient oxygen therapy. It was noted that the Veteran has not had any asthma attacks with episodes of respiratory failure in the past 12 months; he has not had any physician visits for required care of exacerbations. The examiner noted that PFT results, dated in May 2012, are invalid because it did not meet ATS standards. He further noted that the simple spirometry done outside the VA in June 2012 did not show reproductible results and cannot be used as a valid study. The examiner stated that the chest examination was normal. There were no rales, rhonchi or wheezes. The thin linear right thoracotomy scar was not deep, itself nontender but there is rib area tenderness around the midaxillary line, presumably at the operative rib fracture site. The examiner noted that the Veteran was unable to cooperate fully with the PF study possibly due to his cough. He stated that the last valid studies have to be considered representative, and it does not seem that there have been any changes since then; his chest examination remains normal. The examiner stated that the Veteran has not had any changes in the course of his asthma, if he has asthma. He noted that most clinical visits have not been for asthma. The examiner stated that the Veteran's claims file was reviewed. There was no evidence that his lungs or respiratory system was permanently injured. Initially, for years he had rather moderate complaints of pain in the chest wall consistent with the thoracotomy site, where the 5th rib was interrupted for the surgery; he reports that the rib has worsened a lot since he has gotten older. Past notes and the Veteran himself today made it clear that the pain is not pleuritic, it not affected by taking a deep breath, and this eliminates in his opinion any likelihood that it has caused any restriction of respiration such as might affect his breathing. He does not have overall scar pain or tenderness, the scar is not deep or restrictive on examination and the pain is more of chest wall type consistent with the rib surgery. The examiner noted that reconciliation of pulmonary function studies of 2008 and 2012 was requested, but the tests of 2012 are not acceptable nor can the VA pulmonary lab be expected to agree to another attempt. Based on the records, there is no reason to think the 2008 studies will have changed significantly. The only respiratory condition which has been diagnosed is asthma. He may or may not have asthma, as it can be missed on PFTs, but in any case there is no reason to think that it would be secondary to the service incident. Having seen and examined the Veteran today, he saw that the has a very obese abdomen, and he agreed with the pulmonologist who suggested on the prior PFT report that his restriction on the test may be from his obesity, that that is in fact the likely cause (especially now that we know the chest CT scan is normal). The examiner stated that he did not believe that new PFT studies will add anything pertinent to this examination. In summary, the examiner stated that it was his opinion that the Veteran does not have a respiratory condition related to his stab wound while in service. He may have asthma; if so, it is not related to that injury and surgery. Restriction on past PFTs is likely related to his obese abdomen. His chest wall pain is secondary to the surgery, but this examination is of the respiratory system and it is not pleuritic pain and in his opinion it is not the cause of any respiratory condition despite the fact that it has at a prior examination been characterized as such. Received in November 2012 were private treatment records from FSC family practice, dated from June 2012 through September 2012. These records do not reflect treatment for asthma or a respiratory disorder. Another VA examination was conducted on March 14, 2013. At that time, it was reported that the Veteran was stabbed in the chest with a knife in 1982; he had surgery and a chest tube and was hospitalized for 5 days. It was noted that, within one week, he was diagnosed with chest wall pain and then pleurisy. In April 1983, he was diagnosed with dyspnea. The Veteran indicated that the symptoms never got better. In December 1997, he was diagnosed with valley fever (coccidioidyomycosis). He was treated with dilfucan and amphotericin but did not finish the treatment. He was currently taking several bronchodilators in a rescue inhaler and also using a nebulizer. He uses symbicort which is a corticosteroid and a long acting beta-2 agonist. He still complained of chest pain and cough with breathing. The examiner stated that the Veteran's respiratory condition required the use of oral or parenteral corticosteroid medications. It requires the use of low dose corticosteroids; it also requires intermittent courses of bursts of systemic corticosteroids. The examiner noted that the Veteran's condition required the use of inhaled medications. It does require the use of oral bronchodilators. The examiner noted the Veteran required daily bronchodilator therapy. It was also noted that the Veteran did not require the use of antibiotics. He does not require outpatient oxygen therapy. It was noted that the Veteran had one asthma attack with episodes of respiratory failure per week in the past 12 months; and he had physician visits for required care of exacerbations. The examiner noted that the Veteran was evaluated and treated at the emergency department at the VA in Phoenix on February 12, 2013 and was diagnosed with exacerbation of asthma. It was noted that a chest x-ray, dated in February 2013, revealed old healed fracture deformity right posterior 5th rib; short segment linear atelectasis or fibrosis, left lower lung. It was noted that a PFT, performed in March 2013, revealed FEV-1 of 63 percent predicted, FEV-1/FVC of 97 percent, and FVC of 64 percent. The examiner stated that the Veteran had difficulty taking a deep breath. He cannot walk more than 2 blocks, cannot climb more than one flight of stairs. He cannot perform any type of strenuous exercise. He uses a nebulizer twice daily so that he can perform his activities of daily living. He supplements with bronchodilators and rescue inhalers several times daily. The examiner indicated that the Veteran suffered from reactive airway disease/asthma and that that the FEV-1 test result most accurately reflected the Veteran's level of disability. The examiner then reconciled the conflicting PFT results of record, stating that it appeared from the evidence that the PFT results from April 2008 and March 2013 appear to be valid and demonstrate a decline in the FVC and the FEV1 which is consistent with severe airway obstruction. The examiner stated that the PFT results from May 2012 appear to not be entirely accurate. The examiner noted that there was error in administering the May 2012 PFT and, as such, those results did not accurately reflect the Veteran's pulmonary status at that time. The examiner reiterated that the results from April 16, 2008 and March 14, 2013 do accurately reflect the Veteran's pulmonary status. The values reflect severe airway obstruction with reduced diffusing capacity and suggest an early parenchymal process. An independent medical opinion was obtained in May 2013. Upon review of the Veteran's claims folder, and in consideration of cited medical literature, the reviewer opined that the Veteran's asthma was not caused by or proximately due to his traumatic pneumothorax, nor was there any medical or scientific evidence to support a finding that the Veteran's asthma had been aggravated beyond its natural progress by his traumatic pneumothorax. The reviewer further indicated her agreement with the previous assessments that the May 2012 PFT results did not accurately reflect the Veteran's pulmonary status, and stated that the April 2008 and March 2013 PFT results reflected severe airway obstruction with reduced diffusing capacity, which suggested an early parenchymal process. The reviewer found, therefore, that the Veteran's PFTs were reflective of the Veteran's nonservice-connected asthma. Received in June 2013 was a statement from the Veteran's direct supervisor, who indicated her observations of the Veteran's breathing problems and noted that the Veteran often had to take breaks during the workweek to administer breathing treatment and had several times called in sick on account of his breathing problems. The Veteran was afforded another VA examination in July 2013. The examiner noted that the STRs reflect that in August 1982, the Veteran was treated for pain and shortness of breath; a chest x-ray was negative with no physical evidence of pneumonia or hemothorax. He was prescribed Motrin for probable chest wall pain. On the occasion of the separation examination, the Veteran reported lack of breathing and chest pain with coughing. However, clinical evaluation of the respiratory system was normal. The examiner noted that an examination in June 1983 revealed FVC 60 percent, FEV1 57 percent, and FEV1/FVC 78 percent; these findings were compatible with moderate restrictive. The examiner noted that PFTs at separation noted only restrictive component and no obstructive component which one would expect for asthma since asthma is an obstructive lung disease. Therefore, he stated that there is no evidence of obstructive lung disease or asthma at the time of service or at separation from service. The examiner opined that the claimed condition, namely asthma, was less likely than not incurred in or caused by the claimed inservice injury, event or illness. The examiner explained that there is no evidence of asthma symptoms or treatment in service. He noted that the Veteran was treated for a stab wound and traumatic pneumothorax with rib resection in service, but there is no known medical cause of asthma by rib resection or by pneumothorax. The examiner stated that the Veteran's current pneumothorax condition does not affect current respiratory function as there is no evidence of current respiratory compromise due to this condition. The examiner also noted that the Veteran's symptoms do not show any evidence of pleuritis with no pain related to inspiration but instead has muscle pain related to the chest wall as noted on previous ratings examinations. The examiner further noted that PFTs showed restriction with a reversible component which has been noted to be likely due to obesity by pulmonology specialists. The reversibility was likely due to asthma. Therefore, the examiner concluded that the current severity of the pneumothorax residuals was mild and related to muscle pain of the chest wall and scar as described in the October 2012 examination. The examiner stated that the condition does not restrict the Veteran's employment or daily activity. The condition does not cause shortness of breath, aching lungs or decreased physical stamina. It does not require the use of an inhaler or nebulizer. No medications are used to treat this condition other than the use of pain medication. The examiner noted that the Veteran has evidence of moderate persistent asthma requiring chronic medication including inhalational bronchodilators daily, inhalational anti-inflammatory medication daily, intermittent systemic bursts or corticosteroids and the sue of an oral leukotriene inhibitor. His restrictive defect on PFT is most likely related to obesity per pulmonary specialty. The Veteran has required time lost from work for asthma exacerbation for the asthma excaberations and emergency treatment for such; however, he has not required any hospitalization in the past 12 months for his asthma condition. III. Legal Analysis. Disability evaluations are determined by the application of a schedule of ratings which is based upon average impairment of earning capacity. 38 U.S.C.A. § 1155. 38 C.F.R. § 4.1 (2013) requires that each disability be viewed in relation to its history, and that there be emphasis upon the limitation of activity imposed by the disabling condition. 38 C.F.R. § 4.2 (2013) requires that medical reports be interpreted in light of the entire recorded history, and that each disability must be considered from the point of view of the Veteran's working or seeking work. Separate diagnostic codes identify the various disabilities. Where there is a question as to which of two disability evaluations shall be applied, the higher evaluation is to be assigned if the disability picture more nearly approximates the criteria required for that rating. 38 C.F.R. § 4.7. Otherwise, the lower rating is to be assigned. The requirements for evaluation of the complete medical history of the claimant's condition operate to protect claimants against adverse decisions based upon a single, incomplete, or inaccurate report and to enable VA to make a more precise evaluation of the level of the disability and of any changes in the condition. Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Where entitlement to compensation has already been established and an increase in the disability rating is at issue, the present level of disability is of primary concern. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). When there is an approximate balance of evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each such issue shall be given to the claimant. 38 U.S.C.A. § 5107; 38 C.F.R. §§ 3.102, 4.3. In Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990), the Court stated that "a Veteran need only demonstrate that there is an 'approximate balance of positive and negative evidence' in order to prevail." To deny a claim on its merits, the preponderance of the evidence must be against the claim. Alemany v. Brown, 9 Vet. App. 518, 519 (1996), citing Gilbert at 54. The Veteran is currently rated as 10 percent disabled for his for service-connected respiratory disorder. This rating was assigned pursuant to 38 C.F.R. § 4.97, Diagnostic Code 6844. ((Hereinafter, Forced Expiratory Volume in One Second will be abbreviated as "FEV-1"; Forced Vital Capacity as "FVC"; Diffusion Capacity of Carbon Monoxide, Single Breath, as "DLCO (SB)"; and Pulmonary Function Test as "PFT")). Diagnostic Code 6844 provides for evaluations pursuant to the General Rating Formula for Restrictive Lung Disease (General Formula). The General Formula assigns a 10 percent evaluation for is FEV-1 of 71 to 80 percent predicted; or FEV-1/FVC of 71 to 80 percent; or DLCO (SB) 66 to 80 percent predicted. 38 C.F.R. § 4.97, Diagnostic Code 6844. A 30 percent disability rating is warranted where there is FEV-1 of 56 to 70 percent predicted; or FEV-1/FVC of 56 to 70 percent; or DLCO (SB) is 56 to 65 percent predicted. Id. A 60 percent rating is warranted if FEV-1 is 40 to 55 percent of predicted value; or FEV-1/FVC is 40 to 55 percent; or DLCO (SB) is 40 to 55 percent predicted; or if maximum oxygen consumption is 15 to 20 ml/kg/min (with cardiorespiratory limit). Id. A 100 percent disability rating is warranted if FEV-1 is less than 40 percent of predicted value, or; FEV- 1/FVC is less than 40 percent, or; DLCO (SB) is less than 40-percent predicted, or; maximum exercise capacity is less than 15 ml/kg/min oxygen consumption (with cardiac or respiratory limitation); or there is cor pulmonale (right heart failure); right ventricular hypertrophy; pulmonary hypertension (shown by Echo or cardiac catheterization); episode(s) of acute respiratory failure; or the Veteran requires outpatient oxygen therapy. 38 C.F.R. § 4.97, Diagnostic Code 6844. Effective October 6, 2006, VA amended 38 C.F.R. § 4.96 to clarify the use of pulmonary function tests. 71 Fed. Reg. 52,459. As revised, that regulation now mandates that: 1) PFTs are required to evaluate respiratory conditions except: (i) When the results of a maximum exercise capacity test are of record and are 20 ml/kg/min or less. If a maximum exercise capacity test is not of record, evaluation should be based on alternative criteria. (ii) When pulmonary hypertension (documented by an echocardiogram or cardiac catheterization), cor pulmonale, or right ventricular hypertrophy has been diagnosed. (iii) When there have been one or more episodes of acute respiratory failure. (iv) When outpatient oxygen therapy is required. (2) If the DLCO (SB) test is not of record, evaluation should be based on alternative criteria as long as the examiner states why the DLCO (SB) test would not be useful or valid in a particular case. (3) When the PFTs are not consistent with clinical findings, evaluation should be based on the PFTs unless the examiner states why they are not a valid indication of respiratory functional impairment in a particular case. (4) Post-bronchodilator studies are required when PFTs are done for disability evaluation purposes except when the results of pre-bronchodilator PFTs are normal or when the examiner determines that post-bronchodilator studies should not be done and states why. (5) When evaluating based on PFTs, post-bronchodilator results are to be used unless the post-bronchodilator results were poorer than the pre-bronchodilator results. In those cases, the pre- bronchodilator values should be used for rating purposes. (6) When the results of different PFTs (FEV-1, FVC, etc.) are disparate (so that the level of evaluation would differ depending on which test result is used), the test result that the examiner states most accurately reflects the level of disability should be used for evaluation. (7) If the FEV-1 and the FVC are both greater than 100 percent, a compensable evaluation based on a decreased FEV- 1/FVC ratio should not be assigned. In this case, it is noteworthy that the independent medical opinion in May 2013 reported a diagnosis of traumatic pneumothorax with open wound associated with the stab wound from service. The doctor also reported a diagnosis of asthma; however, he also agreed with the other opinions of record that the asthma is not related to the service-connected respiratory condition resulting from the inservice stab wound and thoracotomy. Nonetheless, it is not entirely clear from the medical evidence what portion of the Veteran's current symptoms are due to the lung restriction/pulmonary impairment is due to his service-connected respiratory condition, versus his nonservice-connected asthma. Therefore, in the absence of medical evidence which differentiates between the Veteran's service-connected and nonservice-connected respiratory symptomatology, the Board is precluded from differentiating between such symptomatology. Mittleider v. West, 11 Vet. App. 181, 182 (1998) (per curiam), citing Mitchem v. Brown, 9 Vet. App. 136, 140 (1996). Thus, the Board must consider all such symptoms to be service connected for rating purposes. Id. Therefore, as regards the results of the PFTs, which evaluated what arguably could be the pulmonary residuals of the Veteran's asthma, the Board notes that the PFT results need to be evaluated in accordance with the criteria found at 38 C.F.R. § 4.97, Diagnostic Code 6844 related to restrictive lung disease. As noted in the Background section above, the results of the April 2008 pulmonary function test (PFT) showed that the Veteran's was conducted in April 2008, and it revealed that the Veteran's Forced Expiratory Volume in one second (FEV-1) was 75 percent predicted; his FEV-1/Forced Vital Capacity (FVC) ratio was found to be 88 percent predicted. And, his Diffusion Capacity of the Lung for Carbon Monoxide by the Single Breath Method (DLCO (SB), or DLCO) was 72 percent. The examiner stated that the residuals indicate only a mild restrictive defect and mild decrease in DLCO. Thus, applying the above regulations to the evidence of record, the Veteran is not entitled to a disability rating in excess of 10-percent for his service-connected respiratory disorder. 38 C.F.R. § 4.97, DC 6844. Another PFT was performed in June 2012; however, after review of the clinical findings, the overall opinion of the medical examiners in March 2013, May 2013 and July 2013 is that the PFT results from May 5, 2012 do not accurately reflect the Veteran's pulmonary status. The Veteran underwent another PFT in March 2013. That study revealed that the Veteran's Forced Expiratory Volume in one second (FEV-1) was 63 percent predicted; his FEV-1/Forced Vital Capacity (FVC) ratio was found to be 97 percent predicted. And, his Diffusion Capacity of the Lung for Carbon Monoxide by the Single Breath Method (DLCO (SB), or DLCO) was 67 percent. An FEV-1 of 63 percent meets the criteria for a 30 percent disability rating, but a disability rating of greater than thirty percent is not warranted under Diagnostic Code 6844. Significantly, the Veteran's medical records show that the veteran is not on oxygen therapy, or has cor pulmonale, ventricular hypertrophy, pulmonary hypertension or episodes of acute respiratory failure. The above determination is based upon consideration of applicable rating provisions. Additionally, there is no showing that the Veteran's service-connected respiratory disability has reflected so exceptional or unusual a disability picture as to warrant the assignment of any higher evaluation on an extra-schedular basis. 38 C.F.R. § 3.321(b) (1). His symptoms have been accurately reflected by the schedular criteria. Without sufficient evidence reflecting that the Veteran's disability picture is not contemplated by the rating schedule, referral for a determination of whether an extra-schedular rating is required is not warranted. See Thun v. Peake, 22 Vet. App. 11, 115-16 (2008). The evidence in this case is not so evenly balanced so as to allow application of the benefit-of- the-doubt rule. Gilbert v. Derwinski, 1 Vet. App. 49 (1990); 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102 (2013). ORDER Entitlement to a rating in excess of 10 percent for a respiratory disorder, prior to March 14, 2013, is denied. Entitlement to a disability rating of 30 percent for respiratory disorder, on and after March 14, 2013, is granted. ____________________________________________ J. A. MARKEY Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs