Citation Nr: 1333575 Decision Date: 10/24/13 Archive Date: 10/24/13 DOCKET NO. 13-21 552 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Phoenix, Arizona THE ISSUES 1. Whether new and material evidence has been received to reopen the Veteran's previously denied claim of service connection for skin cancer, to include as due to exposure to radiation and asbestos. 2. Whether new and material evidence has been received to reopen the Veteran's previously denied claim of service connection for a thyroid disorder (claimed as thyroid cancer), to include as due to exposure to radiation and asbestos. 3. Entitlement to service connection for skin cancer, to include as due to exposure to radiation and asbestos. 4. Entitlement to service connection for a thyroid disorder (claimed as thyroid cancer), to include as due to exposure to radiation and asbestos. 5. Entitlement to an initial rating in excess of 10 percent for coronary artery disease. 6. Entitlement to an initial compensable rating for hypertension. REPRESENTATION Veteran represented by: The American Legion WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD Helena M. Walker, Counsel INTRODUCTION The Veteran served on active duty from August 1951 to July 1955. This case comes before the Board of Veterans' Appeals (Board) on appeal of an October 2012 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Jackson, Mississippi, which denied the benefits sought on appeal. Jurisdiction of the Veteran's claims file is currently at the Phoenix, Arizona, RO. The Board is aware that the Veteran sought to reopen his previously denied claim of service connection for thyroid cancer. As shown in the treatment records, there is some question as to whether he actually had thyroid cancer. As such, the Board expanded his claim to include any thyroid disorder. The Veteran testified at a videoconference hearing before the undersigned Veterans Law Judge (VLJ) in August 2013. A transcript of the hearing is associated with the claims file. The October 2012 rating decision declined reopening the claim finding no new and material evidence had been submitted regarding the Veteran's service connection claims. Regardless of the RO's actions, the Board is required to consider whether new and material evidence has been received warranting the reopening of the previously denied claim. See Barnett v. Brown, 83 F.3d 1380 (Fed. Cir. 1996); Jackson v. Principi, 265 F.3d 1366 (Fed. Cir. 2001); see also VAOPGCPREC 05-92; Wakeford v. Brown, 8 Vet. App. 237 (1995) (VA failed to comply with its own regulations by ignoring issue of whether any new and material evidence had been submitted to reopen the Veteran's previously and finally denied claims). In addition to the paper claims files, the Veteran also has an electronic claims file in Virtual VA and Veterans Benefits Management System (VBMS). The Board has reviewed both the paper and electronic claims files in rendering this decision. 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). The issues of entitlement to service connection for skin cancer and a thyroid disorder are addressed in the REMAND portion of the decision below and are REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. FINDINGS OF FACT 1. Service connection for skin cancer and thyroid cancer was denied in an unappealed November 2005 rating decision. 2. Evidence received since the November 2005 rating decision includes evidence that relates to an unestablished fact necessary to substantiate the claim for service connection for skin cancer and a thyroid disorder; such evidence is not cumulative or redundant of evidence already of record. 3. Throughout the entire timeframe on appeal, the Veteran's coronary artery disease is manifested by workload of greater than 7 METs but not greater than 10 METs with fatigue, shortness of breath, and other symptoms, but not by cardiac hypertrophy or dilation. 4. Throughout the appeal period, the Veteran required medication for control of his hypertension, diastolic pressure readings were predominantly less than 100, and systolic pressure readings were predominantly less than 160; however, the record also reflects a past history of diastolic pressure predominantly 100 or more. 5. The Veteran's coronary artery disease and hypertension do not present an exceptional or unusual disability picture. CONCLUSIONS OF LAW 1. New and material evidence has been presented to reopen a claim of entitlement to service connection for skin cancer. 38 U.S.C.A. § 5108 (West 2002); 38 C.F.R. § 3.156 (2013). 2. New and material evidence has been presented to reopen a claim of entitlement to service connection for thyroid disorder. 38 U.S.C.A. § 5108 (West 2002); 38 C.F.R. § 3.156 (2013). 3. The criteria for an initial disability rating greater than 10 percent for coronary artery disease have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. § 4.7, 4.104, Diagnostic Code 7005 (2013). 4. The criteria for an initial 10 percent evaluation for hypertension are met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 4.1, 4.104, Diagnostic Code 7101 (2013). 5. Application of the extraschedular rating provisions is not warranted in this case. 38 C.F.R. § 3.321(b) (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Board has thoroughly reviewed all the evidence in the Veteran's claims file. Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, all the evidence submitted by or on behalf of the Veteran. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (the Board must review the entire record, but does not have to discuss each piece of evidence). The analysis below focuses on the most salient and relevant evidence and on what this evidence shows, or fails to show, on the claim. The Veteran must not assume that the Board has overlooked pieces of evidence that are not explicitly discussed herein. See Timberlake v. Gober, 14 Vet. App. 122 (2000) (the law requires only that the Board address its reasons for rejecting evidence favorable to the Veteran). Veterans Claims Assistance Act of 2000 (VCAA) With respect to the Veteran's claims, VA has met all statutory and regulatory notice and duty to assist provisions. See 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126 (West 2002); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326 (2013). Under the VCAA, when VA receives a complete or substantially complete application for benefits, it is required to notify the Veteran and his representative, if any, of any information and medical or lay evidence that is necessary to substantiate the claim. See 38 U.S.C.A. § 5103(a) (West 2002); 38 C.F.R. § 3.159(b) (2013); Quartuccio v. Principi, 16 Vet. App. 183 (2002). In Pelegrini v. Principi, 18 Vet. App. 112, 120-21 (2004) (Pelegrini II), the United States Court of Appeals for Veterans Claims (Court) held that VA must inform the Veteran of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; (3) that the Veteran is expected to provide; and (4) request that the Veteran provide any evidence in his possession that pertains to the claim. The requirement of requesting that the Veteran provide any evidence in his possession that pertains to the claim was eliminated by the Secretary during the course of this appeal. See 73 Fed. Reg. 23353 (final rule eliminating fourth element notice as required under Pelegrini II, effective May 30, 2008). Thus, any error related to this element is harmless. VA satisfied its duty to notify. With respect to the Veteran's claim for higher initial rating for his hypertension and coronary artery disease, the Board notes that in cases where a compensation award has been granted and an initial disability rating and effective date have been assigned, the typical claim has been more than substantiated, it has been proven, thereby rendering section 5103(a) notice no longer required because the purpose that the notice is intended to serve has been fulfilled. Dingess v. Nicholson, 19 Vet. App. 473 (2006); see also VAOPGCPREC 8-2003 (December 22, 2003). Thus, because service connection for coronary artery disease and hypertension has already been granted, VA's VCAA notice obligations with respect to that issue are fully satisfied, and any defect in the notice is not prejudicial. See Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007); Dunlap v. Nicholson, 21 Vet. App. 112 (2007); see also Goodwin v. Peake, 22 Vet. App. 128, 137 (2008) [where a claim has been substantiated after the enactment of the VCAA, the appellant bears the burden of demonstrating any prejudice from defective VCAA notice with respect to any downstream elements]. For purposes of evaluating the Veteran's request to reopen his claim of entitlement to service connection, the Board observes that in Kent v. Nicholson, 20 Vet. App. 1 (2006), the Court held that with regard to matters that involve a request to reopen a previously denied claim for service connection based upon the receipt of new and material evidence, in addition to providing notice of the evidence and information that is necessary to establish entitlement to service connection, VA must first notify a claimant of the evidence and information that is necessary to reopen the claim. To that end, the Court determined that in the context of a claim to reopen, the VCAA requires that VA must first review the bases for the prior denial of record, and then release a notice letter to the Veteran that explains the meaning of both "new" and "material" evidence, and also describes the particular type(s) of evidence necessary to substantiate any service connection elements that were found to be insufficiently shown at the time of the prior final VA denial. Id. The June 2012 letter informed the Veteran that his claims had been previously denied, and that new and material evidence was needed to substantiate the claims to reopen and described what would constitute such new and material evidence. The letter also specifically explained the basis of the prior denials on the merits, and directed the Veteran to submit any new and material evidence showing that his thyroid disorder and skin cancer were related to service. This letter was fully compliant with the requirements set forth in Kent. Id. As noted above, the Veteran also was afforded a hearing before the undersigned Veterans Law Judge (VLJ) during which he presented oral argument in support of his claims. In Bryant v. Shinseki, 23 Vet. App. 488 (2010), the United States Court of Appeals for Veterans Claims (Court) held that 38 C.F.R. § 3.103(c)(2) (2013) requires that the VLJ/DRO who chairs a hearing fulfill two duties to comply with the above the regulation. These duties consist of (1) the duty to fully explain the issues and (2) the duty to suggest the submission of evidence that may have been overlooked. Here, the VLJ fully explained the issues on appeal during the hearing and generally discussed the basis of the prior determination, the element(s) of the claims that were lacking to substantiate the claims for benefits, and suggested the submission of evidence that would be beneficial to the Veteran's claims. Significantly, the Veteran has not asserted that VA failed to comply with 38 C.F.R. § 3.103(c)(2), nor has he identified any prejudice in the conduct of the Board hearing. By contrast, the hearing focused on the elements necessary to substantiate the claims, and the Veteran, through his testimony, demonstrated that he had actual knowledge of the elements necessary to substantiate his claims. As such, the Board finds that, consistent with Bryant, the VLJ complied with the duties set forth in 38 C.F.R. § 3.103(c)(2). If any notice deficiency is present in this case, the Board finds that any prejudice due to such error has been overcome in this case by the following: (1) based on the communications sent to the Veteran over the course of this appeal, the Veteran clearly has actual knowledge of the evidence the Veteran is required to submit in this case; and (2) based on the Veteran's contentions as well as the communications provided to the Veteran by VA, it is reasonable to expect that the Veteran understands what was needed to prevail. See Shinseki v. Sanders/Simmons, 129 S. Ct. 1696 (2009); Fenstermacher v. Phila. Nat'l Bank, 493 F.2d 333, 337 (3d Cir. 1974) ("[N]o error can be predicated on insufficiency of notice since its purpose had been served."). In order for the Court to be persuaded that no prejudice resulted from a notice error, "the record must demonstrate that, despite the error, the adjudication was nevertheless essentially fair." Dunlap v. Nicholson, 21 Vet. App. 112, 118 (2007). In this case, the Veteran has been continuously represented by an experienced Veterans Service Organization and has submitted argument in support of his claims. These arguments have referenced the applicable law and regulations necessary for a grant of increased ratings and reopening the service connection claims. Thus, the Board finds that the Veteran has actual knowledge as to the information and evidence necessary for him to prevail on his claims and is not prejudiced by a decision in this case. As such, a remand for additional notice would serve no useful purpose and would in no way benefit the Veteran. Sabonis v. Brown, 6 Vet. App. 426, 430 (1994) (remands which would only result in unnecessarily imposing additional burdens on the VA with no benefit flowing to the Veteran are to be avoided). The Board also concludes VA's duty to assist has been satisfied. The Veteran's service treatment records (STRs) and VA medical records are in the file. Private records have been obtained to the extent possible. The Veteran has at no time referenced outstanding records that he wanted VA to obtain or that he felt were relevant to the claims. Additionally, during his August 2013 hearing, he indicated that he was satisfied with all attempts to obtain any outstanding treatment records. With respect to claims for increased ratings, the duty to assist includes, when appropriate, the duty to conduct a thorough and contemporaneous examination of the Veteran. See Green v. Derwinski, 1 Vet. App. 121 (1991). In addition, where the evidence of record does not reflect the current state of the Veteran's disability, a VA examination must be conducted. See Schafrath v. Derwinski, 1 Vet. App. 589 (1991); 38 C.F.R. § 3.327(a) (2013). The RO provided the Veteran appropriate VA examination most recently in September 2012. The VA examination report is thorough and supported by the other treatment evidence of record. The examination report discussed the clinical findings and the Veteran's reported history as necessary to rate the disabilities under the applicable rating criteria. The examination report also discussed the impact of the disability on the Veteran's daily living. Based on the examination, the absence of evidence of worsening symptomatology since the examination, and the fact there is no rule as to how current an examination must be, the Board concludes the September 2012 examination report in this case is adequate upon which to base a decision. See Barr v. Nicholson, 21 Vet. App. 303, 312 (2007) (when VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate). As there is no indication that any failure on the part of VA to provide additional notice or assistance reasonably affects the outcome of this case, the Board finds that any such failure is harmless. See Mayfield v. Nicholson, 19 Vet. App. 103 (2005), rev'd on other grounds, Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). Claims to Reopen Generally, a claim that has been denied in an unappealed RO decision may not thereafter be reopened and allowed. 38 U.S.C.A. § 7105(c). The exception to this rule is 38 U.S.C.A. § 5108, which provides that if new and material evidence is presented or secured with respect to a claim which has been disallowed, the Secretary shall reopen the claim and review the former disposition of the claim. New evidence is defined as existing evidence not previously submitted to agency decisionmakers. Material evidence means evidence that, by itself or when considered with previous evidence of record, relates to an unestablished fact necessary to substantiate the claim. New and material evidence can be neither cumulative nor redundant of the evidence previously of record, and must raise a reasonable possibility of substantiating the claim. 38 C.F.R. § 3.156(a). The Court recently interpreted the language of 38 C.F.R. § 3.156(a) as creating a low threshold, and viewed the phrase "raises a reasonable possibility of substantiating the claim" as "enabling rather than precluding reopening." The Court emphasized that the regulation is designed to be consistent with 38 C.F.R. § 3.159(c)(4), which "does not require new and material evidence as to each previously unproven element of a claim." Shade v. Shinseki, 24 Vet. App. 110 (2010). See also Evans v. Brown, 9 Vet. App. 273, 284 (1996) (the newly presented evidence need not be probative of all the elements required to award the claim, but only need to be probative in regard to each element that was a specified basis for the last disallowance). For the purpose of establishing whether new and material evidence has been submitted, the credibility of evidence is presumed unless the evidence is inherently incredible or consists of statements that are beyond the competence of the person or persons making them. See Justus v. Principi, 3 Vet. App. 510, 513 (1992); Meyer v. Brown, 9 Vet. App. 425, 429 (1996); King v. Brown, 5 Vet. App. 19, 21 (1993). Factual Background and Analysis The RO initially denied service connection for skin cancer and thyroid cancer in November 2005, and the Veteran was notified of this decision that same month. He did not appeal the decision or submit any additional pertinent evidence within the appeal period. The basis for the November 2005 denial of these disabilities was that the Veteran has no diagnosis of thyroid cancer and skin cancer was not shown to be related to his military service. The RO also noted that the Veteran was not shown to be exposed to ionizing radiation during service. The evidence of record in November 2005 consisted of the Veteran's STRs, showing no evidence of thyroid problems or skin cancer; VA treatment records, mainly showing treatment for cardiac issues; and private treatment records showing treatment for skin cancer on the left ear. Evidence received since the November 2005 rating decision includes, VA treatment records, private treatment records, the Veteran's statements, a statement from the Veteran's spouse, and VA examination reports related to his heart problems/hypertension. The VA and private treatment records note a history of thyroid nodules and a diagnosis of transient hypothyroidism. In other words, there is evidence of the possibility of a current thyroid disability. In addition, the Veteran's spouse submitted a statement in August 2013 recalling that the Veteran had a thyroid cancer diagnosis in the 1970s. In her statement, she also indicated that the Veteran had additional skin cancer found on his body. The Veteran has further contended that his skin cancer and thyroid problems may be related to asbestos exposure during service. A May 2002 VA Memorandum regarding asbestos-related claims (received following the November 2005 rating decision) notes that based upon the Veteran's military occupation as an electrician's mate, he had "probable" exposure to asbestos during service. With respect to the thyroid disorder claim, the issue of whether there is current disability was an element of entitlement to service connection that the RO found was not met at the time of the November 2005 rating decision. The evidence received since November 2005 addresses the fact that although the Veteran may not have had thyroid cancer, he may have a current thyroid disorder. The Board finds that this evidence is new and material as it relates to a previously unestablished element of entitlement to service connection. Regarding the skin cancer claim, evidence showing a link between the Veteran's currently diagnosed skin cancer and his military service was an element of entitlement to service connection that the RO found was not met at the time of the November 2005 rating decision. Upon liberal interpretation of the evidence received since the November 2005 rating decision, the Board finds that it generally addresses the fact that the Veteran's skin cancer may have be caused by his "probable" exposure to asbestos in service. The Board finds that this evidence is new and material as it relates to a previously unestablished element of entitlement to service connection. Accordingly, this evidence, the credibility of which is only presumed for the purposes of reopening the claims, is sufficient to reopen the previously-denied claims for service connection for a thyroid disorder and skin cancer. Claims for Increased Ratings Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (Rating Schedule), found in 38 C.F.R. Part 4. The Board attempts to determine the extent to which the Veteran's service-connected disability adversely affects his ability to function under the ordinary conditions of daily life, and the assigned rating is based, as far as practicable, upon the average impairment of earning capacity in civil occupations. 38 U.S.C.A. § 1155; 38 C.F.R. §§ 4.1, 4.10. 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. 38 C.F.R. §§ 4.1, 4.2 (2013); see also Francisco v. Brown, 7 Vet. App. 55 (1994). In Hart v. Mansfield, 21 Vet. App. 505 (2007), however, the Court held that "staged ratings" are appropriate for an increased rating claim when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. The basis of disability evaluation is the ability of the body as a whole, or of the psyche, or of a system or organ of the body to function under the ordinary conditions of daily life including employment. 38 C.F.R. § 4.10. Diagnostic Code 7005 provides ratings for arteriosclerotic heart disease (coronary artery disease), and requires documented coronary artery disease. Arteriosclerotic heart disease (coronary artery disease) resulting in workload of greater than 7 METs but not greater than 10 METs results in dyspnea, fatigue, angina, dizziness, or syncope, or; when continuous medication is required, is rated 10 percent disabling. Arteriosclerotic heart disease resulting in workload of greater than 5 METs but not greater than 7 METs results in dyspnea, fatigue, angina, dizziness, or syncope, or; evidence of cardiac hypertrophy or dilatation on electrocardiogram, echocardiogram, or X-ray, is rated 30 percent disabling. Arteriosclerotic heart disease resulting in more than one episode of acute congestive heart failure in the past year, or; workload of greater than 3 METs but not greater than 5 METs results in dyspnea, fatigue, angina, dizziness, or syncope, or; left ventricular dysfunction with an ejection fraction of 30 to 50 percent, is rated 60 percent disabling. Arteriosclerotic heart disease resulting in chronic congestive heart failure, or; workload of 3 METs or less results in dyspnea, fatigue, angina, dizziness, or syncope, or; left ventricular dysfunction with an ejection fraction of less than 30 percent, is rated 100 percent disabling. 38 C.F.R. § 4.104, Diagnostic Code 7005 (2013). A Note to Diagnostic Code 7005 provides that, if non-service-connected arteriosclerotic heart disease is superimposed on service-connected valvular or other non-arteriosclerotic heart disease, the adjudicator is to request a medical opinion as to which condition is causing the current signs and symptoms. 38 C.F.R. § 4.104. For rating diseases of the heart, one MET (metabolic equivalent) is the energy cost of standing quietly at rest and represents an oxygen uptake of 3.5 milliliters per kilogram of body weight per minute. When the level of METs at which dyspnea, fatigue, angina, dizziness, or syncope develops is required for rating, and a laboratory determination of METs by exercise testing cannot be done for medical reasons, an estimation by a medical examiner of the level of activity (expressed in METs and supported by specific examples, such as slow stair climbing or shoveling snow) that results in dyspnea, fatigue, angina, dizziness, or syncope may be used. 38 C.F.R. § 4.104, Note 2. The RO has evaluated the Veteran's hypertension as noncompensably disabling under 38 C.F.R. § 4.101, Diagnostic Code 7101. A 10 percent rating is assigned for essential hypertension when diastolic pressure is predominantly 100 or more, or; systolic pressure is predominantly 160 or more or; as a minimum evaluation for an individual with a history of diastolic pressure predominantly 100 or more who requires continuous medication for control. A 20 percent rating is assigned for diastolic pressure that is predominantly 110 or more, or; systolic pressure that is predominantly 200 or more. A 40 percent rating is assigned for diastolic pressure that is predominantly 120 or more. A 60 percent rating is assigned where diastolic pressure is predominantly 130 or more. 38 C.F.R. § 4.104, Diagnostic Code 7101. Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. The Board is required to analyze the credibility and probative value of the evidence, account for any evidence that it finds persuasive or unpersuasive, and provide the reasons for its rejection of any material evidence favorable to the claimant. See Daye v. Nicholson, 20 Vet. App. 512, 516 (2006). It is noted that competency of evidence differs from weight and credibility. The former is a legal concept determining whether testimony may be heard and considered by the trier of fact, while the latter is a factual determination going to the probative value of the evidence to be made after the evidence has been admitted. Rucker v. Brown, 10 Vet. App. 67, 74 (1997); Layno v. Brown, 6 Vet. App. 465, 469 (1994); see also Cartright v. Derwinski, 2 Vet. App. 24, 25 (1991) ("although interest may affect the credibility of testimony, it does not affect competency to testify"). In determining whether statements are credible, the Board may consider internal consistency, facial plausibility, and consistency with other evidence submitted on behalf of the claimant. Caluza v. Brown, 7 Vet. App. 498 (1995). Factual Background and Analysis The Veteran contends that his hypertension and coronary artery disease warrant ratings in excess of noncompensable and 10 percent, respectively. By way of background, service connection for coronary artery disease with nontender scar and hypertension was awarded in an October 2012 rating decision-both as secondary to service-connected PTSD. A 10 percent rating for coronary artery disease was assigned, effective September 30, 2010. A noncompensable rating was assigned for hypertension, effective September 30, 2010. Following his September 2010 claim, the Veteran was afforded a VA examination in February 2012, during which the examiner diagnosed the Veteran as having hypertension and coronary artery disease. The examiner indicated that hypertension was diagnosed in 1961 (per the Veteran's report) and coronary artery disease in 2000. The Veteran hypertension has been treated with continuous hypertensive medication since its onset. The examiner indicated that the Veteran's hypertension did not impact his ability to work. The Veteran reported his coronary artery disease symptoms as including, recurring chest pain with negative stress test, history of 4 vessel coronary bypass in 2000, and cardiac catheterization and angiogram with stent placement in December 2011. The Veteran had no history of myocardial infarction, congestive heart failure, arrhythmia, heart valve problems, infectious heart problems, or pericardial adhesions. He denied any additional hospitalizations for his heart disability. Physical examination revealed regular heart rate and rhythm, with no other pertinent physical findings, complications, conditions, or signs/symptoms of a heart problem. EKG performed in 2011 was normal, as was the August 2010 echocardiogram, and 2011 chest x-ray. The December 2011 coronary artery angiogram was abnormal due to 99 percent occlusion of the bypass level. The examiner indicated that his left ventricular ejection fraction was 60 percent. The examiner noted that in May 2010, the Veteran's stress test was negative, and he performed at 7 METS. During the instant examination, the examiner indicated that the Veteran's knee pain caused him to be unable to walk on the treadmill. The examiner checked the box indicating a METs level between 7 and 10 which is consistent with activities such as climbing stairs quickly, moderate bicycling, sawing wood, jogging (6 mph). The examiner noted that this METs level is the lowest activity level at which the Veteran reported symptoms such as shortness of breath and angina. The examiner further found that his METs level limitation is solely due to his heart condition. The examiner opined that the Veteran's heart disability impacted his ability to work inasmuch as his volunteer activities led to fatigue and modest chest distress. The February 2012 VA examiner indicated that the Veteran did have a surgical scar related to his coronary artery disease, but found that it was not painful, unstable, or greater than 39 square centimeters. The Veteran was also afforded another VA heart examination in September 2012. This examination did not address the Veteran's specific symptoms, and merely provided a nexus opinion with respect to his heart and hypertension disorders and his service-connected PTSD. The Veteran continues to receive private treatment for his coronary artery disease and hypertension. He had reported symptoms such as shortness of breath. He continues to take medications to control his hypertension and cholesterol. There is some evidence that he was treated for mild gas discomfort in the chest area in 2010. His cardiologist was notified, but felt it was not significant. Upon careful review of the evidence of record, the Board finds that the Veteran is not entitled to a rating in excess of 10 percent for his service-connected coronary artery disease. The competent and credible evidence of record do not show that the Veteran's workload is greater than 5 METs, but less than 7 METs, nor is there evidence of cardiac hypertrophy or dilation on electrocardiogram, echocardiogram, or x-ray. Indeed, the evidence of record clearly shows a METs of 7. No other stress testing was possible due to the Veteran's knee disability. The Board appreciates the Veteran's assertions that his heart disability is more severely disabling than the 10 percent currently awarded and that his doctors would disagree with the VA examiner's findings. The evidence of record, however, does not support these contentions, nor is the Veteran competent to state the current severity of his heart disability. Indeed, he is competent to describe his symptoms, but he is not competent to determine his workload in METs, nor has he submitted evidence from his private treating professionals showing evidence to support a higher rating. There are private and VA treatment records showing that the Veteran's heart disability does not impact his daily living, and there are even records showing that he is active despite this disability. The Board recognizes that the Veteran underwent two heart-related surgical procedures-including a 2011 angiogram with stent placement. The Board has considered the clinical evidence and lay statements, but finds no evidence to support the next higher rating under Diagnostic Code 7005. The Board has also considered the scar from the Veteran's heart surgery, but based on the findings that it is not painful, unstable, or greater than 39 square centimeters, no separate compensable rating for this scar is warranted under 38 C.F.R. § 4.118, Diagnostic Codes 7800-7806. Having carefully considered all the evidence of record, the Board finds that the evidence supports the assignment of a 10 percent evaluation for hypertension, but no more. A review of the record shows that the Veteran has been continuously treated with antihypertensive medication, Hydrochlorothiazide, since he was initially diagnosed with hypertension in 1961. The schedule provides that a minimum compensable evaluation of 10 percent is warranted where there is a history of diastolic pressure predominately 100 or more and the individual requires continuous medication for control. Although the record shows that the Veteran's diastolic pressure has remained predominately less than 100 throughout the period of this appeal and since 1961, the Board finds all reasonable doubt in the Veteran's favor that he has a past history of diastolic pressure predominately 100 or more prior to 1961, otherwise, he would not be required to take continuous medication for control. However, an evaluation in excess of 10 percent is not warranted because diastolic pressure readings are predominantly less than 100 and systolic pressure readings are predominantly less than 160 during the appeal period. Report of VA examination dated in February 2012 reflects three recent blood pressure readings as: 125/65 (August 2011); 130/80 (February 2012); and 132/78 (February 2012). These findings, and other blood pressure readings from the timeframe on appeal, do not more nearly reflect the criteria for an evaluation in excess of 10 percent, which requires that diastolic pressure is predominantly 110 or more, or systolic pressure is predominantly 200 or more. Again, although the Veteran is competent to report that his disabilities are worse than presently rated, the question of whether a disability meets the schedular criteria for the assignment of a higher evaluation is a factual determination by the Board based on the Veteran's complaints coupled with the medical evidence. Here, although the Veteran may believe that he meets the criteria for the next higher disability ratings, the medical findings do not meet the schedular requirements for higher evaluations, as explained and discussed above. The Board has concluded that the medical evidence, prepared by skilled professionals, is more probative of the degree of disability for his coronary artery disease and hypertension. Furthermore, there is no basis for a staged rating for either disability. Neither the lay nor the medical evidence reflects that the disabilities met the criteria for rating in excess of 10 percent at any time during the appeal period. As such, the Board finds that a uniform disability rating is appropriate for each disability. See Fenderson v. West, 12 Vet. App. 119 (1999). Accordingly, the claim for an initial 10 percent evaluation, and no more, for hypertension is granted, but a rating in excess of 10 percent for coronary artery disease is denied. Additional Considerations The Board also has considered whether the Veteran is entitled to a greater level of compensation on an extraschedular basis. Ordinarily, the VA Schedule will apply unless there are exceptional or unusual factors which would render application of the schedule impractical. See Fisher v. Principi, 4 Vet. App. 57, 60 (1993). According to the regulation, an extraschedular disability rating is warranted based upon a finding that the case presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization that would render impractical the application of the regular schedular standards. See 38 C.F.R. § 3.321(b)(1) (2013). An exceptional case is said to include such factors as marked interference with employment or frequent periods of hospitalization as to render impracticable the application of the regular schedular standards. See Fanning v. Brown, 4 Vet. App. 225, 229 (1993). Under Thun v. Peake, 22 Vet App 111 (2008), there is a three-step inquiry for determining whether a veteran is entitled to an extraschedular rating. First, the Board must determine whether the evidence presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. Second, if the schedular evaluation does not contemplate the Veteran's level of disability and symptomatology and is found inadequate, the Board must determine whether the Veteran's disability picture exhibits other related factors such as those provided by the regulation as "governing norms." Third, if the rating schedule is inadequate to evaluate a veteran's disability picture and that picture has attendant thereto related factors such as marked interference with employment or frequent periods of hospitalization, then the case must be referred to the Under Secretary for Benefits or the Director of the Compensation and Pension Service to determine whether, to accord justice, the Veteran's disability picture requires the assignment of an extraschedular rating. With respect to the first prong of Thun, the evidence in this case does not show such an exceptional disability picture that the available schedular evaluations for the service-connected coronary artery disease and hypertension are inadequate. A comparison between the level of severity and symptomatology of the Veteran's coronary artery disease and hypertension with the established criteria shows that the rating criteria reasonably describe the Veteran's disability levels and symptomatology. Specifically, the Veteran primarily reports shortness of breath, fatigue, and other symptoms. As discussed above, the current 10 percent rating for each is adequate to fully compensate the Veteran for his symptoms. In short, the rating criteria reasonably describe the Veteran's disability level and symptomatology for his coronary artery disease and hypertension. The Board, therefore, has determined that referral of this case for extraschedular consideration pursuant to 38 C.F.R. 3.321(b)(1) is not warranted. The United States Court of Appeals for Veterans Claims has recently held that a request for a TDIU, whether expressly raised by a claimant or reasonably raised by the record, is an attempt to obtain an appropriate rating for disability or disabilities, and is part of a claim for increased compensation; there must be cogent evidence of unemployability in the record. See Rice v. Shinseki, 22 Vet. App. 447 (2009), citing Comer v. Peake, 552 F.3d 1362 (Fed. Cir. 2009). In this case the Veteran has not asserted, and the evidence of record does not show, that his hypertension and coronary artery disease alone render him unemployable. In fact, the 2012 VA examiner found that the Veteran's heart disability would impact his employability inasmuch as it causes fatigue, but he did not opine that the Veteran's hypertension and coronary artery disease would render him unemployable. Accordingly, a claim for TDIU is not raised by this appeal. ORDER New and material evidence having been received; the claim of service connection for skin cancer is reopened. New and material evidence having been received; the claim of service connection for a thyroid disorder is reopened. An initial rating in excess of 10 percent for coronary artery disease is denied. An initial 10 percent rating, but no higher, for hypertension is granted. REMAND In light of the reopening above, the Board finds that further evidentiary development is necessary regarding the Veteran's claims for service connection for thyroid disorder and skin cancer. Namely, the Board finds that the Veteran should be afforded a VA examination for his claimed thyroid disorder and skin cancer. A 2012 VA treatment records shows that the Veteran's abnormal thyroid function test may be possible hyperthyroidism. A February 2013 x-ray of the thyroid revealed a multinodular goiter and enlargement of the thyroid gland. He was eventually diagnosed as having "transient hyperthyroidism" that is possibly related to his heart catheterization or an acute illness. There are times during the appeal period that the Veteran has been euthyroid. The Veteran's wife submitted a statement on his behalf in August 2013. She indicated that in addition to the skin cancer on his left ear, he has had various skin cancers on his arms and back, and left eye. She stated that recently he had a "deep cancer" on his left arm, and cancer on his left knee and right eye. There is clinical evidence showing a history of skin cancer on his left ear, and more recent private treatment records (2007) show squamous cell carcinoma of the left cheek. As noted above, the Veteran's military occupation as an electrician's mate reflects that he had "probable" exposure to asbestos during his military service. It is the Veteran's contentions that his thyroid disorder and skin cancer are related to his asbestos exposure. As such, the Veteran should be afforded a VA examination to review the Veteran's record and determine the likelihood that his currently diagnosed skin cancer and/or thyroid disorder are attributable to his alleged asbestos exposure during service. Accordingly, the case is REMANDED for the following action: (Please note, this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2012). Expedited handling is requested.) 1. The RO or the AMC should undertake appropriate development to obtain any outstanding records pertinent to the Veteran's claims. 2. The Veteran scheduled for a VA examination by a physician with sufficient expertise to determine the nature and etiology of his claimed skin cancer and thyroid disabilities. The claims folders and any pertinent evidence located in an electronic format must be made available to and reviewed by the examiner, and any indicated studies should be performed. Based upon the review of the record and the examination results, the examiner should provide an opinion with respect to each currently present skin cancer and thyroid disorder as to whether there is a 50 percent or better probability that any diagnosed disability is etiologically related to the Veteran's active service, including due to exposure to asbestos. The examiner is asked to presume that the Veteran was exposed to asbestos during service. The rationale for each opinion expressed must also be provided. 3. The RO or the AMC should also undertake any other development it determines to be warranted. 4. Then, the RO or the AMC should readjudicate the Veteran's claims. If the benefits sought on appeal are not granted to the Veteran's satisfaction, a Supplemental Statement of the Case should be issued to the Veteran and his representative and they should be afforded the requisite opportunity to respond before the case is returned to the Board for further appellate action. By this remand, the Board intimates no opinion as to any final outcome warranted. No action is required of the Veteran until he is otherwise notified but he has the right to submit additional evidence and argument on the 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). ______________________________________________ DAVID L. WIGHT Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs