Citation Nr: 1334459 Decision Date: 10/29/13 Archive Date: 11/06/13 DOCKET NO. 06-08 418 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUES 1. Entitlement to an initial rating in excess of 10 percent for residuals of coccidioidomycosis, status post a right thoracotomy. 2. Entitlement to an initial rating in excess of 10 percent for residuals of subretinal hemorrhage of the left eye. REPRESENTATION Appellant represented by: Florida Department of Veterans Affairs WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD Russell P. Veldenz, Counsel INTRODUCTION The Veteran served on active duty from January 1984 to January 2004. These matters come before the Board of Veterans' Appeals (BVA or Board) on appeal from a rating decision issued in August 2004 by the Department of Veterans Affairs (VA) Regional Office (RO) in Wichita, Kansas. Jurisdiction was subsequently transferred to the St. Petersburg RO. The United States Court of Appeals for Veterans Claims (Court) has indicated that a distinction must be made between a Veteran's dissatisfaction with an initial rating assigned following a grant of service connection (so-called "original ratings"), and dissatisfaction with determinations on later filed claims for increased ratings. See Fenderson v. West, 12 Vet. App. 119, 125-26 (1999). Inasmuch as questions currently before the Board were placed in appellate status by a notice of disagreement expressing dissatisfaction with original rating assignments, the Board has characterized those rating issues on appeal as claims for higher initial evaluations of original awards. Analysis of those issues therefore requires consideration of the ratings to be assigned effective from the date of award of service connection for the disabilities at issue. In April 2013, the Veteran testified at a personal hearing before the undersigned Veterans Law Judge, via videoconference. A transcript of the hearing is associated with the claims file. In June 2013, the Board remanded the case to the RO for additional development. As the requested development has been completed, no further action is necessary to comply with the Board's remand directives. Stegall v. West, 11 Vet. App. 268, 271 (1998). At the April 2013 hearing, the Veteran raised a claim of entitlement to service connection for a muscle disability claimed as secondary to the service-connected postoperative residuals of coccidioidomycosis. In July 2013, it was noted that the Veteran had a mild pulmonary function loss and a physician suggested it might be the result of the surgery in service to treat the service-connected coccidioidomycosis. The Veteran contends that the service-connected subretinal hemorrhage disability has caused blurred vision. In April 2013, the Veteran was diagnosed with cataracts, and the Board has determined it raises the issue of entitlement to service connection for cataracts as secondary to the service-connected subretinal hemorrhage. The issues of entitlement to service connection for a muscle disability claimed as secondary to the service-connected postoperative residuals of coccidioidomycosis, service connection for a pulmonary function disability claimed as secondary to the service-connected postoperative residuals of coccidioidomycosis, and service connection for cataracts claimed as secondary to service-connected residuals of a subretinal hemorrhage, have been raised by the record, but have not been adjudicated by the Agency of Original Jurisdiction (AOJ). Therefore, the Board does not have jurisdiction over them, and they are referred to the AOJ for appropriate action. FINDINGS OF FACT 1. Throughout the applicable rating period on appeal, the Veteran's coccidioidomycosis has not demonstrated occasional minor hemoptysis or productive cough. 2. Throughout the applicable rating period on appeal, the Veteran's scars from a right thoracotomy to treat coccidioidomycosis have been shown to cover an area of approximately 14 sq. cm., and to be manifested by subjective complaints of numbness, and catching on deep breath, without demonstration of being painful or unstable, or resulting in limitation of motion or function of the affected part. 3. Throughout the applicable rating period on appeal, residuals from a subretinal hemorrhage have been manifested by mild eye fatigue requiring occasional rest, with no pain or active pathology; the Veteran has demonstrated a normal visual field, with corrected distance vision in both eyes of 20/40 or better. CONCLUSIONS OF LAW 1. The criteria for an initial rating in excess of 10 percent for coccidioidomycosis, to include residuals from a right thoracotomy, have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.97, Diagnostic Codes 6835 (2013), and Diagnostic Codes 7801-7805 (effective before October 23, 2008) 2. The criteria for an initial rating in excess of 10 percent for residuals of a subretinal hemorrhage have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.79, Diagnostic Code 6007 (effective before December 10, 2008). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The VCAA, codified in part at 38 U.S.C.A. §§ 5103, 5103A, and implemented in part at 38 C.F.R § 3.159, amended VA's duties to notify and to assist a claimant in developing information and evidence necessary to substantiate the claims. Duty to Notify Under 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b), when VA receives a complete or substantially complete application for benefits, it will notify the claimant of the following: (1) any information and medical or lay evidence that is necessary to substantiate the claim, (2) what portion of the information and evidence VA will obtain, and (3) what portion of the information and evidence the claimant is to provide. Where, as here, the appeal stems from notice of disagreement with the award of an initial disability rating following the grant of service connection, further VCAA notice is not required. 38 C.F.R. 3.159(b)(3). Rather, the Veteran's appeal as to the initial rating assignment triggers VA statutory duties under 38 U.S.C.A. § 5104 and § 7105. In this regard, a statement of the case was issued in January 2006 which set forth the diagnostic code criteria to be satisfied to warrant a higher initial rating for coccidioidomycosis and an intial rating for residuals of subretinal hemorrhage. Duty to Assist Under 38 U.S.C.A. § 5103A, VA must make reasonable efforts to assist the claimant in obtaining evidence necessary to substantiate the claim. The RO has obtained service treatment records, VA records, and afforded the Veteran VA examinations in March 2004, March 2007, and July 2013, and a hearing before the undersigned in April 2013. The reports of the VA examinations included a review of the Veteran's medical history, including his service treatment records, an interview and an examination of the Veteran, as well as sufficient findings to rate disability. Therefore, the Board concludes that the VA examinations are adequate. 38 C.F.R. § 4.2; see Barr v. Nicholson, 21 Vet. App. 303, 312 (2007) (holding that when VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate). In Bryant v. Shinseki, 23 Vet. App. 488 (2010), the United States Court of Appeals for Veterans Claims held that 38 C.F.R. § 3.103(c)(2) requires that the Veteran Law judge who conducts 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, during the April 2013 hearing, the undersigned explained the issues on appeal, suggested the types of evidence that might be helpful in establishing the claim for a higher rating for coccidioidomycosis and the subretinal hemorrhage disabilities, suggested that an opinion and report be obtained from a physician describing the severity of the disability, and asked questions pertinent to the elements of the claims that were lacking and solicited information as to any potentially outstanding pertinent available evidence. The Veteran was assisted at the hearing by a representative. No pertinent evidence that might have been overlooked and that might substantiate the claim decided herein was identified by the Veteran. The Veteran, through her testimony, demonstrated that she had actual knowledge of the elements necessary to substantiate her claims for higher initial ratings. The Veteran has not suggested any deficiency in the conduct of the hearing. Therefore, the Board finds that, consistent with Bryant, the Veterans Law Judge complied with the duties set forth in 38 C.F.R. § 3.103(c)(2). The Board also notes that the remand in June 2013 in part acknowledged the Veteran's testimony that she had an upcoming appointment with an eye doctor, and that an opinion would be obtained at that time from the eye doctor, for submission to the Board, as to the worsening of symptoms of the service-connected eye disability. After the Board's remand in June 2013. VA also sent a letter to the Veteran asking her to identify any private medical providers and either submit or authorize VA to submit their records. To date, the Veteran has not responded to the letter nor has she provided a report from a physician. As the Veteran has not identified any additional evidence pertinent to the claim and as there are no additional records to obtain, the Board concludes that no further assistance to the Veteran in developing the facts pertinent to the claims is required to comply with the duty to assist. Rating Principles A disability rating is determined by the application of VA's Schedule for Rating Disabilities (Rating Schedule). 38 C.F.R. Part 4. The percentage ratings contained in the Rating Schedule represent, as far as can be practicably determined, the average impairment in earning capacity resulting from diseases and injuries incurred or aggravated during military service and their residual conditions in civil occupations. 38 U.S.C.A. § 1155. 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 for that rating. Otherwise the lower rating will be assigned. 38 C.F.R. § 4.7. The Board will consider whether separate ratings may be assigned for separate periods of time based on facts found, a practice known as "staged ratings," whether it is an initial rating case or not. Fenderson v. West, 12 Vet. App. 119, 126-27 (1999); Hart v. Mansfield, 21 Vet. App. 505, 510 (2007). In considering the severity of a disability, it is essential to trace the medical history of the veteran. 38 C.F.R. §§ 4.1, 4.2, 4.41. Consideration of the whole-recorded history is necessary so that a rating may accurately reflect the elements of disability present. 38 C.F.R. § 4.2; Peyton v. Derwinski, 1 Vet. App. 282, 287 (1991). Claim for an Initial Rating in Excess of 10 Percent for Coccidioidomycosis. The Veteran's coccidioidomycosis is currently rated under 38 C.F.R. § 4.97, Diagnostic Code 6835. The general rating formula for mycotic lung diseases, including coccidioidomycosis under Diagnostic Code 6835 is as follows: When there is chronic pulmonary mycosis with persistent fever, weight loss, night sweats, or massive hemoptysis, then a 100 percent rating is assigned. When there is chronic pulmonary mycosis requiring suppressive therapy with no more than minimal symptoms such as occasional minor hemoptysis or productive cough, then a 50 percent rating is assigned. When there is chronic pulmonary mycosis with minimal symptoms such as occasional minor hemoptysis or productive cough, then a 30 percent rating is assigned. When mycotic lung diseases are asymptomatic with healed and inactive mycotic lesions, then a noncompensable rating is assigned. When the RO granted service connection for coccidioidomycosis in a rating decision dated in August 2004, it included residuals from the surgical treatment, a thoracotomy. The Veteran has scars from that operation. Scars are rated under Diagnostic Codes 7801, 7802, 7803, 7804, or 7805, depending on the predominant disability. During the course of the Veteran's appeal, the rating criteria for the Diagnostic Codes for rating scars were amended effective October 23, 2008. See 73 Fed. Reg. 54710 (October 23, 2008). The amended criteria, however, apply to claims filed on or after October 23, 2008. See 73 Fed. Reg. 54712 (September 23, 2008). Pursuant to the revised regulation, 38 C.F.R. § 4.118, a Veteran who has been rated by VA under Diagnostic Codes 7800, 7801, 7802, 7803, 7804, or 7805 prior to October 23, 2008 may request review under the new version of Diagnostic Codes 7800, 7801, 7802, 7804, and 7805 irrespective of whether the disability has increased since the last review. Service connection has been established effective from February 2004 and the Veteran has not requested a review under the new criteria. Therefore, the appropriate criteria for the entire period on appeal is that of the regulation in effect prior to October 23, 2008, and is set forth below. Under Diagnostic Code 7801, in effect prior to October 23, 2008, scars, other than on the head, face, or neck, that are deep or that cause limited motion are assigned a 40 percent evaluation for an area or areas exceeding 144 square inches (929 sq. cm.), a 30 percent evaluation for an area or areas exceeding 72 square inches (465 sq. cm.), a 20 percent evaluation for an area or areas exceeding 12 square inches (77 sq. cm.), and a 10 percent rating for an area or areas exceeding 6 square inches (39 sq. cm.). Note (1) provides that scars in widely separated areas, as on two or more extremities or on anterior and posterior surfaces of extremities or trunk, are separately rated and combined in accordance with 38 C.F.R. § 4.25. Id. A deep scar is one associated with underlying soft tissue damage. Note (2). Under Diagnostic Code 7802, in effect prior to October 23, 2008, scars, other than on the head, face, or neck, that are superficial and that do not cause limited motion are assigned a 10 percent evaluation for an area or areas of 144 square inches or greater. A ten percent rating is the highest rating available under Diagnostic Code 7802. Scars that are in widely separated areas are separately rated and combined in accordance with § 4.25. Note (1). A superficial scar is one not associated with underlying soft tissue damage. Note (2). Under Diagnostic Code 7803, in effect prior to October 23, 2008, superficial and unstable scars are assigned a 10 percent evaluation. A ten percent rating is the highest rating available under Diagnostic Code 7803. An unstable scar is one where, for any reason, there is frequent loss of covering of skin over the scar. Note (1). A superficial scar is one not associated with underlying soft tissue damage. Note (2). Under Diagnostic Code 7804, in effect prior to October 23, 2008, scars that are superficial and painful on examination are assigned a 10 percent evaluation. A 10 percent rating is the highest rating available under Diagnostic Code 7804. A superficial scar is one not associated with underlying soft tissue damage. Note (1). Other scars are rated on limitation of function of the affected part. 38 C.F.R. § 4.118, Diagnostic Code 7805 (2008). Facts In March 2004, as part of a general VA examination, the Veteran was evaluated for residuals of coccidioidomycosis and the residuals of the right thoracotomy that occurred in service to treat the coccidioidomycosis. The examiner noted as medical history that a tissue culture in service revealed a few coccidioidomycosis spores, but that the final pathology report conclusion was resolving infection. The Veteran complained that since the right thoracotomy in service, she still had right side numbness which feels like she is carrying a weight there. She also complained of pain that occurred 2 times a day in the lung area, which lasts for 10 minutes, and was rated as an aching of 6/10 pain. It is worse in damp weather and cold and is relieved by going inside to a warm place. She indicated there are no flares and denied adverse affect on her occupation, recreation, or activities of daily living. The Veteran had been a smoker of a pack a day, for 20 years. Upon examination, the lungs were clear bilaterally. It was noted that the Veteran was able to do range of motion for various body parts such as her back without fatigue. A chest X-ray demonstrated residuals of right lung surgery but no acute infiltration or consolidation. The diagnosis was coccidioidomycosis resolved by a right thoracotomy with continued numbness and pain in the surgical area but without adverse effects on the Veteran's occupation, recreation, or activities of daily living. In March 2007, an X-ray of the Veteran chest revealed post operative changes of the right lung but no significant interval changes. A pulmonary lung function test in March 2007 showed a post bronchodilator FVC of 102 percent, FEV1 of 92 percent, and FEV1/FVC of 74 percent. The DLCO was recorded at 80 percent of the predicted value. The interpretation was that the Veteran had a mild obstructive lung defect. In a report of VA examination in April 2007, it was indicated that the Veteran was independent in activities of daily living, and had no impediment to her usual occupation. It was reported that "[h]e has had doctor prescribed bed rest or incapacitation in the last 12 months." As to the rest of the examination, the Veteran stated the scar is still numb around the site of the surgery. If she takes a deep breath, it catches on her right side as though it is difficult to inflate. She does not have a productive cough, sputum, or hemoptysis. She does experience hot flashes at night. She has lost weight but was participating in Weight Watchers and the weight loss was stable. She did not have any daytime hypersomolence, anorexia, or dyspnea at rest. She experienced dyspnea walking up stairs. The Veteran did not have a history of emphysema, asthma, recurrent pneumonia, bronchitis, laryngitis, pharyngintis, sinusitis, or upper or lower respiratory allergies. She was not on any medication, oxygen therapy, or used a CPAP at night for sleeping. Upon examination, the respiratory rate was 16. The respiration was regular and rhythmic without abnormalities to percussion of the chest wall. The lungs were clear with good air movement and without wheezes. Her skin was normal. The examiner noted two surgical scars from the 2003 thoracotomy. The first was an 18.5 x 0.75 cm (13.88 sq. cm) hypopigmented flat scar and a 1 cm irregular but linear hypopigmented flat scar. Neither scar exhibited tenderness, induration, tissue loss, or keloid formation. Both scars moved freely with the surrounding skin with no abnormal texture. In July 2013 VA examination, the Veteran gave a history of a wedge resection of her lung for coccidioidomycosis. She does not use corticosteroid medicines or use any inhaled medication, bronchodilators, antibiotics, or outpatient oxygen therapy. The examiner noted a recent CT scan was interpreted as showing a mild decrease in lung function probably related to her past lung surgery. The examiner noted there were no scars greater than 39 square cm that were painful and/or unstable. The Veteran stated she experienced shortness of breath upon exertion or walking up stairs. A pulmonary function test revealed post bronchodilator FVC of 74 percent, FEV1 of 74 percent, and FEV1/FVC of 80 percent. The Veteran testified that after her surgery, the fungus (coccidioidomycosis) was resolved but the physicians told her that the surgery involved cutting nerves and she still has numbness. She also stated three to four times a week the area seizes up and if she lies on that side the wrong way, it cramps up. She is not sure if the symptoms are a lung problem or the muscles of the back have also been damaged. The Veteran is not sure what her lung capacity was before the surgery but she could run and go up stairs. Now, she can climb stairs but finds herself short of breath. She cannot run at all. Analysis Initially, the Board notes it has reviewed all of the evidence in the Veteran's claims file, with an emphasis on the evidence relevant to this appeal. Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, the extensive evidence of record. Indeed, the Federal Circuit has held that the Board must review the entire record, but does not have to discuss each piece of evidence. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000). Therefore, the Board will summarize the relevant evidence where appropriate, and the Board's analysis below will focus specifically on what the evidence shows, or fails to show, as to each claim. After reviewing the evidence before the Board, the Board has determined that the Veteran is not entitled to a rating higher than 10 percent for her coccidioidomycosis disability. There is no evidence of occasional minor hemoptysis or productive cough, and therefore a 30 percent rating is not warranted under Diagnostic Code 6835. Rather, a noncompensable rating is warranted for asymptomatic healed coccidioidomycosis and inactive mycotic lesions. The Veteran has demonstrated shortness of breath when she goes up stairs. Shortness of breath, however, is not listed as part of the schedular criteria for Diagnostic Code 6835. The Board also finds that shortness of breath while climbing stairs does not result in a disability picture that more nearly approximates the criteria for a 30 percent rating under Diagnostic Code 6835. Additionally, despite the Veteran's complaint of shortness of breath, and that pulmonary function test results as outlined above have shown some impairment, these findings have not been clinically attributed to the service-connected lung disability at issue, versus, for example, the Veteran's history of smoking. Although a CT scan in July 2013 was interpreted as showing a mild decrease in lung function "probably related" to her past lung surgery, service connection has not been established to date for impaired pulmonary function as a residual of the disability at issue. As noted above, that matter has been referred to the RO for adjudication. As noted, the Veteran's coccidioidomycosis disability also includes the residuals of a right thoracotomy in service as treatment for the coccidioidomycosis. She has complained of numbness of the scars, and immediate surrounding area, and a feeling that it catches on deep breath. Diagnostic Code 7801 can provide a higher rating only if scars are deep, or cause limited motion, and involve an area of 39 sq. cm. or more. This has not been demonstrated. The Veteran's post surgical scars have not been shown to limit her motion. Diagnostic Codes 7802, 7803 and 7805, as in effect prior to October 2008, do not allow a higher rating for the Veteran's post surgical scars because they have not been shown to cover an area or areas of 144 square inches (929 sq. cm.) or greater, to be unstable, or to affect function of the part affected. Although an April 2007 VA examiner reported the Veteran had doctor prescribed bed rest in the last 12 months, the examiner referred to this female Veteran as a "he", and did not report the number of such episodes. Further, there is no evidence from the clinical records that she had any incapacitating episodes or a flare-up of symptoms where a physician had ordered bed rest. Significantly, however, while the Veteran has not complained that the scars are painful, she has reported that they appear to catch when she takes a deep breath. The Board finds that this is comparable to functional impairment contemplated by Diagnostic Code 7804 for a painful scar. As such, no more than the 10 percent initial rating currently assigned is warranted. It is again noted that a noncompensable rating is warranted under Diagnostic Code 6835. The Board has considered the Veteran's lay assertions. For instance, she has reported numbness and testified that although she can climb stairs, it is hard for her to do so. She can no longer run. In evaluating a claim for an increased schedular disability rating, however, VA must consider the factors as enumerated in the rating criteria discussed above, which in part involves the examination of clinical data gathered by competent medical professionals. Massey v. Brown, 7 Vet. App. 204, 208 (1994). The Board is not free to ignore VA's duly promulgated regulations, which include the Rating Schedule. Franklin v. Brown, 5 Vet. App. 190, 193 (1993). The Board is bound by the law and is without authority to grant benefits on an equitable basis. See 38 U.S.C.A. §§ 503, 7104; Harvey v. Brown, 6 Vet. App. 416, 425 (1994). Furthermore, in rendering a decision on appeal, the Board must analyze the credibility and probative value of the evidence, account for the evidence which it finds to be persuasive or unpersuasive, and provide the reasons for its rejection of any material evidence favorable to the claimant. See Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994); Gilbert v. Derwinski, 1 Vet. App. 49, 57 (1990). Competency is a legal concept in determining whether lay or medical evidence may be considered, in other words, whether the evidence is admissible as distinguished from credibility and weight, factual determinations going to the probative value of the evidence, that is, does the evidence tend to prove a fact, once the evidence has been admitted. Rucker v. Brown, 10 Vet. App. 67, 74 (1997). In this case, the Veteran is competent to report symptoms, such as numbness, and a feeling of catching of a scar, because this requires only personal knowledge as it comes to her through her senses. Layno v. Brown, 6 Vet. App. 465, 469-71 (1994). She is not, however, competent to identify a specific level of disability of this disorder according to the appropriate diagnostic codes, nor is she competent to attribute any symptom or abnormality to her service-connected disability. That involves specialized medical knowledge or training. Competent medical evidence means evidence provided by a person who is qualified through education, training, or experience to offer a medical diagnosis, statement, or opinion. 38 C.F.R. § 3.159. No factual foundation has been established that the Veteran is otherwise qualified through specialized education, training, or experience to offer a medical diagnosis. Such competent evidence concerning the nature and extent of the Veteran's coccidioidomycosis disability have been provided by the medical personnel who have examined her during the current appeal period and who have rendered pertinent opinions in conjunction with the evaluations. The medical findings (as provided in the examination reports and the clinical records) directly address the criteria under which this disability is evaluated. As such, the Board finds these records to be more probative than the Veteran's subjective complaints of increased symptomatology or their relationship to her service-connected coccidioidomycosis disability. Again, the Board acknowledges that a July 2013 CT scan was interpreted as showing a mild decrease in lung function "probably related" to her coccidioidomycosis surgery. As noted above, whether she has a pulmonary function disability caused or aggravated by the coccidioidomycosis has been referred to the RO for appropriate action. As the assigned 10 percent rating reflects the actual degree of impairment shown since the date of claim, there is no basis for a staged rating. Accordingly, for the reasons explained above, the preponderance of the evidence is against a rating higher than 10 percent for coccidioidomycosis and residuals from surgical treatment, and the benefit-of-the-doubt standard of proof does not apply. 38 U.S.C.A. § 5107(b). Claim for a Rating in Excess of 10 Percent for Subretinal Hemorrhage The Veteran's service-connected residuals of a subretinal hemorrhage are rated under Diagnostic Codes 6099-6007, which means the condition is rated by analogy. When an unlisted condition is encountered it is permissible to rate under a closely related disease or injury in which not only the functions affected, but also the anatomical localization and symptomatology are closely analogous. Conjectural analogies will be avoided, as will the use of analogous ratings for conditions of doubtful diagnosis, or for those not fully supported by clinical and laboratory findings, nor will ratings assigned to organic disease and injuries be assigned by analogy to conditions of functional origin. See 38 C.F.R. § 4.20. The "6099" indicates the Veteran's service connected subretinal hemorrhage is an unlisted condition rated by analogy to Diagnostic Code 6007 pertaining to an intraocular hemorrhage. As will be discussed more thoroughly below, the Board finds that Diagnostic Code 6007 is most closely analogous to the Veteran's disability in functions affected, anatomical localization, and symptomatology. The Board notes during the course of the Veteran's appeal, the rating criteria for these Diagnostic Codes were amended effective December 10, 2008, and are applied to all applications for benefits received by VA on or after December 10, 2008. 73 Fed. Reg. 66550 (Nov. 10, 2008). As the Veteran filed her claim in February 2004, the rating criteria in effect prior to December 10, 2008 are applicable to the claim. Under the pre-December 2008 rating schedule, disabilities rated under Diagnostic Code 6007 are to be evaluated from 10 percent to 100 percent for impairment of visual acuity or field loss, pain, rest-requirements, or episodic incapacity, combining an additional rating of 10 percent during continuance of active pathology. The minimum rating during active pathology is 10 percent. 38 C.F.R. § 4.84a, Diagnostic Code 6007 (before December 10, 2008). According to the rating schedule in effect before December 10, 2008, visual acuity is rated on the basis of corrected distance vision. 38 C.F.R. § 4.75. The severity of impaired central visual acuity is determined by comparing visual test results on the Snellen index with the criteria set forth in 38 C.F.R. § 4.84(a), Diagnostic Codes 6061 to 6079. 38 C.F.R. § 4.83a. A 10 percent disability rating is warranted for visual acuity where the vision is 20/50 in one eye and 20/50 in the other eye; or where vision is 20/40 in one eye and 20/50 in the other; or where vision is 20/70 in one and 20/40 in the other. A 20 percent disability rating is warranted for visual acuity where the vision is 20/70 in one eye and 20/50 in the other; or where vision is 20/100 in one eye and 20/50 in the other; or where vision is 20/200 in one and 20/40 in the other; or where vision is 15/200 in one eye and 20/40 in the other. Diagnostic Codes 6077, 6078, and 6079 (2007). Facts The Veteran was provided a VA examination in March 2004. She stated that in service, she started experiencing blurred vision. She was diagnosed with blood behind her retina in her left eye. She reported she has visual distortion ever since. Her visual acuity was 20/25 corrected distance in the right eye and 20/30 + 2 in the left although the examiner noted the Veteran could only see the two side letters with her left eye. Examination of the eyes demonstrated her extraoccular eye movements were full and her visual fields were full. The eyes were normal except the left macula showed a coma shaped retina pigment epithelial defect extending from the fovea infranasally for approximately 0.25 disc diameters. The diagnosis was a retina pigment epithelial changes consistent with a history of subretinal hemorrhage with a small central scatoma of the left eye. In an April 2007 VA examination, the Veteran's visual acuity was 20/20 corrected distance in the right eye and 20/30 + 2 in the left eye. She had a full field of vision as tested by visual confrontation. The Veteran did not have diplopia and had full and orthophoric extraoccular eye movements. The physical examination did not reveal any abnormalities except for mottling of the pigment in the macula. The diagnosis was decreased visual acuity of the left eye likely secondary to the retinal bleed in the left eye. In July 2013. The Veteran was provided a third VA examination. It was noted as medical history that the Veteran had had Lasik eye surgery in 2008, of monovision, distance for the right eye and near for the left eye. The Veteran complained of decreased vision, worse in the right eye than the left. It was also noted that the Veteran had been diagnosed with cataracts in April 2013. On the July 2013 examination, the visual acuity was 20/40 or better corrected distance in the right eye and in the left eye. The VA examiner noted that the lens needed to correct the poorer eye did not differ greater than 3 diopeters from the lens required to correct distant vision. The Veteran did not have diplopia. The examiner found a posterior subcapsular cataract in each eye, which was characterized as preoperative. The examiner noted that the cataracts were the primary reason for decreased visual acuity. The examiner also did a vision of field test and interpreted the results as no contraction or loss of field of vision in either eye. It was noted that the Veteran had not required bed rest due to her eye disability. Analysis As noted, the Veteran is rated under Diagnostic Code 6007 based upon impairment of visual acuity or field loss, pain, rest-requirements, or episodic incapacity, combining an additional rating of 10 percent during continuance of active pathology. As the Veteran's corrected distance visual acuity has been 20/40 or less bilaterally, a higher rating based upon visual acuity is not demonstrated by the evidence of record. In a similar manner, the Veteran's visual field has been described by the 2004 and 2007 VA examinations as full or normal according to the visual confrontation test. The Veteran's visual field contraction was tested in July 2013 and no visual field deficits have been demonstrated. Therefore, a higher rating based upon a visual deficit is not warranted. There is no evidence of pain or episodic incapacity. The Board recognizes that the Veteran has testified that when performing tasks such as working at her computer, she occasionally has to take a break. The Board finds that this type of rest requirement presents a disability picture that more nearly approximates a 10 percent rating than 20 percent rating. Also, there is no evidence of active pathology or other eye disabilities or conditions such as diplopia (double vision). The Board also recognizes that the Veteran has recently been diagnosed with cataracts which may have an effect on visual impairment. The evidence is not clear whether the cataracts are caused by or aggravated by the residuals of her subretinal hemorrhage disability, but as noted above, the issue of service connection for cataracts claimed as secondary to the service-connected subretinal hemorrhage of the left eye has been referred to the RO for appropriate action. Further, although the Veteran believes the severity of her disability of the left eye warrants a higher rating, for the reasons expressed above, the Board finds the medical evidence of the VA examiners and medical providers are more probative than the Veteran's subjective lay complaints of increased symptomatology or their relationship to her service-connected subretinal hemorrhage disability. She has not been shown to have had the requisite medical training to render a competent opinion in this regard. As the assigned 10 percent rating reflects the actual degree of impairment shown since the date of claim, there is no basis for a staged rating. Accordingly, for the reasons explained above, the preponderance of the evidence is against a rating higher than 10 percent for the subretinal hemorrhage of the left eye, and the benefit-of-the-doubt standard of proof does not apply. 38 U.S.C.A. § 5107(b). Extraschedular Consideration Although the Board is precluded by regulation from assigning an extraschedular rating under 38 C.F.R. § 3.321(b)(1) in the first instance, the Board is not precluded from considering whether the case should be referred to the Director of VA's Compensation and Pension Service for a rating. The threshold factor for extraschedular consideration is a finding that the evidence presents such an exceptional disability picture that the available schedular ratings for that service-connected disability are inadequate. This is accomplished by comparing the level of severity and symptomatology of the service-connected disability with the established criteria. If the criteria reasonably describe the disability level and symptomatology, then the disability picture is contemplated by the Rating Schedule, and the assigned schedular rating is, therefore, adequate and referral for an extraschedular rating is not required. Thun v. Peake, 22 Vet. App. 111, 115 (2008), aff'd sub nom. Thun v. Shinseki, 572 F.3d 1366 (Fed. Cir. 2009). Comparing the Veteran's current disability levels and symptomatology to the Rating Schedule, the levels of disability are encompassed by the Rating Schedule. Higher ratings are provided for more severe conditions relating to coccidioidomycosis and subretinal hemorrhage residuals. Furthermore, the Veteran has not been hospitalized for either disability. There is no evidence that the Veteran has lost time at work for either disability and she has also indicated that either accommodations have been made for her at work or she herself has adapted to successfully perform her job duties and handle her symptoms by taking breaks. Either way, she apparently is able to perform her duties to the satisfaction of her employer. In short, the evidence has not shown that there is marked interference with employment. In light of the foregoing, the assigned schedular ratings are adequate and no referral for an extraschedular rating is required under 38 C.F.R. § 3.321(b)(1). In other words, the Board finds that the rating criteria reasonably describe the coccidioidomycosis and subretinal hemorrhage disabilities and their symptomatology, and these symptoms are contemplated by the Rating Schedule under Diagnostic Codes 6007, 6835, and 7804, and the Veteran does not have any symptomatology not already contemplated by the Rating Schedule. Claim for Total Disability Based Upon Individual Unemployability During the appeal period, the Veteran has not expressly raised and the record does not reasonably raise a claim for total disability rating for compensation based on individual unemployability. See Rice v. Shinseki, 22 Vet. App. 447, 453-54 (2009) (in a claim for increase, where the Veteran expressly raises a claim for a total disability rating on the basis of individual unemployability or the claim is reasonably raised by the record, the claim is not a separate claim, but a part of a claim for increase). As noted, although the evidence suggests that the Veteran's disabilities may have affected her employment in the performance of her duties and the severity of the symptoms have been discussed, the Veteran has secured and maintained a job. Therefore, in the circumstances of this case, the Board finds that entitlement to a total disability rating based on individual unemployability has not been raised by the record. ORDER Entitlement to an initial rating in excess of 10 percent for service-connected coccidioidomycosis is denied. Entitlement to an initial rating in excess of 10 percent for service-connected residuals of a subretinal hemorrhage is denied. ____________________________________________ U. R. POWELL Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs