Citation Nr: 1334728 Decision Date: 10/30/13 Archive Date: 11/06/13 DOCKET NO. 07-32 877 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Jackson, Mississippi THE ISSUES 1. Entitlement to service connection for hypertension, to include as secondary to diabetes mellitus, type II. 2. Entitlement to an initial rating in excess of 10 percent for left upper extremity carpal tunnel syndrome. REPRESENTATION Appellant represented by: The American Legion WITNESS AT HEARINGS ON APPEAL Appellant ATTORNEY FOR THE BOARD T. L. Douglas, Counsel INTRODUCTION The appellant is a Veteran who served on active duty from July 1963 to November 1967. This matter comes before the Board of Veterans' Appeals (Board) by order of the United States Court of Appeals for Veterans Claims (hereinafter "the Court") in March 2011, which vacated an April 2009 Board decision and remanded the issues on appeal for additional development. The appeal arose from an October 2006 rating decision by the Jackson, Mississippi, Regional Office (RO) of the Department of Veterans Affairs (VA). The Board remanded these issues for additional development in November 2011. The Board notes that the November 2011 remand also addressed the issue of entitlement to service connection for a kidney disorder for the issuance of a statement of the case (SOC) from an October 2006 notice of disagreement. In correspondence dated in February 2012, however, the Veteran was notified that this issue was included in a June 2007 SOC and that a timely substantive appeal had not been provided. The Veteran was further notified that no additional action would be taken on the issue and of his right to appeal the present decision. Therefore, the issue is not before the Board for appellate review. In September 2008, the Veteran testified at a personal hearing before the undersigned Veterans Law Judge. A copy of the transcript of that hearing is of record. The issues on appeal were adequately explained to him and the submission of evidence which he may have overlooked and which would be advantageous to his position was suggested. See 38 C.F.R. § 3.103(c) (2012). FINDINGS OF FACT 1. Hypertension was not manifest during active service or within one year of service discharge, is not shown to have developed as a result of an established event, injury, or disease during active service nor otherwise as a result of herbicide exposure in service and is not causally related to service-connected diabetes mellitus, type II, to include on an aggravation basis. 2. The Veteran's service-connected left upper extremity carpal tunnel syndrome is manifest by no more than mild incomplete paralysis of the left median nerve. CONCLUSIONS OF LAW 1. Hypertension was not incurred in or aggravated by military service, may not be presumed to have been so incurred or aggravated and is not proximately due to, the result of or aggravated by service-connected diabetes mellitus, type II. 38 U.S.C.A. §§ 1110, 1116, 1154 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.303, 3.304, 3.307, 3.309 (2012). 2. The criteria for an initial rating in excess of 10 percent for left upper extremity carpal tunnel syndrome have not been met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. § 4.124a, Diagnostic Code 8515 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS VA has a duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2012). The Veteran was notified of the duties to assist and of the information and evidence necessary to substantiate his claims by correspondence dated in March 2005, September 2006, and May 2008. The notice requirements pertinent to the issues on appeal have been met and all identified and authorized records relevant to the matter have been requested or obtained. The available record includes incomplete service treatment records, service personnel records, VA treatment and examination reports, private treatment records, and statements and testimony in support of the Veteran's claims. The development requested on remand in November 2011 has been substantially completed. The Board finds there is no evidence of any additional existing pertinent records. Further attempts to obtain additional evidence would be futile. When VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate. VA medical opinions obtained in this case are adequate as they are predicated on a substantial review of the record and medical findings and consider the Veteran's complaints and symptoms. Accordingly, the Board finds that VA's duty to assist with respect to obtaining a VA examination or opinion has been met. 38 C.F.R. § 3.159(c)(4) (2012). The available medical evidence is sufficient for an adequate determination. There has been substantial compliance with all pertinent VA law and regulations and to adjudicate the claim would not cause any prejudice to the appellant. Service Connection Claim Service connection may be granted for a disability resulting from injury suffered or disease contracted in line of duty or for aggravation of preexisting injury suffered or disease contracted in line of duty. 38 U.S.C.A. § 1110 (West 2002); 38 C.F.R. § 3.303 (2012). Where a veteran is seeking service connection for any disability, due consideration shall be given to the places, types, and circumstances of the veteran's service as shown by the veteran's service record, the official history of each organization in which the veteran served, the veteran's medical records, and all pertinent medical and lay evidence. 38 U.S.C.A. § 1154(a) (West 2002). In the case of a veteran who engaged in combat with the enemy in active service with a military, naval, or air organization of the United States during a period of war, VA shall accept as sufficient proof of service-connection of any disease or injury alleged to have been incurred in or aggravated by that service satisfactory lay or other evidence of service incurrence or aggravation of such injury or disease, if consistent with the circumstances, conditions, or hardships of such service, notwithstanding the fact that there is no official record of such incurrence or aggravation in such service. 38 U.S.C.A. § 1154(b) (West 2002); 38 C.F.R. § 3.304(d) (2012). Service connection may also be established on a secondary basis for a disability which is proximately due to or the result of service-connected disease or injury. 38 C.F.R. § 3.310(a) (2012). Establishing service connection on a secondary basis requires evidence sufficient to show that a current disability exists and that the current disability was either proximately caused by or proximately aggravated by a service-connected disability. Allen v. Brown, 7 Vet. App. 439 (1995). In addition, service connection may be granted for any disease diagnosed after discharge, when all of the evidence, including that pertinent to service, establishes the disease was incurred in service. 38 C.F.R. § 3.303(d) (2012). Service connection can be granted for certain chronic diseases, including cardiovascular-renal disease, if manifest to a degree of 10 percent or more within one year of separation from active service. 38 U.S.C.A. §§ 1101, 1112, 1113 (West 2002); 38 C.F.R. §§ 3.307, 3.309 (2012). VA regulations provide that certain disorders associated with herbicide agent exposure in service, including ischemic heart disease, may be presumed service connected. This presumption is rebuttable by affirmative evidence to the contrary. See 38 U.S.C.A. § 1116 (West 2002); 38 C.F.R. §§ 3.307, 3.309 (2012). Veterans diagnosed with an enumerated disease who, during active service, served in the Republic of Vietnam during the period beginning on January 9, 1962, and ending on May 7, 1975, shall be presumed to have been exposed to an herbicide agent, unless there is affirmative evidence to establish that the veteran was not exposed to any such agent during that service. 38 C.F.R. § 3.307. It is noted that the term ischemic heart disease does not include hypertension. The Court has held that even though a disease is not included on the list of presumptive diseases a nexus between the disease and service may nevertheless be established on the basis of direct service connection. See Stefl v. Nicholson, 21 Vet. App. 120, 123 (2007) ("The existence of presumptive service connection for a condition based on exposure to Agent Orange presupposes that it is possible for medical evidence to prove such a link before the National Academy of Sciences recognizes a positive association."). The United States Court of Appeals for the Federal Circuit (Federal Circuit) has held that when a claimed disorder is not included as a presumptive disorder direct service connection may nevertheless be established by evidence demonstrating that the disease was in fact "incurred" during the service. See Combee v. Brown, 34 F.3d 1039 (Fed. Cir. 1994). For the showing of chronic disease in service, there is required a combination of manifestations sufficient to identify a disease entity, and sufficient observation to establish chronicity at the time, as distinguished from merely isolated findings or a diagnosis including the word chronic. Continuity of symptomatology is required only where the condition noted during service is not shown to be chronic or when the diagnosis of chronicity may be legitimately questioned. When the fact of chronicity in service is not adequately supported, then a showing of continuity after discharge is required to support the claim. 38 C.F.R. § 3.303(b) (2012). Continuity of symptomatology applies to those conditions explicitly recognized as chronic. 38 C.F.R. § 3.309(a) (2012); Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). In order to prevail on the issue of service connection on the merits, there must be medical evidence of (1) a current disability; (2) medical, or in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and (3) medical evidence of a nexus between the claimed in-service disease or injury and the present disease or injury. Hickson v. West, 12 Vet. App. 247 (1999). A veteran seeking disability benefits must establish the existence of a disability and a connection between service and the disability. Boyer v. West, 210 F.3d 1351 (Fed. Cir. 2000). Medical evidence is required to demonstrate a relationship between a current disability and the continuity of symptomatology demonstrated if the condition is not one where a lay person's observations would be competent. Clyburn v. West, 12 Vet. App. 296 (1999). Whether lay evidence is competent and sufficient in a particular case is an issue of fact and lay evidence can be competent and sufficient to establish a diagnosis when (1) a layperson is competent to identify the medical condition (sometimes the layperson will be competent to identify the condition where the condition is simple, for example, a broken leg, and sometimes not, for example, a form of cancer), (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007) Lay evidence presented by a veteran concerning his continuity of symptoms after service may be considered credible, and ultimately competent, regardless of a lack of contemporaneous medical evidence. Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006). The Board has the authority to discount the weight and probative value of evidence in light of its own inherent characteristics and its relationship to other evidence. Madden v. Gober, 125 F.3d 1477 (Fed. Cir. 1997). VA may favor one medical opinion over another, provided an adequate reason for doing so is provided. Owens v. Brown, 7 Vet. App. 429 (1995). It is the policy of VA to administer the law under a broad interpretation, consistent with the facts in each case, with all reasonable doubt to be resolved in favor of the claimant. 38 C.F.R. § 3.102 (2012). In this case, the pertinent evidence of record includes service treatment records without indication of complaint, treatment, or diagnosis for hypertension. Upon entrance examination in July 1963 all systems were considered to be normal and the Veteran's blood pressure was 118/76. A November 1967 separation examination revealed all systems were normal and blood pressure was 120/80. Records show the Veteran had service in the Republic of Vietnam from October 1966 to November 1967. Private treatment records dated in August 1995 noted the Veteran had a history of hypertension and that he was maintained on daily medication. Laboratory testing revealed glucose within the normal reference range. A December 2003 report noted an isolated elevation of blood glucose. A January 2004 report noted repeat testing would be performed in three months and if glucose remained elevated adding Glucophage would be considered. A diagnosis of diabetes mellitus was provided in March 2004. Reports dated in August 2005 and October 2006 noted a history of diabetes mellitus since 1996 without additional comments as to etiology. A June 2006 statement from E.M.D., M.D., noted the Veteran had been on medication including Glucophage since August 2005. VA treatment records include diagnoses of hypertension and diabetes mellitus. A June 2006 VA examination report noted the Veteran provided, subjectively, a medical history including a diagnosis of diabetes mellitus in 1996. The examiner provided no additional comments as to diabetes mellitus etiology and did not indicate the claims file was reviewed. The examiner provided diagnoses including essential hypertension and noted the disorder was not caused by diabetes mellitus. In statements and testimony provided in support of his claim the Veteran stated that he was first provided a diagnosis of diabetes mellitus in 1996. In June 2006, he testified that he was provided a diagnosis of diabetes mellitus in 1996 and that he was unable to remember if his diagnosis of hypertension was provided before or after his diabetes diagnosis. At his personal hearing in September 2008 it was asserted that his hypertension was secondary to his diabetes mellitus for which he was provided a diagnosis in 1996. The Veteran stated that he believed he had first been provided a diagnosis of hypertension in the "nineties" and on medication for 15 or 16 years. VA diabetes mellitus examination in August 2010 noted the Veteran reported he was provided a diagnosis of diabetes mellitus in 1996 and that he had high blood pressure since 1995 or 1996. The examiner's diagnoses included essential hypertension, not caused by nor due to his diabetes mellitus. A January 2012 VA medical opinion noted that the Veteran provided a history of diagnoses of hypertension and diabetes having been provided in the mid 1990's, but that a review of the claims file indications of hypertension as early as 1995 and no diagnosis of diabetes prior to 2003. It was the examiner's opinion that the Veteran's hypertension was essential, which was a common diagnosis in more than 90 percent of cases, and that his hypertension was not secondary to his diabetes. His kidney function was noted to be normal so there was no significant renal dysfunction to cause or aggravate his hypertension. The onset of his hypertension was found to have been many years after his active service. It was also noted that the term essential hypertension simply meant that it was a separate diagnosis and was not caused by diabetes. The examiner expressed agreement with the statement as to etiology provided by the June 2006 VA examiner. Based upon the evidence of record, the Board finds hypertension was not manifest during active service or within one year of service discharge and is not shown to have developed as a result of an established event, injury, or disease during active service nor otherwise as a result of herbicide exposure in service. It is also not shown to be causally related to the Veteran's service-connected diabetes mellitus, type II, to include on an aggravation basis. The Veteran's exposure to certain chemical herbicides during service in Vietnam is conceded. The Board finds, however, that the January 2012 VA examiner's opinion is persuasive and based upon adequate rationale. The opinion is shown to have been based upon a thorough examination, a thorough review of the evidence of record, and adequate consideration of the Veteran's statements. The Court has also previously held that hypertension, standing alone and not the result of diabetes-induced renal disease, i.e., essential hypertension, is not found among the complications of diabetes mellitus. Flynn v. Brown, 6 Vet. App. 500, 506 (1994). The Board further finds that the Veteran's statements that his hypertension and diabetes diagnoses were provided around the same time in the mid 1990's are inconsistent with the evidence and are not credible. Private medical records dated in August 1995 show the Veteran had a history of hypertension and was taking medication, but there was no indication of diabetes at that time nor any evidence of increased laboratory glucose testing results or oral diabetes medication use prior to December 2003. The Federal Circuit has recognized the Board's "authority to discount the weight and probity of evidence in light of its own inherent characteristics and its relationship to other items of evidence." Madden v. Gober, 125 F.3d 1477, 1481 (Fed. Cir. 1997). In determining whether evidence submitted by a veteran is credible VA may consider internal consistency, facial plausibility, and consistency with other evidence. See Caluza v. Brown, 7 Vet. App. 498, 511 (1995) (superseded by statute for an unrelated point of law as stated by Duenas v. Principi, 18 Vet. App. 512 (2004)); see also Buchanan v. Nicholson, 451 F.3d 1331, 1337 (Fed. Cir. 2006) (VA can consider bias in lay evidence and conflicting statements of the veteran in weighing credibility); Macarubbo v. Gober, 10 Vet. App. 388 (1997) (holding that the credibility of lay evidence can be affected and even impeached by inconsistent statements, internal inconsistency of statements, inconsistency with other evidence of record, facial implausibility, bad character, interest, bias, self-interest, malingering, desire for monetary gain, and witness demeanor); Pond v. West, 12 Vet. App. 341, 345 (1999) (holding in a case where the claimant was also a physician, and therefore a medical expert, that the Board should properly consider the appellant's own personal interest in the outcome of the case). Similarly, the Board finds that an October 2006 private EMG report, to the extent it indicates the Veteran had diabetes since 1996 that required oral medication, is also not credible. The information report by the examiner appears to have been recorded solely based upon the Veteran's report. The Court has held that evidence which is simply information recorded by a medical examiner, unenhanced by any additional medical comment by that examiner, does not constitute competent medical evidence. LeShore v. Brown, 8 Vet. App. 406, 409 (1995). The Court has also held that "[Doctors'] diagnoses can be no better than the facts alleged by appellant." Swann v. Brown, 5 Vet. App. 229, 233 (1993) While the Veteran is competent to provide evidence as to observations and some medical matters, his statements are, at most, conclusory assertions of a nexus between his hypertension and either his exposure to herbicides during active service or his service-connected diabetes mellitus. As the questions of medical diagnosis and a relationship to service at issue in this case are complex etiological questions akin to the type of medical matters which courts have found laypersons are not competent to provide, his statements are insufficient to establish service connection. Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009) (Board must determine whether claimed disability is type of disability for which a lay person is competent to provide etiology or nexus evidence). The Veteran is not shown to have the requisite medical training to provide such opinions. Therefore, the claim for entitlement to service connection must be denied. When all the evidence is assembled VA is then responsible for determining whether the evidence supports the claim or is in relative equipoise, with the claimant prevailing in either event, or whether a preponderance of the evidence is against the claim in which case the claim is denied. Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990); Ortiz v. Principi, 274 F. 3d 1361 (Fed. Cir. 2001). The preponderance of the evidence in this case is against the claim. Disability Rating Claim Disability evaluations are determined by the application of VA's Schedule for Rating Disabilities (Rating Schedule), 38 C.F.R. Part 4. This Rating Schedule is primarily a guide in the evaluation of disability resulting from all types of diseases and injuries encountered as a result of or incident to military service. The percentage ratings represent as far as can practicably be determined the average impairment in earning capacity resulting from such diseases and injuries and their residual conditions in civil occupations. Generally, the degrees of disability specified are considered adequate to compensate for considerable loss of working time from exacerbations or illnesses proportionate to the severity of the several grades of disability. For the application of this schedule, accurate and fully descriptive medical examinations are required, with emphasis upon the limitation of activity imposed by the disabling condition. Over a period of many years, a veteran's disability claim may require reratings in accordance with changes in laws, medical knowledge and his or her physical or mental condition. It is thus essential, both in the examination and in the evaluation of disability, that each disability be viewed in relation to its history. See 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. § 4.1 (2012). The Court has held that a claim for a higher rating when placed in appellate status by disagreement with the original or initial rating award (service connection having been allowed, but not yet ultimately resolved), remains an "original claim" and is not a new claim for an increased rating. See Fenderson v. West, 12 Vet. App. 119 (1999). In such cases, separate compensable evaluations may be assigned for separate periods of time if such distinct periods are shown by the competent evidence of record during the pendency of the appeal, a practice known as "staged" ratings. Id. at 126. It is the responsibility of the rating specialist to interpret reports of examination in the light of the whole recorded history, reconciling the various reports into a consistent picture so that the current rating may accurately reflect the elements of disability present. 38 C.F.R. § 4.2 (2012). Consideration of factors wholly outside the rating criteria constitutes error as a matter of law. Massey v. Brown, 7 Vet. App. 204, 207-08 (1994). Evaluation of disabilities based upon manifestations not resulting from service-connected disease or injury and the pyramiding of ratings for the same disability under various diagnoses is prohibited. 38 C.F.R. § 4.14 (2012). 8515 The Median Nerve, Paralysis of: Major Minor Complete; the hand inclined to the ulnar side, the index and middle fingers more extended than normally, considerable atrophy of the muscles of the thenar eminence, the thumb in the plane of the hand (ape hand); pronation incomplete and defective, absence of flexion of index finger and feeble flexion of middle finger, cannot make a fist, index and middle fingers remain extended; cannot flex distal phalanx of thumb, defective opposition and abduction of the thumb at right angles to palm; flexion of wrist weakened; pain with trophic disturbances 70 60 Incomplete: Severe 50 40 Moderate 30 20 Mild 10 10 38 C.F.R. § 4.124a, Diagnostic Code 8515 (2012). It is the policy of VA to administer the law under a broad interpretation, consistent with the facts in each case with all reasonable doubt to be resolved in favor of the claimant; however, the reasonable doubt rule is not a means for reconciling actual conflict or a contradiction in the evidence. 38 C.F.R. § 4.3 (2012). The pertinent evidence of record shows the Veteran is right hand dominant and that service connection was established for his diabetes mellitus in a May 2005 rating decision. Private treatment records dated in November 2004 noted a review of systems was specifically negative for paresthesias including in the hands. On VA peripheral nerves examination in June 2006 the Veteran reported paresthesias in the hands and feet for several years. He stated he was able to button his shirt and cut meat. The examiner noted his motor strength was 5/5 with normal tone, bulk, dexterity, and coordination. VA neurological examination in September 2006 revealed motor strength of 4/5 in both hands with poor effort and with normal tone, bulk, dexterity, and coordination. Vibration sense was subjectively decreased in both hands. The examiner noted there had been a significant change in subjective sensory findings in the last three months and the poor motor effort demonstrated was suspicious for malingering. It was noted that the reported distribution of sensory loss was inconsistent with polyneuropathy and was of too rapid a progression to be due to well-controlled diabetes mellitus. An October 2006 addendum noted that electrophysiologic evidence established the presence of left upper extremity carpal tunnel syndrome. It was also noted that diabetes did predispose such compressive neuropathy. Private treatment records from M.C.G., M.D., include an October 2006 report which provided a diagnosis of moderate bilateral carpal tunnel syndrome with overt sensory delay-dispersion with some sensory axon loss, moderate distal motor delay without motor axon loss, and relatively symmetric abnormalities. There was no electrophysiologic evidence of left ulnar nerve entrapment at the wrist or elbow and no clear large fiber sensory or motor polyneuropathy was detected. It was noted that there were rather prominent neurophysiologic changes across the carpal tunnels bilaterally, though hand-arm "symptoms" were reportedly rather mild and not significant. The examiner commented that nocturnal wrist splints may help slow progression. On VA examination in December 2007 the Veteran complained of numbness in all fingers and most of his hands. He stated he had trouble with buttons and laces and that sometimes he had trouble cutting meat at the dinner table. The examiner noted motor strength was at least 4/5 with poor effort and with normal tone, bulk, dexterity, and coordination. Sensation was intact to fine touch, vibration, and position. Reflexes were 1-2+ and equal. It was noted that temperature sense was decreased in the right ulnar side of the hand, but the report is unclear as to which hand. The examiner noted there was electrophysiologic evidence of bilateral carpal tunnel syndrome, but that the Veteran had no physical findings consistent with carpal tunnel syndrome. A February 2008 VA occupational therapy consult note recorded the Veteran's complaints of left hand numbness when he was driving or sleeping that had increased over the past six months. Range of motion testing was within normal limits, there was no edema, and left hand grip was 80 (normal grip was noted to be 76). A left hand splint was issued. A July 2008 private treatment report from Dr. M.C.G. revealed moderate bilateral carpal tunnel syndrome with overt sensory delay-dispersion with some sensory axon loss, moderate distal motor delay without motor axon loss, and relatively symmetric abnormalities. It was noted distal sensory responses in the arms were minimally reduced compared to the October 2006 study, perhaps reflecting a "very mild" sensory polyneuropathy. There was also no electrophysiologic evidence of focal ulnar nerve entrapment at the wrist or elbow in either arm. Dr. M.C.G. commented that though the hand symptoms might be slightly worse, the neurophysiologic abnormalities (transcarpal changes) were stable (unchanged). On VA peripheral nerves examination in August 2010 the Veteran reported numbness to the feet. He stated he did not wear laces and had no trouble with buttons. Motor strength of 5/5 with normal tone, bulk, dexterity, and coordination. Sensation was intact to fine touch, temperature, and position. A diagnosis of mild incomplete sensory loss in the feet due to polyneuropathy, likely as not caused by diabetes was provided, but the examiner noted although the Veteran had electrophysiologic evidence of carpal tunnel syndrome he had no motor or sensory loss referable to the median nerve upon present examination. At his hearing in September 2008 the Veteran testified that he experienced numbness and tingling in the hand and feelings that it was going to sleep. He asserted that an increased rating was warranted and that the disorder had affected his job performance as a mail carrier prior to his retirement. He stated his present activities were restricted due to loss of strength, numbness, and an inability to grab "too far away" unless he wore his brace. VA treatment records dated in March 2011 and October 2011 noted diagnoses of carpal tunnel syndrome. It was further noted that the disorder was asymptomatic. VA examination in January 2012 included diagnoses of diabetic polynephropathy and carpal tunnel syndrome. It was noted the Veteran complained of numbness to the wrists and that his hands hurt all the time. He reported he had trouble reaching his laces, managed buttons okay at times, and did not cut much meat. Mild constant left upper extremity pain was noted. Neurologic examination revealed strength was 5/5 to the left upper extremity on elbow flexion, elbow extension, wrist flexion, wrist extension, grip, and pinch. Reflexes were 1+, decreased, to the left biceps, triceps, and brachioradialis. Light touch/monofilament testing was normal to the left shoulder, inner/outer forearm, and hands/fingers. Position sense and vibration sense were normal to the left upper extremity. Cold sensation was decreased. There was no evidence of muscle atrophy or trophic changes. The examiner found the Veteran did not have upper extremity diabetic peripheral neuropathy, but noted that EMG testing years earlier had revealed abnormalities including to the left upper extremity. The Veteran's peripheral nerve condition and/or peripheral neuropathy was found to have no impact on his ability to work. The examiner found, however, that the examination was, again, not consistent with either carpal tunnel syndrome or diabetic polyneuropathy. There were no motor or sensory findings and no evidence of carpal tunnel syndrome. It was noted there was electrophysiologic evidence of carpal tunnel syndrome in the past, but no other findings and no electrophysiological evidence of large fiber polyneuropathy in the past. It was further noted that given his good glycemic control not much change was expected in his neuropathy. Compression neuropathy such as carpal tunnel syndrome, the examiner stated, was caused by compression of a peripheral nerve by some structure, but that diabetes did not cause compression. Based upon the evidence of record, Veteran's service-connected left upper extremity carpal tunnel syndrome is manifest by no more than mild incomplete paralysis of the left median nerve. The disability is currently evaluated as 10 percent disabling for the under 38 C.F.R. § 4.124a, Diagnostic Code 8515 [paralysis of median nerve]. See 38 C.F.R. § 4.20 (2012) [when an unlisted condition is encountered it will be permissible to rate it under a closely related disease or injury, in which not only the functions affected, but the anatomical localization and symptomatology are closely analogous]. Any change in Diagnostic Code by a VA adjudicator must be specifically explained. See Pernorio v. Derwinski, 2 Vet. App. 625, 629 (1992). Diagnostic Code 8515 specifically references paralysis of the median nerve, which concerns the wrist. Therefore, the Board finds that Diagnostic Code 8515 is the most appropriate, given that the service-connected disability is carpal tunnel syndrome. The terms "mild," "moderate," and "severe" are not defined by applicable VA regulations. Rather than applying a mechanical formula, the Board must evaluate all of the evidence to the end that its decisions are "equitable and just." See 38 C.F.R. § 4.6 (2012). The Board finds that the Veteran's complaints of pain and difficulty with his grip when performing such tasks as driving are mild in nature and that his having been provided wrist splints in February 2008 are not shown to have been due to a more severe disability. In fact, the splints are shown to have been provided for preventative treatment. There is no evidence of any significant limitation in function or any other symptoms which would allow for the assignment of a higher rating based on moderate or greater disability under Diagnostic Code 8515. While the October 2006 and July 2008 private medical reports noted "moderate" carpal tunnel syndrome, a moderate disability for VA compensation purposes under the applicable rating criteria is not supported by the medical evidence of record. The Board also notes that in July 2008 Dr. M.C.G. found only overt sensory delay-dispersion with some sensory axon loss, moderate distal motor delay without motor axon loss, relatively symmetric abnormalities, and distal sensory responses in the arms were minimally reduced compared to the October 2006 study, but that there was no electrophysiologic evidence of focal ulnar nerve entrapment at the wrist or elbow in either arm and that transcarpal changes were stable. The Board notes that carpal tunnel syndrome is defined as "a complex of symptoms resulting from compression of the median nerve in the carpal tunnel, with pain and burning or tingling paresthesias in the fingers and hand, sometimes extending to the elbow." See Wilson v. Brown, 7 Vet. App. 542, 544 (1995) [citing Dorland's Illustrated Medical Dictionary 1632 (1988 27th Ed.)]. As the service-connected disability involves a neurological disability and there is no probative evidence of any manifest service-connected orthopedic disorders, the provisions under DeLuca v. Brown, 8 Vet. App. 202 (1995), are not for application. Symptoms such as incoordination and weakness are specifically contemplated in Diagnostic Code 8515. The Board also finds the apparent inconsistency between the October 2006 and January 2012 VA examiners as to whether diabetes predisposes compression neuropathy is not relevant to the present appeal as all manifest neurological symptoms are considered service connected. Therefore, an initial schedular rating in excess of 10 percent in this case is not warranted. The Board further finds that there is no evidence of any unusual or exceptional circumstances that would take this case outside the norm so as to warrant an extraschedular rating. The Veteran's service-connected left upper extremity carpal tunnel syndrome is found to be adequately rated under the available schedular criteria and the objective findings of impairment are well documented. The Court in Thun v. Peake, 22 Vet. App. 111 (2008), has established a three-step inquiry for determining whether a veteran is entitled to extraschedular rating consideration. First, 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 level of disability and symptomatology and is found to be inadequate, then determine whether the claimant'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, a veteran's disability picture requires the assignment of an extraschedular rating. The evidence is not indicative of a marked interference with employment as a result of the service-connected disability. In fact, the January 2012 VA examiner found the disorder had no impact on the Veteran's ability to work. There is also no evidence of other related factors such as frequent periods of hospitalization due to this disability. Therefore, referral by the RO to the Chief Benefits Director of VA's Compensation and Pension Service, under 38 C.F.R. § 3.321, is not warranted. See Bagwell v. Brown, 9 Vet. App. 337 (1996). ORDER Entitlement to service connection for hypertension, to include as secondary to diabetes mellitus, is denied. Entitlement to an initial rating in excess of 10 percent for left upper extremity carpal tunnel syndrome is denied. ____________________________________________ BARBARA B. COPELAND Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs