Citation Nr: 1436622 Decision Date: 08/15/14 Archive Date: 08/20/14 DOCKET NO. 11-05 482A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Manila, the Republic of the Philippines THE ISSUES 1. Entitlement to service connection for peripheral neuropathy, to include as due to Agent Orange exposure. 2. Entitlement to a disability rating in excess of 10 percent for carpal tunnel syndrome, right hand. REPRESENTATION Veteran represented by: Disabled American Veterans ATTORNEY FOR THE BOARD A. Spector, Associate Counsel INTRODUCTION The Veteran had active service from December 1966 to January 1987. This matter comes before the Board of Veterans' Appeals (Board) on appeal from an August 2009 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Manila, the Republic of the Philippines, which denied the Veteran's claim of service connection for peripheral neuropathy, to include as due to Agent Orange exposure. Additionally, in a December 2010 rating decision, the RO granted service connection for carpal tunnel syndrome of the right hand and assigned a 10 percent disability rating, effective March 25, 2008. In an April 2013 rating decision, the RO assigned an earlier effective date of July 9, 2007 for the grant of service connection for carpal tunnel syndrome of the right hand. The Veteran submitted an additional June 2013 letter disagreeing with the evaluation assigned for his carpal tunnel syndrome of the right hand. In subsequent statements, the Veteran continued to refer to the issue of his carpal tunnel syndrome of the right hand as being on appeal. Therefore, the Board will construe the June 2013 statement as an informal Substantive Appeal as to that issue, and the issue of an initial disability rating in excess of 10 percent for carpal tunnel syndrome of the right hand is currently on appeal before the Board. In addition to the paper claims file, the Board has reviewed the Veteran's electronic claims files (in both Virtual VA and the Veterans Benefits Management System). Additional documents associated with the Veteran's electronic claims file have been reviewed and are either duplicative of evidence of record or do not pertain to the issues on appeal. FINDINGS OF FACT 1. The evidence does not demonstrate that the Veteran is currently diagnosed with peripheral neuropathy. 2. Throughout the pendency of the appeal, the Veteran's service-connected carpal tunnel syndrome of the right hand (major) is shown to be productive of no more than moderate incomplete paralysis of the median nerve, as shown on electromyography (EMG) studies, with complaints of hand numbness, pain, weakness, stiffness, and tingling. CONCLUSIONS OF LAW 1. The criteria for a grant of service connection for peripheral neuropathy are not met. 38 U.S.C.A. §§ 1101, 1110, 1131, 5103, 5103A, 5107 (West 2002 & Supp. 2013); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304 (2013). 2. The criteria for an initial disability rating of 30 percent, but no higher, for carpal tunnel of the right hand, have been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.321, 4.1, 4.3, 4.7, 4.120, 4.123, 4.124, 4.124a, Diagnostic Code 8515 (2013). 3. Application of the extra-schedular rating provisions is not warranted in this case. 38 C.F.R. § 3.321(b) (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Duty to Notify and Assist The 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; 38 U.S.C.A. §§ 3.102, 3.156(a), 3.159 and 3.326(a). Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant and his representative of any information, and any medical or lay evidence, that is necessary to substantiate the claim. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b); Quartuccio v. Principi, 16 Vet. App. 183 (2002). Proper notice from VA must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide in accordance with 38 C.F.R. § 3.159(b)(1). This notice must be provided prior to an initial unfavorable decision on a claim by the agency of original jurisdiction (AOJ). Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). Here, the duty to notify was satisfied by way of a letter sent to the Veteran in March 2008 that fully addressed all notice elements and was sent prior to the initial AOJ decision in the matter of service connection for peripheral neuropathy. The letter informed the Veteran of what evidence was required to substantiate the claim and of the Veteran's and VA's respective duties for obtaining evidence. The letter also provided notice regarding how disability ratings and effective dates are assigned if service connection is awarded. See Dingess v. Nicholson, 19 Vet. App. 473 (2006). Under the circumstances, the Board finds that the notification requirements of the VCAA have been satisfied as to both timing and content for the service connection issue on appeal. The Veteran's increased rating claim for carpal tunnel syndrome of the right hand arise from his disagreement with the initial evaluation assigned following the grant of service connection. Courts have held that once service connection is granted the claim is substantiated, additional notice is not required and any defect in the notice is not prejudicial. Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007), Goodwin v. Peake, 22 Vet. App. 128, 134 (2008), Dunlap v. Nicholson, 21 Vet. App. 112 (2007). Therefore, no further notice is required for this claim. VA must also make reasonable efforts to assist the Veteran in obtaining evidence necessary to substantiate the claim for the benefit sought unless no reasonable possibility exists that such assistance would aid in substantiating the claim. This duty includes assisting with the procurement of relevant records, including pertinent treatment records, and providing an examination when necessary. See 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. The VA has also done everything reasonably possible to assist the Veteran with respect to his claims for benefits, such as obtaining private and VA medical records and providing the Veteran with VA examinations in October 2010, November 2011, December 2011, March 2012, April 2012, and December 2013. As the Veteran has not indicated that he has received additional treatment for the issues on appeal, the Board thus concludes that there are no additional treatment records outstanding with respect to these claims. Consequently, the duty to notify and assist has been satisfied as to the claim now being finally decided on appeal. Smith v. Gober, 14 Vet. App. 227 (2000); Dela Cruz v. Principi, 15 Vet. App. 143 (2001). II. Service Connection Legal Criteria Service connection may be granted for a disease or injury incurred in or aggravated by service. 38 U.S.C.A. §§ 1110, 1131. Service connection may also be granted for any disease diagnosed after discharge, when all of the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Establishing service connection generally requires (1) medical evidence of a current disability; (2) medical, or in certain circumstances, lay evidence of in-service occurrence 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 disability. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004); see Caluza v. Brown, 7 Vet. App. 498, 506 (1995), aff'd per curiam, 78 F.3d 604 (Fed.Cir.1996) (table); see also Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004) However, the absence of a documented disability while in service is not fatal to a claim for service connection. Ledford v. Derwinski, 3 Vet. App. 87, 89 (1992). When a Veteran does not meet the regulatory requirements for a disability at separation, he can still establish service connection by submitting evidence that a current disability is causally related to service. Hensley v. Brown, 5 Vet. App. 155, 159-60 (1993). In a claim for service connection, the requirement of a "current disability" is satisfied if a disorder is diagnosed at the time a claim is filed or at any time during the pendency of the appeal. McClain v. Nicholson, 21 Vet. App. 319, 321 (2007). The Board is charged with the duty to assess the credibility and weight given to evidence. Madden v. Gober, 125 F.3d 1477, 1481 (Fed. Cir. 1997), cert. denied, 523 U.S. 1046 (1998); Wensch v. Principi, 15 Vet. App. 362, 367 (2001). In Jefferson v. Principi, 271 F.3d 1072 (Fed. Cir. 2001), the United States Court of Appeals for the Federal Circuit (Federal Circuit), citing its decision in Madden, recognized that that Board had inherent fact-finding ability. Id. at 1076; see also 38 U.S.C.A. § 7104(a). Moreover, the Court has declared that in adjudicating a claim, the Board has the responsibility to weigh and assess the evidence. Bryan v. West, 13 Vet. App. 482, 488-89 (2000); Wilson v. Derwinski, 2 Vet. App. 614, 618 (1992). In adjudicating these claims, the Board must assess the competence and credibility of the Veteran. See Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006); Washington v. Nicholson, 19 Vet. App. 362, 368-69 (2005). In Barr v. Nicholson, 21 Vet. App. 303 (2007), the Court, citing Layno v. Brown, 6 Vet. App. 465, 467-69 (1994), emphasized that lay testimony is competent if it is limited to matters that the witness has actually observed and is within the realm of the witnesses personal knowledge; see also 38 C.F.R. § 3.159(a)(2) (Competent lay evidence means any evidence not requiring that the proponent have specialized education, training or experience. Lay evidence is competent if it is provided by a person who has knowledge of the facts or circumstances and conveys matters that can be observed and described by a lay person). In Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007), the Federal Circuit commented that competence to establish a diagnosis of a condition can exist when (1) a layperson is competent to identify the medical condition, (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. See also Davidson v. Shinseki, 581 F.3d 1313 (2009) (noting that a layperson may comment on lay-observable symptoms). The Board must assess the credibility and weight of all the evidence, including the medical evidence, to determine its probative value, accounting for the evidence which it finds to be persuasive or unpersuasive, and providing reasons for rejecting any evidence favorable to the claimant. See Masors v. Derwinski, 2 Vet. App. 181 (1992). Equal weight is not accorded to each piece of evidence contained in the record; every item of evidence does not have the same probative value. In determining whether service connection is warranted for a disability, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the Veteran prevailing in either event, or whether a preponderance of the evidence is against the claim, in which case the claim is denied. 38 U.S.C.A. § 5107; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination, the benefit of the doubt is afforded to the Veteran. Analysis Turning to the evidence of record, at the November 2011 and December 2011 diabetes mellitus VA examinations, the examiner did not indicate that the Veteran had peripheral neuropathy, which is a recognized complication of diabetes. The examiner noted neurological symptoms of experiencing pins and needles with a burning sensation in his lower legs and feet at night. He also felt a crawling sensation in the legs since 1983. The examiner noted the August 2011 EMG study which showed carpal tunnel syndrome and moderate, chronic radiculopathy. At the March 2012 VA examination, the VA examiner noted that the Veteran had peripheral nerve conditions, to include radiculopathy, L5, S1, right, acute; radiculopathy, C4, 5, 6, 7, and 8, chronic, right; and carpal tunnel syndrome bilaterally. The Veteran reported mild intermittent pain, paresthesias and/or dysesthesias, and numbness of the upper and lower extremities. Muscle strength, reflexes, and sensory examinations were all listed as normal. The examiner noted the abnormal November 2010, August 2011, and November 2011 EMG-NCV test results. Lastly, the examiner never noted a diagnosis of peripheral neuropathy. The Veteran was afforded a general VA examination in April 2012. The examiner was asked to note the Veteran's current neurologic conditions. The examiner checked off peripheral nerves, however, did not indicate that the Veteran had diabetic sensory-motor peripheral neuropathy. The Veteran was afforded a December 2013 VA examination. The examiner noted that the Veteran had never been and was not currently diagnosed with diabetic peripheral neuropathy. The Veteran's symptoms included mild paresthesias and/or dysesthesias and numbness of the right and left upper and lower extremities. The Veteran's muscle strength, deep tendon reflexes, light touch/monofilament testing, position sense, vibration sensation, and cold sensation of the upper and lower extremities were all noted to be normal. The examiner specifically noted that the Veteran did not have upper or lower extremity diabetic peripheral neuropathy. The examiner discussed the Veteran's EMG-NCV test results. The November 2010 study showed electrophysiological findings consistent with right carpal tunnel syndrome affecting the sensory branch of the median nerve; primary myelinopathic. The August 2011 study showed carpal tunnel syndrome, bilateral, moderate on the right and mild on the left. The entrapment was both axonopathic and myelinopathic. Additionally, the test indicated moderate chronic radiculopathy of the right paracervical at C4, 5, 6, 7, and 8. There was double crush syndrome of the medial nerve. The November 2011 study showed that there was evidence for an acute right lower lumbar radiculopathy affecting the S1 and/or L5 root. Lastly the December 2013 study showed a mild active radiculopathy involving the right spinal roots. Findings were similar to the EMG studies done previously in November 2011 on the lower extremities. A focal neuropathy of the median nerve or a more diffuse polyneuropathy was not seen at that time. The examiner concluded that carpal tunnel syndrome, as well as concomitant radiculopathy, were both not attributable to diabetes mellitus. The examiner submitted an addendum opinion which further stated that the Veteran had no evidence of any diabetic form of neuropathy with his latest evaluation. The previously diagnosed carpal tunnel syndrome, as well as the presently concomitant radiculopathy, are both not attributable to diabetes. As shown above, there is no evidence of record showing a current diagnosis or treatment for peripheral neuropathy. The Veteran's peripheral nerve symptomatology, to include numbness, pain, weakness, tingling, and stiffness have all been attributable to carpel tunnel syndrome and radiculopathy, which have already been service-connected. The November and December 2011 VA examiners specifically did not indicate that the Veteran had peripheral neuropathy. Additionally, the December 2013 VA examiner noted that the Veteran had never been and was not currently diagnosed with diabetic peripheral neuropathy. Further, all EMG test results did not indicate that the Veteran had peripheral neuropathy. Specifically, the November 2011 study indicated that a focal neuropathy of the median nerve or a more diffuse polyneuropathy was not seen at that time. Service connection may only be granted for a current disability; when a claimed condition is not shown, there may be no grant of service connection. See 38 U.S.C.A. § 1131 (West 2002); Rabideau v. Derwinski, 2 Vet. App. 141 (1992) (Congress specifically limits entitlement for service-connected disease or injury to cases where such incidents have resulted in a disability). "In the absence of proof of a present disability there can be no valid claim." See Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). Under these circumstances, for the Board to conclude that the Veteran has peripheral neuropathy that had its origin during service or due to a service-connected disability would be speculation, and the law provides that service connection may not be granted on a resort to speculation or remote possibility. 38 C.F.R. § 3.102; Obert v. Brown, 5 Vet. App. 30, 33 (1993). Simply put, in the absence of a present disability that is related to service, a grant of service connection is clearly not supportable. See Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). The Veteran was advised of the need to submit medical evidence demonstrating a current disorder and a nexus between a current disorder and service by way of letters from the RO to him, but he has failed to do so. A claimant has a responsibility to present and support a claim for benefits under laws administered by the VA, 38 U.S.C.A. § 5107(a), and the Veteran was clearly advised in the letters of the need to submit medical evidence of a current disorder and a relationship between a current disorder and an injury, disease or event in service. A layperson is competent to testify in regard to the onset and continuity of symptomatology. Heuer v. Brown, 7 Vet. App. 379, 384 (1995); Falzone v. Brown, 8 Vet. App. 398, 403 (1995); Caldwell v. Derwinski, 1 Vet. App. 466 (1991). In this case there is no diagnosed disorder for which service connection can be considered. Therefore, the requirement of a "current disability" is not satisfied as there is no evidence of peripheral neuropathy diagnosed at the time the claim was filed or at any time during the pendency of the appeal. McClain v. Nicholson, 21 Vet. App. 319, 321 (2007). Accordingly, service connection for peripheral neuropathy is not established in the absence of competent evidence of a current disorder and a relationship between the current disorder and service. Based on the evidence and analysis above, the Board concludes the criteria for service connection are not met. Because the evidence preponderates against the claims the benefit-of-the-doubt rule does not apply. Gilbert, 1 Vet. App. 49, 54. III. Initial Increased Ratings Legal Criteria Disability ratings are determined by the application of the VA's Schedule for Rating Disabilities, which is based, as far as practically can be determined, on average impairment in earning capacity. Separate diagnostic codes identify the various disabilities. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. Part 4 (2013). Where there is a question as to which of two ratings shall be applied, the higher rating 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 (2013). Ratings for service-connected disabilities are determined by comparing the Veteran's symptoms with criteria listed in VA's Schedule for Rating Disabilities, which is based, as far as practically can be determined, on average impairment in earning capacity. Separate diagnostic codes identify the various disabilities. 38 C.F.R. § Part 4 (2013). Where there is a question as to which of two ratings shall be applied, the higher rating 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 (2013). In Fenderson v. West, 12 Vet. App 119 (1999), the Court emphasized the distinction between a new claim for an increased evaluation of a service-connected disability and a case (such as this one) in which the Veteran expresses dissatisfaction with the assignment of an initial disability evaluation where the disability in question has just been recognized as service-connected. VA must assess the level of disability from the date of initial application for service connection and determine whether the level of disability warrants the assignment of different disability ratings at different times over the life of the claim-a practice known as "staged rating." Pyramiding, the evaluation of the same disability, or the same manifestation of a disability, under different diagnostic codes, is to be avoided. 38 C.F.R. § 4.14. It is possible, however, for a Veteran to have separate and distinct manifestations attributable to the same injury, which would permit a rating under several diagnostic codes. The critical element permitting the assignment of multiple ratings under several diagnostic codes is that none of the symptomatology for any one of the conditions is duplicative or overlapping with the symptomatology of the other condition. Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994). The Board has reviewed all of the evidence in the Veteran's claims file, including his VA treatment records, private treatment records, VA examination reports, and statements submitted in support of his claims. In this regard, the Board notes that, although the Board has an obligation to provide reasons and bases supporting its decision, there is no need to discuss, in detail, all of the extensive evidence of record. Indeed, it has been held that while the Board must review the entire record, it need not discuss each piece of evidence in rendering a decision. See Newhouse v. Nicholson, 497 F.3d 1298, 1302 (Fed. Cir. 2007); Gonzalez v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000). Therefore, the Board's analysis will focus specifically on the evidence that is needed to substantiate the Veteran's claim for an increased disability rating for carpal tunnel syndrome of the right hand. The Veteran was initially granted service connection and assigned a 10 percent disability ratings for carpel tunnel syndrome of the right hand, in accordance with the criteria set forth in the Schedule for Rating Disabilities, 38 C.F.R. Part 4.124a, Diagnostic Code (DC) 8515 (2013). The record here indicates that the Veteran is right handed. Thus, the rating for the service-connected carpal tunnel syndrome of the right hand is based on the right upper extremity being the major hand. Under Diagnostic Code 8515, mild incomplete paralysis warrants a 10 percent rating for the major and minor hands, moderate incomplete paralysis warrants a 30 percent rating for the major hand and 20 percent for the minor hand; and severe incomplete paralysis warrants a 50 percent rating for the major hand and 40 percent for the minor hand. Additionally, complete paralysis of the median nerve of the major hand with 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 warrants a 70 percent rating for the major hand and a 60 percent rating for the minor hand. 38 C.F.R. § 4.124a, Code 8515. In rating peripheral nerve injuries and their residuals, attention should be given to the site and character of the injury, the relative impairment in motor function, trophic changes, or sensory disturbances. 38 C.F.R. § 4.120. A note in the Rating Schedule pertaining to "Diseases of the Peripheral Nerves" provides that the term "incomplete paralysis" indicates a degree of lost or impaired function which is substantially less than that which results from complete paralysis of these nerve groups, whether the loss is due to the varied level of the nerve lesion or to partial nerve regeneration. When the involvement is wholly sensory, the rating should be for the mild, or at most, the moderate degree. 38 C.F.R. § 4.124a. The words "slight," "moderate," and "severe" as used in the various diagnostic codes are not defined in the VA Schedule for Rating Disabilities. Rather than applying a mechanical formula, the Board must evaluate all of the evidence, to the end that its decisions are "equitable and just." 38 C.F.R. § 4.6 (2013). It should also be noted that use of terminology such as "severe" by VA examiners and others, although an element of evidence to be considered by the Board, is not dispositive of an issue. All evidence must be evaluated in arriving at a decision regarding an increased rating. 38 C.F.R. §§ 4.2, 4.6 (2013). Analysis Turning to the evidence of record, private treatment records show that the Veteran was treated for his carpal tunnel syndrome. A November 2010 EMG-NCV study was performed. The findings showed electrophysiological findings consistent with right carpal tunnel syndrome affecting the sensory branch of the medial nerve; primarily myelinopathic. A March 2011 record noted that the Veteran's bilateral carpal tunnel syndrome was on the right more than the left. Additionally, the August 2011 EMG study showed carpal tunnel syndrome, bilateral, moderate on the right and mild on the left. VA treatment records also show complaints of numbness and weakening of the hand grip because of the Veteran's carpal tunnel syndrome. The Veteran was afforded a peripheral nerves VA examination in October 2010. The examiner noted the Veteran's EMG-NCV test findings and a diagnosis of carpal tunnel; however, the examiner did not discuss the severity of the Veteran's condition at that time. The Veteran was afforded VA examinations in November 2011 and December 2011. The examiner noted neurological symptoms of experiencing pins and needles. The examiner noted the August 2011 EMG study which showed carpal tunnel syndrome. The severity of the Veteran's carpal tunnel was not addressed at that time. The March 2012 VA examination noted that the Veteran had peripheral nerve conditions, to include carpal tunnel syndrome bilaterally. The Veteran reported mild intermittent pain, paresthesias and/or dysesthesias, and numbness of the upper extremities. Upon examination, muscle strength, reflexes, and sensory examinations were all listed as normal. Lastly, the examiner noted the abnormal November 2010, August 2011, and November 2011 EMG-NCV test results. The Veteran was afforded a general VA examination in April 2012. The examiner noted the Veteran's diagnosis of carpal tunnel. The Veteran reported numbness and tingling sensation of both hands with difficult in writing and holding objects. Lastly, the examiner also discussed the August 2011 EMG findings noted above. After a review of the evidence of record, the Board finds that the Veteran's right hand carpal tunnel symptoms have been found to display the criteria contemplated by a 30 percent rating under DC 8515: moderate incomplete paralysis of the major hand. The Veteran consistently reported pain, weakness, numbness, and tingling in his hand, which occurred constantly. The Board notes that at the March 2012 VA examination, the Veteran reported mild intermittent pain, paresthesias and/or dysesthesias, and numbness of the upper extremities. However, a March 2011 private treatment record noted that the Veteran's bilateral carpal tunnel syndrome was on the right more than the left. Additionally, the August 2011 EMG study showed carpal tunnel syndrome, bilateral, moderate on the right and mild on the left. Therefore, the preponderance of the evidence shows that the Veteran has had moderate incomplete paralysis of the right (major) hand throughout the appeals period. While he meets the criteria for a 30 percent rating, the Board has determined that he does not meet the criteria for the next higher 50 percent rating, as his right hand carpal tunnel symptomatology does not reveal severe incomplete paralysis. As discussed above, the Veteran's EMG studies have not shown incomplete severe paralysis of the median nerve. Additionally, VA examination reports consist of diagnoses of mild and moderate incomplete paraylysis, but not severe. Therefore, such findings do not warrant a 50 percent evaluation when all the manifestations are considered. See Mauerhan, 16 Vet. App. at 443. The Veteran's right hand carpal tunnel symptoms justify assigning a higher disability rating of 30 percent throughout the entire period of appeal. Mauerhan v. Principi, 16 Vet. App. 436 (2002). The Veteran has had ongoing right hand carpal tunnel symptoms since his service connection claim was granted, and has continued to receive treatment for this disability. Therefore, it is reasonable to conclude that the right hand carpal tunnel symptoms have not changed over the years since service. The Board has considered staged ratings under Hart v. Mansfield, 21 Vet. App. 505 (2007), but concludes that they are not warranted. All reasonable doubt has been resolved in favor of the Veteran in making this decision. The evidence is for the assignment of a higher 30 percent rating throughout the entire period of appeal for the Veteran's right hand carpal tunnel syndrome. 38 U.S.C.A. § 5107(b) (West 2002); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). To the extent that the Veteran has contended that his right hand carpal tunnel is more severely impaired than the rating assigned, the preponderance of the evidence is against the claim; and the benefit of the doubt doctrine is not applicable. See Gilbert v. Derwinski, 1 Vet. App. 49 (1990). IV. Extra-schedular Consideration The rating schedule represents, as far as is practicable, the average impairment of earning capacity. Ratings will generally be based on average impairment. 38 C.F.R. § 3.321(a), (b). To afford justice in exceptional situations, an extra-schedular rating can be provided. 38 C.F.R. § 3.321(b). In a recent case, the Court clarified the analytical steps necessary to determine whether referral for extra-schedular consideration is warranted. See Thun v. Peake, 22 Vet. App. 111 (2008). First, the RO or 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 RO or Board must determine whether the claimant's exceptional 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 C&P Service to determine whether, to accord justice, the Veteran's disability picture requires the assignment of an extra-schedular rating. The symptoms associated with the Veteran's carpal tunnel of the right hand include pain, tingling, weakness, stiffness, and numbness of the hands. However, these symptoms of the Veteran's carpal tunnel of the right hand are not shown to cause any impairment that is not already contemplated by the rating criteria, and the Board finds that the rating criteria reasonably describes his disability. See 38 C.F.R. § 4.124a, DC 8515. For this reason, a referral for consideration of extra-schedular ratings is not warranted for this claim. ORDER Service connection for peripheral neuropathy, to include as due to Agent Orange exposure, is denied. Entitlement to an initial disability rating of 30 percent, but no higher, for carpal tunnel syndrome of the right hand, is granted. ____________________________________________ WAYNE M. BRAEUER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs