Citation Nr: 1442348 Decision Date: 09/22/14 Archive Date: 09/30/14 DOCKET NO. 10-16 380 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Louis, Missouri THE ISSUES 1. Whether new and material evidence has been received to reopen a previously denied claim of service connection for lateral epicondylitis of the left elbow, and if so, whether service connection is warranted. 2. Entitlement to an initial disability rating in excess of 10 percent for dermatitis of the bilateral hands. REPRESENTATION Veteran represented by: Hugh D. Cox, Attorney ATTORNEY FOR THE BOARD Saira Spicknall, Counsel INTRODUCTION The Veteran served on active duty from March 1987 to December 1990. This matter comes to the Board of Veterans' Appeals (Board) on appeal from October 2005, September 2007, March 2009 and May 2009 rating decisions of the St. Louis, Missouri Department of Veterans Affairs (VA) Regional Office (RO). The Virtual VA and Veterans Benefits Management System (VBMS) paperless claims processing systems reflect that additional medical and procedural records have been added to the present appeal, which have been reviewed by the RO. In his May 2010 VA Form 9, the Veteran requested a hearing before a member of the Board. In April 2014, the Veteran's attorney submitted a statement noting that the Veteran no longer wanted a hearing. Accordingly, the Board considers the Veteran's request for a hearing to be withdrawn and will proceed to adjudicate the case based on the evidence of record. See 38 C.F.R. § 20.704 (d), (e) (2013). In January 2014 the Board remanded this case to the RO via the Appeals Management Center (AMC) for further development and it has now been returned to the Board. FINDINGS OF FACT 1. In May 2004, the Board denied service connection for a left elbow disability, to include lateral epicondylitis. 2. The evidence added to the record since the May 2004 Board decision was not previously submitted to agency decisionmakers, is not cumulative or redundant and, by itself or when considered with the previous evidence of record, relates to an unestablished fact necessary to substantiate the claim, and raises a reasonable possibility of substantiating the claim for service connection for lateral epicondylitis of the left elbow. 3. The Veteran's lateral epicondylitis is related to his left elbow injury and laceration due to a fall during his active service. 4. Throughout the duration of the appeal, the Veteran's dermatitis of the bilateral hands has been productive of no more than topical therapy, and not systemic therapy or other immunosuppressive drugs. CONCLUSIONS OF LAW 1. The May 2004 Board decision that denied service connection for left elbow disability, to include lateral epicondylitis, is final. 38 U.S.C.A. § 7104 (West 2002); 38 C.F.R. §§ 20.1100, 20.1104 (2013). 2. New and material evidence has been presented to reopen the claim of service connection for lateral epicondylitis of the left elbow. 38 U.S.C.A. § 1110, 1131, 5108 (West 2002); 38 C.F.R. § 3.156(a) (2013). 3. The criteria for the establishment of service connection for lateral epicondylitis of the left elbow are met. 38 U.S.C.A. §§ 1110, 1131, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.303 (2013). 4. The criteria for the assignment of initial disability rating in excess of 10 percent for the service-connected dermatitis of the bilateral hands have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. § 4.118a, Diagnostic Code (DC) 7806 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veterans Claims Assistance Act (VCAA) Because the Board is reopening and granting his claim for service connection for lateral epicondylitis of the left elbow, any further development or notification action under the VCAA would not avail the Veteran. See 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126 (West 2002 and Supp. 2013). With regard to his increased rating claim, VCAA notice consistent with 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) must: (1) inform the claimant about the information and evidence not of record that is necessary to substantiate the claim; (2) inform the claimant about the information and evidence that VA will seek to provide; and (3) inform the claimant about the information and evidence that the claimant is expected to provide. 38 C.F.R. § 3.159(b)(1) (2013). To the extent possible, VCAA notice, as required by 38 U.S.C.A. § 5103(a) (West 2002), must be provided to a claimant before an initial unfavorable decision on a claim for VA benefits. Pelegrini v. Principi, 18 Vet. App. 112 (2004); see also Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). This appeal arises from disagreement with an initial evaluation following the grant of service connection. Once service connection is granted, the claim is substantiated and additional VCAA notice is not required; any defect in the notice is not prejudicial. Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007); Dunlap v. Nicholson, 21 Vet. App. 112 (2007). Filing a notice of disagreement begins the appellate process, and any remaining concerns regarding evidence necessary to establish a more favorable decision with respect to downstream elements (such as an effective date) are appropriately addressed under the notice provisions of 38 U.S.C.A. §§ 5104 and 7105. Goodwin v. Peake, 22 Vet. App. 128 (2008). Where a claim has been substantiated after the enactment of the VCAA, the appellant bears the burden of demonstrating any prejudice from defective VCAA notice with respect to the downstream elements. Id. There has been no allegation of prejudice with regard to the notice in this case, hence further VCAA notice is not required with regard to the initial rating appeal. VA also has a duty to assist the Veteran in the development of the claims. This duty includes assisting the Veteran in the procurement of service treatment records (STRs) and pertinent treatment records and providing an examination when necessary. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. All relevant evidence necessary for an equitable resolution of the issues on appeal has been identified and obtained, to the extent possible. The evidence of record includes STRs, VA and private medical records, VA examinations, and statements and testimony from the Veteran and his attorney. The August 2005, February 2007, November 2008 and April 2012 VA skin examination reports reflect that the examiners reviewed the Veteran's pertinent medical history, documented his current complaints, and rendered diagnoses consistent with the remainder of the evidence of record, and therefore, the examinations are adequate for adjudication purposes in terms of addressing the applicable rating criteria. Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008); see also Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). Accordingly, the Board finds that no prejudice to the Veteran will result from the adjudication of his claims in this Board decision. Rather, remanding this case to the RO for further VCAA development would be an essentially redundant exercise and would result only in additional delay with no benefit to the Veteran. See Bernard v. Brown, 4 Vet. App. 384, 394 (1993); see also Sabonis v. Brown, 6 Vet. App. 426, 430 (1994). There is no indication there exists any additional evidence that has a bearing on this case that has not been obtained and that is obtainable. The Veteran and his attorney have been accorded ample opportunity to present evidence and argument in support of this appeal. All pertinent due process requirements have been met. See 38 C.F.R. § 3.103 (2013). In January 2014, the Board remanded this case to afford the Veteran an opportunity to testify at a hearing before a member of the Board. In February 2014, the RO notified him that a hearing had been scheduled in April 2014. Then, as noted above, the Veteran's attorney withdrew his hearing request. There was substantial compliance with the Board's remand directive. See Stegall v. West, 11 Vet. App. 268 (1998); Dyment v. West, 13 Vet. App. 141, 146-47 (1999). Analysis 1. New and Material Evidence Because the Board previously denied the Veteran's claim seeking entitlement to service connection for a left elbow disability, to include lateral epicondylitis, in a May 2004 rating decision. The Veteran appealed the denial to the U. S. Court of Appeals for Veterans Claims (Court). In a March 2007 Memorandum Decision, the Court affirmed the Board's denial. The Veteran then appealed to the U. S. Court of Appeals for the Federal Circuit, which dismissed the case for lack of jurisdiction in December 2008. Therefore, the May 2004 Board decision is final. Generally, a claim, which has been denied in a Board decision or an unappealed RO decision, may not thereafter be reopened and allowed. 38 U.S.C.A. §§ 7104(b), 7105(c) (West 2002). The exception to this rule is 38 U.S.C.A. § 5108, which provides that if new and material evidence is presented or secured with respect to a claim which has been disallowed, the Secretary shall reopen the claim and review the former disposition of the claim. 38 U.S.C.A. § 5108 (West 2002). New evidence means existing evidence not previously submitted to agency decisionmakers. Material evidence means existing evidence that, by itself or when considered with previous evidence of record, relates to an unestablished fact necessary to substantiate the claim. New and material evidence can be neither cumulative nor redundant of the evidence of record at the time of the last prior final denial of the claim sought to be reopened, and must raise a reasonable possibility of substantiating the claim. 38 C.F.R. § 3.156(a) (2013). VA must review all of the evidence received since the last final decision in order to determine whether the claim may be reopened. See Hickson v. West, 12 Vet. App. 247, 251 (1999). For the limited purpose of determining whether new and material evidence has been received to reopen a finally adjudicated claim, the recently submitted evidence will be presumed credible. See Kutscherousky v. West, 12 Vet. App. 369, 371 (1999) (per curiam). The May 2004 Board decision denied the claim for service connection for a left elbow disability, to include lateral epicondylitis, on the basis that the left elbow injury in service was acute and transitory in nature and resolved without any residual disability and that the competent clinical evidence of record did not demonstrate that a current left elbow disability, to include lateral epicondylitis, was related to the Veteran's military service. The Board finds that the newly received evidence after the May 2004 Board decision when considered in conjunction with the previous evidence of record, presents a more complete picture of the origin of the Veteran's lateral epicondylitis of the left elbow. Hodge v. West, 155 F.3d 1356 (Fed. Cir. 1998). In particular, the private medical opinions by Dr. C.N.B., furnished in November 2005 and March 2012 indicate that his lateral epicondylitis of the left elbow was related to the left elbow injury and laceration incurred during his active service. This evidence is not cumulative or redundant and, by itself or when considered with the previous evidence of record, relates to unestablished facts necessary to substantiate the claim, and raises a reasonable possibility of substantiating the claim for service connection for lateral epicondylitis of the left elbow. See 38 U.S.C.A. § 5108 (West 2002); 38 C.F.R. §§ 3.156(a), 3.303 (2013). Therefore, the claim is reopened. 2. Service Connection After a careful review of the record, and resolving all doubt in favor of the Veteran, the Board has determined, based upon the probative evidence of record, that the Veteran has a current diagnosis of lateral epicondylitis of the left elbow which was related to his left elbow injury incurred during his active service, and thus service connection for lateral epicondylitis for the left elbow is warranted. Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C.A. §§ 1110, 1131 (West 2002); 38 C.F.R. § 3.303(a) (2013). In addition, service connection may 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). Service connection requires competent evidence showing: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004), citing Hansen v. Principi, 16 Vet. App. 110, 111 (2002); see also Hickson v. West, 12 Vet. App. 247, 253 (1999); see also Caluza v. Brown, 7 Vet. App. 498 (1995). In statements presented throughout the duration of the appeal, the Veteran has maintained that he injured his left elbow during a fall while he was on active duty and has had continued problems since that time, which Board finds are competent, credible and ultimately probative. Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007); see Baldwin v. West, 13 Vet. App. 1 (1999). STRs reflect the Veteran was treated for residuals of a fall in November 1989 which included laceration to the left elbow. At that time an initial evaluation revealed a restricted range of motion and laceration to the posterior left elbow, however x-rays found no evidence of fracture or dislocation and re-test revealed a full range of motion in the left elbow. He was subsequently followed up for the left elbow laceration in November 1989, wherein sutures were provided. The post service medical evidence, including private medical records from July 1998 to March 2012 and VA medical records from July 2001 to March 2012, reflect that the Veteran has been treated for and diagnosed with lateral epicondylitis of the left elbow as early as April 2000. In an April 2000 private treatment report, the Veteran reported having pain in the lateral aspect of the left elbow, which began about three to four months ago, but he also reported that he really had been having problems since 10 years earlier when he fell while he was in the Air Force. At that time he did not recall any specific recent injury. He was diagnosed with left lateral epicondylitis. A July 2001 VA examination reflects that the Veteran reported sustaining a left elbow injury while stationed in the Air Force and began to have left elbow pain one to one and a half years ago. He was diagnosed with lateral epicondylitis and the examiner opined that, due to the fact that the left and right arms were now having medical epicondylitis, along with the fact that he worked for the U.S. Post Office shuffling mail and doing repetitive motions, it was more likely than not that this disability was not related to his service injury. In a November 2001 private medical record, the Veteran was diagnosed with posttraumatic epicondylitis of the left elbow, which the private physician, Dr. M.S.C., found had probably initially began with his injury in service and then persisted. He also found that the history the Veteran gave of an injury in service seemed reasonable that the precipitating cause for his symptoms in his left upper extremity was the injury to his elbow while he was in the Air Force. In November 2005 and March 2012, a private physician, Dr. C.N.B., provided medical opinions regarding the Veteran's left elbow. In a November 2005 letter, he stated that he reviewed the Veteran's medical records, including STRs, post-service medical records, medical opinions, lab reports, lay statements and medical literature. He opined that it was more likely than not that the Veteran's current epicondylitis and left elbow arm problems were secondary to his fall in service. Dr. C.N.B. explained that the Veteran had a serious fall in service which resulted in trauma to the left elbow and laceration with sutures. He noted the Veteran had problems with his elbow ever since that injury according to his statements and the history of private physician Dr. M.S.C. Dr. C.N.B. then reported that the elbow was a complicated joint and therefore it often resulted in scar and within the joint capsule thereby resulting in a chronic inflammatory process, known in medicine as the suffix "itis." He noted the Veteran currently suffered from epicondylitis as per the note from Dr. M.S.C, dated in November 2001. Dr. C.N.B. then concluded that it was his medical opinion that it was more likely than not that the Veteran's current epicondylitis and left elbow arm problems were secondary to his fall in service for the following reasons: he entered service with a normal physical; he had a serious fall in service, which resulted in sutures; he now had epicondylitis without other plausible etiology; and the opinion was consistent with the opinion of Dr. M.S.C., an orthopedic surgeon. In his March 2012 letter, Dr. C.N.B. noted the x-ray findings of the Veteran's left elbow were likely due to his service injury, as his records did not support another more likely cause. The Board finds that the Veteran's lay statements, the VA examination, and the November 2001, November 2005 and March 2012 private opinions, taken together, place the evidence in relative equipoise. Therefore, the Board resolves all doubt in favor of the Veteran, and finds the probative evidence of record demonstrates his lateral epicondylitis of the left elbow is related to his left elbow injury during active service. Thus, service connection for lateral epicondylitis of the left elbow is warranted. 38 C.F.R. §§ 3.102, 3.303 (2013). See also 38 U.S.C.A. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). 3. Increased Initial Rating After a careful review of the record, the Board has determined, based upon the probative evidence of record, that that his dermatitis of the bilateral hands does not warrant an initial disability rating in excess of 10 percent under DC 7806. 38 C.F.R. § 4.118 (2013). Disability ratings are determined by applying the criteria set forth in the VA's Schedule for Rating Disabilities, which is based on the average impairment of earning capacity resulting from disability. Separate diagnostic codes identify the various disabilities. See 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1 (2013). If two evaluations are potentially applicable, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for the higher evaluation; otherwise, the lower evaluation will be assigned. See 38 C.F.R. § 4.7 (2013). Any reasonable doubt regarding the degree of disability will be resolved in favor of the Veteran. 38 C.F.R. § 4.3 (2013). In order to evaluate the level of disability and any changes in condition, it is necessary to consider the complete medical history of the Veteran's condition. Schafrath v. Derwinski, 1 Vet. App. 589, 594 (1991). Where the question for consideration is the propriety of the initial evaluation assigned after the grant of service connection, evaluation of the medical evidence since the effective date of the grant of service connection and consideration of the appropriateness of "staged ratings" is required. See Fenderson v. West, 12 Vet. App. 119, 126 (1999). At the time of an initial rating, separate ratings can be assigned for separate periods of time based on facts found - this practice is known as "staged ratings." Id. at 126. The Veteran's dermatitis of the bilateral hands has been rated under DC 7806, which provides that dermatitis or eczema that involves less than 5 percent of the entire body or less than 5 percent of exposed areas affected, and; no more than topical therapy is required during the past 12-month period, is rated noncompensably (0 percent) disabling. Dermatitis or eczema that involves at least 5 percent, but less than 20 percent, of the entire body, or at least 5 percent, but less than 20 percent, of exposed areas affected, or; intermittent systemic therapy such as corticosteroids or other immunosuppressive drugs required for a total duration of less than six weeks during the past 12-month period, is rated 10 percent disabling. Dermatitis or eczema that involves 20 to 40 percent of the entire body or 20 to 40 percent of exposed areas affected, or; systemic therapy such as corticosteroids or other immunosuppressive drugs required for a total duration of six weeks or more, but not constantly, during the past 12-month period, is rated 30 percent disabling. Dermatitis or eczema that involves more than 40 percent of the entire body or more than 40 percent of exposed areas affected, or; constant or near-constant systemic therapy such as corticosteroids or other immunosuppressive drugs required during the past 12-month period, is rated 60 percent disabling. 38 C.F.R. § 4.118 (2013). The medical evidence of record, including private medical records from July 1998 to March 2012, VA medical records from July 2001 to March 2012 and VA examinations from August 2005, February 2007, November 2008 and April 2012, reflect that the Veteran's current dermatitis of the hands is productive of no more than topical, and not systemic therapy or other immunosuppressive drugs. Specifically, the medical evidence demonstrates that he has used topical urea lotion, triamcinolone acetonide cream and hydrocortisone cream for treatment of his symptoms. A December 2004 VA outpatient treatment report reflects the Veteran was prescribed triamcinolone acetonide cream, a topical corticosteroid, for his dermatitis. In the August 2005 and February2007 VA examinations, the Veteran reported treatment for his hands with triamcinolone acetonide cream, a topical corticosteroid, and had used both moisturizing and corticosteroid creams. In fact, the Veteran has also reported in several statements during the pendency of the appeal that he has used urea lotion and hydrocortisone cream, a topical corticosteroid, for his hands, which is also reflected in his VA prescriptions. The April 2012 VA examiner found that the Veteran used topical medications. In addition, the Board finds that the Veteran's dermatitis of the hands are not productive of dermatitis or eczema that encompassed that involves 20 to 40 percent of the entire body or 20 to 40 percent of exposed areas affected. In this regard, all VA examinations throughout the duration of the appeal reflect that his dermatitis of both hands involved at least 5 percent, but less than 20 percent, of the entire body, or at least 5 percent, but less than 20 percent, of exposed areas affected. See VA examinations from August 2005, February 2007, November 2008 and April 2012. Thus, the probative evidence of record does not demonstrate the use of more than topical therapy for his dermatitis of the bilateral hands. Therefore, an initial disability rating in excess of 10 percent is not warranted for dermatitis of the bilateral hands at any time throughout the entire period of the appeal. See 38 C.F.R. §§ 4.3, 4.7 (2013). The Board is cognizant that, the Court has held that the frequency, duration, and outbreaks of skin disease exacerbations must be addressed by rating adjudicators, and that a skin disorder should be considered, whenever possible, at a time when it is most disabling. Ardison v. Brown, 6 Vet. App. 405; (1994); Bowers v. Brown, 2 Vet. App. 675 (1992). The Board notes that the Veteran has provided credible statements and testimony regarding his symptoms of his dermatitis of the bilateral hands, to include during periods of flare ups. See Baldwin v. West, 13 Vet. App. 1 (1999). The Board has also considered former Diagnostic Codes 7800, 7801, 7802, 7804 and 7805 however they do not apply in this case as the Veteran's dermatitis of the hands does not include not scars. See 38 C.F.R. § 4.118, Diagnostic Codes 7800, 7801, 7802, 7804 and 7805 (2013). The Board has considered the Veteran's statements regarding the severity of his dermatitis symptoms and has relied on his report in determining appropriate disability ratings under the benefit-of-the-doubt doctrine. 38 C.F.R. §§ 4.3, 4.7. He is competent to report on factual matters of which he has firsthand knowledge, such as experiencing flare ups of skin disease, itching, and the names of his medications. His statements are also credible, and thus, probative. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007); Baldwin, 13 Vet. App. 1 (1999). Where he has not discussed particular findings that are necessary for application to the rating criteria, the Board has accorded greater probative weight to objective medical findings of record which specifically address the rating criteria and determine whether his medications are topical as opposed to systemic. See Guerrieri v. Brown, 4 Vet. App. 467, 470-71 (1993). Extraschedular Consideration and Total Disability Rating Based on Individual Unemployability (TDIU) There is no evidence of exceptional or unusual circumstances to warrant referring this claim for extra-schedular consideration. 38 C.F.R. § 3.321(b)(1) (2013). The threshold factor for extraschedular consideration is a finding that the evidence presents such an exceptional disability picture that the available schedular evaluations for the service-connected disability at issue are inadequate. Therefore, initially, there must be a comparison between the level of severity and the symptomatology of the claimant's disability with the established criteria provided in the rating schedule for the disability. If the criteria reasonably describe the claimant's disability level and symptomatology, then the disability picture is contemplated by the rating schedule, the assigned evaluation is therefore adequate, and no referral for extraschedular consideration is required. Thun v. Peake, 22 Vet. App. 111 (2008), aff'd, Thun v. Shinseki, 572 F.3d 1366 (Fed. Cir. 2009). However, if the schedular evaluation does not contemplate the claimant'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." 38 C.F.R. 3.321(b)(1) (2013). Related factors include "marked interference with employment" and "frequent periods of hospitalization." Id. As described above, the manifestations of the Veteran's dermatitis are contemplated by the schedular criteria set forth in Diagnostic Code 7806. Specifically, the amount of areas affected and the types of medication taken are contemplated. However, the Veteran has competently and credibly stated that his hands become dry and as a result crack, flake, and bleed. These are not symptoms that are contemplated by the applicable rating criteria. This leads the Board to the second step described in Thun, which is if the schedular evaluation does not contemplate the claimant's level of disability and symptomatology and is found inadequate, the RO or Board must determine whether the claimant's disability picture exhibits other related factors such as those provided by the regulation as "governing norms." 38 C.F.R. § 3.321(b)(1) (related factors include "marked interference with employment" and "frequent periods of hospitalization"). Id. The Board finds that the Veteran's dry hands with resulting cracking, flaking, and bleeding do not cause marked interference with employment or frequent periods of hospitalization. First, during the appeal period, he has not been hospitalized for his dermatitis. At his April 2012 VA examination, the examiner found that in the winter the Veteran's dermatitis impacted his ability to work because his hands became sore. However, the medical and lay evidence of record does not show that he has missed work due to his dermatitis. Generally, the degrees of disability specified are considered adequate to compensate "considerable loss of working time ...proportionate to the severity of the several grades of disability." See 38 C.F.R. § 4.1 (2013). See 38 C.F.R. § 4.1 (2013). Therefore, as the evidence does not establish that the Veteran's disability picture exhibits other related factors such as those provided by the regulation as "governing norms." Therefore the Board finds that referral to the Under Secretary for Benefits or the Director, Compensation Service, for consideration of an extraschedular evaluation for the itching scars, throughout the appeal period under 38 C.F.R. § 3.321 is not warranted. The Board notes that under Johnson v. McDonald, 2013-7104, 2014 WL 3844196 (Fed. Cir. Aug. 6, 2014), a Veteran may be awarded an extraschedular rating based upon the combined effect of multiple conditions in an exceptional circumstance where the evaluation of the individual conditions fails to capture all the service-connected symptoms experienced. However, in this case, after applying the benefit of the doubt under of Mittleider v. West, 11 Vet. App. 181 (1998), there are no additional service-connected symptoms that have not been attributed to a specific service-connected condition. Accordingly, this is not an exceptional circumstance in which extraschedular consideration may be required to compensate the Veteran for a disability that can be attributed only to the combined effect of multiple conditions. Finally, when entitlement to a total disability rating based on individual unemployability (TDIU) under the provisions of 38 C.F.R. § 4.16 is raised during the adjudicatory process of evaluating the underlying disabilities, it is part of the claim for benefits for the underlying disabilities. Rice v. Shinseki, 22 Vet. App. 447, 453-54 (2009). A TDIU claim is considered reasonably raised when a veteran submits medical evidence of a disability, makes a claim for the highest rating possible, and submits evidence of service-connected unemployability. See Roberson v. Principi, 251 F.3d 1378, 1384 (Fed. Cir. 2001). In this case, the Veteran has not asserted, and the evidence does not show that the Veteran is unemployable due to his service-connected disabilities. Because there is no evidence of unemployability, further consideration of entitlement to TDIU is not required. Jackson v. Shinseki, 587 F.3d 1106 (Fed. Cir. 2009). In reaching these conclusions, the Board has considered the applicability of the benefit-of-the-doubt doctrine. 38 U.S.C.A. 5107(b) ; 38 C.F.R. § 3.102 (2013); Gilbert v. Derwinski, 1 Vet. App. 49 (1991); Alemany v. Brown, 9 Vet. App. 518 (1996). ORDER Service connection for lateral epicondylitis of the left elbow is granted. An initial disability rating in excess of 10 percent for dermatitis of the bilateral hands is denied. ____________________________________________ D. MARTZ AMES Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs