Citation Nr: 1508066 Decision Date: 02/24/15 Archive Date: 02/26/15 DOCKET NO. 04-41 615 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Oakland, California THE ISSUES 1. Entitlement to an increased evaluation for dermatographic urticaria, currently evaluated as noncompensably disabling prior to August 21, 2014, and as 10 percent disabling from August 21, 2014. 2. Entitlement to an increased initial evaluation for left foot neuropathy, currently evaluated as 10 percent disabling. 3. Entitlement to a total disability evaluation based on individual unemployability (TDIU). REPRESENTATION Appellant represented by: Karl Kazmierczak, Esq. ATTORNEY FOR THE BOARD McBrine, M., Counsel INTRODUCTION The Veteran had active service from July 1981 to March 1990. This appeal comes before the Board of Veterans' Appeals (Board) from multiple rating decisions of the RO in Oakland, California. In September 2011, the Board remanded the issue of entitlement to a compensable rating for dermatographism, to afford the Veteran a requested Board hearing. The Veteran subsequently withdrew his hearing request in writing, indicating that he no longer wished to attend a hearing. These issues were remanded to the RO for further development in February 2014, and now return again before the Board. The issue of entitlement to TDIU is again REMANDED to the Agency of Original Jurisdiction (AOJ). The issue of entitlement to service connection for bladder incontinence claimed due to the service-connected back disability has not been adjudicated by the RO, but is reasonably raised by the record (see June 2009 report of Craig N. Bash, M.D.). The issue was referred in the prior Board decision, but the Board does not see that any action was taken on the previous referral. Therefore, the issue is AGAIN referred to the RO for appropriate action. See 38 C.F.R. §19.9(b) (2014). FINDINGS OF FACT 1. For the period prior to August 21, 2014, the Veteran's service connected dermatographic urticaria has not been shown to be generally productive of any significant symptoms, had no laryngeal involvement, and did not have recurrent episodes occurring at least four times during the past 12-month period and responding to treatment with antihistamines or sympathomimetics. 2. For the period from August 21, 2014, the Veteran's service connected dermatographic urticaria has not been shown to be generally productive of more than minimal symptomatology, without laryngeal involvement or debilitating episodes, and not requiring systemic immunosuppressive therapy. 3. The Veteran's left foot neuropathy causes minimal symptomatology, including pain, and has not been shown to be productive of symptomatology consistent with a finding of moderate, incomplete paralysis. CONCLUSIONS OF LAW 1. For the period prior to August 21, 2014, the criteria for the assignment of a compensable rating for the Veteran's service-connected dermatographic urticaria have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 3.321, 3.326, 4.1, 4.2, 4.3, 4.7, 4.10, 4.40, 4.45, 4.59, 38 C.F.R. § 4.104, 4.118, Diagnostic Codes 7118, 7825 (2014). 2. For the period prior from August 21, 2014, the criteria for the assignment of a rating in excess of 10 percent for the Veteran's service-connected dermatographic urticaria have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 3.321, 3.326, 4.1, 4.2, 4.3, 4.7, 4.10, 4.40, 4.45, 4.59, 38 C.F.R. § 4.104, 4.118, Diagnostic Codes 7118, 7825 (2014). 3. The criteria for the assignment of a rating in excess of 10 percent for the Veteran's service-connected left foot neuropathy have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 3.321, 3.326, 4.1, 4.2, 4.3, 4.7, 4.10, 4.40, 4.45, 4.59, 38 C.F.R. § 4.104, 4. 4.124a, Diagnostic Code 8521 (2014). REASONS AND BASES FOR FINDINGS AND CONCLUSION The Board has thoroughly reviewed all the evidence in the Veteran's claims file. Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, all the evidence submitted by or on behalf of the Veteran. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (noting that the Board must review the entire record, but does not have to discuss each piece of evidence). The analysis below focuses on the most salient and relevant evidence and on what this evidence shows, or fails to show, on the claim. The Veteran must not assume that the Board has overlooked pieces of evidence that are not explicitly discussed herein. See Timberlake v. Gober, 14 Vet. App. 122 (2000) (finding that the law requires only that the Board address its reasons for rejecting evidence favorable to the Veteran). Please note that this claims file is completely virtual. Stegall Considerations As noted above, the Board previously remanded this claim in February 2014 for further development; specifically for further VA examinations the severity of these claimed disabilities. The Veteran was provided with further VA examinations in August 2014, all available records were associated with the Veteran's file, and his claim was readjudicated in a September 2014 SSOC. Thus, there is compliance with the Board's remand instructions. See Stegall v. West, 11 Vet. App. 268, 271 (1998) (noting that where the remand orders of the Board are not complied with, the Board errs as a matter of law when it fails to ensure compliance). Veterans Claims Assistance Act of 2000 (VCAA) With respect to the Veteran's claims, VA has met all statutory and regulatory notice and duty to assist provisions. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2014); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2014). Under the VCAA, when VA receives a complete or substantially complete application for benefits, it is required to notify the Veteran and his or her representative, if any, of any information and 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). In Pelegrini v. Principi, 18 Vet. App. 112, 120-21 (2004) (Pelegrini II), the United States Court of Appeals for Veterans Claims (Court) held that VA must inform the Veteran of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; (3) that the Veteran is expected to provide; and (4) request that the Veteran provide any evidence in his or her possession that pertains to the claim. The requirement of requesting that the Veteran provide any evidence in his possession that pertains to the claim was eliminated by the Secretary during the course of this appeal. See 73 Fed. Reg. 23353 (final rule eliminating fourth element notice as required under Pelegrini II, effective May 30, 2008). Thus, any error related to this element is harmless. The Board also points out that, as one of these claims is ensuing from the grant of an initial rating, a lessened duty exists. Nevertheless, the Board finds that the VCAA letters dated in December 2005, November 2007, November 2010, and May 2012, as well as the prior remand in February 2014, satisfied the duty to notify provisions. See 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b) (1); Quartuccio, at 187. The Veteran was advised that it was ultimately his responsibility to give VA any evidence pertaining to the claims. The letters informed him that additional information or evidence was needed to support his claims, and asked him to send the information or evidence to VA. See Pelegrini II, at 120-121. Furthermore, even if any notice deficiency is present in this case, the Board finds that any prejudice due to such error has been overcome in this case by the following: (1) based on the communications sent to the Veteran over the course of this appeal, the Veteran clearly has actual knowledge of the evidence the Veteran is required to submit in this case; and (2) based on the Veteran's contentions as well as the communications provided to the Veteran by VA, it is reasonable to expect that the Veteran understands what was needed to prevail. See Shinseki v. Sanders/Simmons, 129 S. Ct. 1696 (2009); Fenstermacher v. Phila. Nat'l Bank, 493 F.2d 333, 337 (3d Cir. 1974) (finding that "no error can be predicated on insufficiency of notice since its purpose had been served."). In order for the Court to be persuaded that no prejudice resulted from a notice error, "the record must demonstrate that, despite the error, the adjudication was nevertheless essentially fair." Dunlap v. Nicholson, 21 Vet. App. 112, 118 (2007). In this case, the Veteran has been continuously represented by an experienced attorney and has submitted argument in support of his claims. These arguments have referenced the applicable laws and regulations. Thus, the Board finds that the Veteran has actual knowledge as to the information and evidence necessary for him to prevail on his claims and is not prejudiced by a decision in this case. As such, a further remand for additional notice would serve no useful purpose and would in no way benefit the Veteran. Sabonis v. Brown, 6 Vet. App. 426, 430 (1994) (noting that remands which would only result in unnecessarily imposing additional burdens on the VA with no benefit flowing to the Veteran are to be avoided). The Board also concludes VA's duty to assist has been satisfied. The Veteran's service treatment records and relevant VA medical records are in the file. All records identified by the Veteran as relating to the claims have been obtained, to the extent possible. The Board finds that the record contains sufficient evidence to make a decision on the claims. The duty to assist also includes providing a medical examination or obtaining a medical opinion when such is necessary to make a decision on the claim. 38 C.F.R. § 3.159(c)(4)(i). In this case, the Board notes that the Veteran was provided with multiple VA examinations during the course of this appeal, most recently in May 2013. The VA examination reports reflect that the examiners reviewed the Veteran's past medical history, recorded his current complaints, conducted appropriate evaluations of the Veteran, rendered appropriate diagnoses and opinions consistent with the remainder of the evidence of record, and provided sufficient information to evaluate the Veteran's claim. Additionally, the Veteran has not stated nor is there evidence indicating that there has been a material change in the severity of his disabilities since he was last examined in August 2014. See 38 C.F.R. § 3.327(a) (2014). The duty to assist does not require that a claim be remanded solely because of the passage of time since an otherwise adequate VA examination was conducted. See VAOPGCPREC 11-95 (April 7, 1995). The Board concludes that the examination reports of record are adequate for purposes of rendering a decision in the instant appeal. See 38 CF.R. § 4.2 (2013); see also Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). The Veteran and his representative have not contended otherwise. As there is no indication that any failure on the part of VA to provide additional notice or assistance reasonably affects the outcome of this case, the Board finds that any such failure is harmless. See Mayfield v. Nicholson, 19 Vet. App. 103 (2005), rev'd on other grounds, Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). Legal Criteria The Veteran contends that an increased rating is warranted for his service connected skin and left foot disabilities. For the following reasons, the Board finds that increased ratings are not warranted. Disability evaluations are determined by the application of a schedule of ratings, which is based on average impairment of earning capacity. See 38 U.S.C.A. § 1155 (West 2014); 38 C.F.R. Part 4 (2014). Separate rating codes identify the various disabilities. See 38 C.F.R. Part 4. When there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. See 38 C.F.R. § 4.7. Any reasonable doubt regarding the degree of disability is resolved in favor of the Veteran. See 38 C.F.R. § 4.3. In general, when an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). When the appeal arises from an initial assigned rating, as in one of the claims on appeal, consideration must be given to whether staged ratings should be assigned to reflect entitlement to a higher rating at any point during the pendency of the claim. See Fenderson v. West, 12 Vet. App. 119 (1999). However, staged ratings are also appropriate in any increased-rating claim in which distinct time periods with different ratable symptoms can be identified. See Hart v. Mansfield, 21 Vet. App. 505 (2007). The assignment of a particular diagnostic code is "completely dependent on the facts of a particular case." Butts v. Brown, 5 Vet. App. 532, 538 (1993). One diagnostic code may be more appropriate than another based on such factors as an individual's relevant medical history, diagnosis, and demonstrated symptomatology. Any change in diagnostic code by a VA adjudicator must be specifically explained. See Pernorio v. Derwinski, 2 Vet. App. 625, 629 (1992). Separate disabilities arising from a single disease entity are to be rated separately. See 38 C.F.R. § 4.25 (2014); see also Esteban v. Brown, 6 Vet. App. 259, 261 (1994). Pyramiding, the evaluation of the same disability, or the same manifestation of a disability, under different diagnostic codes, is to be avoided when rating a Veteran's service-connected disabilities. See 38 C.F.R. § 4.14 (2014). In general, after the evidence has been assembled, it is the Board's responsibility to evaluate the entire record. See 38 U.S.C.A. § 7104(a) (West 2002). When there is an approximate balance of evidence regarding the merits of an issue material to the determination of the matter, the Board resolves the benefit of the doubt for each such issue in favor of the claimant. See 38 U.S.C.A. § 5107; 38 C.F.R. §§ 3.102, 4.3. The standard of proof to be applied in decisions on claims for VA benefits is set forth in 38 U.S.C.A. § 5107(b). Under that provision, VA shall consider all information and lay and medical evidence of record in a case before the Secretary with respect to benefits under laws administered by the Secretary. The Board must determine the value of all evidence submitted, including lay and medical evidence. See Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006). The evaluation of evidence generally involves a three-step inquiry. First, the Board must determine whether the evidence comes from a "competent" source. The Board must then determine if the evidence is credible, or worthy of belief. See Barr v. Nicholson, 21 Vet. App. 303 at 308 (2007) (observing that once evidence is determined to be competent, the Board must determine whether such evidence is also credible). The third step of this inquiry requires the Board to weigh the probative value of the proffered evidence in light of the entirety of the record. 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 facts or circumstances and conveys matters that can be observed and described by a lay person. 38 C.F.R. § 3.159(a). However, in ascertaining the competency of lay evidence, the Courts have generally held that a layperson is not capable of opining on matters requiring medical knowledge. Routen v. Brown, 10 Vet. App. 183 (1997). Competent medical evidence is evidence provided by a person who is qualified through education, training, or experience to offer medical diagnoses, statements, or opinions. Competent medical evidence may also include statements conveying sound medical principles found in medical treatises. It also includes statements contained in authoritative writings, such as medical and scientific articles and research reports or analyses. 38 C.F.R. § 3.159(a)(1). After determining the competency and credibility of evidence, the Board must then weigh its probative value. In this function, the Board may properly consider internal inconsistency, facial plausibility, and consistency with other evidence submitted on behalf of the claimant. See Madden v. Brown, 125 F.3d 1447 (Fed Cir. 1997) (holding that the Board has the "authority to discount the weight and probative value of evidence in light of its inherent characteristics in its relationship to other items of evidence"). The Veteran's skin disability is currently rated by analogy under Diagnostic Code 7118 for angioneurotic edema (swelling, similar to hives, occurring beneath the skin). 38 C.F.R. § 4.104. Under this Diagnostic Code, a 10 percent rating is assigned for attacks without laryngeal involvement lasting one to seven days and occurring two to four times a year. Attacks without laryngeal involvement lasting one to seven days and occurring five to eight times a year, or attacks with laryngeal involvement of any duration occurring once or twice a year are rated 20 percent disabling. A 40 percent rating is assigned for attacks without laryngeal involvement lasting one to seven days or longer and occurring more than eight times a year; or attacks with laryngeal involvement of any duration occurring more than twice a year. 38 C.F.R. § 4.104, Diagnostic Code 7118. Another potentially applicable code is Diagnostic Code 7825 for urticaria (hives). Under this diagnostic, a 10 percent rating is warranted where there is evidence of recurrent episodes occurring at least four times during the past 12-month period and responding to treatment with antihistamines or sympathomimetics. A 30 percent rating is warranted where there is evidence of recurrent debilitating episodes occurring at least four times during the past 12-month period and requiring intermittent systemic immunosuppressive therapy for control. A maximum 60 percent rating is warranted where there is evidence of recurrent debilitating episodes occurring at least four times during the past 12-month period despite continuous immunosuppressive therapy. 38 C.F.R. § 4.118 , Diagnostic Code 7825. The Veteran's foot disability is rated under Diagnostic Code 8521, concerning nerve damage of the popliteal nerve. Diagnostic Code 8521 assigns a 10 percent rating for mild, incomplete paralysis of the external popliteal nerve. A 20 percent rating is assigns for moderate, incomplete paralysis. A 30 percent rating is assigned for severe, in complete paralysis. A 40 percent rating is assigned for complete paralysis with foot drop and slight droop of the first phalanges of all toes, cannot dorsiflex the foot, extension (dorsal flexion) of proximal phalanges of toes lost; abduction of foot lost, adduction weakened; anesthesia covers entire dorsum of foot and toes. 38 C.F.R. § 4.124a , Diagnostic Code 8521. In every instance where the schedule does not provide a zero percent evaluation for a diagnostic code, a zero percent evaluation shall be assigned when the requirements for a compensable evaluation are not met. 38 C.F.R. § 4.31 (2014). Facts and Analysis Taking into account all relevant evidence, the Board finds that the Veteran is currently properly rated as noncompensably disabled for his service connected dermatographic urticaria prior to August 21, 2004. As noted above, to warrant an increased rating, the Veteran would have to be found to have attacks without laryngeal involvement lasting one to seven days and occurring two to four times a year, or evidence of recurrent episodes occurring at least four times during the past 12-month period and responding to treatment with antihistamines or sympathomimetics. The Board simply finds that this criteria have not been met. Reviewing the evidence of record for this period, the Veteran received a VA dermatological examination in January 2006. At that time, he noted an in service acute onset of erythema while stationed in the Philippines. He reported that at present, when it does affect him it is mainly on his back and torso, and occasionally his upper legs. He complained of pruritus and difficulty sleeping when he has a rash. While there were no lesions on examination, the examiner drew a 3-4 inch mark on the Veteran's back which became slightly pale followed by a red color that lasted for several minutes. The Veteran submitted a June 2009 opinion paper from a private health care professional. At that time, the professional stated that the Veteran had several abnormal skin areas which were becoming worse and were aggravated by soap and sun. The physician stated that the Veteran should "have his code increased" due to the pain and discomfort associated with his skin lesions. The Board recognizes this opinion, however, it finds it of limited probative as the professional clearly did not examine the Veteran's skin, as he provided no specific information as to the current state of the Veteran's skin, and no information as to the frequency and duration of episodes, and indeed no specific diagnosis, and has not offered any basis for his opinion that is supported by any actual medical evidence of record. There is no indication in any medical records that sun and soap cause the Veteran increased skin pain. Thus, the Board finds this opinion to be of minimal probative value. The Veteran had a general medical examination in February 2010. At that time he reported problems with his skin as a child. A report of VA general medical examination dated November 2012 noted no evidence of any skin condition. Thus, the evidence for this time period shows minimal problems with the Veteran's skin, and no evidence of attacks without laryngeal involvement lasting one to seven days and occurring two to four times a year, or evidence of recurrent episodes occurring at least four times during the past 12-month period and responding to treatment with antihistamines or sympathomimetics. The Veteran's symptomatology during this time, if any, appears to be minimal. As such, the Board finds that the criteria for a compensable evaluation have not been met, for this time period. Likewise, for the period from August 21, 2004, the Board finds that the criteria for an evaluation higher than 10 percent, for the Veteran's service connected dermatographic urticarial, have not been met. In order to warrant a higher evaluation, the Veteran would have to be found to have to be found to have attacks without laryngeal involvement lasting one to seven days and occurring five to eight times a year, or attacks with laryngeal involvement of any duration occurring once or twice a year, or recurrent debilitating episodes occurring at least four times during the past 12-month period and requiring intermittent systemic immunosuppressive therapy for control. The Board also finds this criteria have not been met. Reviewing the evidence of record for this period, the Veteran received a VA examination for his skin on August 21, 2004. At that time, the Veteran was found to have a skin diagnosis of dermatographic urticaria. The Veteran reported that scratching the back, neck, abdomen, or right forearm caused raised lesions that disappeared after a few minutes. The Veteran occasionally used Benadryl and cortisone cream for treatment of uticaria, but for less than 6 weeks over the past year. The Veteran did not currently have any visible skin condition, on examination. The Veteran reported occurrences of uticaria 3 to 4 times a month, with episodes lasting 3 minutes to 30 minutes. The examiner was unable to estimate the percentage of body affected as there was no current skin rash. This evidence does not show attacks lasting one to seven days, nor does it show any laryngeal involvement, or any evidence of debilitating episodes. As such, the Board finds that the criteria is not met for this period. Finally, taking into account all relevant evidence, the Board finds that an increased rating is not warranted for the Veteran's left foot neuropathy. The Board points out that the Veteran was recently service connected for peripheral neuropathy of both lower extremities, which specifically is numbness, and therefore cannot be compensated twice for that specific symptom. However, to warrant an increase for his left foot neuropathy, the Veteran would have to be found to have symptomatology of the foot consistent with a finding of moderate, incomplete paralysis. The Board simply does not find that to be the case. Upon January 2006 VA examination, the Veteran was able to walk on heels and toes, and perform tandem gait. He did not report any specific foot pain at that time. March 2008 neurological testing showed glove and stocking hypoesthesia in all extremities. The Veteran had a VA examination and addendum for this disability in March 2008 and November 2008. At that time, the Veteran reported sharp foot pain, of a level 9 on a scale of 1 to 10. He reported that nothing reduced the pain, and that pain medicines only masked it. He uses a brace to help with ambulation. Upon standing, there were no symptoms of swelling. Antalgia was noted on the left with walking. There were no walking or standing limitations. There was no instability or tenderness noted. The Veteran was diagnosed with peripheral nerve damage versus radiculopathy of the left foot. He also reported a burning pain in his foot, which the examiner stated was a neuropathic condition. The Veteran submitted a June 2009 opinion paper from a private health care professional. However, that professional did not directly address the Veteran's left foot problem. The Veteran had a general medical examination in February 2010, which specifically addressed his foot pain. He reported that since his injury in service, he had occasional discomfort in the dorsum of the left foot and also getting in and out of the shower. He noted that this occasionally caused tendonitis, but he had none at present. He does not take any medication for this. Examination showed no evidence of swelling, tenderness, or instability of the foot. Gait was normal. He could not walk on heels or toes on the left side. There was no unusual shoe wear, and no evidence of deformities. The examiner suggested that the Veteran probably had an injury to his peroneal nerve which resulted in mild dorsiflexor weakness of the left ankle, and mild to moderate discomfort in the dorsum of the left foot. A November 2010 report of VA examination primarily for peripheral neuropathy found reduced sensation to pin prick from the feet to half way up the legs. Multiple November 2012 report of VA examinations indicated that the Veteran's strength testing in his left lower extremity was normal, The Veteran was noted to have mild numbness in the left lower extremity. The Veteran received a VA examination in August 2014, primarily for peripheral neuropathy, for which he was granted service connection by a September 2014 VA examination. He was noted to have mild pain and numbness in the left lower extremity. Deep tendon reflexes were absent in the ankles. The Veteran's gait was noted to be normal. EMG testing showed reduced velocity and amplitude in the sensory motor nerves of both legs due to neuropathy. Considering this specific disability, and setting aside the Veteran's numbness related to his other service connected disability of peripheral neuropathy, the Board finds this disability only consists of mild symptomatology, including mild pain and weakness. As such, the Board finds the criteria for an increased evaluation, specifically moderate, incomplete paralysis, have not been met. As such, the Board finds that the criteria for a higher evaluation for the Veteran's service connected left foot and skin disabilities are not met, and therefore the preponderance of the evidence of record is against these claims. As the preponderance of the evidence is against the claims, the benefit-of-the-doubt doctrine does not apply, and increased ratings must be denied. 38 U.S.C.A. § 5107(b) (West 2002); Gilbert v. Derwinski, 1 Vet. App 49, 55-57 (1990). Extraschedular Consideration Under Thun v. Peake, 22 Vet App 111 (2008), there is a three-step inquiry for determining whether a Veteran is entitled to an extraschedular rating. First, the Board must determine whether the evidence presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. Second, if the schedular evaluation does not contemplate the claimant's level of disability and symptomatology and is found inadequate, the Board must 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, the Veteran's disability picture requires the assignment of an extraschedular rating. With respect to the first prong of Thun, the evidence in this case does not show such an exceptional disability picture that the available schedular evaluations for the service-connected disabilities is inadequate. A comparison between the level of severity and symptomatology of the Veteran's skin and left foot disabilities with the established criteria found in the rating schedule for this disability shows that the rating criteria reasonably describes the Veteran's disability level and symptomatology. The Board has been unable to identify an exceptional or unusual disability picture, and neither has the Veteran. The Board therefore has determined that referral of this case for extraschedular consideration pursuant to 38 C.F.R. 3.321(b)(1) is not warranted. ORDER Entitlement to an increased evaluation for dermatographic urticaria, currently evaluated as noncompensably disabling prior to August 21, 2014, and as 10 percent disabling from August 21, 2014, is denied Entitlement to an increased initial evaluation for left foot neuropathy, currently evaluated as 10 percent disabling, is denied. REMAND As to the Veteran's claim of entitlement to a total disability rating based on individual unemployability (TDIU), the Board notes that recently, the Veteran was granted service connection for peripheral neuropathy of both the upper and the lower extremities. In addition, the Veteran was granted an increased rating for his service connected skin condition. All of the Veteran's service connected disabilities, combined, warrant a 90 percent evaluation. Although the Veteran's highest evaluation is only 30 percent, considering that many of these disabilities have a common etiology, the Board finds it likely that the schedular percentage requirements for a grant of TDIU have been met. As such, and considering that the Veteran has recently had multiple new disabilities service connected, and considering there is no such opinion of record, the Board is of the opinion that the Veteran would be entitled to an examination that actually addresses the impact of the service-connected disabilities, combined, on the Veteran's ability to work. Accordingly, the case is REMANDED for the following action: 1. Afford the Veteran an appropriate VA examination to obtain an opinion as to the impact of the service-connected disabilities on the Veteran's ability to work. The Veteran's claims file, to include a complete copy of this REMAND, must be provided to the examiner(s) designated to examine the Veteran, and the examination report(s) should note review of the file. The examiner(s) should interview the Veteran as to his employment and education history. The examiner(s) should provide an opinion as to whether it is at least as likely as not (i.e., there is at least a 50 percent probability) that the Veteran's multiple service connected disabilities preclude employment consistent with the Veteran's education and occupational experience, without taking into account his age or any nonservice-connected disability. The examiner(s) should set forth a rationale for the conclusions reached. 2. After ensuring that the requested action is completed, the RO or AMC should re-adjudicate the claim on appeal, taking into consideration provisions of 38 C.F.R. § 4.16(b). If the benefits sought are not fully granted, the RO or AMC must furnish a supplemental statement of the case (SSOC), before the claims file is returned to the Board, if otherwise in order. The appellant has the right to submit additional evidence and argument on the matter or matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West 2014). ______________________________________________ Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs