Citation Nr: 1553641 Decision Date: 12/23/15 Archive Date: 12/30/15 DOCKET NO. 15-19 352 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Manila, the Republic of the Philippines THE ISSUES 1. Whether new and material evidence has been submitted to reopen a claim for bilateral cataracts. 2. Whether new and material evidence has been submitted to reopen a claim for a neck disability. 3. Entitlement to service connection for bilateral cataracts. 4. Entitlement to service connection for a neck disability. 5. Entitlement to service connection for a dental disability. 6. Entitlement to service connection for diabetes mellitus. 7. Entitlement to an evaluation in excess of 30 percent for chronic sinusitis. 8. Entitlement to an evaluation in excess of 10 percent for hypertension. 9. Entitlement to a compensable evaluation for colonic polyp, status post polypectomy. REPRESENTATION California Department of Veterans Affairs WITNESSES AT HEARING ON APPEAL Appellant, Spouse ATTORNEY FOR THE BOARD K. Anderson, Associate Counsel INTRODUCTION The Veteran had active service from January 1960 to January 1980. These matters come to the Board of Veterans' Appeals (Board) from May 2013, June 2013 and August 2014 rating decisions from the Department of Veterans Affairs (VA) Regional Office (RO) in Manila, the Republic of the Philippines. The Veteran testified at a hearing before the Board in September 2015. An AVLJ who conducts a hearing must fully explain the issues and suggest the submission of evidence that may have been overlooked. Bryant v. Shinseki, 23 Vet. App. 488 (2010). Here, during the hearing, the Veteran declined representation; however, the AVLJ asked relevant questions concerning the Veteran's symptoms and the resulting impairment, as well as the effect of his disability on his daily life and his occupation. The Veteran has not asserted that VA failed to comply with 38 C.F.R. § 3.103(c)(2). At the Veteran's hearing, it was noted that he appeared without a representative and wanted to go forward without such representative. The Veteran had appointed the California Department of Veterans Affairs as his representative in March 2005 but opted to go forward without their assistance during his hearing. The issue of entitlement to service connection for teeth and gum problems is addressed in the REMAND portion of the decision below and is REMANDED to the Agency of Original Jurisdiction (AOJ). This appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2015). 38 U.S.C.A. § 7107(a)(2) (West 2014). FINDINGS OF FACT 1. An unappealed rating decision from December 2005 denying service connection for bilateral cataracts and a neck disability is final. 2. Since the December 2005 rating decision, evidence that is new, which relates to an unestablished fact necessary to substantiate the claims of service connection for bilateral cataracts and a neck disability, and is neither cumulative nor redundant, and raises a reasonable possibility of substantiating the claims have been received. 3. The Veteran's currently diagnosed bilateral cataracts is not casually or etiologically related to the Veteran's service. 4. The Veteran's currently diagnosed neck disability is not related to any injury or incident in service. 5. Diabetes mellitus was not manifested in service, has not been productive of symptoms continuously since service, or to a compensable degree within one year of service discharge, and any current diabetes mellitus is not otherwise etiologically related to such service. 6. The Veteran has sinusitis with more than six non- incapacitating episodes per year characterized by headaches and pain, without evidence of radical surgery with chronic osteomyelitis, or; near constant sinusitis characterized by headaches, pain and tenderness of affected sinus, and purulent discharge or crusting after repeated surgeries. 7. The Veteran's hypertension is controlled with continuous medication and does not manifest with a history of diastolic blood pressure elevation to predominately 110 or more systolic pressure predominately 200 or more. 8. The Veteran's colonic polyp, status post polypectomy does manifest with symptoms of frequent episodes of bowel disturbance with abdominal distress. CONCLUSIONS OF LAW 1. The December 2005 rating decision denying service connection for bilateral cataracts and a neck disability is final. 38 U.S.C.A. § 7105(c) (West 2014); 38 C.F.R. §§ 3.104, 3.160, 20.1103 (2015). 2. New and material evidence has been received with respect to the claims of entitlement to service connection for bilateral cataracts and a neck disability; the claim is reopened. 38 U.S.C.A. § 5108 (West 2014); 38 C.F.R. § 3.156 (a) (2015). 3. Bilateral cataracts was not incurred in or aggravated by active service. 38 U.S.C.A. §§ 1110, 5107 (West 2014); 38 C.F.R. § 3.303 (2015). 4. The Veteran's neck disability was not incurred in or aggravated by active service. 38 U.S.C.A. §§ 1110, 5107 (West 2014); 38 C.F.R. § 3.303 (2015). 5. The criteria for service connection for diabetes mellitus have not been met. 38 U.S.C.A. §§ 1110, 5107 (West 2014); 38 C.F.R. §§ 3.303, 3.307, 3.309 (2015). 6. The criteria for a rating in excess of 30 percent for service-connected chronic sinusitis have not been met. 38 U.S.C.A. § 1155 (West 2014); 38 C.F.R. §§ 3.102, 3.321, 4.1, 4.7, 4.97, Diagnostic Code 6512 (2015). 7. The criteria for an evaluation in excess of 10 percent for hypertension have not been met. 38 U.S.C.A. § 1155, 5107 (West 2014); 38 C.F.R. §§ 3.321, 4.1, 4.104, Diagnostic Code 7101 (2015). 8. The criteria for a compensable rating for colonic polyp, status post polypectomy are not met. 38 U.S.C.A. §§ 1155, 5107 (West 2014); 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.114, Code 7343-7399 (2015). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS New and Material The Veteran is seeking to reopen claims for service connection for bilateral cataracts and a neck disability that was previously denied by the RO. For the reasons that follow, the Board concludes that the prior denial if final, new and material evidence has been received, and reopening is warranted. In March 2005, the Veteran filed a claim for vision loss and residual pain from a neck injury. The RO denied service connection for both claims for lack of current diagnoses in a December 2005 rating decision. The Veteran was provided notice of the adverse decision and of his procedural and appellant rights in a December 2005 letter. He submitted a notice of disagreement to the decision in January 2006 to the denial of service connection for a neck disability only. On the Veteran's February 2007 substantive appeal (VA-9) the Veteran withdrew is his claims for service connection for a neck disability. The December 2005 rating decision is final. 38 U.S.C.A. § 7105; 38 C.F.R. § 20.1103. A final decision cannot be reopened and considered on the merits unless new and material evidence is presented. 38 U.S.C.A. § 5108. New evidence means existing evidence not previously submitted to agency decision makers. 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). The evidence received since the December 2005 denial included diagnoses for bilateral cataracts and a neck disability. This evidence is new as it was not of record at the time of the last final denial. This evidence is also material as it addresses the grounds of the last prior final denial and raises a reasonable possibility of substantiating the claim of service connection for a neck disability and bilateral cataracts. Consequently, reopening the Veteran's claim for service connection for a neck disability and bilateral cataracts is warranted. 38 C.F.R. § 3.156. Service Connection Under 38 U.S.C.A. § 7104, Board decisions must be based on the entire record, with consideration of all the evidence. In Timberlake v. Gober, 14 Vet. App. 122 (2000), the Court held, in pertinent part, that the law requires only that the Board address its reasons for rejecting evidence favorable to the claimant. The Federal Circuit has also held that the Board must review the entire record, but does not have to discuss each piece of evidence. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000). 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 the claimant. Service connection may be established for disability resulting from personal injury suffered or disease contracted in line of duty in the active military, naval, or air service. 38 U.S.C.A. §§ 1110, 1131. That an injury or disease occurred in service is not enough; there must be chronic disability resulting from that injury or disease. If there is no showing of a resulting chronic condition during service, then a showing of continuity of symptomatology after service is required to support a finding of chronicity. 38 C.F.R. § 3.303(b). Service connection may also be granted for any injury or disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease or injury was incurred in service. 38 C.F.R. § 3.303(d). In order to establish service connection for the claimed disorder, there must be competent and credible evidence of (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a nexus between the claimed in-service disease or injury and the current disability. See Hickson v. West, 12 Vet. App. 247, 253 (1999); see also Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007); Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006). It is VA's defined and consistently applied policy to administer the law under a broad interpretation, consistent, however, with the facts shown in every case. When, after careful consideration of all procurable and assembled data, a reasonable doubt arises regarding service origin, the degree of disability, or any other point, such doubt will be resolved in favor of the claimant. By reasonable doubt it is meant that an approximate balance of positive and negative evidence exists which does not satisfactorily prove or disprove the claim. Reasonable doubt is a substantial doubt and one within the range of probability as distinguished from pure speculation or remote possibility. See 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102 (2015). Bilateral cataracts The Veteran has asserted entitlement to service connection for vision loss. Specifically, he asserts that his currently diagnosed cataracts are related to service. After careful review of the evidence, the Board finds that service connection for bilateral cataracts is not warranted. As evidence to support his claim, the Veteran submitted a diagnosis for bilateral cataracts from Dr. R.B. dated February 2012. As such, the first element of service connection has been met. The remaining questions are whether there is evidence of an in-service occurrence of an injury or disease and competent evidence of a nexus between the current disability and the in-service disease or injury. A report of medical history from October 1979 notes that the Veteran did not wear glasses or contact lenses and had vision in both eyes. A Report of Medical Examination from October 1979 notes that Veteran was evaluated as clinically normal. A review of his service treatment records did not reveal any complaints of treatment for vision loss or cataracts during service. A Report of Medical Examination from August 1975 and October 1979 notes that the Veteran had 20/20 vision without correction. There is a treatment note from October 1971 stating that the Veteran's vision was normal with complaints of soreness in eyes and in June 1960 he was diagnosed with mild conjunctivitis and given a prescription for bacitracin. Post service treatment notes do not related the Veteran's current diagnosis of bilateral cataracts to his active military service. There is no evidence of record that connects the Veteran's bilateral cataracts to his active duty service other than the Veteran's own statements. The Veteran testified at his hearing that he had to wear reading glasses in service. His wife testified that he had inflammation of the eyes in service and he had 20/30 or 20/40 vision. She also stated that the Veteran began wearing reading glasses after service. While the Veteran is competent to report sensory or observed symptoms, and his testimony in that regard is entitled to some probative weight. See Washington v. Nicholson, 19 Vet. App. 362, 368 (2005). He generally is not, however, competent to diagnose a medical disorder or render an opinion as to the cause or etiology of any current disorder because he does not have the requisite medical knowledge or training. See Rucker v. Brown, 10 Vet. App. 67, 74 (1997) (stating that competency must be distinguished from weight and credibility, which are factual determinations going to the probative value of the evidence). In this instance, therefore, the Veteran as a lay person has not been shown to be capable of making medical conclusions, especially as to complex medical diagnoses such as cataracts. Thus, his statements regarding a nexus to service are not competent. See Jandreau, 492 F.3d at 1377 (explaining in footnote 4 that a Veteran is competent to provide a diagnosis of a simple condition such as a broken leg, but not competent to provide evidence as to more complex medical questions). Further, the wife's statements that the Veteran had less than 20/20 vision or that he was diagnosed for reading glasses in-service is not supported by the record. The evidence of record does not show that the Veteran's current bilateral cataracts are due to any event, injury, or disease incurred in service. Based upon a review of the evidence, the Board concludes that service connection is not warranted for the Veteran's eye disability. The Board acknowledges the Veteran's belief that his eye disability is related to his military service. However, the Board notes that as a layman, the Veteran has no competence to give a medical opinion on the diagnosis or etiology of a condition. Consequently, lay assertions of medical diagnosis or etiology cannot constitute evidence upon which to grant the claim for service connection. Lathan v. Brown, 7 Vet. App. 359, 365 (1995). Accordingly, the Board concludes that the preponderance of the evidence is against the Veteran's claim of service connection for his eye disability, and the benefit of the doubt rule does not apply. See 38 U.S.C.A. § 5107 (West 2014). Neck Disability The Veteran has asserted a claim for service connection for a neck disability. Specifically, he contends that his current neck disability is related to a motor vehicle accident he had during his active military service in 1973. After a careful review of the evidence of record the Board finds that service connection for a neck disability is not warranted. The Veteran has been diagnosed, by his private physician R.A. in January 2014, with severe bilateral foraminal stenosis with moderate to severe central canal stenosis. Marked multilevel spondylosis with degenerative retrolisthesis. Severe left foraminal stenosis with mild narrowing of the central canal. As such, the first element of service connection has been met. Service treatment notes reveal complaints of pain over the cervical spine area diagnosed as myositis. He was prescribed Darvon and Norflex; the Veteran did not have any further complaints of neck pain. A treatment note from 1973 documents that he was involved in a motor vehicle accident and had complaints of stiffness of his neck. It was noted that he had bilateral cervical muscle pain and some loss of motion, with no neurological deficits. He was diagnosed with cervical muscle strain. The Veteran had no other complaints of neck pain in service. His Report of Medical History and Report of Medical Examination from October 1979, completed shortly before retirement, were silent for complaints of neck pain or a diagnosis of a neck disability. The Veteran was evaluated as clinically normal. As such, the Board is led to believe that his muscle strain resolved in service. However, the second element of service connection has been met. The Veteran was afforded a VA examination of his cervical spine in February 2013. He was diagnosed with cervical strain and cervical discospondylosis. The examiner opined that the Veteran's current diagnosis of a neck disability was less likely than not related to his active military service, to include the 1973 motor vehicle accident. The rationale provided was that his service treatment records show that his December 1964 neck myositis was acute and transitory, was treated adequately and healed completely without any development into a chronic compensable condition. The Veteran's 1965 Report of Medical Examination completed at re-enlistment showed a normal spine, and the found the Veteran fit for re-enlistment. The examiner also stated that his Report of Medical History from October 1979 denied any recurrent back pain, and his Report of Medical Examination for the same date showed a normal spine. There is no mention of chronic neck condition. Thus proving that his 1973 cervical strain was acute and transitory and was treated adequately. The examiner did not find any medical evidence in the record that the Veteran's neck disability manifested to a compensable degree within one year of service. As such, the overall determination was that his current disability is not related to an injury or incident in service. As evidence to support his claim, the Veteran submitted a diagnosis from his private physician Dr. R.C. dated February 2012 diagnosing the Veteran with cervical pain. The Veteran also submitted treatment notes for his neck pain from his physical therapist, M.S. dated March 2014, showing that he is being treated for cervical pain. The Veteran submitted other treatment notes regarding his neck disability; however, none of the Veteran's private treatment notes related his current disability to his active military service. The Veteran testified at his hearing that he has been suffering from neck pain for a long time and that it is related to the car accident he had in service. While the Board finds the Veteran and his wife competent and credible to report experiencing neck pain in service and after service, they are not probative to the issue of nexus. Lay evidence can be competent and sufficient to establish a diagnosis of a condition 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 Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007); see also Barr v. Nicholson, 21 Vet. App. 303 (2007). Although lay observers are competent to give evidence about what they experience, they are not competent to diagnose any medical disorder or render an opinion as to the cause or etiology of any current disorder because they do not have the requisite medical knowledge or training. See Rucker v. Brown, 10 Vet. App. 67, 74 (1997). As such, the lay testimony from the Veteran and his spouse are of little value in determining whether there is a nexus or a link between the Veteran's current disability and an in-service event or injury. See Buchanan v. Nicholson, 451 F.3d 1331, 1335 (Fed. Cir. 2006). Here, there is no competent evidence indicating that the Veteran was diagnosed with a cervical spine disability until 2013, a period of more than 33 years since the Veteran separated from service. No medical professional has ever linked the current problems to the reported in-service injury, and lay testimony is not competent on this point. The preponderance of the evidence is against the Veteran's claim for service connection for a neck disability. Consequently, the benefit-of-the-doubt rule does not apply, and the claim must be denied. 38 U.S.C.A. § 5107(b) (West 2014); Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). Diabetes Mellitus The Veteran has asserted entitlement to service connection for diabetes mellitus. Specifically, he claims that his diabetes is related to his appendectomy that he underwent in service in 1972. After a careful review of the evidence of record the Board finds that service connection for diabetes mellitus is not warranted. The Veteran's claim for service connection for diabetes mellitus involves a chronic disease. 38 C.F.R. § 3.309(a). Diabetes mellitus is specifically named as a chronic disease. Id. For chronic diseases, service connection may be awarded where chronicity during service, continuity of symptomatology after service, or manifestations to a compensable degree within one year of service separation is shown. Walker v. Shinseki, 708 F.3d 1331, 1337 (Fed. Cir. 2013); 38 C.F.R. §§ 3.303(b), 3.307, 3.309. The Veteran does have a current diagnosis of diabetes mellitus and as such the first element of service connection has been met. The evidence does not establish that the Veteran's diabetes mellitus was "chronic" during his active service. Service treatment records do not reveal a diagnosis or treatment for diabetes mellitus in service. The Veteran's Report of Medical Examinations from December 1965, September 1971, August 1975, October 1979 all show that a urinalysis was performed and the Veteran's sugar was negative every time. At the Veteran's hearing he stated that pre-operative test results revealed that his glucose level was 126, but his urinalysis was negative and there is no diagnosis of diabetes associated with this glucose level. There is no additional evidence of record that states that the Veteran was diagnosed with diabetes mellitus in service. As such, the Board finds this statement by the Veteran not probative, especially considering that all testing completed after his surgery showed negative sugar results upon urinalysis testing and there is no additional competent medical or lay evidence that shows that diabetes mellitus was "chronic" during active service or that he had characteristics necessary to identify the disease entity at that time. 38 C.F.R. § 3.303(b). Further, there is no evidence of continuity of symptomatology. The first diagnosis of record for diabetes mellitus is 2004, but the Veteran reported at his hearing that he was diagnosed in 2000. However, either date of diagnosis does not establish continuity of symptomatology and service connection is not warranted on this basis. Certain chronic diseases, such as diabetes mellitus, may be presumed to have occurred in service if manifested to a degree of 10 percent within one year of service discharge. 38 C.F.R. §§ 3.307, 3.309(a). However, the presumption of service connection does not apply in this case because, as noted above, the Veteran was discharged in 1980 and there were no identified possible manifestations of diabetes mellitus before 2000. Service connection is not warranted on a presumptive basis. Id. In light of the foregoing, the Board concludes that service connection is not warranted for diabetes mellitus on the basis of chronicity, continuity of symptomatology, compensable manifestations within one year of separation from service, or nexus to some incident in service. Accordingly, the Board concludes that the preponderance of the evidence is against the claim for service connection for diabetes mellitus, and the benefit of the doubt rule does not apply. 38 U.S.C.A. § 5107. Increased Ratings Disability ratings are determined by the application of the facts presented to VA's Schedule for Rating Disabilities (Rating Schedule) at 38 C.F.R. Part 4. The percentage ratings contained in the Rating Schedule represent, as far as can be practicably determined, the average impairment in earning capacity resulting from diseases and injuries incurred or aggravated during military service and the residual conditions in civilian occupations. 38 U.S.C.A. § 1155; 38 C.F.R. §§ 3.321(a), 4.1. In evaluating the severity of a particular disability, it is essential to consider its history. 38 C.F.R. § 4.1; Peyton v. Derwinski, 1 Vet. App. 282 (1991). Where there is a question as to which of two evaluations shall be applied, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that evaluation. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. Where entitlement compensation has already been established and an increase in disability rating is at issue, the present level of the Veteran's current disability is of primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). The Board has reviewed all evidence of record, as required; however, the more critical evidence consists of the evidence generated during the appeal period. The Board is required to not only to evaluate the medical evidence of record since the filing of the claim for an increased rating but also consider the appropriateness of a "staged rating" (i.e., assignment of different ratings for distinct periods of time, based on the facts). See Hart v. Mansfield, 21 Vet. App. 505 (2007). Sinusitis The Veteran contends that he is entitled to a higher evaluation for his service connected sinusitis. The Veteran was service connected for his sinusitis in 2005 that was evaluated as non-compensable. In January 2012, the Veteran filed a claim for an increased evaluation and the RO granted such increase to 30 percent in a May 2013 rating decision. The Board will review the evidence of record to determine whether the Veteran is entitled to an evaluation in excess of 30 percent. Sinusitis is rated under Diagnostic Code 6514. 38 C.F.R. § 4.97, Diagnostic Code 6514. A 30 percent rating is assigned where there are 3 or more incapacitating episodes of sinusitis per year requiring prolonged (lasting 4 to 6 weeks) antibiotic treatment, or more than 6 non-incapacitating episodes of sinusitis per year characterized by headaches, pain, and purulent discharge or crusting. Id. The next and highest schedular rating of 50 percent is assigned following radical surgery with chronic osteomyelitis, or; near constant sinusitis characterized by headaches, pain and tenderness of affected sinus, and purulent discharge or crusting after repeated surgeries. Id. The Veteran had a VA examination in February 2013 examination to determine the current severity of his sinusitis. At the examination the Veteran was diagnosed with chronic sinusitis and allergic rhinitis. He complained of recurrent nasal congestion with associated nasofrontal headache and frequent sneezing. Objective evidence noted that his frontal and maxillary sinuses are affected by his disability. However, there were not findings, signs or symptoms attributable to chronic sinusitis. Further, it was reported that the Veteran had 7 or more non-incapacitating episodes over the past 12 months, but no incapacitating episodes of sinusitis requiring prolonged (4 to 6 weeks) of antibiotic treatment in the past 12 months. There was no report that the Veteran had surgery for his disability. In regards to his rhinitis, there was evidence of greater than 50 percent obstruction of the nasal passage on both sides, but no other conditions. At the end of the examination it was noted that the Veteran had no active sinus infection. Sinusitis was diagnosed based on history. His primary problem was his uncontrolled rhinitis, allergic in nature. His deviated septum was non-traumatic in origin. Given this, the evidence supports only a 30 percent rating as there is no evidence of radical surgery with chronic osteomyelitis. In addition, there is no lay or medical evidence of near constant sinusitis or purulent discharge or crusting after repeated surgeries. As such, none of the criteria necessary for a 50 percent rating under the applicable criteria are met, and the manifestations do not more nearly approximate these criteria. The potential application of an extraschedular rating for sinusitis will be discussed below. Hypertension The Veteran is currently assigned a 10 percent rating for hypertension under Diagnostic Code 7101. Under Diagnostic Code 7101, hypertension with diastolic pressure predominantly 100 or more, or; systolic pressure predominantly 160 or more, or; minimum evaluation for an individual with a history of diastolic pressure predominantly 100 or more who requires continuous medication for control, is rated 10 percent disabling. 38 C.F.R. § 4.104. Hypertension with diastolic pressure predominantly 110 or more, or; systolic pressure predominantly 200 or more, is rated 20 percent disabling. 38 C.F.R. § 4.104, Diagnostic Code 7101. Hypertension with diastolic pressure predominantly 120 or more is rated 40 percent disabling. Id. Hypertension with diastolic pressure predominantly 130 or more is rated 60 percent disabling. Id. Blood pressure readings from the Veteran's private doctor with a diagnosis of essential hypertension were the following: June 2012 118/78; September 2012 125/72; December 2012 140/88; and in February 2014 122/76. The Veteran underwent a VA examination in March 2012 to determine the current severity of the Veteran's hypertension disability. At this examination the Veteran reported that his blood pressure ranges between 130/80 to 140/90 most days of the week; however, he still has elevated blood pressure once a week with readings ranging from 145/82 to 188/102 despite regular intake of medication. He claimed to experience headaches and dizziness when his blood pressure was elevated. Due to his persistent blood pressure elevations, Carvedilol was added to his medications by his private physician in February 2012. The examiner noted that he had a history of diastolic blood pressure elevation to predominately 100 or more. The Veteran claimed that he had diastolic blood pressure range of 100-102 once a month since 2009 which was manifested with headaches and dizziness. His blood pressure readings at this examination were 160/100 (sitting); 170/100 (standing); and 170/90 (supine). The second set of blood pressure readings were 150/100 (supine); 160/100 (standing); and 160/100 (sitting). Thus, the evidence does not suggest that the Veteran meets the criteria for a rating in excess of 10 percent as his diastolic and systolic readings are not predominately at the levels listed under Diagnostic Code 7101. As such, the Board finds a preponderance of the evidence is against a higher rating, the benefit of the doubt doctrine does not apply, and the claim must be denied. The potential application of an extraschedular rating for hypertension will be discussed below. Colon Polyps The Veteran is service connected for residuals of polypectomy and is currently has a non-compensable rating. The Veteran has asserted entitlement to a higher rating. Specifically, the Veteran has a history of having intestinal polyps removed. The Veteran's residuals of his polypectomy has been rated under 38 C.F.R. § 4.114 Diagnostic Codes 7344-7399. In this instance, the hyphenated diagnostic code indicates that the Veteran's residuals of polypectomy, an unlisted disability for which specific rating criteria do not exist, is rated by analogy under any of diseases listed in the section for the digestive system. As such, the most analogous rating criteria for the Veteran's condition are those associated with Diagnostic Code 7319 for irritable colon syndrome. Under Code 7319, a 10 percent rating is warranted for moderate irritable colon syndrome with frequent episodes of bowel disturbances with abdominal distress. A (maximum) 30 percent rating is warranted for severe irritable colon syndrome with diarrhea or alternating diarrhea and constipation, with more or less constant abdominal distress. 38 C.F.R. § 4.114, Code 7319. In July 2010, the Veteran underwent a VA examination to determine the current severity of his digestive disability. At this examination it was noted that the Veteran had follow-up colonoscopies in 2003, 2007, and 2010 and at each of the colonoscopies additional polyps were removed and all were reported at benign. At the last examination the Veteran was told that he had "redness" or inflammation of the colon. He also reported instances of intermittent stomach pain with occasional diarrhea and excessive flatulence. His private physician requires him to repeat his colonoscopies every three years. Upon examination it was noted that there was a history of nausea of less than once per week. He reported other symptoms such as, bloating, flatulence, anorexia, alternating diarrhea and constipation. However, no partial bowel obstruction was noted, but he did report moderate abdominal pain of three to six hours less than once per month. At the end of the examination, the Veteran was diagnosed with recurrent benign polyps of the colon status post polypectomies with chronic mild gastrointestinal complaints of abdominal pain, diarrhea and constipation. The Veteran had another VA examination of his digestive tract in May 2012. At this examination it was noted that the Veteran had been diagnosed with hemorrhoids, grade II; as well as diverticulosis, transverse, descending and sigmoid colon. At this examination, he complained of abdominal pain, with feelings of bloating and occasional diarrhea. As evidence to support his claim, the Veteran submitted private treatment records, primarily in the form of colonoscopy and endoscopy reports. A report from March 2003 notes that the Veteran had mild bilateral diverticular disease of the colon and this diagnosis had been continued by his private physician. The most recent private treatment note from April 2010 notes that the Veteran's colon was clean and visualization was excellent showing evidence of diverticular disease on the left side of the colon. A polyp was removed and the Veteran was requested to return in three years. The evidence of record does show that the Veteran suffers from recurring colon polyps as well as diverticulitis of the colon and hemorrhoids. However, the evidence of does not show that he suffers from moderate irritable colon syndrome with symptoms of frequent episodes of bowel disturbances with abdominal distress. The Diagnostic Code for diverticulitis is 7327, and the instructions state to rate diverticulitis as irritable colon syndrome, peritoneal adhesions, or colitis, ulcerative, depending upon the predominant disability picture. As such, the Veteran's diverticulitis diagnosis does not affect his current rating, as the symptoms for residuals of polypectomy are manifested by diverticulitis and hemorrhoids. Hemorrhoids are rated under 7336, and in order for the Veteran to receive a compensable rating under this diagnostic code, there would need to be evidence of large or thrombotic, irreducible, with excessive redundant tissue, evidencing frequent recurrences. There is nothing in the record suggesting that the Veteran suffers from this level symptomatology of hemorrhoids. A higher rating for the Veteran's for residuals of polypectomy is not warranted, as the treatment records do not reveal moderate or severe symptoms of irritable colon syndrome, diverticulitis or hemorrhoids. The potential application of an extraschedular rating for residuals of polypectomy will be discussed below. Additional Considerations In exceptional cases an extraschedular rating may be provided. 38 C.F.R. § 3.321. The threshold factor for extraschedular consideration is a finding that the evidence before VA presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. Therefore, initially, there must be a comparison between the level of severity and symptomatology of the claimant's service-connected disability with the established criteria found in the rating schedule for that disability. Thun v. Peake, 22 Vet. App. 111 (2008). Under the approach prescribed by VA, if the criteria reasonably describes the claimant's disability level and symptomatology, then the claimant's disability picture is contemplated by the rating schedule, the assigned schedular rating is, therefore, adequate, and no referral is required. In the second step of the inquiry, however, if the schedular rating 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) (related factors include "marked interference with employment" and "frequent periods of hospitalization"). When the rating schedule is inadequate to evaluate a claimant's disability picture and that picture has 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 for completion of the third step, a determination of whether, to accord justice, the claimant's disability picture requires the assignment of an extraschedular rating. Id. Turning to the first step of the extraschedular analysis, the Board does not find any symptoms or functional impairment that is not already encompassed by the currently assigned ratings. The Veteran's symptoms, of headaches and pain from sinus pressure; occasional diarrhea, abdominal pain, and constipation from his digestive disability; and controlled hypertension are all contemplated in the ratings assigned. As such, it is not found that any of the disabilities meet the "governing norms" of an extraschedular rating. Further, referral for consideration of an extraschedular rating is not warranted, as the evidence does not show hospitalization due to the Veteran's service-connected disabilities discussed above. The Board also finds that the rating schedule is adequate, even in regard to the collective and combined effect of all of the Veteran's service connected disabilities, including the issues on appeal. Accordingly, referral for extraschedular consideration is not warranted under the circumstances of this case. Johnson v. McDonald, 762 F.3d 1362 (Fed. Cir. 2014). Based on the foregoing, the Board finds the schedular evaluations are adequate, and referral is not required. 38 C.F.R. § 3.321; Thun v. Peake, 22 Vet. App. 111 (2008). Duties to Notify and Assist When VA receives a complete or substantially complete application for benefits, it must notify the claimant of the information and evidence not of record that is necessary to substantiate a claim, which information and evidence VA will obtain, and which information and evidence the claimant is expected to provide. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126; 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a). See also Quartuccio v. Principi, 16 Vet. App. 183 (2002); Pelegrini v. Principi, 18 Vet. App. 112 (2004). In cases such as this, where service connection has been granted and an initial disability rating and effective date have been assigned, the typical service connection claim has been more than substantiated, it has been proven, thereby rendering 38 U.S.C.A. § 5103(a) notice no longer required because the purpose that the notice is intended to serve has been fulfilled. Dingess v. Nicholson, 19 Vet. App. 473 (2006); Dunlap v. Nicholson, 21 Vet. App. 112 (2007). The appellant bears the burden of demonstrating any prejudice from defective notice with respect to downstream elements. Goodwin v. Peake, 22 Vet. App. 128 (2008). There has been no allegation of such error in this case. In any event, VA provided the Veteran notice letters in July 2010, January 2012, and January 2013 that fully addressed all notice elements. These letters informed the Veteran of what evidence was required to substantiate his underlying claim, and of the Veteran's and VA's respective duties for obtaining evidence. The Veteran has been afforded a meaningful opportunity to participate effectively in the processing of his claim and given ample time to respond. In light of the above, the Board finds that all notices required by VCAA and implementing regulations were furnished to the Veteran and that no useful purpose would be served by delaying appellate review to send out additional VCAA notice letters. VA must also make reasonable efforts to assist the appellant 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 claims. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159 (2015). Service treatment records are associated with claims file. All post-service VA and private treatment records identified by the Veteran have also been obtained. The Veteran has not identified any additional records that should be obtained prior to a Board decision. Therefore, VA's duty to further assist the Veteran in locating additional records has been satisfied. See 38 U.S.C.A. § 5103A(d); see also 38 C.F.R. § 3.159 (c)(4) (2015). The Veteran was provided VA examinations in July 2010, February 2012 March 2012, May 2012, and February 2013, which are adequate for the purposes of determining service connection and increased ratings as they involved a review of the Veteran's pertinent medical history as well as a clinical evaluation of the Veteran, and provide an etiological opinion with supporting rationale. See generally Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). In light of the foregoing, the Board is satisfied that all relevant facts have been adequately developed to the extent possible; no further assistance to the appellant in developing the facts pertinent to the issue on appeal is required to comply with the duty to assist. 38 U.S.C.A. §§ 5103 and 5103A; 38 C.F.R. § 3.159. ORDER The claim of service connection for bilateral cataracts is reopened; the appeal is granted to this extent only. The claim of service connection for a neck disability is reopened; the appeal is granted to this extent only. Service connection for bilateral cataracts is denied. Service connection for a neck disability is denied. Service connection for diabetes mellitus is denied. An evaluation in excess of 30 percent for chronic sinusitis is denied. An evaluation in excess of 10 percent for hypertension is denied. A compensable evaluation for residuals of colonic polyp, status post polypectomy is denied. REMAND The Veteran has asserted entitlement to service connection for a dental disability. Specifically, the Veteran has asserted his current teeth and gum problems are related to his active service. Service treatment records note significant dental work completed during the Veteran's service. Under normal circumstances, service connection for gum problems are not ratable for VA compensation and service connection for dental conditions are limited to such cases that involve loss of teeth due to loss of part of the maxilla or mandible as well as temporomandibular articulation. The Veteran's service treatment records complaints of pain in the left TMJ area; specifically, the Veteran had increased pain with side to side opening and closing motions. The oral clinical examination revealed extreme range of mandibular motion, crepitus and popping of left TMJ and two other diagnoses related to his molar area. The Veteran was also diagnosed with periodontal disease in October 1974. As such the Board is remanding this issue for a VA dental opinion on whether his current teeth problems are related to his complaints, diagnosis and treatment of teeth problems in service. VA has a duty to provide a VA examination when the record lacks evidence to decide the Veteran's claim and there is evidence of (1) a current disability, (2) an in-service event, injury, or disease, and (3) some indication that the claimed disability may be associated with the established event, injury, or disease. See 38 C.F.R. § 3.159(c)(4) (2015); see also McLendon v. Nicholson, 20 Vet. App. 79 (2006). Accordingly, the case is REMANDED for the following action: (Please note, this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c). Expedited handling is requested.) 1. The RO/AMC is requested to schedule the Veteran for a VA dental examination with an appropriate examiner in order to evaluate the current nature and etiology of his claimed dental disorder. The claims folder must be made available to and be reviewed by the examiner in conjunction with the examination. All testing deemed necessary should be conducted and the results reported in detail. Following review of the claims file and examination of the Veteran, the examiner is asked to state the current diagnosis for any dental disorder found, to include whether the Veteran has any loss of tooth due to loss of maxilla or mandible bone due to trauma or disease such as osteomyelitis, treatable carious teeth, replaceable missing teeth, dental or alveolar abscesses, periodontal disease or temporomandibular disability. For any dental disorder found, the examiner should state whether such is more likely, less likely, or at least as likely as not (50 percent or greater probability) due to any dental trauma during military service, or his complaints of dental and jaw pain in service. The examiner should address any dental treatment records in the claims file, and any lay evidence regarding any trauma suffered in service, symptomatology in service and continuity of symptomatology after service. The examiner is also asked to specifically interpret the Veteran's service dental treatment. All opinions should be accompanied by a clear rationale. If the examiner opines that any of the above questions cannot be resolved without resorting to speculation, then a detailed medical explanation as to why this is so should be provided. 2. Following any additional indicated development, the RO/AMC should review the claims file and readjudicate the Veteran's claims of service connection for a dental disability. If the benefits sought on appeal remain denied, the Veteran and his representative should be furnished a supplemental statement of the case and given the opportunity to respond thereto before the case is returned to the Board. 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). ______________________________________________ R. FEINBERG Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs