Citation Nr: 1600271 Decision Date: 01/05/16 Archive Date: 01/12/16 DOCKET NO. 95-18 347 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Boise, Idaho THE ISSUES 1. Entitlement to a compensable rating for residuals of lacerations to the fourth and fifth fingers on the right hand on or after July 16, 1999. 2. Entitlement to a 10 percent rating for multiple noncompensable service-connected disabilities pursuant to 38 C.F.R. § 3.324 on or after July 16, 1999. 3. Entitlement to a total disability rating for compensation purposes based on individual unemployability. REPRESENTATION Veteran is represented by: Kathy L. Lieberman, Esq. ATTORNEY FOR THE BOARD C. Banister, Associate Counsel INTRODUCTION The Veteran served on active duty from December 1957 to June 1962. These matters come before the Board of Veterans' Appeals (Board) on appeal rating decisions dated April 1994 and November 1994 by the Department of Veterans Affairs (VA) Regional Office (RO) in Fort Harrison, Montana. Jurisdiction over the Veteran's claims file was subsequently transferred to the RO in Boise, Idaho. In May 1995, the Veteran filed a claim of entitlement to a total disability rating for compensation purposes based on individual unemployability (TDIU). In March 2007, the Board noted that the Veteran's May 1995 TDIU claim had not been adjudicated and referred the claim to the RO for appropriate action. In a September 2007 rating decision, the RO denied the Veteran's TDIU claim. Although the Veteran did not perfect an appeal of the RO's September 2007 rating decision, a claim of entitlement to TDIU is part and parcel of an increased rating claim when such claim is raised by the record. See Rice v. Shinseki, 22 Vet. App. 447 (2009). Throughout the pendency of this appeal, the Veteran asserted that he was unemployable, at least in part, due to his service-connected residuals of lacerations to the fourth and fifth fingers of the right hand. Thus, the Board finds that a claim of entitlement to TDIU has been raised by the record as part of the above-captioned increased rating claim. Accordingly, the issue has been added to the title page. 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. Beginning July 16, 1999, the Veteran's service-connected residuals of lacerations to the right fourth and fifth fingers have been manifested by a one-centimeter scar on the right fourth digit over the proximal interphalangeal joint and a white, well-healed, two-centimeter scar on the right fifth proximal phalanx, which were neither painful nor unstable. 2. The evidence of record does not show that the Veteran's noncompensable service-connected disabilities interfere with normal employability. 3. The evidence of record does not show that the Veteran's service-connected disabilities preclude him from securing or following a substantially gainful occupation consistent with his education and occupational experience. CONCLUSIONS OF LAW 1. Beginning July 16, 1999, the criteria for a compensable rating for residuals of lacerations to the fourth and fifth fingers on the right hand have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2014); 38 C.F.R. § 4.118 Diagnostic Code 7804 (2015). 2. The criteria for a 10 percent rating based on multiple noncompensable service-connected disabilities have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2014); 38 C.F.R. § 3.324 (2015). 3. The criteria for TDIU have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2014); 38 C.F.R. §§ 3.340, 3.341, 4.16, 4.17 (2015). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS In an April 1994 rating decision, service connection was granted for scars, residual of a laceration to the right hand, and a noncompensable rating was assigned, effective November 3, 1987. Thereafter, the Veteran submitted a notice of disagreement with respect to the initial noncompensable rating. In a November 1994 rating decision, the RO confirmed and continued the noncompensable rating assigned to the Veteran's service-connected residuals of lacerations to the ring and little fingers of the right hand. Thereafter, the Veteran perfected an appeal. In December 1998, the Board remanded the above-captioned claims in order to obtain updated treatment records and Social Security Administration records. The Board also directed the RO to provide the Veteran with a new VA examination in which the examiner commented on the Veteran's pain, weakened movement, excess fatigability, and incoordination and to render an opinion as to the nature and etiology of any neurological impairment. While in remand status, the RO obtained the named records. In July 1999, the Veteran underwent a VA examination in which the examiner commented on the Veteran's orthopedic and neurologic impairment. In June 2001, the Board assigned an initial 10 percent rating to the Veteran's service-connected residuals of lacerations to the right fourth and fifth fingers from November 3, 1987, through July 15, 1999, and a noncompensable rating beginning July 16, 1999. Thereafter, the Veteran appealed the Board's June 2001 decision to the Court of Appeals for Veterans Claims (Court). In a January 2003 Joint Motion for Remand (Joint Motion), the parties agreed that VA failed to provide the Veteran with proper statutory notice. See 38 U.S.C.A. § 5103(a). Thereafter, the Court issued an order vacating, in relevant part, the portion of the Board's June 2001 decision that denied a compensable rating for residuals of lacerations to the right fourth and fifth fingers and denied a separate 10 percent rating for multiple noncompensable service-connected disabilities under 38 C.F.R. § 3.324. In December 2003, the Board remanded the above-captioned claims in order to provide the Veteran with proper notice and a new VA examination to determine the current severity of his service-connected residuals of lacerations to the right fourth and fifth fingers. In doing so, the Board directed the examiner to report all neurologic and orthopedic manifestations of the Veteran's service-connected disabilities, including any limitation of motion. In February 2004, the Veteran underwent a VA examination, during which the examiner opined that any neurologic abnormalities in the Veteran's right hand were not related to his service-connected residuals of lacerations to the right fourth and fifth fingers. The examiner also indicated that the Veteran's complaint of knuckle pain was likely due to arthritic changes. In July 2004, the Board denied the Veteran's claim for a compensable rating for his service-connected residuals of lacerations to the right fourth and fifth fingers beginning July 16, 1999, and denied a 10 percent under 38 C.F.R. § 3.324. Thereafter, the Veteran appealed the Board's July 2004 decision to the Court. In a January 2006 Joint Motion, the parties agreed that the Board's July 2004 decision failed to discuss "all the described manifestations of [the Veteran's] service-connected hand disabilities." Specifically, the Board was directed to discuss whether the Veteran raised claims of other injuries to his right hand and whether such claims were inextricably intertwined with the claim for a compensable rating for residuals of lacerations to the right fourth and fifth fingers. Additionally, the parties agreed that VA must obtain a medical opinion as to whether the Veteran's arthritis of the hand is related to his service-connected residuals of lacerations to the right fourth and fifth fingers. In a January 2006 Order, the Court granted the Joint Motion and remanded the claims for action consistent with the terms of the Joint Motion. In March 2007, the Board referred the issue of whether new and material evidence was submitted to reopen the previously-denied claim of entitlement to service connection for a broken tip of the right middle finger. Additionally, the Board remanded the above-captioned claims in order to obtain a medical opinion as to whether the Veteran's arthritis of the hand was related to his service-connected residuals of lacerations to the right fourth and fifth fingers and whether the Veteran's service-connected disabilities interfered with normal employability. While in remand status, the Veteran underwent a VA examination in April 2007, during which the examiner opined that the Veteran's arthritis was less likely related to his service-connected injury and more likely related to age. In August 2007, the examiner opined that the Veteran's service-connected disabilities would not interfere with employability. In a September 2007 rating decision, the RO denied reopening the issue of entitlement to service connection for a right hand injury, fracture to the middle finger, and the Veteran did not perfect an appeal. In March 2008, the Board determined that the RO failed to address the issue of entitlement to service connection for right hand arthritis, claimed as a total right hand disability, and remanded, rather than referred, the claim for adjudication by the RO. Additionally, the Board determined that the April 2007 and August 2007 opinions were inadequate because the examiner failed to provide a rationale. Therefore, the Board remanded the claims to obtain a supplemental opinion. The Veteran underwent VA examinations in April 2008 and September 2008, during which the examiners provided the requested opinions with rationales. In April 2009, the Board remanded the above-captioned claims in order to provide the Veteran with proper notice. Vazques-Flores v. Peake, 22 Vet. App. 37 (2008). Additionally, the Board determined that the RO had not adjudicated the issue of entitlement to service connection for a "total right hand disability," to include arthritis. Therefore, the Board remanded the above-captioned claims as inextricably intertwined with the issue of entitlement to service connection for a right hand disability, including arthritis. While in remand status, the RO sent the Veteran the proper notice in May 2009. In a June 2009 rating decision, the RO denied service connection for a right hand disability, including arthritis, claimed as loss of use of the right hand, and the Veteran did not perfect an appeal. In a September 2015 supplemental statement of the case, the RO confirmed the noncompensable rating assigned to the Veteran's service-connected residuals of lacerations to the right fourth and fifth fingers beginning July 16, 1999, and denied a 10 percent rating pursuant to 38 C.F.R. § 3.324. The Veteran's claim was then returned to the Board for further appellate review. Based on the foregoing, the Board finds that there has been substantial compliance with the Board's prior remand directives. See Stegall v. West, 11 Vet. App. 268, 271 (1998). I. Duties to Notify and Assist VA has a duty to notify and assist veterans in substantiating claims for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2014); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.3216(a) (2015). Proper notice from VA must inform the veteran of any information and medical or lay evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the veteran is expected to provide. Quartuccio v. Principi, 16 Vet. App. 183, 187 (2002). This notice must be provided prior to an initial unfavorable decision on a claim by the RO. Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112, 120 (2004). The RO's January 2004, May 2007, and May 2009 letters to the Veteran contained the requisite notice. See id. The duty to assist the Veteran has also been satisfied. The RO obtained the Veteran's service treatment records, Social Security Administration records, and all available VA and private treatment records. See 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. In an appellate brief submitted to the Court pursuant to the Veteran's appeal of the July 2004 Board decision, the Veteran's attorney asserted that VA did not fulfill its duty to assist when it failed to obtain private treatment records identified by the Veteran during a hearing before a decision review officer. In April 2007, the RO sent the Veteran a letter requesting that he return signed authorizations for the named private treatment providers; however, the Veteran did not respond. See Wood v. Derwinski, 1 Vet. App. 190, 193 (1991) (noting that VA's duty to assist veterans is not always a "one-way street"). Accordingly, the Board finds that VA has made reasonable efforts to obtain the Veteran's private treatment records, and there is no indication that additional evidence relevant to the issues being decided herein is available and not part of the record. See Pelegrini, 18 Vet. App. at 116. During the relevant period on appeal, the Veteran was provided VA examinations in July 1999, February 2004, April 2007, April 2008, and September 2008. The examiners reviewed the evidence of record and administered thorough clinical evaluations, which provided findings pertinent to the rating criteria. Furthermore, the February 2004 examiner provided an opinion as to whether any neurological abnormality was related to the Veteran's service-connected residuals of lacerations to the right fourth and fifth fingers, and the April 2008 examiner provided an opinion as to whether the Veteran's arthritis was related to his service-connected residuals of lacerations to the right fourth and fifth fingers. As such, the Board finds that the Veteran has received adequate VA examinations. See Barr v. Nicholson, 21 Vet. App. 303, 311 (2007); see also Stegall, 11 Vet. App. at 271. 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 claim, the Board finds that any such failure is harmless. See Mayfield, 20 Vet. App. at 542-43; see also Dingess/Hartman, 19 Vet. App. at 486; Shinseki v. Sanders, 129 S. Ct. 1696 (2009) (reversing prior case law imposing a presumption of prejudice on any notice deficiency and clarifying that the burden of showing that an error is harmful or prejudicial normally falls upon the party attacking the agency's determination); Fenstermacher v. Phila. Nat'l Bank, 493 F.2d 333, 337 (3d Cir. 1974) ("[N]o error can be predicated on insufficiency of notice since its purpose had been served."). II. Entitlement to a Compensable Rating for Residuals of Lacerations to the Right Fourth and Fifth Fingers Beginning July 16, 1999 Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (Rating Schedule). 38 C.F.R. Part 4 (2015). The Rating Schedule is primarily a guide in the evaluation of disability resulting from all types of diseases and injuries encountered as a result of or incident to military service. The ratings are intended to compensate, as far as can practicably be determined, the average impairment of earning capacity resulting from such diseases and injuries and their residual conditions in civilian occupations. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1 (2015). Beginning July 16, 1999, the Veteran's service-connected residuals of lacerations to the right fourth and fifth fingers has been assigned a noncompensable rating pursuant to the criteria set forth in 38 C.F.R. § 4.118, Diagnostic Code 7804, relating to scars. The rating criteria for scars were amended during the pendency of this appeal, effective August 30, 2002. See 67 Fed. Reg. 49590- 49599 (July 31, 2002). The previous version of Diagnostic Code 7804 provided for a 10 percent rating for scars which are superficial, tender, and painful on objective demonstration. 38 C.F.R. § 4.118, Diagnostic Code 7804 (2002). Similarly, under the current version of Diagnostic Code 7804, a 10 percent disability rating is warranted for one or two scars that are unstable or painful; a 20 percent disability rating is warranted for three or four scars that are unstable or painful; and a maximum 30 percent schedular rating is warranted for five or more scars that are unstable or painful. 38 C.F.R. § 4.118, Diagnostic Code 7804. An unstable scar is one where, for any reason, there is frequent loss of covering of the skin over the scar. 38 C.F.R. § 4.118, Diagnostic Code 7804, Note (1). During a July 1999 VA examination, the Veteran reported sustaining an in-service injury when his right hand went through a window during a motor vehicle accident. The Veteran's lacerations were sutured, his hand was splintered for two or three weeks, and he was placed on light duty for two or three weeks. The Veteran denied any further treatment after his discharge from active duty. The Veteran exhibited good dexterous use of both hands. The examiner observed a foreshortened right long finger where the distal tip was amputated, a very slightly dystrophic nail, and some faint incisions on the right hand, which were not truly visible or painful. There was also an incisional scar over the dorsum of the right little finger, measuring two centimeters. The Veteran could easily bring all fingers to the palmar surface. There was no evidence of contractures. He exhibited "entirely normal" motion of the metacarpophalangeal joints, proximal interphalangeal joints, and distal interphalangeal joints. It was noted that "there [was] not much in the way of subjective complaints," but the Veteran did report some stiffness and soreness. The examiner indicated that the objective examination was unremarkable. There was no evidence of instability or pain on use. The Veteran not expected to have any functional limitation caused by injury to either hand. The examiner observed no pain visually manifested with movement of right hand fingers, no atrophy, no motor loss, no appreciable sensory loss, no objective manifestations of disuse, and functional impairment due to pain. With regard to the Veteran's reports of stiffness and pain, the examiner indicated that "the only discernable pathology is the partial amputation of the distal phalanx of the right long finger." In July 1999, the Veteran also underwent a VA neurological examination, during which he reported right hand cramping, pain, and numbness with pain through the metacarpal and interphalangeal joints. There was no swelling or obvious scarring on either hand. Electrodiagnostic studies revealed mild right carpal tunnel syndrome. The examiner observed evidence of a laceration in the tip of his right third finger, but nothing on the fourth or fifth fingers of the right hand. There was no obvious weakness, incoordination, muscle wasting, or pain visibly manifested on movement of the fingers of either hand. Other than carpal tunnel syndrome, the examiner indicated that there was "little else to be found on the examination today to help better understand the [Veteran's] reports of the functional impairment with his hands." An August 2003 private treatment record revealed diagnoses of polyneuropathy in the hands; degenerative changes in hands; and carpal tunnel syndrome on right. The private treatment provider opined as follows: The etiology of the absent ulnar sensory responses may be due to the polyneuropathy or may possibly be due to ulnar nerve entrapment at Guyon's canal. He does not appear to have evidence of cubital tunnel. The most likely etiology of his sensory neuropathy is his alcohol abuse. In an October 2003 addendum, the private treatment provider indicated that "additional potential causes of sensory peripheral polyneuropathy include vitamin deficiencies, medications, or other metabolic process." During a February 2004 VA examination, the Veteran reported pain in the knuckles of both hands, which was aggravated by gripping objects. He also reported occasionally dropping objects. The examiner indicated that "[t]here does not seem to be any residuals of lacerations of the tip of the fourth and fifth fingers on the right hand." There was a loss of pain sensation in the fingers of both hands, extending up to the wrist joint, bilaterally. The examiner indicated that electrodiagnostic findings were consistent with median nerve entrapment, carpal tunnel syndrome, on the right and mild primary sensory polyneuropathy. The examiner opined that the Veteran's service-connected disabilities were "less likely than not to be causing any significant paralysis." In support of this, the examiner provided the following rationale: The most likely etiology of [the Veteran's] sensory neuropathy is alcohol abuse. . . . Sensation on the prior examination of [July 1999] does not indicate any sensory loss. The change in sensory findings from [July 1999] to [February 2004] seems to indicate an alcohol abuse etiology since nothing in the history of findings would indicate any other cause. During an April 2007 VA examination, the Veteran reported pain in knuckles of both hands, pain in the fingers, cramping pain at the proximal interphalangeal joints, loss of feeling in the fingertips, and difficulty picking up objects. The examiner indicated that the Veteran likely had arthritis involving the proximal interphalangeal joints of all fingers of both hands. The examiner opined that it was "more likely that not that [the Veteran's] osteoarthritis of the fingers of both hands [was] related to age and less likely than not related to his prior injury to the hands." The examiner also attributed the loss of feeling in the fingertips to a diagnosis of peripheral neuropathy, which was "less likely than not related to his prior injury and more likely than not related to his prior alcoholism." In August 2007, the April 2007 examiner provided the following addendum: It is my opinion that the Veteran's service-connected residuals of right hand laceration of fourth and fifth fingers and residuals of left hand injury would not cause significant interference with normal employability. In April 2008, a VA examiner provided the following opinion with respect to the etiology of the Veteran's arthritis of the hands: [The Veteran] suffered a minor injury and laceration of the tips of the right fourth and fifth fingers. This healed uneventfully and he had a quick recovery from it and there is absolutely no reason why a minor laceration at the tip of his fingers would be a factor in his later developing bilateral pain in both hands of the joints of the fingers of each hand. The etiology of the arthritis seems most logically due to an aging process and the fact that the two hands were about equal is another point to make that the arthritis was unrelated to the injury in the right hand. He had a very minor laceration which was sutured and healed uneventfully. There have been no complications from this and there is no reason to believe that his later development of arthritis in both of his hands had anything to do with his injury. During a September 2008 VA examination, the Veteran reported pain and stiffness prior to his discharge from active duty. However, the examiner indicated that a November 1993 x-ray of the right hand showed an old trauma to the tuft of the right third digit, but no evidence of osteoarthritis at that time. X-rays of both hands performed in April 2007 revealed degenerative changes in both hands at the interphalangeal joints. A physical examination revealed a white, well-healed scar on the right fifth proximal phalanx measuring two centimeters on the dorsal aspect and a one-centimeter scar on the right fourth digit over the proximal interphalangeal joint on the dorsal aspect. The diagnosis was bilateral osteoarthritis of the hands, right greater than the left. The Veteran stated that he stopped working eight or nine years earlier due to pain in his hands. The examiner opined that the Veteran's arthritis would preclude him from any type of work with his hands. As previously noted, beginning July 16, 1999, the Veteran's service-connected residuals of lacerations to the right fourth and fifth fingers have been assigned a noncompensable rating pursuant to the criteria set forth in 38 C.F.R. § 4.118, Diagnostic Code 7804. In order for a compensable rating to be warranted under the old rating criteria, the evidence of record must demonstrate, at a minimum, that the Veteran's residuals of lacerations to the right fourth and fifth fingers more nearly approximate a superficial scar that was tender and painful on objective demonstration. Id. Similarly, under the current rating criteria, the evidence of record must demonstrate, at a minimum, that the Veteran's residuals of lacerations to the right fourth and fifth fingers more nearly approximate one or two scars that are painful or unstable. Id. A review of the record reveals no evidence to support a finding that the Veteran's scar was painful, tender, or unstable. Throughout the period on appeal, the Veteran's service-connected residuals of lacerations to the right fourth and fifth fingers were manifested by a one-centimeter scar on the right fourth digit over the proximal interphalangeal joint and a white, well-healed, two-centimeter scar on the right fifth proximal phalanx. The July 1999 VA examiner described the Veterans scars as faint incisions, which were not truly visible or painful. The July 1999 neurological VA examiner observed no obvious swelling scarring on either hand. The February 2004 VA examiner indicated that "[t]here does not seem to be any residuals of lacerations of the tip of the fourth and fifth fingers on the right hand." As the medical evidence of record does not show that the Veteran's scars were painful, tender, or unstable, the Board finds that a compensable rating is not warranted under either the old or current rating criteria for any distinct period on appeal. See 38 C.F.R. § 4.118, Diagnostic Code 7804; Fenderson v. West, 12 Vet. App. 119, 126 (1999). The Board has also considered whether the Veteran's service-connected residuals of lacerations to the right fourth and fifth fingers warrant a higher disability rating under an alternative diagnostic code relating to scars. However, the evidence of record does not show any manifestations of the Veteran's service-connected residuals of lacerations to the right fourth and fifth fingers which would warrant a compensable rating under an alternate diagnostic code. See 38 C.F.R. § 4.118, Diagnostic Codes 7800, 7801, 7802, 7805 (2015). The record shows that the Veteran has complained of bilateral hand pain, cramping, stiffness, numbness, and decreased grip strength. However, these symptoms have been attributed to non-service connected disabilities, including carpal tunnel syndrome, arthritis, polyneuropathy, and the partial amputation of the distal phalanx of the right middle finger. In a May 1995 rating decision, service connection was denied for bilateral carpal tunnel syndrome. In a September 2007 rating decision, the RO denied reopening the previously-denied claim of entitlement to service connection for a right hand injury, fracture to the middle finger. In a June 2009 rating decision, service connection was denied for a right hand disability, including arthritis, claimed as loss of use of the hand. Moreover, the April 2008 VA examiner opined that the Veteran's arthritis of the hands was due to aging and unrelated to the Veteran's in-service injury to the right hand. The February 2004 VA examiner opined that the Veteran's sensory neuropathy was most likely due to alcohol abuse. The Veteran's private treatment provider opined that his symptoms of sensory neuropathy were likely due to alcohol abuse, vitamin deficiencies, medications, or other metabolic process. As there is no competent medical evidence of record linking the Veteran's symptoms of pain, cramping, stiffness, numbness, and decreased grip strength to the in-service motor vehicle accident or his service-connected residuals of lacerations to the right fourth and fifth fingers, the Board finds that a compensable rating is not warranted based on these symptoms. Generally, evaluating a disability using the corresponding or analogous diagnostic codes contained in the Rating Schedule is sufficient. See 38 C.F.R. §§ 4.20, 4.27 (2015). Because the ratings are averages, an assigned rating may not completely account for each individual veteran's circumstance, but nevertheless would still be adequate to address the average impairment in earning capacity caused by disability. In exceptional cases where the rating is inadequate, it may be appropriate to assign an extraschedular rating. 38 C.F.R. § 3.321(b) (2015). The threshold factor for extraschedular consideration is a finding that the evidence before VA presents such an exceptional disability picture that the available schedular evaluation for that service-connected disability is inadequate, a task performed either by the RO or the Board. Id.; see Thun v. Peake, 22 Vet. App. 111, 115 (2008), aff'd, 572 F.3d 1366 (2009); see also Fisher v. Principi, 4 Vet. App. 57, 60 (1993) ("[R]ating [S]chedule will apply unless there are 'exceptional or unusual' factors which render application of the schedule impractical"). Therefore, initially, there must be a comparison between the level of severity and symptomatology of a veteran's service-connected disability with the established criteria found in the Rating Schedule for that disability. Thun, 22 Vet. App. at 115. If the criteria reasonably describe the veteran's disability level and symptomatology, then the disability picture is contemplated by the Rating Schedule, the assigned schedular evaluation is, therefore, adequate, and no referral is required. The Board finds the Veteran's disability picture is not so unusual or exceptional in nature as to render the already assigned schedular ratings inadequate. As determined above, the Veteran's service-connected residuals of lacerations to the right fourth and fifth fingers are manifested a one-centimeter scar on the right fourth digit over the proximal interphalangeal joint and a white, well-healed, two-centimeter scar on the right fifth proximal phalanx. When comparing this disability picture with the symptoms contemplated by the rating criteria, the Board finds that the Veteran's experiences are congruent with the disability picture represented by the noncompensable rating. Additionally, the Veteran may be awarded an extraschedular rating based on the combined effect of multiple conditions in an exceptional circumstance where the evaluation of the individual conditions fails to capture all the service-connected disabilities experienced. Johnson v. McDonald, 762 F.3d 1362 (Fed. Cir. 2014). However, in this case, there are no additional symptoms that have not been attributed to a specific service-connected disability. See Mittleider v. West, 11 Vet. App. 181 (1998). 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. III. Entitlement to a 10 Percent Rating Under 38 C.F.R. § 3.324 Beginning July 16, 1999 A veteran with two or more separate, permanent, service-connected disabilities of such character as clearly to interfere with normal employability, even though none of the disabilities may be of compensable degree under the Rating Schedule, shall be awarded a 10 percent rating, but not in combination with any other rating. 38 C.F.R. § 3.324. Service connection is currently in effect for residuals of lacerations to the right fourth and fifth fingers and residuals of an injury to the left hand. Each of these disabilities has been assigned a noncompensable rating beginning July 16, 1999. As found above, since July 16, 1999, the Veteran's service-connected residuals of lacerations to the right fourth and fifth fingers have been manifested by a one-centimeter scar on the right fourth digit over the proximal interphalangeal joint and a white, well-healed, two-centimeter scar on the right fifth proximal phalanx, which were neither painful nor unstable. In an April 2009 decision, the Bord found that since July 16, 1999, the Veteran's service-connected residuals of a left hand injury were asymptomatic without tenderness, pain, arthritis, or limitation of function. Specifically, it was noted that the medical evidence of record indicated that the Veteran's complaints of left hand pain and limitation of function were due to nonservice-connected disabilities, including osteoarthritis, neuropathy, and carpal tunnel syndrome, and were unrelated to the Veteran's service-connected residuals of a left hand injury. Based on the foregoing, the Board finds that the record does not show that the Veteran's noncompensably rated service-connected disabilities interfere with normal employability. Although the September 2008 VA examiner opined that the Veteran's arthritis would preclude him from any type of work with his hands, as previously noted, service connection is not in effect for arthritis. As the Veteran's symptoms of bilateral hand pain, cramping, stiffness, numbness, and decreased grip strength have been attributed to nonservice-connected disabilities, there is no basis under the cited regulation for the assignment of a 10 percent rating based on multiple noncompensable service-connected disabilities. See 38 C.F.R. § 3.324. IV. Entitlement to TDIU VA will grant TDIU when the evidence shows that a veteran is precluded by reason of a service-connected disability or disabilities from obtaining and maintaining substantially gainful employment consistent with his education and occupational experience. See 38 C.F.R. §§ 3.340, 3.341, 4.16. The relevant issue is not whether the veteran is unemployed or has difficulty obtaining employment, but whether the veteran is capable of performing the physical and mental acts required by employment. Van Hoose v. Brown, 4 Vet. App. 361, 363 (1993). Advancing age, any impairment caused by conditions that are not service-connected, and prior unemployability status must be disregarded when determining whether a veteran is currently unemployable. 38 C.F.R. §§ 4.16(a), 4.19. TDIU may be assigned when the schedular rating is less than total, where, if there is only one disability, the disability is rated at 60 percent or more, or where, if there are two or more disabilities, at least one disability is rated 40 percent or more and there is sufficient additional disability to bring the combined rating to 70 percent or more. 38 C.F.R. § 4.16(a). Where the percentage requirements for TDIU are not met, a total disability rating may nevertheless be assigned on an extraschedular basis when the veteran is unable to secure or follow a substantially gainful occupation as a result of his or her service-connected disability or disabilities. 38 C.F.R. § 4.16(b). The Board is precluded from assigning a TDIU rating on an extraschedular basis in the first instance. Instead, the Board must refer any claim that meets the criteria for referral for consideration of entitlement to a TDIU on an extraschedular basis to the Director of Compensation and Pension Service. See Bowling v. Principi, 15 Vet. App. 1, 10 (2001). Service connection is currently in effect for residuals of lacerations to the right fourth and fifth fingers and residuals of an injury to the left hand, both of which were assigned a 10 percent rating from November 3, 1987, through July 15, 1999, and a noncompensable rating beginning July 16, 1999. Thus, the Veteran's combined disability rating has not met the minimum schedular criteria for TDIU for any period on appeal. See 38 C.F.R. § 4.16(a). However, the Veteran's claim may be referred to the Director of Compensation and Pension Service for consideration of entitlement to TDIU on an extraschedular basis if the evidence demonstrates that the Veteran is unable to secure or follow a substantially gainful occupation as a result of his service-connected disabilities. 38 C.F.R. § 4.16(b). As found above, the Veteran's service-connected residuals of lacerations to the right fourth and fifth fingers have been manifested by a one-centimeter scar on the right fourth digit over the proximal interphalangeal joint and a white, well-healed, two-centimeter scar on the right fifth proximal phalanx, which were neither painful nor unstable. The record reveals that the Veteran's complaints of bilateral hand pain and limitation of function have been attributed to nonservice-connected disabilities. Thus, the record does not show that the Veteran's service-connected disabilities preclude him from securing or following a substantially gainful occupation. Accordingly, referral for extraschedular TDIU is not warranted. In reaching this decision, the Board considered the doctrine of reasonable doubt; however, as the preponderance of the evidence is against the Veteran's claims, the doctrine is not for application. See Gilbert v. Derwinski, 1 Vet. App. 49, 56 (1990). ORDER A compensable rating for residuals of lacerations to the fourth and fifth fingers of the right hand for the period beginning July 16, 1999, is denied. A 10 percent rating for multiple noncompensable service-connected disabilities pursuant to 38 C.F.R. § 3.324 for the period beginning July 16, 1999, is denied. TDIU is denied. ____________________________________________ JOY A. MCDONALD Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs