Citation Nr: 1622274 Decision Date: 06/03/16 Archive Date: 06/13/16 DOCKET NO. 10-25 669 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Roanoke, Virginia THE ISSUES 1. Entitlement to service connection for left arm numbness. 2. Entitlement to service connection for a left calf growth, to include as a result of exposure to ionizing radiation. 3. Entitlement to service connection for a cervical spine disorder. 4. Entitlement to service connection for a left ring finger laceration. 5. Entitlement to service connection for a left forearm growth, to include as a result of exposure to ionizing radiation. 6. Entitlement to service connection for exposure to foreign matter. 7. Entitlement to service connection for heat exhaustion. 8. Entitlement to service connection for a left knee disorder. 9. Entitlement to service connection for neurodermatitis nodular of the left scalp. 10. Entitlement to an initial compensable rating for tension headaches, residuals of concussion. REPRESENTATION Veteran represented by: Disabled American Veterans WITNESSES AT HEARING ON APPEAL The Veteran and his spouse ATTORNEY FOR THE BOARD C. Bosely, Counsel INTRODUCTION The Veteran had active service from March 1987 to April 2007. This matter comes before the Board of Veterans' Appeals (Board) on appeal from an August 2009 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Roanoke, Virginia. The Veteran and his spouse testified at a Board hearing before the undersigned Veterans Law Judge sitting in Washington, D.C. A transcript of the hearing has been associated with the record. At such time, the Veteran waived Agency of Original Jurisdiction (AOJ) consideration of the evidence associated with the record since the issuance of the May 2010 statement of the case. 38 C.F.R. § 20.1304(c) (2015). Also, as the undersigned held the record open for 60 days for the receipt of additional evidence, such was received in March 2016 and the Veteran again waived AOJ consideration of it. Therefore, the Board may properly consider all newly received evidence. This appeal was processed using the Virtual VA and Virtual Benefits Management System (VBMS) paperless claims processing systems. The issues of service connection for (1) left arm numbness; (2) a cervical spine disorder; (3) a left knee disorder; and (4) a left calf growth, are addressed in the REMAND portion of the decision below and are REMANDED to the AOJ. FINDINGS OF FACT 1. In January 2016, which was prior to the promulgation of a decision in the appeal, the Veteran testified at the Board hearing that a withdrawal of the appeal concerning the issues of service connection for heat exhaustion, left ring finger laceration, and exposure to foreign matter was requested. 2. Current disorders involving neurodermatitis nodular of the scalp and a left forearm growth are shown to have been incurred during service. 3. For the entire appeal period, the Veteran's tension headache disability is shown to have been productive of a disability picture involving characteristic prostrating attacks occurring on an average once a month over last several months with functional effects involving pain and other limitations affecting his daily life at work and home; however, these headaches are not productive of severe economic inadaptability. CONCLUSIONS OF LAW 1. The criteria for withdrawal of an appeal by the Veteran have been met as to the issue of service connection for heat exhaustion. 38 U.S.C.A. § 7105(b)(2), (d)(5) (West 2014); 38 C.F.R. § 20.204 (2015). 2. The criteria for withdrawal of an appeal by the Veteran have been met as to the issue of service connection for left ring finger laceration. 38 U.S.C.A. § 7105(b)(2), (d)(5) (West 2014); 38 C.F.R. § 20.204 (2015). 3. The criteria for withdrawal of an appeal by the Veteran have been met as to the issue of service connection for exposure to foreign matter. 38 U.S.C.A. § 7105(b)(2), (d)(5) (West 2014); 38 C.F.R. § 20.204 (2015). 4. The criteria to establish service connection for a disability manifested by neurodermatitis nodular of the left scalp are met. 38 U.S.C.A. §§ 1101, 1110, 1131, 1154, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.307, 3.309 (2015). 5. The criteria to establish service connection for a disability manifested by a left forearm growth are met. 38 U.S.C.A. §§ 1101, 1110, 1131, 1154, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.307, 3.309 (2015). 6. The criteria for the assignment of an initial rating of 30 percent, but no higher, for tension headaches, residuals of concussion, are met. 38 U.S.C.A. §§ 1155, 5107 (West 2014); 38 C.F.R. §§ 3.102, 4.1, 4.2, 4.3, 4.7, 4.124a DC 8100 (2015). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Withdrawn Claims The Board may dismiss any appeal which fails to allege specific error of fact or law in the determination being appealed. 38 U.S.C.A. § 7105 (West 2014). An appeal may be withdrawn as to any or all issues involved in the appeal at any time before the Board promulgates a decision. 38 C.F.R. § 20.204 (2015). Withdrawal may be made by the appellant or by his or her authorized representative. 38 C.F.R. § 20.204. In the present case, the Veteran withdrew his appeal at the January 2016 Board hearing as it concerns the issues involving heat exhaustion, left ring finger laceration, and exposure to foreign matter. Hence, there remain no allegations of errors of fact or law for appellate consideration with regard to those issues. Accordingly, the Board does not have jurisdiction to review the appeal as to those issues, and they are dismissed. II. Service Connection Claims As the Board's decision to grant service connection for neurodermatitis nodular of the scalp and a left forearm growth herein constitutes a complete grant of the benefits sought on appeal, no further action is required to comply with the Veterans Claims Assistance Act of 2000 (VCAA) and the implementing regulations. Service connection may be granted for a disability resulting from disease or injury incurred coincident with or aggravated by service. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303. Service connection generally requires evidence satisfying three criteria: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship ("nexus") between the present disability and the disease or injury incurred or aggravated during service. See Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009); Hickson v. West, 12 Vet .App. 247, 253 (1999). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102; see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). The Veteran maintains that neurodermatitis nodular of the scalp and a left forearm growth were incurred during service. Here, in applying the law to the facts of the case, the Board finds that the evidence is at least in a state of relative equipoise on all material elements of the two claims involving neurodermatitis nodular of the scalp and left forearm growth. First, there is no material dispute that a current condition has been diagnosed. The Veteran and his wife both testified at the January 2016 Board hearing as to the existence of ongoing disabilities involving neurodermatitis nodular of the scalp and a left forearm growth. See Board Hr'g Tr. 19, 28-29, 39. Furthermore, at the hearing, the scalp condition was observed to involve a very small, dime shaped scar or discoloration on the left side of the face approximately parallel to the eye, between the eye and the ear. See Board Hr'g Tr. 20-21. As the occurrence of these disabilities is within the competence of a lay person to observe, this evidence establishes the existence of a present disability for each condition. See Fountain v. McDonald, 27 Vet. App. 258, 274-5 (2015). Next, it is not reasonably in dispute that each condition first manifested during service. In addition to the competent and credible lay evidence of such, the Veteran's service treatment records (STRs) in November 2006 document a lump on the forehead that had been present for the past 4 years; it was occasionally tender. The diagnosis was neurodermatitis nodular of the scalp. With regard to the left forearm, STRs in October 1999 and May 2002 show a diagnosis of lipoma. Accordingly, the in-service incurrence of each condition is established. Finally, the evidence tends to make it at least equally likely that each current condition has been ongoing since service. At his Board hearing, the Veteran credibly and competently testified that the left forehead nodule has continued to recur until he underwent surgery after service. See Board Hr'g Tr. 19. With regard to the left arm lipoma, the Veteran likewise testified that he still has it. See Board Hr'g Tr. 28-29. In light of this evidence, a nexus between the current disabilities and the diseases shown during service is established. At this juncture, the Board wishes to acknowledge the Veteran's main contention, which is that these two conditions result from his exposure to ionizing radiation during service. See Board Hr'g Tr. 10-13. As it pertains to the outcome of this appeal regarding these two medical conditions, his exposure to ionizing radiation exposure is not directly relevant. Rather, it is the evidence showing the direct onset of these conditions during service that is determinative. Thus, these two claims do not need to be remanded to develop the Veteran's contention that they result from exposure to ionizing radiation. In light of the foregoing, after resolving all reasonable doubt in the Veteran's favor, the Board finds that the evidence is in a state of relative equipoise on all material elements of the claims, including the nexus requirement. Accordingly the claims must be granted. See 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102; Gilbert, supra. III. Initial Rating Claim The Veteran also maintains that an increased initial rating is warranted for his headache disability. A. Due Process Considerations VA has a duty to notify a claimant as to the information and evidence necessary to substantiate a claim for VA benefits. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). With regard to the Veteran's underlying claim for service connection for his headache disability as a residual of a concussion, he was sent a comprehensive letter in January 2009, which was sent prior to the August 2009 rating decision on appeal. See 38 U.S.C.A. § 5103. Thereafter, the Veteran appealed with respect to the initially assigned rating for his headache disability following the grant of service connection. Once service connection is granted the claim is substantiated and additional notice is not required. A case-specific notice is not required as to the downstream issues involved in the appeal for a higher initial disability rating, and any other notice defect is deemed not prejudicial. See 38 U.S.C.A. § 5103(a)(1); VAOPGCPREC 6-2014 (VA is authorized to provide notice under § 5103(a) before a claim is filed, including on the standard application forms); see also Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007); Dunlap v. Nicholson, 21 Vet. App. 112 (2007). Therefore, the duty to notify is satisfied. VA has a duty to notify a claimant as to the information and evidence necessary to substantiate a claim for VA benefits. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). Here, the Veteran was sent a comprehensive letter in January 2009, which was sent prior to the August 2009 rating decision on appeal. See 38 U.S.C.A. § 5103. Otherwise, the Veteran's claim arises from his disagreement with the initial evaluation assigned following the grant of service connection. Once service connection is granted the claim is substantiated and additional notice is not required. A case-specific notice is not required as to the downstream issues involved in the appeal for a higher initial disability rating, and any other notice defect is deemed not prejudicial. See 38 U.S.C.A. § 5103(a)(1); VAOPGCPREC 6-2014 (VA is authorized to provide notice under § 5103(a) before a claim is filed, including on the standard application forms); see also Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007); Dunlap v. Nicholson, 21 Vet. App. 112 (2007). Therefore, the duty is satisfied. VA is also required to make reasonable efforts to help a claimant obtain evidence necessary to substantiate the claim. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159(c)(d). VA will help a claimant obtain records relevant to the claim(s) whether or not the records are in Federal custody, and VA will provide a medical examination and/or opinion when necessary to make a decision on the claim. 38 C.F.R. § 3.159(c)(4). The duty to assist extends to providing assistance to obtain sufficiently identified VA medical records or records of examination or treatment at non-VA facilities authorized by VA, regardless of their relevance. Sullivan v. McDonald, 815 F.3d 786, 793 (Fed. Cir. 2016). The duty to assist is not unlimited, and subsection (d) to § 3.159 provides an important limitation: "VA will refrain from providing assistance in obtaining evidence for a claim if the substantially complete application for benefits indicates that there is no reasonable possibility that any assistance VA would provide to the claimant would substantiate the claim." Id. VA has met the duty to assist the Veteran in the development of the claim being decided herein. His service treatment records have been obtained and appear to be complete. Also, those private records the Veteran has authorized VA to obtain have also been obtained. He did not identify and authorize VA to obtain any other relevant information. Furthermore, VA examinations have been conducted in April 2009, May 2009, and June 2009, and they are adequate to inform the Board's judgment on those complex medical matters raised in this appeal. See Monzingo v. Shinseki, 26 Vet. App. 97, 105-06 (2012); McLendon v. Nicholson, 20 Vet. App. 79 (2006); see also 38 U.S.C.A. § 5103A(d)(2) (West 2014). There is no indication that his symptoms have materially increased in severity since the last VA examination was conducted for the disability. See 38 C.F.R. §§ 3.326, 3.327; Snuffer v. Gober, 10 Vet. App. 400, 403 (1997). Rather, the Veteran has maintained that his headache symptomatology has remained constant during the appeal period and is of a severity so as to warrant a compensable rating. Accordingly, the evidentiary record appears to be complete. As noted in the Introduction section, the Veteran testified at a hearing before the Board in January 2016. In Bryant v. Shinseki, 23 Vet. App. 488 (2010), the United States Court of Appeals for Veterans Claims (Court) held that 38 C.F.R. § 3.103(c)(2) requires that the Veterans Law Judge who conducts a hearing fulfill two duties to comply with the above the regulation. These duties consist of (1) the duty to fully explain the issues and (2) the duty to suggest the submission of evidence that may have been overlooked. Here, during the January 2016 hearing, the undersigned Veterans Law Judge noted the issue on appeal. See Board Hr'g Tr. 3. Additionally, testimony regarding the nature and severity of the Veteran's service-connected tension headaches was solicited, to include the type and frequency of the symptoms he experiences as a result of such disability, as well as the impact such has on his daily life and employment. See Board Hr'g Tr. 3-7, 20, 36, 39. Therefore, not only was the issue "explained . . . in terms of the scope of the claim for benefits," but "the outstanding issues material to substantiating the claim," were also fully explained. See Bryant, 23 Vet. App. at 497. Moreover, the undersigned explored whether the Veteran had any treatment at VA or whether it was all through private treatment providers. The Veteran explained that all treatment was through private providers, and he had submitted relevant evidence from his doctor. See Board Hr'g Tr. 37. Under these circumstances, nothing gives rise to the possibility that evidence had been overlooked with regard to the Veteran's claim. As such, the Board finds that, consistent with Bryant, the undersigned complied with the duties set forth in 38 C.F.R. § 3.103(c)(2) and that the Board may proceed to adjudicate the claim based on the current record. For the above reasons, the Board finds the duties to notify and assist have been met, all due process concerns have been satisfied, and the appeal may be considered on the merits at this time. B. Analysis The Veteran is seeking a higher initial rating for his headache disability. The appeal period now before the Board begins in January 2009, which is when service connection was granted for this condition. See Fenderson v. West, 12 Vet. App. 119 (1999). This disability has been assigned a noncompensable percent rating throughout the initial rating period on appeal. Disability ratings are determined by the application of VA's Schedule for Rating Disabilities. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. The basis of disability evaluations is the ability of the body as a whole, or of the psyche, or of a system or organ of the body to function under the ordinary conditions of daily life including employment. 38 C.F.R. § 4.10. Because the ability to overcome the handicap of disability varies widely among individuals, the disability ratings are based primarily upon the average impairment in earning capacity resulting from a service-connected disability, that is, upon the economic or industrial handicap which must be overcome and not from individual success in overcoming it. See 38 C.F.R. § 4.15. Where there is a question as to which of two disability ratings shall be applied, the higher disability rating will be assigned if the disability picture more nearly approximates the criteria required for that rating. 38 C.F.R. § 4.7. Otherwise, the lower rating will be assigned. Id. All potential applicable diagnostic codes, whether or not raised by a claimant, must be considered. Schafrath v. Derwinski, 1 Vet. App. 589, 593 (1991). Furthermore, when it is not possible to separate the effects of the service-connected disability from a nonservice-connected condition, such signs and symptoms must be attributed to the service-connected disability. 38 C.F.R. § 3.102; Mittleider v. West, 11 Vet. App. 181, 182 (1998) (per curiam). Where entitlement to compensation already has been established and 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). However, where a claimant is awarded service connection and assigned an initial disability rating, separate ratings can be assigned for different periods of time since the effective date for the award of service connection ("known as staged ratings"). See Fenderson v. West, 12 Vet. App. 119, 125-27 (1999). Staged ratings are appropriate in any case when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. See Hart v. Mansfield, 21 Vet. App. 505, 510 (2007). After careful consideration of the evidence, any reasonable doubt remaining on any material question of law or fact is to be resolved in favor of the claimant. 38 C.F.R. § 4.3; Fagan v. Shinseki, 573 F.3d 1282, 1287 (2009). The Veteran's headache disability has been assigned disability ratings under Diagnostic Code (DC) 8100 of 38 C.F.R. § 4.124a. The Veteran's tension headache disability is rated by analogy to DC 8100, which pertains to migraine headaches. See 38 C.F.R. § 4.20. The applicable rating schedule is set forth as follows: 8100 Migraine: With very frequent completely prostrating and prolonged attacks productive of severe economic inadaptability 50 With characteristic prostrating attacks occurring on an average once a month over last several months 30 With characteristic prostrating attacks averaging one in 2 months over last several months 10 With less frequent attacks 0 Medical reports may not use the word "prostration." However this is an adjudicative determination based on the extent to which the facts meet the definition of the term. See M21-1, III.iv.4.G.7.c. Accordingly, "prostrating," as used in 38 CFR 4.124a, DC 8100, means "causing extreme exhaustion, powerlessness, debilitation or incapacitation with substantial inability to engage in ordinary activities." See M21-1, III.iv.4.G.7.a. Completely prostrating as used in 38 CFR 4.124a, DC 8100, means extreme exhaustion or powerlessness with essentially total inability to engage in ordinary activities. See M21-1, III.iv.4.G.7.b. Prostration is substantially defined by how the disabled individual subjectively feels and functions when having migraine headache symptoms. See M21-1, III.iv.4.G.7.c. Examples of prostrating symptoms include 1) experiencing severe headaches and vomiting when exposed to light; 2) not engaging in any activities when this occurs; and 3) must rest or sleep during these episodes. See M21-1, III.iv.4.G.7.d; see also Kowalew v. McDonald, No. 14-0869, 2015 WL 3954095, at *4 (Vet. App. June 30, 2015) (The M21 creates statements of policy, when they provide context to a claim, cannot be ignored by the Board). "Productive of economic inadaptability" can be read as having either the meaning of "producing" or "capable of producing," and nowhere in DC 8100 is "inadaptability" defined, nor can a definition be found elsewhere in title 38 of the Code of Federal Regulations. But, nothing in DC 8100 requires that the claimant be completely unable to work in order to qualify for a 50 percent rating. Pierce v. Principi, 18 Vet. App. 440, 445-46 (2004). In this case, the Board has carefully considered all assembled evidence and potentially applicable diagnostic codes, and finds that the Veteran's headache disability picture more nearly approximates the rating criteria for an initial 30 disability rating, but no higher. The reasons for this decision follow. Specifically, the evidence shows characteristic prostrating attacks occurring on an average at least once a month over last several months. The Veteran has consistently reported headaches occurring 2 to 3 times per week. Beginning with an April 2009 VA examination, he reported experiencing headaches on average of 2 times per week and lasting for 1 hour. He gave an identical account at a May 2009 VA examination. By a June 2009 VA examination, the Veteran complained of headaches on average of 3 to 5 times per week, lasting 45 minutes to 1.5 hours. He similarly informed a private doctor in December 2009 that he had headaches "ever[y] few day[s]." Then in a February 2010 supporting statement, the Veteran wrote that he continued to have headaches as much as 4 times a week. His private doctor wrote in an August 2015 letter that the Veteran's "headaches are moderate to severe and occur 1-2 times per week and last for 45 minutes." That same month, August 2015, a friend of the Veteran wrote a supporting letter also stating that he had headaches a minimum of twice a week. Most recently, the Veteran testified at the January 2016 Board hearing that he continued to have headaches one to two times per week. See Board Hr'g Tr. 4. This evidence establishes that the Veteran's headaches occur at least once a month over last several months. The Veteran has also established that these headaches often, but not always, involve characteristic prostrating attacks. At the April 2009 VA examination, the Veteran testified that when headaches occurred, he was able to go to work (but required medication). It was also noted on VA examination in May 2009 that his headache symptoms did not interfere with work. The Board finds that his ability to go to work during a headache is inconsistent with characteristic prostrating attacks. See M21-1, III.iv.4.G.7.a., d. However, by comparison, the June 2009 VA examination notes his report that the ability to perform activities of daily living during a flare-up was "hard," and the functional impairment was that he could not perform those activities without medication during headache attacks, and daily activities become "very difficult." Consistent with this report, the Veteran's friend in August 2015 explained that his headaches caused the Veteran to wear sunglasses during all daylight hours, keep all lighting off while indoors, and be unable to drive for over 30 minutes at a time due to light sensitivity and pain. Likewise, the Veteran's foreman at his work wrote in a September 2015 supporting statement that the Veteran would complain of headaches that "would basically incapacitate his ability to work," and, on those occasions the Veteran would take sick leave. The Veteran gave similar testimony at the Board hearing, to the extent "the vast majority of" his headaches "last between 30 and 45 minutes at a rate that's . . . incapacitating." Board Hr'g Tr. 5. He explained that "[b]asically, I can't do anything but then it subsides as time goes." Board Hr'g Tr. 5. This evidence does not show that the Veteran's headaches have always involved characteristic prostrating attacks as they did not prevent him from working or performing activities of daily living. However, this evidence makes it reasonably certain that the headaches have routinely involved a substantial inability to engage in ordinary activities, with symptoms involving severe headaches when exposed to light and needing to rest or sleep during these episodes. These symptoms are consistent with characteristic prostrating attacks. See M21-1, III.iv.4.G.7.a., d. Thus, the evidence is at least in a state of relative equipoise in showing headaches involving characteristic prostrating attacks occurring on an average at least once a month over last several months. Thus, an initial 30 percent disability rating is warranted. See 38 C.F.R. § 4.124a, DC 8100. However, the next higher rating, 50 percent, is not warranted. The Veteran has nearly consistently reported headaches occurring more than 2 to 3 times per month often lasting for hours. These symptoms could be considered very frequent and completely prostrating and prolonged. However, the 50 percent criteria in the rating schedule are written in the conjunctive with an additional factor requiring headaches productive of severe economic inadaptability. Therefore, the frequency and severity of his headaches alone cannot support assignment of the 50 percent rating absent the "severe economic adaptability." See Tatum v. Shinseki, 23 Vet. App. 152, 156 (2009); Middleton v. Shinseki, 727 F.3d 1172, 1178 (Fed. Cir. 2013). Here, the evidence does not establish that the headaches have become productive of severe economic inadaptability, which is required for a 50 percent rating. See 38 C.F.R. § 4.124a , DC 8100. Specifically, as indicated, VA examinations in April 2009 and May 2009 show that the Veteran's headache symptoms did not interfere with his work. By comparison, in June 2009, a VA examiner noted that the Veteran could not go to work during an attack. A friend wrote in August 2015 that the Veteran's headaches caused him to wear sunglasses during all daylight hours, keep all lighting off while indoors, and be unable to drive over 30 minutes at a time due to light sensitivity and pain. The Veteran's foreman at work similarly wrote in September 2015 that his headaches "would basically incapacitate his ability to work," and the Veteran would take sick leave on those occasions. The Veteran himself explained at his January 2016 Board hearing that if a headache occurred during working hours, he was "done," and would just go home for the day. Board Hr'g Tr. 5. However, if he was already at work, he would go to his supervisor who would let him lie on the couch because "the last thing I can do is drive a car." Board Hr'g Tr. 35-36. He used roughly four hours every week of sick leave, which is why he ended the prior year with only three days of sick leave. See Board Hr'g Tr. 6, 36. Most recently, a private provider wrote in support of the Veteran's appeal in February 2016 that the Veteran "suffers from frequent debilitating headaches." A different private provider wrote in March 2016 that the Veteran continued to have "severe" issues with headaches, and his "overall status was more or less the same." Such evidence presents a picture of an individual who is capable of adapting his economic activity to the symptoms of his headaches. In this regard, the Veteran has maintained full-time employment throughout the appeal period and, while his headaches require him to take sick leave each week, he still maintains a positive balance of sick leave. Thus, it cannot be found that the headaches produce or are capable of producing severe economic inadaptability. Consequently, the Board finds that the Veteran's level of adaptability is inconsistent with the "severe economic inadaptability" required for a 50 percent rating. See 38 C.F.R. § 4.124a. There is some indication that the Veteran's headaches are further improved by treatment. For instance, an August 2015 letter from a private doctor states that the Veteran's headaches are " significantly improved with relaxation techniques." A March 2016 letter from a private doctor also states that the Veteran's headaches "have shown some improvement with [medication]." This evidence does not factor into this decision, however, because a higher disability rating may not be denied on the basis of relief provided by medication when those effects are not specifically contemplated by the rating criteria, such as here in DC 8100. See Jones v. Shinseki, 26 Vet. App. 56, 63 (2012). As a final matter, the Board notes that there are no alternative diagnostic codes under which the Veteran's tension headache disability may be analogously rated. See e.g., Copeland v. McDonald, 27 Vet. App. 333, 337 (2015). The Board's findings above are based on the rating schedule. Generally, it must be remembered that the degrees of disability specified in the rating schedule are considered adequate to compensate for considerable loss of working time from exacerbations or illnesses proportionate to the severity of the several grades of disability. 38 C.F.R. § 4.1. In this regard, the basis of disability evaluations is the ability of the body as a whole, or of the psyche, or of a system or organ of the body to function under the ordinary conditions of daily life including employment. See 38 C.F.R. § 4.10. The disability evaluations are based upon this functional impairment-the lack of usefulness, of these parts or systems, especially in self-support. See id. Moreover, the rating schedule is based primarily upon the average impairment in earning capacity, that is, upon the economic or industrial handicap which must be overcome and not from individual success in overcoming it. 38 C.F.R. § 4.15. To afford justice in exceptional situations, however, an extraschedular rating may also be assignable. 38 C.F.R. § 3.321(b). The Board may not, in the first instance, assign an increased rating on an extraschedular basis, but may determine whether referral for extraschedular consideration is warranted, provided that it articulates the reasons or bases for that determination. See Bagwell v. Brown, 9 Vet. App. 337, 339 (1996). An extraschedular disability rating is warranted if the case presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization that application of the regular schedular standards would be impracticable. 38 C.F.R. § 3.321(b)(1). In Thun v. Peake, 22 Vet. App. 111, 115-16 (2008), the explained how the provisions of 38 C.F.R. § 3.321 are applied. Specifically, the Court stated that the determination of whether a claimant is entitled to an extraschedular rating under § 3.321 is a three-step inquiry. First, it must be determined whether the evidence presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. In this regard, the Court indicated that 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. Under the approach prescribed by VA, if the criteria reasonably describe the claimant's disability level and symptomatology, then the claimant's disability picture is contemplated by the rating schedule, the assigned schedular evaluation is, therefore, adequate, and no referral is required. Second, if the schedular evaluation does not contemplate the claimant's level of disability and symptomatology and is found inadequate, the RO or Board must determine whether the claimant's exceptional disability picture exhibits other related factors such as "marked interference with employment" and "frequent periods of hospitalization." Third, when an analysis of the first two steps reveals that the rating schedule is inadequate to evaluate a claimant'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. Id. Limiting referrals for extraschedular evaluation to considering a Veteran's disabilities individually ignores the compounding negative effects that each individual disability may have on the Veteran's other disabilities. Section § 3.321(b)(1) performs a gap-filling function, accounting for situations in which a Veteran's overall disability picture establishes something less than total unemployability, but where the collective impact of a Veteran's disabilities are nonetheless inadequately represented. Johnson v. McDonald, 762 F.3d 1362 (Fed. Cir. 2014). Therefore, referral for extraschedular consider may also be made to consider the compound/combined impact of multiple service-connected disabilities in determining whether referral for extraschedular consideration is needed. See id. In this case, referral for extraschedular consideration is not warranted. The Veteran's service-connected tension headache disability is manifested by signs and symptoms such as characteristic tension headaches involving the need to isolate himself from his family or work and take medication. See, e.g., Board Hr'g Tr. 4-5. These signs and symptoms, and their resulting functional impairments, are expressly contemplated by the rating schedule, which provides for disability ratings based on a broad and non-exclusive continuum pertaining to the severity, frequency, and duration of the characteristic prostrating attacks of headaches. See 38 C.F.R. § 4.124a , DC 8100. Therefore, the rating schedule was purposely designed to compensate for all symptoms of his headache disability. Finally, the Board notes that the Veteran is service-connected for other disabilities, including posttraumatic stress disorder and hemorrhoids. However, referral for extraschedular consideration has not been argued by the Veteran or reasonably raised by the record. See Yancy v. McDonald, 27 Vet. App. 484, 495 (2016). Even if it was argued or raised, after applying the benefit of the doubt in this case, there appear to be no additional symptoms or effects that have not been attributed to a specific service-connected disability. 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. Johnson, 762 F.3d 1362. Based on the foregoing, the Board need not proceed to consider the second factor, viz., whether there are attendant thereto related factors such as marked interference with employment or frequent periods of hospitalization. Consequently, the Board concludes that referral of this case for consideration of an extraschedular rating is not warranted. Thun, supra; Bagwell v. Brown, 9 Vet. App. 337, 338-39 (1996); Floyd v. Brown, 9 Vet. App. 88, 96 (1996). In Rice v. Shinseki, 22 Vet. App. 447 (2009), the Court held that a claim for total disability rating for compensation based on individual unemployability (TDIU) is part of an increased rating claim when such claim is expressly raised by the Veteran or reasonably raised by the record. The Court further held that when evidence of unemployability is submitted at the same time that the Veteran is appealing the initial rating assigned for a disability, the claim for TDIU will be considered part and parcel of the claim for benefits for the underlying disability. Id. In the instant case, as the evidence of record reflects that the Veteran has maintained full-time employment throughout the appeal period, the issue of entitlement to a TDIU has not been raised by the Veteran or the record and, as such, need not be considered further. To conclude, the Board finds that the Veteran's disability picture and symptomatology of his headache disability, taken as a whole and in combination with the subjective and objective evidence, has more nearly approximated the criteria for a 30 percent rating, but not higher, under DC 8100, throughout the appeal period. 38 U.S.C.A. § 5107; 38 C.F.R. §§ 3.102, 4.3; Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). Therefore, after resolving all reasonable doubt in the Veteran's favor, the appeal is granted to this extent. ORDER The appeal regarding the issue of entitlement to service connection for heat exhaustion is dismissed. The appeal regarding the issue of entitlement to service connection for left ring finger laceration is dismissed. The appeal regarding the issue of entitlement to service connection for exposure to foreign matter is dismissed. Service connection for neurodermatitis nodular of the left scalp is granted. Service connection for a left forearm growth is granted. An initial 30 percent rating, but no higher, for tension headaches, residuals of concussion, is granted, subject to the laws and regulations governing payment of monetary benefits. REMAND The claims of service connection for (1) left arm numbness; (2) a cervical spine disorder; (3) a left knee disorder; and (4) a left calf growth, must be remanded for further development. Missing STRs At his Board hearing, the Veteran testified that he had a growth removed from his left leg at Fort Eustis after service in 2007 or 2008. See Board Hr'g Tr. 26. Because those records are in the custody of a Federal department, they should be obtained. Radiation Exposure The Veteran maintains that he was exposed to radiation up to 500 occasions during service, which resulted in a left calf growth. See Board Hr'g Tr. 13. This included his service as an explosive ordinance disposal, which involved operating a portable X-ray machine. See Board Hr'g Tr. 10-11. In this same capacity, he also handled the penetrators of armor piercing tank rounds, which were made of depleted uranium. See Board Hr'g Tr. 11. Additionally, he was involved in nuclear emergency training operations, which resulted in direct exposure to a live source of radiation. See Board Hr'g Tr. 11. He indicated that he had been "issued many radiation dosimeter badges, but did not wear it every time." See Board Hr'g Tr. 12-13. In support of this appeal, the Veteran submitted a MedicineNet.com article in February 2010, which lists precancerous lesions, benign tumors, and skin changes as effects of chronic exposure to low levels of radiation over a long period of time. At present, the steps set forth in 38 C.F.R. § 3.311 have not been completed. Because the Veteran has submitted competent medical evidence that the claimed condition may be a radiogenic disease, such development is needed, to include an estimate of the levels of radiation to which he was likely exposed during his service. See 38 C.F.R. § 3.311(b)(4). VA Examinations With specific regard to the claimed left arm numbness, cervical spine, and knee conditions, a VA examination is needed to address the complex medical issues raised by the claims. With regard to the left arm numbness and cervical spine, the Veteran maintains that he first started having symptoms after a car accident in February 1995. See Board Hr'g Tr. 14, 31. He was also hit with a pipe on the top of his head during service. See Board Hr'g Tr. 34. The Board notes that the Veteran's STRs document treatment in the emergency room in February 1995 for neck strain after a car accident. Thus, there appears to be no reasonable dispute that this injury occurred. However, the STRs also repeatedly refer to a pre-service injury. An undated medical record (apparently after the February 1995 car accident) documents a history of a fracture to C6-7 in 1986. A January 2005 emergency room record (after being struck on the head with a pipe) also documents a primary medical history of fractured neck in 1986. Thus, there is some question as to whether a cervical spine condition preexisted service and, if so, whether it was aggravated by the in-service events. A VA examination is needed to address these complex medical questions. With regard to the left knee, the Veteran maintains that he first having left knee pain as "a young troop in 1989," and his knee had never been the same since 1989. See Board Hr'g Tr. 16. In fact, he explained, he thought he was going to be discharged from service at one point due to his left knee. See Board Hr'g Tr. 16. His left knee symptoms then continued intermittently throughout his service and since his retirement. See Board Hr'g Tr. 23, 25. The Veteran's STRs show treatment, consistent with his testimony, in September 1989, starting the month prior. (An undated medical record, likely created in August 1989, shows symptoms starting 3 days prior.) However, in conflict with his testimony, he underwent physical examinations thereafter, including in June 1990 and October 1999, at which times he denied all pertinent symptoms. Thus, it is unclear whether any current knee condition is related to the initial complaints in 1989. In March 2016, the Veteran's private doctor wrote a letter documenting the Veteran's "concern about some subacute vs. chronic left knee pain that he has." The doctor stated that "[t]his is also documented in his prior records though we had not previously addressed it. . . . . Xray imaging showed some mild to moderate arthritis in the left knee." It is not clear to the Board that this statement is intended to represent a nexus opinion favorably relating the current condition to service. If so, the Veteran is invited to seek clarification from this doctor. See, e.g., Savage v. Shinseki, 24 Vet. App. 259, 270, dismissed, 458 F. App'x 896 (Fed. Cir. 2011). Otherwise, a VA examination is needed to address these complex medical questions. Accordingly, the case is REMANDED for the following action: 1. Invite the Veteran to seek clarification from the private physician who submitted a letter in March 2016 addressing his left knee disorder as to whether he intended to offer a favorable medical opinion relating the Veteran's current left knee disorder to his military service. 2. Obtain all of the Veteran's treatment records from Fort Eustis not already associated with the claims file. All reasonable attempts should be made to obtain such records. If any records cannot be obtained after reasonable efforts have been made, issue a formal determination that such records do not exist or that further efforts to obtain such records would be futile, which should be documented in the claims file. The Veteran must be notified of the attempts made and why further attempts would be futile, and allowed the opportunity to provide such records, as provided in 38 U.S.C.A. § 5103A(b)(2) and 38 C.F.R. § 3.159(e). 3. Undertake all steps necessary to complete the action directed in 38 C.F.R. § 3.311 regarding radiation exposure, to include for preparation of a dose estimate, to the extent feasible, based on available methodologies. The dose estimate should establish the highest likely radiation dose(s) to which the Veteran was exposed during his service. 4. Next, the Under Secretary for Benefits should determine whether it is at least as likely as not that any exposure to ionizing radiation during the Veteran's service caused or contributed to his development of a left calf growth. 5. After completing all development set forth in paragraphs 1-4 above, and unless that development results in a grant of the benefit sought, arrange for the Veteran to undergo a VA examination to address the claimed left calf growth disorder. The relevant information in the claims file must be made available to the examiner for review. Accordingly, the examiner is asked to review the pertinent evidence, including the Veteran's lay assertions regarding the history of his symptomatology, and undertake any indicated studies. Based on the examination results, the examiner is asked to provide an expert medical opinion on each of the following question: Is it at least as likely as not (i.e., at least equally probable) that a left calf growth had its onset directly during the Veteran's service or is otherwise causally related to any event or circumstance of his service? In answering this question, please articulate the reasons underpinning your conclusions. That is, (1) identify what facts and information, whether found in the record or outside the record, support your opinion, and (2) explain how that evidence justifies your opinion. A report of the examination should be prepared and associated with the Veteran's VA claims file. 6. After completing all development set forth in paragraphs 1-2 above, arrange for the Veteran to undergo a VA examination to address the claimed left arm numbness and cervical spine disorder. The relevant information in the claims file must be made available to the examiner for review. Accordingly, the examiner is asked to review the pertinent evidence, including the Veteran's lay assertions regarding the history of his symptomatology, and undertake any indicated studies. Based on the examination results, the examiner is asked to provide an expert medical opinion on each of the following questions: (a) Provide a current diagnosis for any and all disorders found associated with left arm numbness and the cervical spine. If the Veteran previously had any such medical condition, but it is no longer extant, when did that condition resolve? (b) Did any diagnosed condition preexist the Veteran's active service, which began in March 1987? In answering this question, the examiner is asked to address medical records in the Veteran's STRs, including an undated record and a January 2005 medical record indicating a pre-service neck fracture in 1986. (c) If preexisting his service, did the condition worsen (i.e., increase in severity) during service? If yes, was that worsening due to the natural progress of the disease? How certain are you in your answers to questions (b) and (c)? Would any doctor with the same information reasonably be able to reach a different conclusion? (d) For each diagnosed disorder, is it at least as likely as not (i.e., at least equally probable) that the disorder had its onset directly during the Veteran's service or is otherwise causally related to any event or circumstance of his service? If you determined in questions (b) and (c) that a condition preexisted service, this should include consideration of whether the current condition represents the current manifestation of that same preexisting condition. In answering question (d), the examiner is asked to address the Veteran's treatment during service in February 1995 for a neck strain after a car accident, plus treatment in January 2005 after being struck on the head by a neighbor, which treatment included X-ray of the cervical spine. (e) If not directly related to service on the basis of question (b), is any left arm numbness proximately due to, the result of, or caused by any other medical condition(s)? If so, please identify the other medical condition(s). (f) If not caused by another medical condition, has any left arm numbness been aggravated (made permanently worse or increased in severity) by any other medical condition(s)? If so, please identify the other medical condition(s). Also, please identify whether any increase in severity was due to the natural progress of the disease. In answering all questions (a) to (f), please articulate the reasons underpinning your conclusions. That is, (1) identify what facts and information, whether found in the record or outside the record, support your opinion, and (2) explain how that evidence justifies your opinion. A report of the examination should be prepared and associated with the Veteran's VA claims file. 7. After completing all development set forth in paragraphs 1-2 above and, if that development does not allow for a full grant of the benefit sought on appeal, arrange for the Veteran to undergo a VA examination to address the claimed left knee disorder. The relevant information in the claims file must be made available to the examiner for review. Accordingly, the examiner is asked to review the pertinent evidence, including the Veteran's lay assertions regarding the history of his symptomatology, and undertake any indicated studies. Based on the examination results, the examiner is asked to provide an expert medical opinion on each of the following questions: (a) Provide a current diagnosis for any and all left knee disorders found extant. If the Veteran previously had any such medical condition, but it is no longer extant, when did that condition resolve? (b) For each diagnosed disorder, is it at least as likely as not (i.e., at least equally probable) that the disorder had its onset directly during the Veteran's service or is otherwise causally related to any event or circumstance of his service? In answering question (b), the examiner is asked to address treatment during service in 1989 and 1990 for left knee pain. The examiner is also asked to consider the Veteran's current testimony that he has had recurrent left knee symptoms since 1989. In answering all questions (a) to (b), please articulate the reasons underpinning your conclusions. That is, (1) identify what facts and information, whether found in the record or outside the record, support your opinion, and (2) explain how that evidence justifies your opinion. A report of the examination should be prepared and associated with the Veteran's VA claims file. 8. After completing the above actions, to include any other development as may be indicated by any response received as a consequence of the actions taken in the preceding paragraphs, the Veteran's claims should be readjudicated based on the entirety of the evidence. If the claims remain denied, the Veteran and his representative should be issued a supplemental statement of the case. An appropriate period of time should be allowed for response. Thereafter, the case should be returned to the Board for further appellate consideration, if otherwise in order. The Board intimates no opinion as to the outcome of this case. The Veteran need take no action until so informed. The purpose of this REMAND is to ensure compliance with due process considerations. The Veteran has the right to submit additional evidence and argument on the matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). These claims must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board 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). ______________________________________________ A. JAEGER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs