Citation Nr: 1802615 Decision Date: 01/11/18 Archive Date: 01/23/18 DOCKET NO. 10-45 118 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in San Diego, California THE ISSUES 1. Entitlement to service connection for diabetes mellitus, type II, (DM) to include as secondary to the service-connected hypertension and sleep apnea. 2. Entitlement to an initial compensable rating for sinusitis for the period prior to September 8, 2016, and in excess of 30 percent thereafter. REPRESENTATION Appellant represented by: The American Legion ATTORNEY FOR THE BOARD R.M.K., Counsel INTRODUCTION The Veteran served on active duty from February 1958 to February 1978. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a June 2009 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in San Diego, California. In February 2011 and October 2016 hearings were held before a Decision Review Officer (DRO) at the RO. Transcripts of the hearings are of record. A July 2015 Board decision denied a compensable rating for sinusitis. The Veteran appealed the Board's decision to the United States Court of Appeals for Veterans Claims (Court). In June 2016 the parties, the Veteran and the legal representative for the VA, the Office of General Counsel, filed a Joint Motion for Partial Remand to vacate the Board's decision denying a compensable rating for sinusitis and to remand the case to the Board. The Court granted the Joint Motion in June 2016. In August 2016 the Board remanded the case to the RO for additional development, to include a VA medical examination. In an October 2016 rating decision, the RO granted the Veteran a 30 percent rating for sinusitis, effective September 8, 2016, the date of the VA medical examination. The Veteran continued his claim for a higher rating. In January 2017 the Board remanded the case again for further development. When the issue of sinusitis was most recently before the Board in July 2017, it was remanded for additional evidentiary development. It has since been returned to the Board for further appellate action. The issues of entitlement to separate ratings for loss of smell and loss of taste, as secondary to the service-connected rhinitis, have been raised by the record. These issues have not been adjudicated by the Agency of Original Jurisdiction (AOJ); therefore, the Board does not have jurisdiction over them, and they are referred to the AOJ for appropriate action. 38 C.F.R. § 19.9 (b) (2017). This appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900 (c) (2017). 38 U.S.C.A. § 7107 (a) (2) (West 2014). This appeal was processed using the Veterans Benefits Management System (VBMS) and Virtual VA paperless claims processing systems. These records were reviewed in connection with the decision below. FINDINGS OF FACT 1. The weight of the competent and credible evidence shows that the Veteran does not currently have DM, nor has he had such during the pendency of the claim. 2. Prior to September 8, 2016, the Veteran's sinusitis was not shown to have been manifested by one or two incapacitating episodes per year requiring prolonged (four to six weeks) antibiotic treatment, or; three to six non-incapacitating episodes per year characterized by headaches, pain, and purulent discharge or crusting or by manifestations approximating such level of severity. 3. Since September 8, 2016, the Veteran's sinusitis has not been shown as 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. CONCLUSIONS OF LAW 1. The criteria for service connection for DM have not been met. 38 U.S.C.A. §§ 1110, 1131, 5107 (West 2014); 38 C.F.R. § 3.303 (2017). 2. Prior to September 8, 2016, a compensable rating for sinusitis is not warranted. 38 U.S.C.A. §§ 1155, 5107 (2014); 38 C.F.R. §§ 4.1, 4.21, 4.31, 4.97, Diagnostic Codes 6510 - 6514 (2017). 3. Since September 8, 2016, a rating in excess of 30 percent for sinusitis is not warranted. 38 U.S.C.A. §§ 1155, 5107 (2014); 38 C.F.R. §§ 4.1, 4.21, 4.31, 4.97, Diagnostic Codes 6510 - 6514 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Board has reviewed all the evidence in the electronic claims file. Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, all the evidence submitted by or on behalf of the appellant. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (noting that the Board must review the entire record, but does not have to discuss each piece of evidence). The analysis below focuses on the most salient and relevant evidence and on what this evidence shows, or fails to show, on the claims. The appellant must not assume that the Board has overlooked pieces of evidence that are not explicitly discussed herein. See Timberlake v. Gober, 14 Vet. App. 122 (2000) (explaining that the law requires only that the Board address its reasons for rejecting evidence favorable to the Veteran). Duties to Notify and Assist VA satisfied its duty to notify the Veteran pursuant to the Veterans Claims Assistance Act of 2000 (VCAA) in a September 2008 letter. 38 U.S.C.A. §§ 5100, 5102-5103A, 5106, 5107, 5126 (West 2014); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a), 4.2 (2017). The Veteran's appeal regarding his sinusitis arises from an appeal of the initial evaluation following the grant of service connection. Once service connection is granted the claim is substantiated, additional notice is not required. Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007); Dunlap v. Nicholson, 21 Vet. App. 112 (2007); 38 C.F.R. § 3.159 (b)(3)(i) (no duty to provide notice upon receipt of a notice of disagreement); VAOPGCPREC 8-2003 (in which the VA General Counsel interpreted that separate notification is not required for "downstream" issues following a service connection grant, such as initial rating and effective date claims). Based on the foregoing, adequate notice was provided to the Veteran prior to the transfer and certification of this case to the Board and complied with the requirements of 38 U.S.C. § 5103 (a) and 38 C.F.R. § 3.159 (b), and no further notice is needed. Concerning the duty to assist, the record reflects that VA has made reasonable efforts to obtain relevant records adequately identified by the Veteran, including his service treatment records, post-service treatment records, and VA examination reports. The Veteran was provided February 2011 and October 2016 hearings before a DRO at the RO. As there is no allegation that the hearings provided to the Veteran were deficient in any way, further discussion of the adequacy of the hearings is not necessary. Dickens v. McDonald, 814 F.3d 1359 (Fed. Cir. 2016). As noted above, the issue of sinusitis was most recently before the Board in July 2017 when it was remanded to obtain an addendum VA opinion. An addendum opinion was received in August 2017. Accordingly, there has been substantial compliance with the Board's remand directives. Stegall v. West, 11 Vet. App. 268 (1998). Service Connection Claim Generally, service connection may be granted for disability or injury incurred in or aggravated by active military service. See 38 U.S.C.A. §§ 1110, 1131 (West 2014); 38 C.F.R. § 3.303 (2017). In order to establish service connection for the claimed disorder, there must be (1) competent evidence of a current disability; (2) medical, or in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and (3) competent evidence of a nexus between the claimed in-service disease or injury and the current disability. See Hickson v. West, 12 Vet. App. 247, 253 (1999). The determination as to whether these requirements are met is based on an analysis of all the evidence of record and the evaluation of its credibility and probative value. See Baldwin v. West, 13 Vet. App. 1, 8 (1999). Service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. DM is a chronic disease listed under 38 C.F.R. § 3.309 (a); therefore, the presumptive service connection provisions based on "chronic" in-service symptoms and "continuous" post-service symptoms under 38 C.F.R. § 3.303 (b) apply. Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Presumptive periods are not intended to limit service connection to diseases so diagnosed when the evidence warrants direct service connection. The presumptive provisions of the statute and VA regulations implementing them are intended as liberalizations applicable when the evidence would not warrant service connection without their aid. 38 C.F.R. § 3.303(d). In this case, as outlined below, the Board finds that the weight of the competent and credible evidence shows that the Veteran does not currently have DM, nor has he had such during the pendency of the claim. Therefore, Hickson element (1) is not met. The Board acknowledges that private treatment records show assessments of DM. Dr. D.S. submitted correspondence in February 2010, stating in pertinent part that the Veteran had DM. Dr. I.T. submitted correspondence in March 2010 and February 2011, stating that the Veteran was treated for DM. The Veteran was afforded a VA examination in September 2011 in which the examiner noted a diagnosis of DM in 2006. M.A., physician assistant, submitted correspondence in February 2015 stating that the Veteran was currently experiencing DM. Dr. M.G. submitted correspondence in November 2016, stating that he was the attending physician for the Veteran and was treating him for DM. Conversely, Dr. G.A. submitted correspondence in April 2015, stating that he was asked by VA to determine if the Veteran had impaired fasting glucose (IFG) or DM. Dr. G.A. stated that the Veteran's highest A1C was 6.1 percent, and he did not have any blood glucose values above 126; therefore, the Veteran's diagnosis was IFG and did not meet lab criteria for DM. The Veteran was afforded a VA examination in April 2015 in which the examiner noted review of treatment notes, to specifically include a note from January 2007 of "abnl Alc," but that the note did not include an A1C value or lab results and there was no diagnosis of DM. The examiner stated that the next treatment note of February 2007 showed that DM appeared on the diagnosis list, but with no justification. The VA examiner noted that there were also labs from 2008 and 2011, none of which fulfilled the criteria for a diagnosis of DM; there were also lab results consisting of glucoses and A1C values done from 2005 to 2010 which showed that the Veteran had fasting glucose of 116 and A1C of 5.8 in 2005. The VA examiner noted that Dr. G.A. concluded that, although some of the treatment notes state DM as diagnosis, the diagnosis of DM was incorrect, and the correct diagnosis was IFG. The VA examiner stated that there was no diagnosis of DM at that time. The Veteran was also afforded a VA examination in July 2017 in which the examiner stated that the Veteran did not have a verified diagnosis of DM. The examiner stated that there was insufficient evidence to confirm or verify a diagnosis of DM; although there was some mention of DM in treatment notes, it was not clear how the diagnosis came about, whether it was self-reported or verified. The VA examiner stated that there was no objective lab result submitted to verify a diagnosis of DM, and that taking the medication Metformin did not verify a diagnosis of DM as Metformin was prescribed for other conditions other than DM. The examiner noted that the Veteran's past endocrinologist also noted that he did not fulfill laboratory criteria for a diagnosis of DM. The Board notes that greater weight may be placed on one physician's opinion than another's depending on factors such as the reasoning employed by the physicians. Gabrielson v. Brown, 7 Vet. App. 36, 40 (1994). Additionally, while the findings of a physician are medical conclusions that the Board cannot ignore or disregard, Willis v. Derwinski, 1 Vet. App. 66 (1991); the Board is free to assess medical evidence and is not obligated to accept a physician's opinion. Wilson v. Derwinski, 2 Vet. App. 614 (1992). In this case, the Board finds that the April 2015 and July 2017 VA opinions are the most persuasive. To this point, the VA opinions were based upon thorough review of the evidence of record, to specifically include analysis of the Veteran's A1C values, blood glucose levels, and private treatment records that purported to show diagnoses of DM. The VA examiners stated that although there was some mention of DM in treatment notes, it was not clear how the diagnosis came about, whether it was self-reported or verified. The VA examiners sought clarification from the Veteran's past endocrinologist to confirm that he did not fulfill laboratory criteria for a diagnosis of DM. Here, the competent, credible, and probative evidence of record does not show that the Veteran has a current disability for VA benefits purposes due to his IFG laboratory reading. As such, the Veteran does not have a current DM disability under the law, and as a result, service connection cannot be granted. In the absence of proof of a present disability there can be no valid claim. Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). The Board acknowledges that the Veteran is competent to testify as to his beliefs that he has DM. However, there is nothing in the record to suggest that the Veteran has the appropriate training, experience, or expertise to render a medical diagnosis or opinion regarding etiology. See 38 C.F.R. § 3.159 (a)(1) (2017) (setting forth that competent medical evidence means evidence provided by a person who is qualified through education, training, or experience to offer medical diagnoses, statements, or opinions). While the Veteran was competent to report what he has experienced, he was not competent to ascertain the diagnosis or etiology of any current condition, as the causative factors for such are not readily subject to lay observation. These assertions are outweighed by the competent and probative medical opinion. See Charles v. Principi, 16 Vet. App. 370, 374-75 (2002); Layno v. Brown, 6 Vet. App. 465 (1994). Therefore a diagnosis cannot be established, and the criteria of Hickson element (1) are not met. With regards to presumptive service connection, the weight of the evidence shows no chronic symptoms of DM during service, no continuous symptoms of the condition since service, and that DM did not manifest to a compensable degree within one year of service. To this point, service treatment records are absent for any showing of chronic symptoms, testing, or diagnosis for DM. As such, presumptive service connection is not warranted. In reaching this determination, the Board acknowledges that VA is statutorily required to resolve the benefit-of-the-doubt in favor of the Veteran when there is an approximate balance of positive and negative evidence regarding the merits of an outstanding issue. That doctrine, however, is not applicable in this case because the preponderance of the evidence is against the Veteran's claim. See Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990); 38 U.S.C.A. § 5107(b) (West 2014). Disability Ratings Disability evaluations are determined by evaluating the extent to which a Veteran's service-connected disability adversely affects his ability to function under the ordinary conditions of daily life, including employment, by comparing the Veteran's symptomatology with the criteria set forth in the Schedule for Rating Disabilities (Rating Schedule). 38 U.S.C.A. § 1155; 38 C.F.R. §§ 4.1, 4.2, 4.10. If two evaluations are potentially applicable, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that evaluation; otherwise, the lower evaluation will be assigned. 38 C.F.R. § 4.7. However, the evaluation of the same disability under various diagnoses, known as pyramiding, is to be avoided. 38 C.F.R. § 4.14. Any reasonable doubt regarding a degree of disability is resolved in favor of the Veteran. 38 C.F.R. § 4.3. The Veteran's entire history is to be considered when making disability evaluations. See generally 38 C.F.R. § 4.1; Schafrath v. Derwinski, 1 Vet. App. 589 (1995). The Board acknowledges that a claimant may experience multiple distinct degrees of disability that might result in different levels of compensation from the time the increased rating claim was filed until a final decision is made. Hart v. Mansfield, 21 Vet. App. 505 (2007); Fenderson v. West, 12 Vet. App 119 (1999). Initially, it is noteworthy that the Veteran was also awarded service connection for rhinitis, rated 30 percent. The matter of the rating for rhinitis is not before the Board, and symptoms and pathology attributed to that disability (e.g., polyps, obstruction) may not be considered in rating sinusitis (see 38 C.F.R. § 4.14 ). The General Rating Formula for Sinusitis, provided for Diagnostic Codes 6510 through 6514, provides the following: a 10 percent rating for one or two incapacitating episodes per year of sinusitis requiring prolonged (lasting four to six weeks) antibiotic treatment, or; three to six non-incapacitating episodes per year of sinusitis characterized by headaches, pain, and purulent discharge or crusting; a 30 percent rating for three or more incapacitating episodes per year of sinusitis requiring prolonged (lasting four to six weeks) antibiotic treatment, or; more than six non-incapacitating episodes per year of sinusitis characterized by headaches, pain, and purulent discharge or crusting; and a 50 percent rating, the maximum available, 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. For VA purposes, an incapacitating episode of sinusitis means one that requires bed rest and treatment by a physician. See 38 C.F.R. § 4.97, Diagnostic Codes 6510 through 6514, Note. Sinusitis - Prior to September 8, 2016 The Veteran was afforded a VA examination in March 2009 in which he reported one to two episodes of acute sinusitis per year lasting one to two weeks characterized by high fevers, facial pressure and pain, headaches, and purulent drainage from the nose. Treatment was noted as antibiotics. He reported that during periods of sinus infection, he had moderate impairment in his ability to perform daily activities and performed things more slowly but worked through it. The Veteran was afforded a VA examination in February 2010 in which it was noted that there was no congestion, facial pain, or headache; and there were no incapacitating episode requiring bedrest and treatment by a physician. On physical examination there was no tenderness of the sinuses and X-rays were normal. The diagnosis was sinusitis by history, no acute sinusitis at present. At the February 2011 DRO hearing, the Veteran testified that he was having congestion, headache, and occasional ear pain. He took prescribed medication daily. The Veteran was afforded a VA examination in February 2015 in which he denied facial pressure and pain but had purulent nasal discharge at times. On physical examination he reported episodes of sinusitis and purulent discharge. He had had two non-incapacitating episodes of sinusitis characterized by headaches, pain, and purulent discharge or crusting in the past 12 months. He did not have any incapacitating episodes of sinusitis requiring prolonged use of antibiotics treatment in the past 12 months. The examiner noted that the Veteran endorsed a history consistent with chronic sinusitis; his symptoms were well controlled. The Veteran submitted a statement in July 2016, noting that he continued to have two non-incapacitating episodes of sinusitis per year with associated symptoms of high fevers, facial pressure and pain, congestion, headaches, ear pain, and purulent drainage and crusting of the nose. He listed three different medications he took for temporary relief of symptoms, in addition to antibiotics. He also indicated that he experienced stuffy nose, sneezing, difficulty breathing, fatigue, irritability, and a loss of a sense of smell. Based on review of the evidence of record prior to September 8, 2016, the Board finds that a compensable rating for sinusitis is not warranted. Again, the Board points out that a 10 percent rating is warranted under Diagnostic Codes 6510 through 6514 for one or two incapacitating episodes per year of sinusitis requiring prolonged (lasting four to six weeks) antibiotic treatment, or; three to six non-incapacitating episodes per year of sinusitis characterized by headaches, pain, and purulent discharge or crusting Prior to September 8, 2016, sinusitis was not shown to have been manifested by one or two incapacitating episodes per year requiring prolonged (four to six weeks) antibiotic treatment, or; three to six non-incapacitating episodes per year characterized by headaches, pain, and purulent discharge or crusting. The Board notes that the Veteran complained of headaches, pain, and purulent discharge or crusting. However, the record does not show any incapacitating episodes of sinusitis during the period under consideration, and the Veteran did not report having more than two non-incapacitating episodes in a year; that is, in March 2009 he reported one or two non-incapacitating (as described) episodes per year, and in February 2015 he reported having one non-incapacitating episode in the past year. Consequently, a schedular compensable rating for sinusitis prior to September 8, 2016, is not warranted. Sinusitis - Since September 8, 2016 As noted above, in an October 2016 rating decision, the RO granted the Veteran a 30 percent rating for sinusitis, effective September 8, 2016. The Veteran submitted a statement in September 2016 that he suffered from his sinus problems with the worst times during the winter and spring related to pollen season. He stated that he used over-the-counter nasal spray. The Veteran was afforded a VA examination in September 2016 in which his symptoms were noted to include chronic running nose that responded to nasal spray and seven or more non-incapacitating episodes of sinusitis characterized by headaches, pain, and purulent discharge or crusting occurring in the past 12 months (but no requirement of prolonged antibiotic treatment). The Veteran had no incapacitating episodes, and there was no radiographic evidence of air fluid levels to suggest acute sinusitis. In January 2017 the Board remanded this claim, in pertinent part to schedule the Veteran for a VA examination to ascertain the severity of his sinusitis. The examiner was specifically requested to address whether there was an anatomical or pathological basis for any loss of a sense of smell and/or taste due to the Veteran's sinusitis or due to the medications prescribed for the treatment of sinusitis. The Veteran was afforded a VA examination in February 2017 in which his symptoms were noted to include nasal congestion, itchy watery eyes, sneezing that was worse in the springtime, occasional facial pain/pressure in the maxillary area as well as decreased ability to smell. He did not have thick, purulent nasal drainage, but noted some occasional anterior nasal "yellow" drainage. He reported three non-incapacitating episodes of sinusitis characterized by headaches, pain, and purulent discharge or crusting occurring in the past 12 months. The Veteran had no incapacitating episodes. The examiner stated that the Veteran's nasal congestion and current nasal complaints were mostly due to his untreated rhinitis; his sinusitis was only very mild and did not have a significant impact on his quality of life. The examiner stated that the Veteran's rhinitis and sinusitis were not the cause of his severe anosmia (loss of sense of smell), as his smell complaints were far out of proportion to objective findings on examination. In July 2017 the Board found that the February 2017 VA examiner failed to address whether the Veteran's losses of sense of smell/taste were due to medications prescribed for the sinusitis. Therefore, the Board remanded the claim to obtain an addendum opinion. An addendum VA opinion was received in August 2017 in which the examiner stated in pertinent part that the Veteran did not have sinusitis. The examiner stated that the Veteran was diagnosed with total anosmia; allergic rhinitis was a common cause of anosmia. The examiner stated that while it was typically temporary, anosmia could be permanent; it was not related to medications used to treat allergic rhinitis, but due to the inflammation of the olfactory mucosa. The examiner explained that anosmia would cause hypogeusia (reduced ability to taste things) as most taste sensation was actually smell; these were the same thing and did not represent separate disease processes. The examiner opined that it was more likely than not (greater than 50 percent) that the Veteran's anosmia was caused by his service-connected allergic rhinitis. Based on review of the evidence of record since September 8, 2016, the Board finds that a rating in excess of 30 percent for sinusitis is not warranted. Since September 8, 2016, the Veteran was not shown to require radical surgery with chronic osteomyelitis for his sinusitis; nor did he experience near constant sinusitis characterized by headaches, pain and tenderness of affected sinus, and purulent discharge or crusting after repeated surgeries. To this point, the Veteran has not required surgery for his sinusitis, there was no radiographic evidence of air fluid levels to suggest acute sinusitis in September 2016, and recent examinations either found very mild sinusitis or no confirmed sinusitis of any kind. Consequently, a schedular rating in excess of 30 percent for sinusitis since September 8, 2016, is not warranted. The Board has also reviewed the remaining diagnostic codes for the Veteran's sinusitis and finds that the evidence does not support a higher rating under any alternate diagnostic codes relevant to the disability. See 38 C.F.R. § 4.118 (2017). To this point, the Board acknowledges that VA rating criteria provides for a rating for loss of a sense of smell and loss of a sense of taste, where there is an anatomical or pathological basis for the condition. See 38 C.F.R. § 4.87a, Codes 6275 and 6276. However, the August 2017 VA examiner opined that it was more likely than not (greater than 50 percent) that the Veteran's anosmia was caused by his service-connected allergic rhinitis. As previously noted, the matter of the rating for rhinitis is not before the Board; the issues regarding separate ratings for loss of smell and loss of taste are referred to the AOJ for appropriate action. The Board has also considered the Veteran's statements describing his symptoms for the sinusitis, and he is certainly competent to report any observable symptoms. See Charles v. Principi, 16 Vet. App. 370, 374 (2002) (finding veteran competent to testify to symptomatology capable of lay observation); Layno v. Brown, 6 Vet. App. 465, 469 (1994) (noting competent lay evidence requires facts perceived through the use of the five senses). However, the Board finds that the Veteran's lay evidence is outweighed by the competent and credible medical evidence that evaluates the extent of any impairment attributable to the service-connected sinusitis based on objective data coupled with the lay complaints. The VA examiners have the training and expertise necessary to administer the appropriate tests for a determination of the type and degree of the impairment associated with the Veteran's complaints. In addition, their reports provide sufficient information to allow the Board to apply the schedular criteria. For these reasons, greater evidentiary weight is placed on the examination findings in regard to the type and degree of impairment. In sum, because the preponderance of the evidence is against the Veteran's claims, the benefit-of-the-doubt doctrine is not for application and the claims must be denied. See 38 U.S.C.A. § 5107 (b) (West 2014); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Total rating for compensation purposes based on individual unemployability (TDIU) Finally, the Board is cognizant of the ruling of the Court in Rice v. Shinseki, 22 Vet. App. 447 (2009). In Rice, the Court held that a claim for a TDIU, either expressly raised by the Veteran or reasonably raised by the record, involves an attempt to obtain an appropriate rating for a disability and is part of the claim for an increased rating. The Board finds that the issue of entitlement to a TDIU has not been reasonably raised by the record. ORDER Entitlement to service connection for DM is denied. Entitlement to an initial compensable rating for sinusitis for the period prior to September 8, 2016, and in excess of 30 percent thereafter is denied. ____________________________________________ K. J. ALIBRANDO Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs