Citation Nr: 1802909 Decision Date: 01/12/18 Archive Date: 01/23/18 DOCKET NO. 13-09 472A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUES 1. Entitlement to service connection for a disability manifested by loss of peripheral vision to include as secondary to service-connected disease or injury. 2. Entitlement to service connection for a cervical spine disability to include as secondary to service-connected disease or injury. 3. Entitlement to service connection for a right shoulder disability to include as secondary to service-connected disease or injury. 4. Entitlement to service connection for a left shoulder disability to include as secondary to service-connected disease or injury. 5. Entitlement to service connection for a disability manifested by sleep disturbance, to include sleep apnea and to include as secondary to service-connected disease or injury. 6. Entitlement to service connection for bilateral carpal tunnel syndrome to include as secondary to service-connected disease or injury. 7. Entitlement to a disability rating in excess of 30 percent for residuals of injury to the right fifth cranial nerve with conversion insufficiency and headaches. 8. Entitlement to a total disability rating based upon individual unemployability due to service-connected disabilities (TDIU). REPRESENTATION Veteran represented by: J. Michael Woods, Attorney at Law ATTORNEY FOR THE BOARD Arif Syed, Counsel INTRODUCTION The Veteran had active service from November 1967 to November 1970. These matters come before the Board of Veteran's Appeals (Board) from October 2009 and July 2012 rating decisions of the Department of Veteran Affairs (VA), Regional Office (RO) in St. Petersburg, Florida. In April 2015, the Board remanded the Veteran's claims. The Veteran's VA claims folder has been returned to the Board for further appellate proceedings. In the case of Rice v. Shinseki, 22 Vet. App. 447 (2009), the United States Court of Appeals for Veterans' Claims (Court) held, in substance, that every claim for a higher evaluation includes a claim for TDIU where the Veteran claims that his service-connected disability prevents him from working. In this case, the Board notes that a private treatment record from H.S., M.D., dated April 2014 indicates that the Veteran is unable to sustain the stress of gainful activity secondary to the level of all of his service-connected conditions which includes his residuals of injury to the right fifth cranial nerve with conversion insufficiency and headaches. Accordingly, in light of the holding in Rice, the issue on appeal includes entitlement to TDIU. In an October 2013 rating decision, the RO denied the Veteran's claims of entitlement to service connection for a back disability, a right hip disability, a left hip disability, anxiety, and depression. The electronic Veterans Appeals Control and Locator System (VACOLS) as well as the Veterans Benefits Management System (VBMS) claims folder indicate that the Veteran filed a notice of disagreement (NOD) with the denial of these claims in September 2014. The VBMS claims folder further reflects that the RO acknowledged receipt of the NOD in a letter to the Veteran dated February 2016. Accordingly, as the receipt of the NOD with respect to the Veteran's back disability, right hip disability, left hip disability, anxiety, and depression claims have all been acknowledged by the RO, this situation is distinguishable from Manlincon v. West, 12 Vet. App. 238 (1999), where a NOD had not been recognized. As VACOLS and VBMS reflect that the NOD has been recognized and that additional action is pending at the RO with regard to the back disability, right hip disability, left hip disability, anxiety, and depression claims, Manlincon is not applicable in this case. The issues of entitlement to service connection for a cervical spine disability, a right shoulder disability, and a left shoulder disability are addressed in the REMAND portion of the decision below and are REMANDED to the Agency of Original Jurisdiction (AOJ). FINDINGS OF FACT 1. Sleep apnea that is caused by his service-connected residuals of injury to the nose with deviated septum. 2. A disability manifested by peripheral vision loss is not currently manifest and did not manifest at any point during the appeal period. 3. The Veteran's residuals of injury to the right fifth cranial nerve with conversion insufficiency and headaches is manifested by no worse than severe, incomplete paralysis of the fifth (trigeminal) cranial nerve. CONCLUSIONS OF LAW 1. Sleep apnea is caused by service-connected residuals of injury to the nose with deviated septum. 38 C.F.R. § 3.310 (2017). 2. A disability manifested by peripheral vision loss was not incurred in or aggravated by service. 38 U.S.C. § 1110 (2012); 38 C.F.R. § 3.303 (2017). 3. A disability manifested by peripheral vision loss is not proximately due to or the result of (causation or aggravation) a service connected disease or injury. 38 C.F.R. § 3.310 (2017). 4. The criteria for the assignment of a rating in excess of 30 percent for residuals of injury to the right fifth cranial nerve with conversion insufficiency and headaches have not been met. 38 U.S.C. § 1155 (2012); 38 C.F.R. § 4.124a, Diagnostic Code 8205 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran seeks entitlement to service connection for a disability manifested by sleep disturbances and a disability manifested by loss of peripheral vision as well as entitlement to an increased disability rating for residuals of injury to the right fifth cranial nerve with conversion insufficiency and headaches. Stegall concerns In April 2015, the Board remanded the Veteran's sleep disturbance, loss of peripheral vision, and residuals of injury to the right fifth cranial nerve with conversion insufficiency and headaches and ordered the agency of original jurisdiction (AOJ) to obtain outstanding Social Security Administration (SSA) records. The AOJ was to also obtain a VA medical opinion as to the etiology of the Veteran's sleep disturbances and loss of peripheral vision claims as well as an examination to determine the severity of his residuals of injury to the right fifth cranial nerve with conversion insufficiency and headaches. The Veteran's claims were then to be readjudicated. Pursuant to the Board's remand instructions, the agency of original jurisdiction (AOJ) attempted to obtain outstanding SSA records. This will be discussed in detail below. Further, VA medical opinions were obtained in July 2016 as to the etiology of the Veteran's disabilities manifested by sleep disturbance and loss of peripheral vision. The Veteran was also provided a VA examination in July 2016 for his residuals of injury to the right fifth cranial nerve with conversion insufficiency and headaches. The Veteran's claims were readjudicated via a December 2016 supplemental statement of the case (SSOC). Accordingly, the Board's remand instructions have been substantially complied with. See Stegall v. West, 11 Vet. App. 268, 271 (1998) [where the remand orders of the Board are not complied with, the Board errs as a matter of law when it fails to ensure compliance]. Duties to Notify and Assist VA has a duty to notify the claimant and the claimant's representative, if any, of any information, and any medical or lay evidence, not previously provided to the Secretary that is necessary to substantiate the claim. This notice must specifically inform the claimant of which portion, if any, of the evidence is to be provided by the claimant and which part, if any, VA will attempt to obtain on behalf of the claimant. See 38 U.S.C. § 5103(a) (2012); 38 C.F.R. § 3.159(b) (2017). In a letter mailed to the Veteran in May 2009, prior to the initial adjudication of his service connection claims, VA satisfied this duty. VA also has a duty to assist a claimant in the development of his claims. See 38 U.S.C. § 5103A (2012); 38 C.F.R. § 3.159(c) (2017). Here, reasonable efforts have been made to assist the Veteran in obtaining evidence necessary to substantiate his claims. The pertinent evidence of record includes statements from the Veteran and his wife, service treatment records, and post-service VA and private treatment records. In general, VA's duty to assist includes obtaining records from the Social Security Administration (SSA). See Murincsak v. Derwinski, 2 Vet. App. 363 (1992). The record demonstrates that the Veteran is currently in receipt of SSA benefits. The record further demonstrates that the RO requested records in connection with the Veteran's SSA disability benefits claim from the SSA in February 2016, and in a subsequent response dated February 2016, the SSA informed the RO that there are no medical records available in connection with the Veteran's SSA disability benefits claim. The Veteran was informed of the negative response from the SSA in a letter dated June 2016. The Veteran has not submitted or identified any outstanding evidence pertaining to his SSA records which could be obtained to substantiate the claims. Additionally, the Veteran was afforded VA examinations in January 2013 and July 2016 for his claimed disability manifested by loss of peripheral vision and in October 2009 and July 2016 for his residuals of injury to the right fifth cranial nerve with conversion insufficiency and headaches. The VA examination reports reflect that the examiners interviewed and examined the Veteran, reviewed his past medical history, documented his current medical conditions, and rendered appropriate diagnoses consistent with the remainder of the evidence of record. Furthermore, these examination reports contain sufficient information to rate the Veteran's residuals of injury to the right fifth cranial nerve with conversion insufficiency and headaches under the appropriate diagnostic criteria. Neither the Veteran nor his attorney has raised any issues with the duty to notify or duty to assist. See Scott v McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015) (holding that "the Board's obligation to read filings in a liberal manner does not require the Board . . . to search the record and address procedural arguments when the veteran fails to raise them before the Board."); Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016) (applying Scott to duty to assist argument). The Board finds that under the circumstances of this case, VA has satisfied the notification and assistance provisions of the law, and that no further action need be undertaken on the Veteran's behalf. Service connection for disability manifested by sleep disturbance The Veteran contends that he has a disability manifested by sleep disturbance that is related to his service. He alternatively contends that his disability is related to his service-connected residuals of injury to the nose with deviated septum. See, e.g., a private treatment record from H.S., M.D., dated April 2014. Veterans are entitled to compensation from VA if they develop a disability "resulting from personal injury suffered or disease contracted in line of duty, or for aggravation of a preexisting injury suffered or disease contracted in line of duty." 38 U.S.C. § 1110 (wartime service), 1131 (peacetime service). To establish a right to compensation for a present disability, a veteran must show: "(1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service"-the so-called "nexus" requirement. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed.Cir. 2004). Service connection is also warranted for disability which is proximately due to or the result of a service-connected disease or injury. When service connection is thus established for a secondary condition, the secondary condition shall be considered a part of the original condition. 38 C.F.R. § 3.310(a). Any increase in severity of a non-service connected disease or injury that is proximately due to or the result of a service connected disease or injury, and not due to the natural progress of the nonservice connected disease or injury will be service connected. However, VA will not concede that a non-service-connected disease or injury was aggravated by a service-connected disease or injury unless the baseline level of severity of the nonservice-connected disease or injury is established by medical evidence created before the onset of aggravation and the receipt of medical evidence establishing the current level of severity of the nonservice-connected disease or injury. The rating activity will determine the baseline and current levels of severity under the Schedule for Rating Disabilities (38 C.F.R. Part 4) and determine the extent of aggravation by deducting the baseline level of severity, as well as any increase in severity due to the natural progress of the disease, from the current level. 38 C.F.R. § 3.310(b). For secondary service connection to be granted, generally there must be (1) evidence of a current disability; (2) evidence of a service-connected disease or injury; and (3) nexus evidence establishing a connection between the service-connected disability and the current disability. See Wallin v. West, 11 Vet. App. 509, 512 (1998). When service connection is thus established for a secondary condition, the secondary condition shall be considered a part of the original condition. 38 C.F.R. § 3.310 (2017); see Harder v. Brown, 5 Vet. App. 183, 187 (1993). Additional disability resulting from the aggravation of a nonservice-connected condition by a service-connected condition is also compensable under 38 C.F.R. § 3.310(a). See Allen v. Brown, 7 Vet. App. 439, 448 (1995). The Board notes that the Veteran has not claimed that his disabilities on appeal are the result of combat with the enemy. Therefore, the combat provisions of 38 U.S.C. § 1154 (2012) are not for consideration. After the evidence is assembled, it is the Board's responsibility to evaluate the entire record. See 38 U.S.C. § 7104(a) (2012). When there is an approximate balance of evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each issue shall be given to the claimant. See 38 U.S.C.A. § 5107 (2012); 38 C.F.R. §§ 3.102, 4.3 (2017). In Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990), the United States Court of Appeals for Veterans Claims (Court) stated that "a veteran need only demonstrate that there is an 'approximate balance of positive and negative evidence' in order to prevail." To deny a claim on its merits, the preponderance of the evidence must be against the claim. See Alemany v. Brown, 9 Vet App. 518, 519 (1996), citing Gilbert, 1 Vet. App. at 54. As will be discussed below, the Board finds that the most probative evidence of record demonstrates that the Veteran currently has sleep apnea that is secondary to his service-connected residuals of injury to the nose with deviated septum. As such, service connection on a direct basis will not be discussed herein. A probative medical opinion is of record concerning the issue of nexus for the Veteran's disability manifested by sleep disturbance in the form of an August 2014 private opinion by Dr. H.S. Specifically, after review of the Veteran's medical history, Dr. H.S. assessed the Veteran with sleep apnea and concluded that it is more likely than not that the Veteran's service-connected deviated nasal symptom aggravates his current obstructive sleep apnea. Dr. H.S.'s rationale for his conclusion was based on his review of the Veteran's medical history as well as medical literature, in particular an article titled "Effects of Nasal Pathologies on Obstructive Sleep Apnea" which showed that abnormalities in the nose and pharynx can cause or aggravate snoring or sleep apnea. Dr. H.S. also noted that while the Veteran is a smoker and overweight and that these factors can cause sleep apnea, it was clear to him that the deviated nasal septum also aggravated the sleep apnea. He further noted that the Veteran had the deviated septum in service and has had sleeping difficulty since then. In this case, the Board finds that the most probative evidence supports a finding that the Veteran currently has sleep apnea that is aggravated by his service-connected residuals of injury to the nose with deviated septum. In this regard, the Board finds the medical opinion of Dr. H.S. highly probative as such opinion was based on thorough review of the Veteran's medical history. While the Board acknowledges that a VA examiner opined in a July 2016 VA opinion report that the Veteran's residuals of injury to the nose with deviated septum did not cause or aggravate his diagnosed sleep apnea, the Board notes that the examiner's opinion was based on her finding that medical literature does not support a finding of causation or aggravation. However, the examiner did not address the medical article referenced by Dr. H.S. in his April 2014 private report which indicates a deviated septum can cause or aggravate sleep apnea. She also did not address in her rationale the Veteran's report of sleeping difficulty since his deviated septum. Therefore, the Board finds that the July 2016 VA opinion is outweighed in probative value by the private report from Dr. H..S. Accordingly, there is a competent and credible basis to conclude that the Veteran's current sleep apnea is caused by his service-connected residuals of injury to the nose with deviated septum, particularly when reasonable doubt is resolved in his favor. See 38 U.S.C. § 5107(b) (2012); 38 C.F.R. § 3.102 (2017). Therefore, service connection for a disability manifested by sleep disturbance, specifically sleep apnea, as secondary to the Veteran's service-connected residuals of injury to the nose with deviated septum is warranted. See 38 U.S.C. § 1110; 38 C.F.R. § 3.303, 3.310. Service connection for disability manifested by loss of peripheral vision The Veteran contends that he has a disability manifested by loss of peripheral vision that is related to his service. He alternatively contends that his disability is related to his service-connected disabilities which are sleep apnea, residuals of injury to the right fifth cranial nerve with conversion insufficiency and headaches, residuals of injury to the nose with deviated septum, and residuals of fracture to the intraorbital rim and front-zygomatic suture. See the Veteran's claim for VA benefits dated January 2009. The evidence of record establishes that the Veteran does not have a current disability manifested by loss of peripheral vision. In January 2013, the Veteran was afforded a VA examination to determine the nature and etiology of his claimed loss of peripheral vision. After examination of the Veteran, the VA examiner diagnosed the Veteran with pseudophakia but did not indicate the Veteran had a disability manifested by loss of peripheral vision. In a July 2016 VA medical opinion, the VA examiner reported that a March 1970 service treatment record revealed a diagnosis of a tripod fracture, specifically fracture of the right fronto-zygomatic suture with involvement of the floor of the orbit (the right infraorbital rim was involved in the facture), secondary to a motor vehicle accident. The treatment record further noted a subconjunctival hemorrhage was also noted on the right eye, with normal fundi and full extraocular motilities. The Veteran had open reduction with wiring of the fractures, and no post-op diplopia was reported. Pertinently, there is no mention of peripheral vision loss in the STRs. The examiner further reported that there is currently no ocular pathology to account for peripheral visual field loss of either eye, and specifically no traumatic optic atrophy/neuropathy or traumatic glaucoma was noted on examination, which would be the most likely cause of peripheral vision loss due to service given his history of trauma to the right orbit. Moreover, there was a slight decrease to cranial nerve V sensitivity noted on testing the right side, consistent with a fracture to the infraorbital rim where this nerve (V2 branch) emanates from the orbit, but this nerve is not responsible for any vision. The examiner also noted that while the kinetic visual field testing did demonstrate a superior field deficit to the right eye only, it is possible this is due to poor testing, an eyelid, or even malingering. In any event, since no optic nerve damage or retinal disease was found on examination to cause a field defect, the Veteran did not have a disability manifested by peripheral vision loss. In this case, the Board finds that the most probative evidence weighs against finding that the criteria have been met for a current disability manifested by peripheral vision loss. In this regard, the Board finds it highly probative that the VA examiners opined that the Veteran does not have peripheral vision loss based upon a thorough examination. The Board further notes that there is no medical evidence contrary to the VA examination reports indicating that the Veteran has normal peripheral vision pathology during the appeal period. The Board has considered the Veteran's statements that he has a disability manifested by peripheral vision loss. The Veteran is competent to provide evidence of that which he experiences, including his symptomatology and medical history. Layno v. Brown, 6 Vet. App. 465, 469 (1994). In addition, lay evidence can be competent and sufficient to establish a diagnosis of a condition when: (1) a layperson is competent to identify the medical condition; (2) the layperson is reporting a contemporaneous medical diagnosis; or, (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007)); Kahana v. Shinseki, 24 Vet. App. 428, 433, n.4 (2011). However, competence must be distinguished from probative weight. Although the Veteran is competent to relate what he experiences through the senses, the lay evidence is lacking in detail to support the conclusion that there is a current disability manifested by peripheral vision loss. The Veteran's lay assertions are therefore afforded less probative weight, and less credibility than the VA examination reports. In this instance, the Board concludes that the most probative evidence establishes that the Veteran does not have a disability manifested by peripheral vision loss. The existence of a current disability is the cornerstone of a claim for VA disability benefits. See Degmetich v. Brown, 104 F.3d 1328 (Fed. Cir. 1997). Therefore, in the absence of current disability, there can be no valid claim. See Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). In this case, there is no disability that resulted from a disease or injury. Under the circumstances, the Veteran has not met the regulatory requirements to establish service connection for a disability manifested by peripheral vision loss under any theory of entitlement and service connection must be denied. In reaching this conclusion, the Board has considered the applicability of the benefit-of-the-doubt doctrine. Here, however, as the preponderance of the evidence is against the claim, that doctrine is not applicable. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). Higher evaluation for residuals of injury to the right fifth cranial nerve with conversion insufficiency and headaches Disability ratings are assigned in accordance with the VA's Schedule for Rating Disabilities and are intended to represent the average impairment of earning capacity resulting from disability. See 38 U.S.C.A. § 1155 (2012); 38 C.F.R. §§ 3.321(a), 4.1 (2017). Separate diagnostic codes identify the various disabilities. See 38 C.F.R. Part 4 (2017). Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. See 38 C.F.R. § 4.7 (2017). "Staged" ratings are appropriate for any rating claim 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 (2007); Fenderson v. West, 12 Vet. App. 119 (1999). The Veteran's residuals of injury to the right fifth cranial nerve with conversion insufficiency and headaches disability has been evaluated under 38 C.F.R. § 4.124a, Diagnostic Code 8205 (paralysis of fifth (trigeminal) cranial nerve). Under Diagnostic Code 8205, a 10 percent rating is warranted for moderate incomplete paralysis of the nerve; a 30 percent rating is warranted for severe incomplete paralysis of the nerve; and a 50 percent rating is warranted for complete paralysis of the nerve. The rating is dependent on relative degree of sensory manifestation or motor loss. 38 C.F.R. § 4.124a, Diagnostic Code 8205. In this case, Diagnostic Code 8205 is the appropriate rating code in this matter because it identifies the specific nerve affected and adequately encompasses the Veteran's neurological symptoms. The Veteran was provided a VA examination in October 2009. The Veteran reported severe headaches 3 to 4 times a week and that the pain last about 10 minutes on average and caused his right eye to spasm. He denied migraine symptoms of nausea/vomiting/photo or audio sensitivity. He also reported that just wiping his nose would often send a sharp electrical pain from the nose down across the right side of his face and that dental cleaning on the right upper incisors and canine region can also cause this sensation. The Veteran did not report any effects of the disability on daily activities. Upon examination, the VA examiner reported normal motor function and that all cranial nerves were intact. The examiner further noted severe right sensation of lacinating or electric shock pain, moderate involuntary painless facial twitching or spasm, and mild weakness or paralysis of facial muscles. The Veteran also had watery right eye but no mouth and throat symptoms. Sensory pain examination revealed decrease in right forehead, chin, and side of face and absence in the cheek. Light touch revealed decrease in the right forehead, chin and entire side of face and absence in the cheek. Corneal reflex was normal. The examiner diagnosed the Veteran with status post head/face trauma from motor vehicle accident in service with residual neuropathy of the right fifth cranial nerve. The Veteran was provided another VA examination in July 2016. The examiner documented a diagnosis of residuals of injury to the right fifth cranial nerve with conversion insufficiency and headaches. The Veteran reported numbness on the right side of his face and inside of his mouth. He had pain in the right temple several times per week that can last up to 15 minutes. He also had difficulty concentrating when pain occurred. He did not use medication for treatment. Upon examination, the VA examiner documented severe intermittent pain, paresthesias and/or dysesthesias, and numbness on the mid face and side of mouth and throat in the right fifth cranial nerve. Muscle impairment was mild, and sensory testing was decreased on the right upper face and forehead and lower face, and absent on the right mid face. The examiner specifically documented severe incomplete paralysis of the right fifth cranial nerve. Regarding the Veteran's headaches, the VA examiner noted constant head pain on the right side of the head that lasted less than one day. The Veteran's headaches were not prostrating. The Board also notes the April 2014 private treatment record from Dr. H.S. wherein he reported that the Veteran had headaches 3-4 times per week which left him bedridden. Based on the evidence of record, the Board finds that a disability rating in excess of 30 percent is not warranted for the Veteran's residuals of injury to the right fifth cranial nerve with conversion insufficiency and headaches at any time during the appeal period. In this regard, the Board acknowledges the Veteran's complaints of pain and numbness on the right side of his head and that his headaches have left him bedridden. Also, the October 2009 VA examiner reported absence of sensation on the right cheek. However, the examiner only reported decreased sensation in the in right forehead, chin, and side of face. Further, the examiner noted moderate involuntary painless facial twitching or spasm and mild weakness or paralysis of facial muscles. Also, the July 2016 VA examiner specifically characterized the Veteran's disability as severe incomplete paralysis. Moreover, while sensory testing was absent on the right mid face, it was only decreased on the right upper face and forehead and lower face. Additionally, the Veteran denied prostrating headaches during the July 2016 VA examination. Thus, while the Board acknowledges that the lay and medical evidence indicates neurological impairment in the right fifth cranial nerve, the evidence as a whole shows that the overall level of functional impairment resulting therefrom is no more than severe and does not result in complete nerve paralysis. The Veteran is rated under Diagnostic Code 8502, which reflects his primary disability (residuals of injury to the right fifth cranial nerve with conversion insufficiency and headaches). Although the Veteran evidences headaches, such symptoms are considered in the assignment of the 30 percent rating for his residuals of injury to the right fifth cranial nerve with conversion insufficiency and headaches. In addition, he does not have migraine and his symptoms do not rise to the level of migraine. We find his reports of the severity of headache to be not credible.his assertion is unsupported by credible evidence. Therefore, separately rating the Veteran under Diagnostic Code 8100 for headaches would constitute pyramiding. In this regard, 38 C.F.R. § 4.14 precludes the evaluation of the "same disability" or the "same manifestations" under various diagnoses, as such would violate the rule against pyramiding. Accordingly, the Board finds that a disability rating in excess of 30 percent is not warranted for the Veteran's residuals of injury to the right fifth cranial nerve with conversion insufficiency and headaches at any time during the appeal period. The Veteran's increased rating claim is therefore denied. With regard to extraschedular consideration, neither the Veteran nor his attorney has raised any issue pertaining to this matter, nor have any other issues pertaining to extraschedular consideration been reasonably raised by the record. See Doucette v. Shulkin, 28 Vet. Ap. 366, 369-70 (2017) (confirming that the Board is not required to address issues unless they are specifically raised by the claimant or reasonably raised by the evidence of record). ORDER Entitlement to service connection for sleep apnea is granted. Entitlement to service connection for a disability manifested by loss of peripheral vision to include as secondary to service-connected disease or injury is denied. Entitlement to a disability rating in excess of 30 percent for residuals of injury to the right fifth cranial nerve with conversion insufficiency and headaches is denied. REMAND With regard to the Veteran's claims of service connection for a cervical spine disability, a right shoulder disability, and a left shoulder disability, he contends that these disabilities are related to service, or alternatively secondary to his service-connected disabilities which are sleep apnea, residuals of injury to the right fifth cranial nerve with conversion insufficiency and headaches, residuals of injury to the nose with deviated septum, and residuals of fracture to the intraorbital rim and front-zygomatic suture. See, e.g., the Veteran's claims for VA benefits dated October 2009. Regarding his service connection claim for bilateral carpal tunnel syndrome, he contends that this disability is related to his service or is alternatively secondary to his service-connected sleep apnea as the sleep apnea caused sleep disturbances which caused him to sleep in uncomfortably positions which hurt his wrists. See, e.g., a statement from the Veteran dated September 2012. While the Board acknowledges that the above-referenced claims were remanded in in April 2015 for VA examinations to be provided in order to determine whether the Veteran's cervical spine, right shoulder, left shoulder, and bilateral carpal tunnel syndrome are related to service, there is no medical opinion of record which indicates whether the Veteran's cervical spine, right shoulder, and left shoulder disabilities are caused or aggravated by his service-connected disabilities, or whether his bilateral carpal tunnel syndrome is caused or aggravated by his service-connected sleep apnea. In light of the foregoing, the Board finds that opinions as to these matters should be obtained on remand. Under Rice v. Shinseki, 22 Vet. App. 447 (2009), a claim for TDIU is part of an increased rating claim when such is raised by the record. As noted in the Introduction above, it appears that a claim for TDIU has been raised based in part on the Veteran's service-connected residuals of injury to the right fifth cranial nerve with conversion insufficiency and headaches. See a private treatment record dated April 2014 from Dr. H.S. On remand, the AOJ should request that the Veteran submit a completed application for increased compensation based on unemployability (VA Form 21-8940), and upon receipt of this form, take any appropriate action deemed necessary to adjudicate his claim. Accordingly, the case is REMANDED for the following action: 1. Contact the Veteran and request that he file a completed application for increased compensation based on unemployability (VA Form 21-8940), and upon receipt of this form, take any appropriate action deemed necessary to adjudicate his TDIU claim. 2. Thereafter, schedule the Veteran for a VA examination to determine the nature and etiology of his cervical spine disability, right shoulder disability, left shoulder disability, and bilateral carpal tunnel syndrome. The claims folder must be made available to the examiner. The examiner should then provide an opinion as to the following: a. Whether it is at least as likely as not (50 percent or greater probability) that the Veteran has a cervical spine disability that is caused or aggravated by his service-connected disabilities which are sleep apnea, residuals of injury to the right fifth cranial nerve with conversion insufficiency and headaches, residuals of injury to the nose with deviated septum, and residuals of fracture to the intraorbital rim and front-zygomatic suture. b. Whether it is at least as likely as not (50 percent or greater probability) that the Veteran has a right shoulder disability that is caused or aggravated by his service-connected disabilities which are sleep apnea, residuals of injury to the right fifth cranial nerve with conversion insufficiency and headaches, residuals of injury to the nose with deviated septum, and residuals of fracture to the intraorbital rim and front-zygomatic suture. c. Whether it is at least as likely as not (50 percent or greater probability) that the Veteran has a left shoulder disability that is caused or aggravated by his service-connected disabilities which are sleep apnea, residuals of injury to the right fifth cranial nerve with conversion insufficiency and headaches, residuals of injury to the nose with deviated septum, and residuals of fracture to the intraorbital rim and front-zygomatic suture. d. Whether it is at least as likely as not (50 percent or greater probability) that the Veteran has bilateral carpal tunnel syndrome that is caused or aggravated by his service-connected disabilities which are sleep apnea, residuals of injury to the right fifth cranial nerve with conversion insufficiency and headaches, residuals of injury to the nose with deviated septum, and residuals of fracture to the intraorbital rim and front-zygomatic suture. The examiner must provide a rationale for his or her opinion. 3. Review the claims folder to ensure that all of the foregoing requested development is completed, and arrange for any additional development indicated. Then readjudicate the claims on appeal and include consideration of a TDIU award. If any of the benefits sought remain denied, issue an appropriate supplemental statement of the case and provide the Veteran and his attorney with the requisite period of time to respond. The Veteran has the right to submit additional evidence and argument on the matter or matters the Board has remanded. See Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C. §§ 5109B, 7112 (2012). ______________________________________________ H.N. SCHWARTZ Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs