Citation Nr: 18147385 Decision Date: 11/06/18 Archive Date: 11/05/18 DOCKET NO. 12-00 300A DATE: November 6, 2018 ORDER The application to reopen the claim of entitlement to service connection for dizziness is granted. The application to reopen the claim of entitlement to service connection for blurred vision is granted. The application to reopen the claim of entitlement to service connection for fatigue is granted. Service connection for a chronic disability manifested by dizziness is denied. Service connection for a chronic disability manifested by blurred vision is denied. Service connection for a chronic disability manifested by fatigue is denied. Service connection for a bilateral hip disorder is denied. A rating in excess of 30 percent for tension headaches, to include on an extraschedular basis, is denied. For the rating period beginning January 29, 2015, a rating in excess of 30 percent for coronary artery disease (CAD), to include on an extraschedular basis, is denied. A 10 percent rating, but no higher, for left wrist strain with painful limitation of motion is granted. A 10 percent rating, but no higher, for a left thumb strain is granted. A rating in excess of 10 percent for a residual scar of the left forearm and wrist is denied. An effective date prior to January 8, 2008, for the grant of service connection for left carpal tunnel syndrome (CTS) is denied. An effective date prior to January 8, 2008, for the grant of service connection for left wrist strain is denied. An effective date prior to January 8, 2008, for the grant of service connection for left thumb strain is denied. An effective date of January 4, 2001, but no earlier, for the grant of service connection for coronary artery disease (CAD) is granted. FINDINGS OF FACT 1. In an unappealed February 1997 rating decision, the RO denied reopening the claims for service connection for dizziness, blurred vision, and fatigue. 2. Evidence received since the February 1997 rating decision is new and material and raises a reasonable possibility of substantiating the claims of entitlement to service connection for dizziness, blurred vision, and fatigue. 3. The Veteran’s dizziness, blurred vision, or fatigue are symptoms of his service-connected headache and CAD disabilities and are not shown to be independent medical entities. 4. The Veteran does not have a bilateral hip disability and his hip pain does not amount to functional impairment of earning capacity. 5. The Veteran has daily headaches lasting a few minutes to an hour, although no more than a few a month are prostrating and do not result in severe economic inadaptability. 6. The Veteran’s CAD disability as of January 29, 2015, was manifested by a METs level of greater than 5 but not greater than 7 resulting in dyspnea and angina without cardiac hypertrophy or cardiac dilation, left ventricular dysfunction with an ejection fraction of 50 percent or less, or chronic congestive heart failure. 7. The Veteran’s left wrist strain disability is manifested by painful motion with palmar flexion limited to, at worst, 50 degrees and dorsiflexion to more than 15 degrees. 8. The Veteran’s left thumb strain disability is manifested by painful motion. 9. The scar of the left forearm/wrist involves a single painful scar. 10. In an October 1972 decision, the Board denied the claim for service connection for residuals of a shell fragment wound of the left forearm and wrist. The Veteran did not appeal that decision to the Court. 11. On January 8, 2008, VA received an informal claim for service connection for a left median nerve injury. There is no record between October 1972 and January 2008, indicating an intent to file a formal or informal claim for service connection for a left wrist, thumb, or CTS disability. 12. A claim for service connection for a heart disorder was pending before the VA between May 3, 1989 and the effective date of the applicable statute or regulation establishing the presumption of service connection for CAD (i. e., August 31, 2010). 13. The Veteran was first diagnosed with CAD on January 4, 2001. CONCLUSIONS OF LAW 1. The February 1997 rating decision declining to reopen the claim of service connection for dizziness, blurred vision, and fatigue is final. 38 U.S.C. § 7105 (2012); 38 C.F.R. § 20.1103 (2017). 2. New and material evidence has been received since the last final denial of service connection for dizziness, and the claim is reopened. 38 U.S.C. §§ 5108, 7105 (2012); 38 C.F.R. § 3.156 (a) (2017). 3. New and material evidence has been received since the last final denial of service connection for blurred vision, and the claim is reopened. 38 U.S.C. §§ 5108, 7105 (2012); 38 C.F.R. § 3.156 (a) (2017). 4. New and material evidence has been received since the last final denial of service connection for fatigue, and the claim is reopened. 38 U.S.C. §§ 5108, 7105 (2012); 38 C.F.R. § 3.156 (a) (2017). 5. The criteria to establish service connection for a chronic disability manifested by dizziness are not met. 38 U.S.C. §§ 1110, 5102, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303 (2017). 6. The criteria to establish service connection for a chronic disability manifested by blurred vision are not met. 38 U.S.C. §§ 1110, 5102, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303 (2017). 7. The criteria to establish service connection for a chronic disability manifested by fatigue are not met. 38 U.S.C. §§ 1110, 5102, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303 (2017). 8. The criteria to establish service connection for a bilateral hip disorder are not met. 38 U.S.C. §§ 1110, 5107 (2012); 38 C.F.R. §§ 3.303, 3.304 (2017). 9. The criteria for a rating in excess of 30 percent for headaches, to include on an extraschedular basis, are not met. 38 U.S.C. § 1155, 5107 (2012); 38 C.F.R. §§ 3.321, 4.1, 4.4, 4.124a, Diagnostic Code 8100 (2017). 10. The criteria for a rating in excess of 30 percent for CAD beginning January 29, 2015 are not met. 38 U.S.C. § 1155, 5107 (2012); 38 C.F.R. §§ 3.321, 4.1, 4.4, 4.104, Diagnostic Code 7005 (2017). 11. The criteria for a separate 10 percent rating for painful limitation of the left wrist (strain) are met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5215 (2017). 12. The criteria for a separate 10 percent rating for painful limitation of the left thumb (strain) are met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5228 (2017). 13. The criteria for a rating in excess of 10 percent for a residual scar of the left forearm and wrist are not met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.102, 4.3, 4.7, 4.118, Diagnostic Codes 7801-7805 (2017). 14. The criteria for the assignment of an effective date prior to January 8, 2008, for the award of service connection for left wrist CTS are not met. 38 U.S.C. § 5110 (2012); 38 C.F.R. § 3.400 (2017). 15. The criteria for the assignment of an effective date prior to January 8, 2008, for the award of service connection for a left wrist strain are not met. 38 U.S.C. § 5110 (2012); 38 C.F.R. § 3.400 (2017). 16. The criteria for the assignment of an effective date prior to January 8, 2008, for the award of service connection for a left thumb strain are not met. 38 U.S.C. § 5110 (2012); 38 C.F.R. § 3.400 (2017). 17. The criteria for an effective date of January 4, 2001, but not earlier, for the grant of service connection for CAD are met. 38 U.S.C. § 5110 (a), 5101(a) (2012); 38 C.F.R. §§ 3.1 (p), 3.151(a), 3.155, 3.400, 3.816 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active military service from February 1967 to March 1970. He received the Purple Heart and Combat Action Ribbon, among other decorations, for this service. This appeal comes to the Board of Veterans’ Appeals (Board) from August 2009 and December 2010 rating decisions by the Department of Veterans Affairs (VA) Regional Office (RO) in Houston and Waco, Texas. By way of procedural background, in September 2016, the Board adjudicated the following issues: (1) denied an initial rating in excess of 10 percent for left carpal tunnel syndrome with median nerve deficit prior to January 29, 2015 and in excess of 20 percent thereafter; (2) denied a rating in excess of 30 percent for tension headaches; (3) denied a compensable rating for residuals of head shell fragment wound; (4) denied a rating in excess of 10 percent for coronary artery disease prior to January 29, 2015 and in excess of 30 percent thereafter; (5) denied reopening the claim for service connection for right Bell’s palsy; (6) denied reopening the claim for service connection for skin growths; (7) denied reopening the claim for service connection for shortness of breath; (8) reopened and denied the claim for service connection for chest pain; (9) reopened and denied the claim for service connection for sinusitis; (10) reopened and denied the claim for service connection for joint pain and stiffness; (11) denied service connection for diabetes; (12) denied service connection for allergic rhinitis; (13) denied service connection for nose bleeds; (14) denied service connection for a bilateral hip disability; (15) denied service connection for polyp of the vocal cord; (16) denied service connection for throat infections; (17) denied service connection for gastroesophageal reflux disease; (18) denied service connection for ear infections; (19) denied service connection for prostate infection; (20) denied service connection for blood vessel inflammation; (21) denied service connection for bronchiectasis; (22) denied service connection for muscle spasm; and (23) denied service connection for respiratory condition. Additionally, the September 2016 decision remanded the claims for (1) entitlement to a rating in excess of 10 percent for a residual scar associated with a shell fragment wound to the left forearm and wrist; (2) entitlement to an initial compensable rating for left wrist and thumb strain; and (3) entitlement to service connection for dizziness; (4) entitlement to service connection for blurred vision; (5) entitlement to service connection for fatigue; (6) entitlement to an earlier effective date for the grant of service connection for coronary artery disease; (7) entitlement to an earlier effective date for the grant of service connection for left carpal tunnel syndrome; and (8) entitlement to an earlier effective for the grant of service connection for left wrist strain with left thumb strain. The Veteran appealed the September 2016 Board decision to the U.S. Court of Appeals for Veterans Claims (Court). In a September 2017 Memorandum Decision, the Court set aside and remanded that portion of the Board decision that (1) denied a rating in excess of 30 percent for tension headaches; (2) denied a rating in excess of 30 percent for CAD beginning January 29, 2015; and (3) denied service connection for a bilateral hip disorder. The Court affirmed the remaining issues adjudicated in the September 2016 Board decision. The eight issues that had been remanded by the Board were not addressed as the Court was without jurisdiction to address these nonfinal matters. Following the September 2016 remand, the following issues were readjudicated in a July 2017 supplemental statement of the case: (1) entitlement to a rating in excess of 10 percent for a residual scar associated with a shell fragment wound of the left forearm and wrist; (2) entitlement to an initial compensable rating for left wrist and thumb strain; (3) entitlement to service connection for dizziness; (4) entitlement to service connection for blurred vision; (5) entitlement to service connection for fatigue; (6) entitlement to an earlier effective dates for the grant of service connection for coronary artery disease; (7) entitlement to an earlier effective date for the grant of service connection for left carpal tunnel syndrome; and (8) entitlement to an earlier effective for the grant of service connection for left wrist strain with left thumb strain. As such, these issues are properly before the Board for further appellate consideration. Application to Reopen the Claims for Service Connection for Dizziness, Blurred Vison, and Fatigue The prior September 2016 Board remand did not characterize the claims for service connection for dizziness, blurred vision, and fatigue as to include an application to reopen the claims. However, a review of the record shows that the RO previously denied reopening these claims in a February 1997 rating decision. The Veteran was notified of the rating decision, but did not appeal the decision. As such, the February 1997 rating decision became final. 38 U.S.C. § 7105; 38 C.F.R. § 20.1103. A claim will be reopened in the event that new and material evidence is presented. 38 U.S.C. § 5108. Because the February 1997 rating decision was the last final disallowance, the Board must review all of the evidence submitted since that rating decision to determine whether the Veteran’s claims for service connection should be reopened and re-adjudicated on a de novo basis. Evans v. Brown, 9 Vet. App. 273 (1996). If new and material evidence is presented or secured with respect to a claim which has been disallowed, the Board shall reopen the claim and review the former disposition of the claim. 38 U.S.C. § 5108. With regard to petitions to reopen previously and finally disallowed claims, the Board must conduct a two-part analysis. First, the Board must determine whether the evidence presented or secured since the prior final disallowance of the claim is “new and material.” Second, if the Board determines that the evidence is “new and material,” it must reopen the claim and evaluate the merits of the claim in view of all the evidence, both new and old. Manio v. Derwinski, 1 Vet. App. 140, 145 (1991). Section 3.156(a) provides as follows: A claimant may reopen a finally adjudicated claim by submitting new and material evidence. New evidence means existing evidence not previously submitted to agency decision makers. Material evidence means existing evidence that, by itself or when considered with previous evidence of record, relates to an unestablished fact necessary to substantiate the claim. New and material evidence can be neither cumulative nor redundant of the evidence of record at the time of the last prior final denial of the claim sought to be reopened, and must raise a reasonable possibility of substantiating the claim. 38 C.F.R. § 3.156 (a) (2017). The threshold for determining whether new and material evidence raises a reasonable possibility of substantiating a claim is “low.” See Shade v. Shinseki, 24 Vet. App. 110, 117 (2010). In determining whether evidence is new and material, the “credibility of the evidence is to be presumed.” Justus v. Principi, 3 Vet. App. 510, 513 (1992). Pursuant to the Board’s September 2016 remand, the Veteran was afforded VA eye, ear, and chronic fatigue syndrome examinations in January 2017, which addressed his claimed blurred vision, dizziness, and fatigue. The Board finds that these medical examinations are new as such evidence was not of record prior to the issuance of the 1997 rating decision. Further, this evidence is material as these VA examinations contain reports by the Veteran regarding the exact nature of his claimed disorders and the onset date and circumstance of his symptoms—to include during service. Accordingly, the Board finds that the newly added evidence relates to an unestablished fact necessary to substantiate the Veteran’s claims of service connection for dizziness, blurred vision, and fatigue. 38 C.F.R. § 3.156 (a). As such, the Veteran’s claims are reopened. Service Connection Laws and Regulations Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active military, naval, or air service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303 (a). 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. 38 C.F.R. § 3.303 (d). Only chronic diseases listed under 38 C.F.R. § 3.309 (a) (2017) are entitled to the presumptive service connection provisions of 38 C.F.R. § 3.303 (b). Walker v. Shinseki, 708 F.3d 1331 Fed. Cir. 2013). Establishing service connection generally requires (1) medical 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) medical evidence of a nexus between the claimed in-service disease or injury and the present disability. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). The U.S. Court of Appeals for Veterans Claims (Court) has held that “Congress specifically limits entitlement for service-connected disease or injury to cases where such incidents have resulted in a disability. In the absence of proof of a present disability there can be no valid claim.” Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992); see also Rabideau v. Derwinski, 2 Vet. App. 141, 143-44 (1992). In rendering a decision on appeal, the Board must analyze the credibility and probative value of the evidence, account for the evidence which it finds to be persuasive or unpersuasive, and provide the reasons for its rejection of any material evidence favorable to the claimant. Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994); Gilbert v. Derwinski, 1 Vet. App. 49, 57(1990). Competency of evidence differs from weight and credibility. Competency is a legal concept determining whether testimony may be heard and considered by the trier of fact, while credibility is a factual determination going to the probative value of the evidence to be made after the evidence has been admitted. Rucker v. Brown, 10 Vet. App. 67, 74 (1997); Layno v. Brown, 6 Vet. App. 465, 469 (1994); see also Cartright v. Derwinski, 2 Vet. App. 24, 25 (1991) (“although interest may affect the credibility of testimony, it does not affect competency to testify”). Generally, the degree of probative value which may be attributed to a medical opinion issued by a VA or private treatment provider takes into account such factors as its thoroughness and degree of detail, and whether there was review of the claims file. See Prejean v. West, 13 Vet. App. 444, 448-9 (2000). Also significant is whether the examining medical provider had a sufficiently clear and well-reasoned rationale, as well as a basis in objective supporting clinical data. See Bloom v. West, 12 Vet. App. 185, 187 (1999); Hernandez-Toyens v. West, 11 Vet. App. 379, 382(1998); see also Claiborne v. Nicholson, 19 Vet. App. 181, 186 (2005) (rejecting medical opinions that did not indicate whether the physicians actually examined the veteran, did not provide the extent of any examination, and did not provide any supporting clinical data). The Court has held that a bare conclusion, even one reached by a health care professional, is not probative without a factual predicate in the record. Miller v. West, 11 Vet. App. 345, 348 (1998). A significant factor to be considered for any opinion is the accuracy of the factual predicate, regardless of whether the information supporting the opinion is obtained by review of medical records or lay reports of injury, symptoms and/or treatment, including by a veteran. See Harris v. West, 203 F.3d 1347, 1350-51 (Fed. Cir. 2000) (examiner’s opinion based on accurate lay history deemed competent medical evidence in support of the claim); Kowalski v. Nicholson, 19 Vet. App. 171, 177 (2005) (holding that a medical opinion cannot be disregarded solely on the rationale that the medical opinion was based on history given by the veteran); Reonal v. Brown, 5 Vet. App. 458, 461 (1993) (holding that the Board may reject a medical opinion based on an inaccurate factual basis). When all the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the veteran prevailing in either event, or whether a preponderance of the evidence is against a claim, in which case, the claim is denied. 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102. Dizziness, Blurred Vision, and Fatigue The Veteran maintains that he has dizziness, blurred vision, and fatigue as a result of an in-service head injury. The Veteran’s service records reflect that he was hit by enemy mortar fragments in June 1968. Pursuant to the Board’s September 2016 remand, the Veteran was afforded a VA eye examination in January 2017. At that time, the examiner indicated that the Veteran had stable ocular health, age-related visually insignificant nuclear sclerosis cataract, refractive error, and correctable casual acuity in each eye (20/20 near and distance). The Veteran was also found to have visually insignificant left eye corneal scar. Notably, the examiner indicated that there was no evidence of uncorrectable blurred vision either in the Veteran’s service treatment records or during the examination. The Veteran’s blurred vision was correctable with spectacle correction in both service and presently. As such, the examiner stated that there was no diagnosis of blurred vision. The Veteran was also afforded a VA ear examination in January 2017. The examiner reviewed the claims file and noted that the Veteran had a head injury in 1968 due to small fragments of shrapnel which resulted in a small scar on the scalp. The Veteran had one episode of dizziness in service, which was unrelated to his head injury as it was found to be related to a GI condition which resolved without residual. Medical records following service separation were unremarkable for dizziness and fatigue. An MRI of the brain in 2013 was also normal. The examiner specifically noted that the Veteran had “a number of other medical conditions that are more likely related to issues with symptom of fatigue and dizziness.” The examiner also noted that there was no dizziness or fatigue condition that would occur at that time of the incident (in-service head injury), then resolved without residual, and then return many years later. For these reasons, the examiner opined that the Veteran’s dizziness and fatigue were less likely than not related to service. A January 2017 VA examination report for chronic fatigue syndrome (CFS) indicated that a review of service treatment records and current medical records showed no evidence of CFS or of a fatigue condition. The Board also notes that the Veteran’s symptoms of blurred vision and dizziness have been considered with the currently assigned 30 percent rating for the Veteran’s tension headache disability. See June 2014 VA treatment record (noting chronic headaches associated with dizziness); see also January 2015 VA examination (where the Veteran reported headaches with associated blurred vision, photophobia, and dizziness). As the probative and persuasive evidence fails to show that the Veteran has separate disability entities manifested by blurred vision, dizziness, and fatigue, his claimed symptoms alone do not rise to the level of separate disabilities for VA compensation purposes. Brammer, 3 Vet. App. at 223. As the preponderance of the evidence is against the above claims, the benefit of the doubt doctrine is not applicable. 38 U.S.C. 5107 (b) (2014); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Bilateral Hip Disability The Veteran contends he has arthritis in his hips related to his service. After a thorough review of the record, the Board finds that service connection for the Veteran’s claimed bilateral hip disability is not warranted. In this regard, the evidence simply does not show that he has a current hip disability. Congress has specifically limited service connection to instances where there is current disability that has resulted from disease or injury. In the absence of a current disability, the analysis ends, and the claim for service connection for a bilateral hip disability cannot be granted. See Gilpin v. West, 155 F.3d 1353 (Fed. Cir. 1998); Brammer, supra. At an October 1987 medical consultation after a post-service motor vehicle crash, the Veteran reported low back, buttock, and hip pain; however, a specific diagnosis pertaining to the Veteran’s hips was not provided. A June 2014 VA treatment record reflects that the Veteran reported an aching, sharp pain in his legs and hips. VA treatment records also show that the Veteran has been diagnosed with degenerative joint disease, although records do not specify that the condition is in his hips. The Board is cognizant of Saunders v. Wilkie, 886 F.3d 1356, 1361 (Fed. Cir. 2018) wherein the United States Court of Appeals for the Federal Circuit (Court) held that pain alone can constitute a disability for VA purposes when such pain amounts to functional impairment of earning capacity. In this case, the Board notes that the Veteran has not provided any medical evidence describing any symptoms or functional impairment; nor has he submitted a clinical diagnosis pertaining to the hips. In other words, and even assuming that the Veteran does experience some hip pain, the evidence of record does not show that the Veteran’s pain results in functional impairment of earning capacity. Moreover, even if the Board were to accept that the Veteran is currently diagnosed with a hip disability, the evidence does not support that the condition is related to his service. In this regard, arthritis is not on the list of diseases presumptively associated with herbicide exposure; therefore, service connection is not warranted under 38 C.F.R. § 3.307. See 38 C.F.R. § 3.309 (e). Further, a preponderance of the evidence is against finding that the condition onset in service or within one year of his separation from service or is due to service. As noted in the December 2017 Court memorandum decision, a November 1969 service treatment note reflects that the Veteran complained of pain and weakness in his left hip and sharp, intermittent pain the right hip. However, the remaining in-service treatment records are absent for any further complaints or treatment relating to the hips. The Veteran’s musculoskeletal system and lower extremities were also noted as normal on his February 1970 separation examination. Further, the Veteran himself has not contended that the condition had its onset in service and has not reported a continuity of symptomatology since service. Notably, the Veteran has filed multiple claims since his separation from service in 1970 without previous complaint of a hip disability, suggesting a more recent onset of the condition. See Maxson v. Gober, 230 F.3d 1330 (Fed. Cir. 2000) (a lengthy period without complaint or treatment is evidence that there has not been a continuity of symptomatology, and can weigh against the claim). While the Board acknowledges the Veteran’s contention that he has a bilateral hip disability that is related to his service, to include his herbicide exposure, the Board assigns his contention little probative weight. The Veteran is certainly competent to report hip pain; however, the etiology of degenerative joint disease is a complex medical question not capable of lay observation and is not the type of medical issue for which a lay opinion may be accepted as competent evidence. Arthritis is diagnosed by x-rays. In sum, there is no competent medical opinion suggesting the Veteran has a hip disability, to include degenerative joint disease, related to his service. Based on the forgoing, the Board finds that a preponderance of the evidence is against service connection for a hip disability, the benefit of the doubt doctrine does not apply, and the claim must be denied. Increased Ratings—Laws and Regulations Disability evaluations are determined by evaluating the extent to which a Veteran’s service-connected disability adversely affects his or her ability to function under the ordinary conditions of daily life, including employment, by comparing his or her symptomatology with the criteria set forth in the Schedule for Rating Disabilities. The percentage ratings represent as far as can practicably be determined the average impairment in earning capacity resulting from such diseases and injuries and the residual conditions in civilian occupations. Generally, the degree of disabilities specified are considered adequate to compensate for considerable loss of working time from exacerbation or illness proportionate to the severity of the several grades of disability. 38 U.S.C. § 1155 (2012); 38 C.F.R. § 4.1 (2017). Separate diagnostic codes identify the various disabilities and the criteria for specific ratings. If two disability evaluations are potentially applicable, the higher evaluation will be assigned to the disability picture that more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7 (2017). Any reasonable doubt regarding the degree of disability will be resolved in favor of the Veteran. 38 C.F.R. § 4.3 (2017). However, the evaluation of the same disability under various diagnoses, known as pyramiding, is to be avoided. 38 C.F.R. § 4.14 (2017). Staged ratings are appropriate if the factual findings show distinct time periods where the service-connected disability exhibited symptoms that would warrant different ratings. See Hart v. Mansfield, 21 Vet. App. 505 (2007); Fenderson v. West, 12 Vet. App. 119, 126 (1999). Headaches In the September 2017 Memorandum Decision, the Court indicated that the medical evidence showed documented reports by the Veteran of short-term memory loss associated with his headaches. The Court vacated the Board’s denial and remanded the issue as it determined that the Board had failed to consider whether referral for an extraschedular rating for the Veteran’s headaches was warranted and whether short-term memory loss is contemplated by the rating criteria. The Court did not indicate any deficiencies in the Board’s schedular rating analysis in denying a rating in excess of 30 percent for the Veteran’s headaches disability. As such, that portion of the September 2016 Board decision is incorporated by reference herein. As it pertains to whether referral for consideration of an extraschedular rating is warranted for the Veteran’s headaches, the Court has set out a three-part test, based on the language of 38 C.F.R. § 3.321 (b)(1), for determining whether a Veteran is entitled to an extraschedular rating: (1) the established schedular criteria must be inadequate to describe the severity and symptoms of the claimant’s disability; (2) the case must present other indicia of an exceptional or unusual disability picture, such as marked interference with employment or frequent periods of hospitalization; and (3) the award of an extraschedular disability rating must be in the interest of justice. Thun v. Peake, 22 Vet. App. 111 (2008), aff’d, Thun v. Shinseki, 572 F.3d 1366 (Fed. Cir. 2009). In this case, although impairment in short-term memory symptomatology as described by the Veteran is not expressly contemplated by the rating criteria for headaches, the Board does not find that the evidence of record reflects an exceptional or unusual disability picture, to include such factors as marked interference with employment or frequent periods of hospitalization. At his June 2008 VA examination, the Veteran reported that he was able to take care of some household chores, but was unable to go to work when having a headache. He reported that his symptoms of throbbing temple pain, neck pain, and pain atop the head occurred as often as once a day with each occurrence lasting two hours. An April 2013 VA treatment record notes the Veteran reported occasional headaches. A June 2014 VA treatment record noted chronic headaches associated with dizziness and forgetfulness. At his January 2015 VA examination, the Veteran reported that he had sharp headache pain between three to four minutes to an hour occurring three to five times per day. He reported associated blurred vision, photophobia, and dizziness as well as loss of short-term memory. The Veteran stated that he experienced severe headaches that resulted in his inability to function several times a month. The examiner indicated that the Veteran has characteristic prostrating attacks of headache pain once a month, but that the headaches were not very prostrating and prolonged attacks were not productive of severe economic inadaptability. In sum, the weight of the evidence of record demonstrates that the Veteran has reported that only several of the headaches a month cause him to not be able to function, at which point he is unable to work. During a January 2015 VA examination report, the examiner specifically indicated that only one headache a month would be considered a prostrating attack of headache pain. The examiner specifically indicated that the Veteran’s headaches were not productive of severe economic inadaptability. Further, although the Veteran has reported he is unable to go to work during his worst headaches, such difficulty is already considered by the rating criteria, which addresses economic inadaptability. As such, the Board finds that the Veteran’s headaches disability, to include his periodic short-term memory loss, does not result in marked interference with employment. The evidence also does not show hospitalization due to the Veteran’s headaches. Therefore, the Board finds the schedular evaluation is adequate, and referral is not required. 38 C.F.R. § 3.321; Thun, 22 Vet. App. 111. For these reasons, the Board finds that a rating in excess of 30 percent for tension headaches, to include on an extraschedular basis, is not warranted. CAD In the September 2017 Memorandum Decision, the Court set aside and remanded the issue for an increased rating in excess of 30 percent for CAD since January 29, 2015. Specifically, the Court indicated that a January 2015 VA examiner found that the Veteran’s CAD “impacted his ability to work.” However, despite this finding by the examiner, the Court noted that the Board did not offer analysis or address the examiner’s finding. The Board incorporates by reference the Board’s September 2016 analysis regarding the CAD disability beginning January 29, 2015, to include consideration by the Board as to whether referral for consideration of an extraschedular rating was warranted. Further, and specifically regarding the January 2015 VA examiner’s finding that the Veteran’s CAD disability impacted his ability to work, the Board finds that generally, consideration of entitlement to a total disability rating based on individual unemployability (TDIU) would be appropriate as there was evidence of unemployability due to a service-connected disability. See Rice v. Shinseki, 22 Vet. App. 447 (2009) (where the Court stated that a claim for a TDIU due to service-connected disability is part and parcel of an increased rating claim when such claim is raised by the record). In this case, however, the Board finds that any claim of entitlement to a TDIU is moot for the period beginning January 29, 2015. The Court held in Bradley v. Peake, 22 Vet. App. 280 (2008), that there could be a situation where a veteran has a schedular total rating for a particular service-connected disability, and could establish a TDIU rating for another service-connected disability in order to qualify for SMC under 38 U.S.C. § 1114 (s) by having an “additional” disability of 60 percent or more (“housebound” rate). See 38 U.S.C. § 1114 (s). Thus, Bradley made it such that even with the assignment of a total schedular rating, the issue of TDIU was potentially not moot. The Board concludes that the facts of Bradley are sufficiently distinguishable from the facts of this case such that the holding in Bradley is inapplicable and the Veteran’s TDIU claim is in fact moot. Specifically, the Veteran has already been granted a 100 percent disability rating for his psychiatric disability and has been granted an award of special monthly compensation (SMC) based on additional service-connected disabilities independently ratable at 60 percent or more as of January 29, 2015. As the Veteran has already been awarded SMC and therefore would have no need to establish a TDIU rating in order to qualify for SMC under 38 U.S.C. § 1114 (s), the holding in Bradley is not applicable in this case. Therefore, the TDIU claim is moot for the appeal period beginning January 29, 2015. Left Wrist Strain The Veteran has been separately evaluated for left wrist carpal tunnel syndrome, which was most recently adjudicated in the September 2016 Board decision and affirmed by the Court’s memorandum decision. The Veteran’s left wrist scar is also separately evaluated as discussed in the section below. As such, the Board will only consider symptoms associated with the Veteran’s left wrist strain in this section. The Veteran’s service-connected left wrist strain is rated as 0 percent disabling throughout the relevant period under 38 C.F.R. § 4.71a, Diagnostic Code 5215, which pertains to limitation of motion of the wrist. Under Diagnostic Code 5215, a maximum 10 percent rating is warranted when palmar flexion of the wrist is limited in line with the forearm or when dorsiflexion of the wrist is less than 15 degrees on either the major arm or the minor arm. Also relevant to rating disabilities of the wrist is 38 C.F.R. § 4.71a, Diagnostic Code 5214, which provides ratings based on ankylosis of the wrist. Under Diagnostic Code 5214, for the major arm, a 30 percent rating is warranted for favorable ankylosis of the wrist in dorsiflexion between 20 degrees and 30 degrees; a 40 percent rating is warranted for ankylosis of the wrist in any other position, except favorable; and a maximum 50 percent rating is warranted for unfavorable ankylosis of the wrist in any degree of palmar flexion or with ulnar or radial deviation. Normal range of motion of the wrist includes dorsiflexion (extension) from zero to 70 degrees, palmar flexion from zero to 80 degrees, ulnar deviation from zero to 45 degrees, and radial deviation from zero to 20 degrees. See 38 C.F.R. § 4.71a, Plate I (2017). Turning to the evidence of record, the Veteran underwent a VA examination in July 2009. During the evaluation, the Veteran reported pain in the left wrist that traveled to his shoulder and back. Upon examination, there was tenderness in the left wrist, but no signs of edema, effusion, weakness, redness, or heat. Range of motion testing of the left wrist showed dorsiflexion limited to 60 degrees with pain starting at 60 degrees. Palmar flexion was limited to 50 degrees, with pain starting at 50 degrees. The joint function was not additionally limited by pain, fatigue, weakness, lack of endurance or incoordination. X-rays of the left wrist were within normal limits and there was no indication of arthritis. The remaining evidence of record does not include range of motion testing of the Veteran’s left wrist. Upon review of the evidence of record, the Board finds that the Veteran is entitled to a separate 10 percent rating for painful motion of the left wrist. Whether or not arthritis is present, painful motion should be considered to determine whether a separate or higher rating is warranted under 38 C.F.R. § 4.59, which provides that the Rating Schedule is meant to allow for at least the minimum compensable rating for the joint to recognize actually painful, unstable or malaligned joints, due to healed injury. Burton v. Shinseki, 25 Vet. App. 1 (2011). In this case, the July 2009 VA examiner indicated that the Veteran’s left wrist was limited to 60 degrees in dorsiflexion and to 50 degrees in palmar flexion with pain. As such, the Board finds that a separate rating of 10 percent is warranted for painful motion of the left wrist under Burton. The evidence does not support additional staged ratings for any time period on appeal or a higher rating under a different Diagnostic Code as the Veteran’s left wrist joint is not ankylosed. For these reasons, the Board finds that a separate 10 percent rating for the Veteran’s left wrist strain disability is warranted for the rating period on appeal. Left Thumb Strain As noted above, the Veteran has been separately evaluated for left wrist carpal tunnel syndrome, which was most recently adjudicated in the September 2016 Board decision and affirmed by the Court’s memorandum decision. The Veteran’s left wrist scar and limitation of motion associated with a left wrist strain has also been separately evaluated as discussed in the sections herein. As such, the Board will only consider symptoms associated with the Veteran’s left thumb strain in this section. The Veteran’s service-connected left thumb strain is rated as 0 percent disabling throughout the relevant period under 38 C.F.R. § 4.71a, Diagnostic Code 5228, which pertains to limitation of motion of the thumb. Under 38 C.F.R. § 4.71a, DC 5228, a gap of less than one inch between the thumb pad and the fingers, with the thumb attempting to oppose the fingers, is noncompensable. A gap of 1 to 2 inches between the thumb pad and the fingers, with the thumb attempting to oppose the fingers, is rated at 10 percent. 38 C.F.R. § 4.71a, DC 5228. A maximum schedular 20 percent rating is warranted for limitation of motion of the thumb with a gap of more than two inches (5.1 cm.) between the thumb pad and the fingers, with the thumb attempting to oppose the fingers. Id. The evidence includes a July 2009 VA examination. At that time, the Veteran reported pain and aching in the left hand fingers. He reported difficulty with grasping, typing and lifting. Upon range of motion testing, the Veteran had reduced palmar abduction in the left thumb limited to 50 degrees, with pain at 50 degrees. There was also a 2-centimeter gap between the thumb and the ring finger when attempting to oppose the fingers. As noted in the previous section, the plain language of 38 C.F.R. § 4.59 indicates that it is the intention of the schedular rating criteria to recognize painful, unstable, or malaligned joints, due to healed injury, as entitled to at least the minimum compensable rating for the joint. 38 C.F.R. § 4.59. See Burton, 25 Vet. App. 1. As the Veteran’s left thumb disability is rated under a diagnostic code containing a 10 percent rating and he has clearly exhibited painful motion, the Board finds that a 10 percent rating for the Veteran’s thumb disability is warranted. See 38 C.F.R. § 4.59. The remaining evidence of record does not include range of motion testing of the Veteran’s left thumb more nearly approximating limitation of motion of the thumb with a gap of more than two inches (5.1 cm.) between the thumb pad and the fingers, with the thumb attempting to oppose the fingers. For these reasons, the Board finds that a separate 10 percent rating, but no higher, for the Veteran’s left thumb strain disability is warranted for the rating period on appeal. Left Forearm and Wrist Scar The Veteran’s left forearm/wrist scar disability has been assigned a disability rating under Diagnostic Code 7804 of 38 C.F.R. § 4.118, for unstable or painful scars. The rating schedule for evaluating different types of scars (not including the head, face, or neck) is set forth as follows: 7801 Burn scar(s) or scar(s) due to other causes, not of the head, face, or neck, that are deep and nonlinear: Area or areas of 144 square inches (929 sq. cm.) or greater warrant a 40 percent rating. Area or areas of at least 72 square inches (465 sq. cm.) but less than 144 square inches (929 sq. cm.) warrant a 30 percent rating. Area or areas of at least 12 square inches (77 sq. cm.) but less than 72 square inches (465 sq. cm.) warrant a 20 percent rating. Area or areas of at least 6 square inches (39 sq. cm.) but less than 12 square inches (77 sq. cm.) warrant a 10 percent rating. Note (1): A deep scar is one associated with underlying soft tissue damage. Note (2): If multiple qualifying scars are present, or if a single qualifying scar affects more than one extremity, or a single qualifying scar affects one or more extremities and either the anterior portion or posterior portion of the trunk, or both, or a single qualifying scar affects both the anterior portion and the posterior portion of the trunk, assign a separate evaluation for each affected extremity based on the total area of the qualifying scars that affect that extremity, assign a separate evaluation based on the total area of the qualifying scars that affect the anterior portion of the trunk, and assign a separate evaluation based on the total area of the qualifying scars that affect the posterior portion of the trunk. The midaxillary line on each side separates the anterior and posterior portions of the trunk. Combine the separate evaluations under §4.25. Qualifying scars are scars that are nonlinear, deep, and are not located on the head, face, or neck. 7802 for burn scar(s) or scar(s) due to other causes, not of the head, face, or neck, that are superficial and nonlinear: Area or areas of 144 square inches (929 sq. cm.) or greater warrant a 10 percent rating. 7804 Scar(s), unstable or painful: Five or more scars that are unstable or painful warrant a 30 percent rating. Three or four scars that are unstable or painful warrant a 20 percent rating. One or two scars that are unstable or painful warrant a 10 percent rating. Note (1): An unstable scar is one where, for any reason, there is frequent loss of covering of skin over the scar. Note (2): If one or more scars are both unstable and painful, add 10 percent to the evaluation that is based on the total number of unstable or painful scars. Note (3): Scars evaluated under diagnostic codes 7800, 7801, 7802, or 7805 may also receive an evaluation under this diagnostic code, when applicable. In June 2008 and July 2009 VA examination reports, the examiners indicated that the Veteran had a scar on the left wrist and arm that resulted in pain and tightness in the arm. During the July 2009 evaluation, the examiner indicated that there was a scar on the left wrist that was linear. The scar measured 9.4 centimeters and was not painful on examination. The scar did not limit motion and there were no other limitations due to the scar. The Veteran was afforded a VA scar examination in January 2015. At that time, the examiner indicated that the Veteran’s left forearm scar was neither painful nor unstable. Upon examination, the Veteran was noted to have a linear surgical scar from the left palm of the hand to the wrist. The scar measured 9.0 centimeters. The Board finds that a disability rating higher than 10 percent must be denied as the evidence does not show a disability picture more nearly approximating three or four scars that are unstable or painful. The service-connected disability involves a single, linear scar on the arm and wrist. As shown most recently on the 2015 VA examination, the scar is 9.0 cm (or measured 9.4 cm on the prior VA examinations), superficial, and linear, so not an area or areas of 144 square inches (929 sq. cm.) or greater, and not nonlinear. 38 C.F.R. § 4.118, DC 7801, 7802. Finally, although the scar causes disabling effects such as some limitation of motion of the wrist, the Veteran is already assigned a separate disability rating, as discussed herein, for those effects. Accordingly, the disability does not manifest any symptoms consistent with a higher rating, primarily because there is one painful scar and not three or more. Therefore, the preponderance of the evidence is against a higher rating and the benefit-of-the-doubt doctrine is not applicable. See 38 U.S.C. § 5107 (b); 38 C.F.R. §§ 3.102, 4.3. Therefore, a rating higher than 10 percent is not warranted. Earlier Effective Date Claims—Laws and Analysis Generally, the effective date of an award of service connection is the date the claim was received or the date entitlement arose, whichever is later. 38 U.S.C. § 5110 (a); 38 C.F.R. § 3.400. The same is true for an award based on a claim reopened after final adjudication, as VA laws and regulations stipulate that the effective date of such an award shall be fixed in accordance with the facts found, but shall not be earlier than the date the claim was received, or the date entitlement arose, whichever is later. See Id.; 38 C.F.R. § 3.400 (r). The effective date for a grant of service connection following a final prior disallowance is the date of receipt of the application to reopen, or the date entitlement arose, whichever is later. 38 U.S.C. § 5110; 38 C.F.R. § 3.400. A formal claim is one that has been filed in the form prescribed by VA. See 38 U.S.C. § 5101 (a); 38 C.F.R. § 3.151 (a). An informal claim may be any communication or action, indicating intent to apply for one or more benefits under VA law. See Thomas v. Principi, 16 Vet. App. 197 (2002); see also 38 C.F.R. §§ 3.1 (p), 3.155(a) (2017). An informal claim must be written, see Rodriguez v. West, 189 F. 3d. 1351 (Fed. Cir. 1999), and it must identify the benefit being sought. Brannon v. West, 12 Vet. App. 32, 34-5 (1998). Informal claims were recognized prior to March 24, 2015, after which a proper claim form must be filed. Left CTS, Wrist Strain, and Thumb Strain The Board notes that the Veteran was granted service connection for a residual scar associated with a left forearm and wrist shell fragment wound in an April 1970 rating decision. A 10 percent rating was assigned under Diagnostic Code 7804 for a painful scar. The Veteran also sought service connection for residuals (other than the scar) for his shell fragment wound of the left forearm and wrist. In an October 1972 decision, the Board denied the claim for service connection for residuals of a shell fragment wound of the left forearm and wrist. The Veteran did not appeal this decision to the Court within the allotted time period. Thus, while recognizing that the Veteran filed his original claim for service connection for a left arm and hand disorder in 1970, the corresponding October 1972 Board decision denied the claim, and the Veteran did not appeal this decision, and it therefore became final. An unappealed decision of the RO or the Board becomes final and binding and is not subject to revision on the same factual basis in the absence of clear and unmistakable error. Previous determinations which are final and binding will be accepted as correct in the absence of clear and unmistakable error. Where evidence establishes such error, the prior decision will be reversed or amended. 38 U.S.C. §§ 5109A, 7111 (2012); 38 C.F.R. §§ 3.105, 20.1400 (2017). Clear and unmistakable error (CUE) in prior decisions; however, has not been asserted in this case. There is no additional evidence on record that makes any reference to the Veteran’s left CTS, wrist, or thumb until January 8, 2008 and February 2008, where he filed his petition to reopen. The RO subsequently granted service connection for left wrist CTS, left wrist strain, and left thumb strain in an August 2009 rating decision. The RO assigned an effective date of January 8, 2008, for all disabilities pertaining to the left wrist CTS, left wrist strain, and left thumb strain. The Board reviewed all relevant evidence and finds no basis under the law to award an effective date earlier than January 8, 2008, the date of his petition to reopen. Significantly, the relevant regulation provides that any award based on a subsequently filed application for benefits can be made effective no earlier than the date of the new application, in this case, January 8, 2008. As indicated, finality determinations contained within the prior final decisions that denied service connection can only be addressed through a claim of CUE as to those decisions. See 38 U.S.C. §§ 5109A, 7111 (2012); 38 C.F.R. §§ 3.104, 3.105, 20.1400 (2017). The Veteran has not claimed CUE in the prior decision as of the date of this decision. Additionally, no correspondence was received from the Veteran mentioning his intent to apply for service connection between the issuance of the Board’s 1972 decision (the date of the last final and binding decision denying claimed disability) and January 8, 2008 (the date of his most recent petition). The Board recognizes the Veteran’s argument that he had these disorders prior to the effective date assigned. Nevertheless, even if these disorders were shown in medical records at an earlier time, the mere presence of medical evidence does not establish an intent to seek service connection. See Brannon v. West, 12 Vet. App. 32, 34-35 (1998) (holding that the mere receipt of medical records could not be construed as an informal claim); see also Criswell v. Nicholson, 20 Vet. App. 501, 503 (2006) (“[W]here there can be found no intent to apply for VA benefits, a claim for entitlement to such benefits has not been reasonably raised.”). In summary, the effective date for a grant of service connection following a final prior disallowance is the date of receipt of the application to reopen, or the date entitlement arose, whichever is later. 38 U.S.C. § 5110; 38 C.F.R. § 3.400. As such, the RO has already assigned the earliest possible effective date for its grant of the claims for left wrist CTS, left wrist strain, and left thumb strain, which was determined to be January 8, 2008. Consequently, there is no legal basis upon which to award an effective date prior to January 8, 2008. The Board is bound by the law governing the assignment of effective dates in its determination in this case. See 38 U.S.C. § 7104 (c). The claims of entitlement to an effective date earlier than January 8, 2008 for the award of service connection for left wrist CTS, left wrist strain, and left thumb strain must be denied. CAD As noted in the previous section, in general, the effective date of an evaluation and award of compensation based on an original claim, a claim reopened after final disallowance, or a claim for increase will be the date the claim was received or the date the entitlement arose, whichever is later. See 38 U.S.C. § 5110 (a); 38 C.F.R. § 3.400. However, pursuant to the orders of the United States District Court in the Nehmer class action, the VA promulgated special rules for the effective dates of presumptive service connection granted based on exposure to herbicides. See 38 C.F.R. § 3.816; see also Nehmer v. United States Veterans’ Administration, 712 F. Supp. 1404 (N.D. Cal. 1989); Nehmer v. United States Veterans’ Administration, 32 F. Supp. 2d 1175 (N.D. Cal. 1999); Nehmer v. Veterans’ Administration of the Government of the United States, 284 F.3d 1158 (9th Cir. 2002). In order to avail himself of the special rules for effective dates, a veteran must qualify as a Nehmer class member pursuant to 38 C.F.R. § 3.307 (a)(6) (2017) and have a covered herbicide disease as provided in 38 C.F.R. § 3.309 (e) (2017), which includes ischemic heart disease (also known as CAD). 38 C.F.R. § 3.816 (2017). As a Nehmer class member, certain effective dates apply based on whether the veteran was denied compensation for such a disability between September 25, 1985 and May 3, 1989; or if there was a claim for benefits pending before the VA between May 3, 1989 and the effective date of the applicable statute or regulation establishing the presumption of service connection for the disability; in this instance August 31, 2010. 38 C.F.R. § 3.816 (c). In either of these instances, the effective date of the award will be the date such claim was received or the date the disability arose, whichever is later. 38 C.F.R. § 3.816 (c). In this case, the Veteran was denied service connection for “heart problems” in a January 1985 rating decision. While the Veteran filed a claim for a heart disorder in 1984, the claim was denied in January 1985 and that decision became final. The special rules promulgated by VA for Nehmer class members concerning effective dates do not apply to claims denied prior to September 25, 1985. Nonetheless, in January 1997, the Veteran filed a claim for service connection for “difficulty breathing,” “shortness of breath,” and “fatigue.” These claims were denied in a February 1997 rating decision. The Veteran also filed a new claim for CAD in January 2008. The Board finds that the Veteran’s February 1997 claim reasonably includes symptomatology contemplated by a heart disorder. This determination is legally consistent with the RO’s previous determination of an effective date prior to the January 2008 claim for CAD. As such, the Board finds that the Veteran did submit a claim for service connection for a heart condition between May 3, 1989, and August 31, 2010, the date on which the liberalizing law that added ischemic heart disease as a disease presumptively due to in-service exposure to herbicides became effective. See Liesegang v. Sec’y of Veterans Affairs, 312 F.3d 1368 (Fed. Cir. 2002). Under 38 C.F.R. § 3.816 (c)(2), the effective date of the award will be the later of the date the claim was received by VA or the date the disability arose. VA treatment records show that the onset date of CAD was January 4, 2001. As such, because the Veteran filed a claim for a heart disorder in January 1997, the earliest effective date for the award of service connection for CAD is January 4, 2001— i. e., the later of the date the claim was received by VA (January 1997) and the date the disability arose (January 2001). For these reasons, the Board finds that an effective date of January 4, 2001, for the grant of service connection for CAD is granted. S. B. MAYS Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD R. Casadei, Counsel