Citation Nr: 18161320 Decision Date: 12/31/18 Archive Date: 12/31/18 DOCKET NO. 16-44 198 DATE: December 31, 2018 ORDER Entitlement to an earlier effective date prior to August 26, 2014 for the grant of service connection for loss of teeth (22 and 12) is denied. Entitlement to an earlier effective date prior to August 26, 2014 for the grant of an increased disability rating for maxilla, postoperative residuals of inter-maxillary fixation and reduction is denied. Entitlement to an earlier effective date prior to August 26, 2014 for the grant of an increased disability rating for vascular headaches is denied. Entitlement to a disability rating in excess of 10 percent for right medial epicondylitis is denied. Entitlement to an initial compensable rating for loss of teeth (22 and 12) is denied. Entitlement to a disability rating in excess of 40 percent for maxilla, postoperative residuals of inter-maxillary fixation and reduction is denied. Entitlement to a disability rating in excess of 30 percent for mandible, postoperative residuals of inter-maxillary fixation and reduction is denied. REMANDED Entitlement to a disability rating in excess of 30 percent for vascular headaches is remanded. Entitlement to a disability rating in excess of 10 percent for a cervical strain is remanded. Entitlement to a total disability rating based upon individual unemployability (TDIU) is remanded. Entitlement to service connection for sleep apnea is remanded. Entitlement to service connection for hypertension is remanded. Entitlement to service connection for GERD is remanded. Entitlement to service connection for PTSD is remanded. Entitlement to service connection for insomnia is remanded. Entitlement to a compensable rating for exostosis, right third metacarpal is remanded. Entitlement to a disability rating in excess of 10 percent for thoracic strain with DDD of L4-5 is remanded. Entitlement to a disability rating in excess of 10 percent for bilateral foot pain with stress reactions of metatarsals is remanded. Entitlement to a disability rating in excess of 10 percent for conjunctivitis, chronic is remanded. Entitlement to a disability rating in excess of 10 percent for left inguinal hernia is remanded. Entitlement to a compensable rating for laceration, left eyebrow is remanded. Entitlement to a disability rating in excess of 10 percent for left zygoma fracture is remanded. FINDINGS OF FACT 1. No claim, formal or informal, for service connection for loss of teeth was received prior to August 26, 2014. 2. In January 2001 rating decision, service connection for post-operative residuals, intermaxillary fixation and reduction of mandible was granted; a noncompensable rating was assigned, effective January 1, 2001. 3. In January 2001 rating decision, service connection for vascular headaches was granted; a noncompensable rating was assigned, effective January 1, 2001. 4. The Veteran did not perfect an appeal of the initial ratings assigned for post-operative residuals, intermaxillary fixation and reduction of mandible or vascular headaches. The January 2001 rating decision became final. 5. Following the final January 2001 rating decision, the earliest claim for an increased rating for post-operative residuals, intermaxillary fixation and reduction of mandible was received on August 26, 2014. 6. It is not factually ascertainable that the Veteran’s increase in disability of his service-connected post-operative residuals, intermaxillary fixation and reduction of mandible manifested within one year prior to receipt of his August 26, 2014 claim. 7. Following the final January 2001 rating decision, the earliest claim for an increased rating for vascular headaches was received on August 26, 2014. 8. It is not factually ascertainable that the Veteran’s increase in disability of his service-connected vascular headaches manifested within one year prior to receipt of his August 26, 2014 claim. 9. The Veteran’s right medial epicondylitis has been manifested by limitation of flexion to 135 degrees and limitation of extension to 15 degrees. 10. The Veteran’s right medial epicondylitis has not manifested with limitation of flexion to 90 degrees or extension to 75 degrees. 11. The Veteran’s loss of teeth (22 and 12) does not more nearly approximate all upper anterior teeth missing, all lower anterior teeth missing, or all upper and lower teeth missing on one side. 12. The Veteran’s maxilla, postoperative residuals of inter-maxillary fixation and reduction does not result in, or more nearly approximate, loss of more than half of the maxilla. 13. The severity and symptomatology of the Veteran’s impairment of the maxilla is adequately contemplated by the rating schedule. 14. The Veteran’s mandible, postoperative residuals of inter-maxillary fixation and reduction is not manifested by at least half of the mandible or inter-incisional range of less than 10 millimeters. CONCLUSIONS OF LAW 1. The criteria for the assignment of an effective date of earlier than August 26, 2014 for the grant of service connection for loss of teeth (22 and 12) have not been met. 38 U.S.C. §§ 5103, 5103A, 5107, 5110 (2012); 38 C.F.R. §§ 3.1, 3.151, 3.155, 3.400 (2017). 2. The criteria for an effective date prior to August 26, 2014, for the award of a 40 percent rating for maxilla, post-operative residuals intermaxillary fixation and reduction have not been met. 38 U.S.C. §§ 1155, 5110 (2012); 38 C.F.R. §§ 3.155, 3.157(a), 3.400(o), 4.7, 4.150, Diagnostic Code (DC) 9915 (2017). 3. The criteria for an effective date prior to August 26, 2014, for the award of a 30 percent rating for vascular headaches have not been met. 38 U.S.C. §§ 1155, 5110 (2012); 38 C.F.R. §§ 3.155, 3.157(a), 3.400(o), 4.7, 4.124a, DC 8100 (2017). 4. The criteria for a rating in excess of 10 percent for (dominant) right medial epicondylitis have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.1-4.14, 4.40, 4.45, 4.71a, DCs 5003, 5206, 5207-5212 (2017). 5. The criteria for entitlement to an initial compensable rating for loss of teeth (22 and 12) have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.1-4.7, 4.10, 4.150, DC 9913 (2017). 6. The criteria for a rating in excess of 40 percent for maxilla, postoperative residuals of inter-maxillary fixation and reduction have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.321, 4.1, 4.3, 4.7, 4.10, 4.150 DCs 9915, 9914, 9916 (2017). 7. The criteria for a rating in excess of 30 percent for mandible, postoperative residuals of inter-maxillary fixation and reduction have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.321, 4.1, 4.3, 4.7, 4.10, 4.150 DCs 9905, 9901-9904, 9906-9907 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from January 1977 to December 2000. The January 2015 rating decision granted a 40 percent rating for post-operative residuals, intermaxillary fixation and reduction of mandible. The Veteran filed a notice of disagreement (NOD) with the assigned rating in March 2015. Subsequent to the Veteran’s appeal, the AOJ granted a separate evaluation of 30 percent for mandible, postoperative residuals of inter-maxillary fixation and reduction from the Veteran’s 40 percent rating, which was characterized as maxilla, postoperative residuals of inter-maxillary fixation and reduction. As this grant, however, did not represent a total grant of benefits sought for the entire period on appeal, the Veteran’s claim for a higher disability rating for his post-operative residuals of the maxilla and mandible remain pending before the Board. AB v. Brown, 6 Vet. App. 35 (1993). Effective Date of Service Connection for Loss of Teeth In a January 2015 rating decision, the VA Regional Office (RO) granted service connection for loss of teeth (number 22 and 12), effective August 26, 2014. In March 2015, the Veteran filed an NOD with the effective date assigned for the grant of service connection. While the Veteran has indicated that an earlier effective date for the grant of service connection for loss of teeth is warranted, the Board does not find that a claim for service connection for loss of teeth was received prior to August 26, 2014; accordingly, entitlement to an effective date prior to August 26, 2014 must be denied. Unless specifically provided otherwise, the effective date for a grant of service connection is the day after separation from service or day entitlement arose, if a claim is received within one year of separation from service; otherwise, the date of receipt of claim, or the date entitlement arose, whichever is later. 38 U.S.C. § 5110 (b)(1) (2012); 38 C.F.R. § 3.400 (b)(2)(i) (2017). Prior to March 24, 2015, after which a formal claim application is required, a claim is a formal or informal communication, in writing, requesting a determination of entitlement or evidencing a belief in entitlement, to a benefit. 38 C.F.R. § 3.1 (p). Any communication or action, indicating an intent to apply for one or more benefits under the laws administered by VA, from a claimant, his duly authorized representative, a Member of Congress, or some person acting as next friend of a claimant who is not sui juris, may be considered an informal claim. 38 C.F.R. § 3.155 (2015). The evidence does not indicate that a formal or informal claim was received by VA for service connection for loss of teeth was received by VA prior to August 26, 2014 (the date service connection was granted). Under 38 U.S.C. § 5101 (a), a specific claim must be filed in order for benefits to be paid or furnished to any individual under the laws administered by VA. See 38 U.S.C. § 5101; 38 C.F.R. § 3.151 (a). As the evidence does not indicate (and the Veteran does not appear to contend) that he submitted a claim for entitlement to service connection for loss of teeth prior to August 26, 2014, an effective date prior to that date is not warranted. Even if the evidence of record indicates that the Veteran suffered from loss of teeth (number 22 and 12) prior to August 26, 2014, the effective date for entitlement to service connection is assigned based upon the later of either the date of receipt of claim or the date entitlement arose. See 38 C.F.R. § 3.400 (2017). As the preponderance of the evidence is against the claim, the benefit-of-the-doubt does not apply, and the Veteran’s claim for an effective date prior to August 26, 2014 for service connection for loss of teeth (number 22 and 12) must be denied. 38 U.S.C. § 5107 (b); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Effective Date of Increased Ratings for Headaches and Maxilla Residuals The relevant law and regulations provide that the effective date of an award of increased compensation “shall not be earlier than the date of receipt of the application thereof.” 38 U.S.C. § 5110(a). The effective date for an award of increased compensation will be the date of receipt of claim or the date entitlement arose, whichever is later. 38 C.F.R. § 3.400(o)(1). An exception to that rule applies, however, where the evidence demonstrates that a factually ascertainable increase in disability occurred within the one-year period preceding the date of receipt of a claim for increased compensation. If an increase in disability occurred within one year prior to date of receipt of the claim, the increase is effective as of the date the increase was “factually ascertainable.” If the increase occurred more than one year prior to date of receipt of the claim, the increase is effective the date of receipt of the claim. If the increase occurred after the date of receipt of the claim, the effective date is the date of increase. 38 C.F.R. 3.400 (o)(1)(2). The United States Court of Veterans Appeals (Court) has indicated that it is axiomatic that the fact that must be found, in order for entitlement to an increase in disability compensation to arise, is that the service-connected disability must have increased in severity to a degree warranting an increase in compensation. See Hazan v. Gober, 10 Vet. App. 511, 519 (1992) (noting that, under section 5110(b)(2), which provides that the effective date of an award of increased compensation shall be the earliest date of which it is ascertainable that an increase in disability had occurred, “the only cognizable ‘increase’ for this purpose is one to the next disability level” provided by law for the particular disability). Thus, determining whether an effective date assigned for an increased rating is correct or proper under the law requires (1) a determination of the date of the receipt of the claim for the increased rating as well as (2) a review of all the evidence of record to determine when an increase in disability was “ascertainable.” Id. at 521. Any communication or action indicating intent to apply for one or more benefits under the laws administered by VA from a claimant may be considered an informal claim. An informal claim must identify the benefit sought. 38 C.F.R. § 3.155(a). Once a formal claim for pension or compensation has been allowed or a formal claim for compensation disallowed for the reason that the service-connected disability is not compensable in degree, receipt of one of the following will be accepted as an informal claim for increased benefits or an informal claim to reopen: (1) A report of examination or hospitalization by VA or uniformed services, where such report relates to examination or treatment of a disability for which service-connection has previously been established or when a claim specifying the benefit sought is received within one year from the date of such examination, treatment or hospital admission; (2) Evidence from a private physician or layman, with the date of receipt of such evidence accepted when the evidence is within the competence of the physician or lay person and shows the reasonable probability of entitlement to benefits; (3) When submitted by or on behalf of the Veteran and entitlement is shown, date of receipt by VA of examination reports, clinical records, and transcripts of records will be accepted as the date of receipt of a claim if received from State, county, municipal, recognized private institutions, or other Government hospitals. 38 C.F.R. § 3.157(b). In a January 2001 rating decision, the RO granted service connection for post-operative residuals, intermaxillary fixation and reduction of mandible and assigned a noncompensable rating, effective January 1, 2001. The rating decision also granted service connection for vascular headaches and assigned a noncompensable rating, effective January 1, 2001. The Veteran did not file an appeal of these decisions and the rating decision became final. 38 U.S.C. § 7105 (2012); 38 C.F.R. §§ 3.104 (a), 20.1103 (2017). Subsequently, the Veteran filed a claim for increase for both conditions in August 2014. In January 2015, an increased evaluation of 40 percent was granted for postoperative residuals of inter-maxillary fixation and reduction, effective August 26, 2014, the date his claim for an increased evaluation was received. The January 2015 rating decision also granted an increased evaluation of 30 percent for vascular headaches, effective August 26, 2014. In March 2015, the Veteran filed an NOD and disagreed with the effective dates assigned for the 40 percent evaluation for postoperative residuals of inter-maxillary fixation and reduction and the 30 percent evaluation for vascular headaches. The Veteran has not provided argument for why he believes that an earlier effective date is warranted for the ratings assigned for either condition. As the Veteran’s previous claims became final, a higher rating cannot be granted prior to the filing of a new claim for an increase in rating. Review of the record does not demonstrate that the Veteran filed a claim for increase for either his postoperative residuals of inter-maxillary fixation and reduction or his vascular headaches until August 26, 2014. As the Veteran’s claims for an increased rating were not received by VA prior to August 26, 2014, an earlier date than August 26, 2014, cannot be granted unless the evidence demonstrates that a factually ascertainable increase in disability occurred within the one-year period preceding the date of receipt of a claim. 38 C.F.R. § 3.400 (o)(1)(2). As it must be factually ascertainable increase in disability occurred, the Board must determine whether the evidence indicates that the criteria for a 40 percent rating for postoperative residuals of inter-maxillary fixation and reduction or a 30 percent evaluation for vascular headaches became manifest within a year prior to August 26, 2014. With regard to the Veteran’s postoperative residuals of inter-maxillary fixation, the Veteran’s 40 percent rating was assigned pursuant to DC 9915, maxilla loss of half or less. Under Diagnostic Code 9915, a noncompensable rating is warranted when there is loss of less than 25 percent of the maxilla replaceable by prosthesis; a 20 percent rating is warranted when there is loss of less than 25 percent of the maxilla not replaceable by prosthesis; a 30 percent rating is warranted when there is loss of 25 to 50 percent of the maxilla replaceable by prosthesis; and a 40 percent rating is warranted when there is loss of 25 to 50 percent of the maxilla not replaceable by prosthesis. 38 C.F.R. § 4.150, DC 9915 (2017). The evidence of record does not document that the Veteran was diagnosed with loss of 25 to 50 percent of the maxilla not replaceable by prosthesis within a year prior to August 26, 2014. The October 2000 VA examination indicates that the Veteran underwent intermaxillary fixation and reduction of the mandible in October 1982. The history provided by the Veteran during his January 2015 VA examination did not indicate any recent surgery or bone loss of the maxilla. The Veteran’s medical records also do not demonstrate that the Veteran developed loss of 25 to 50 percent of the maxilla within the year prior to August 26, 2014. Accordingly, the Board finds that it was not factually ascertainable that the Veteran’s postoperative residuals of inter-maxillary fixation and reduction manifested to the degree that warranted a 40 percent rating based upon loss of bone within a year prior to August 26, 2014. As such, the Board finds that an effective date prior to August 26, 2014, for the increase of postoperative residuals of inter-maxillary fixation and reduction to 40 percent is not warranted. 38 C.F.R. §§ 3.400, 4.3, 4.150, DC 9915 (2017). With regard to the Veteran’s vascular headaches, the Veteran’s 30 percent rating was assigned pursuant to DC 8100, migraines. Under DC 8100, a 30 percent evaluation is assigned for migraines with characteristic prostrating attacks occurring on an average of once a month over the last several months. A maximum 50 percent evaluation is warranted for migraines with very frequent completely prostrating and prolonged attacks, productive of severe economic inadaptability. 38 C.F.R. § 4.124a, DC 8100 (2017). The evidence of record does not document that the Veteran vascular headaches manifested with characteristic prostrating attacks occurring on an average of once a month over the last several months within a year prior to August 26, 2014. The history provided by the Veteran during his January 2015 VA examination did not indicate that the prostrating attacks caused by his headaches had begun within the year prior to his claim. Further, treatment records from the neurology clinic at the Madigan Army Medical Center report that the Veteran was using triptans very regularly in 2011 to treat his headache symptoms and that his migraine symptoms increased after a head injury in 2012. Records from the Neurology clinic in September 2015 also indicate that the Veteran’s headaches worsened after his fall and that he was suffering from headaches approximately twice per week that do not respond to medication 20-30 percent of the time. As the evidence indicates a history of prostrating attacks caused by his headaches prior to 2011 and after his 2012 head injury and it is unclear from the evidence when the Veteran’s migraines manifested to the degree that they cause characteristic prostrating attacks occurring on an average of once a month over the period of several months, the Board finds that the evidence does not indicate that it is factually ascertainable that the Veteran’s headaches manifested to a degree warranting a 30 percent rating within the one-year period preceding the Veteran’s August 26, 2014 claim for an increase. As such, the Board finds that an effective date prior to August 26, 2014 for the increased rating of 30 percent for the Veteran’s vascular headaches is not warranted. 38 C.F.R. §§ 3.400, 4.3, 4.124a, DC 8100 (2017). In sum, as the January 2001 rating decision became final and based upon the evidence from the one-year period prior to the Veteran’s August 26, 2014 claims for increased ratings for post-operative residuals, intermaxillary fixation and reduction of mandible and vascular headaches, entitlement to an effective date prior to August 26, 2014 the award of a 40 percent disability rating for post-operative residuals, intermaxillary fixation and reduction of mandible and the award of a 30 percent disability rating vascular headaches is not warranted. As the preponderance of the evidence is against the Veteran’s claims, the benefit-of-the-doubt rule does not apply, and the claims must be denied. 38 U.S.C. § 5107(b) (2012); 38 C.F.R. §§ 4.3, 4.7 (2017); Gilbert, 1 Vet. App. at 55 (1990). Increased Ratings, Generally Disability evaluations (ratings) are determined by evaluating the extent to which a veteran’s service-connected disability adversely affects his ability to function under the ordinary conditions of daily life, including employment, by comparing the symptomatology with the criteria set forth in the Schedule for Rating Disabilities (Rating Schedule). 38 U.S.C. § 1155; 38 C.F.R. §§ 4.1, 4.2, 4.10. In evaluating a disability, the Board considers the current examination reports in light of the whole recorded history to ensure that the current rating accurately reflects the severity of the condition. The Board has a duty to acknowledge and consider all regulations that are potentially applicable. Schafrath v. Derwinski, 1 Vet. App. 589 (1991). 38 C.F.R. §§ 4.1, 4.2, 4.10. Disability of the musculoskeletal system is primarily the inability, due to damage or infection in parts of the system, to perform the normal working movements of the body with normal excursion, strength, speed, coordination and endurance. Functional loss may be due to the absence or deformity of structures or other pathology, or it may be due to pain, supported by adequate pathology and evidenced by the visible behavior in undertaking the motion. Weakness is as important as limitation of motion, and a part that becomes painful on use must be regarded as seriously disabled. 38 C.F.R. § 4.40. However, in Mitchell v. Shinseki, 25 Vet. App. 32 (2011), the Court held that, although pain may cause a functional loss, pain itself does not rise to the level of functional loss as contemplated by VA regulations applicable to the musculoskeletal system. Rather, pain may result in functional loss, but only if it limits the ability to perform the normal working movements of the body with normal excursion, strength, speed, coordination, or endurance. Id., quoting 38 C.F.R. § 4.40. With respect to joints, in particular, the factors of disability reside in reductions of normal excursion of movements in different planes. Inquiry will be directed to more or less than normal movement, weakened movement, excess fatigability, incoordination, pain on movement, swelling, deformity or atrophy of disuse. 38 C.F.R. § 4.45. In determining the degree of limitation of motion, the provisions of 38 C.F.R. §§ 4.10, 4.40, and 4.45 are for consideration. See DeLuca v. Brown, 8 Vet. App. 202 (1995). 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. When all the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with a 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. § 4.3. Where entitlement to compensation has already been established and an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). Separate ratings can be assigned for separate periods of time based on the facts found, a practice known as “staged” ratings. See Hart v. Mansfield, 21 Vet. App. 505. Here, the Board finds that the Veteran’s symptoms related to his service-connected right medial epicondylitis and his dental conditions on appeal have not significantly changed throughout the appeal period and that uniform disability ratings are warranted. Id. Entitlement to an Increased Rating for a Right Elbow Disability In August 2014, the Veteran submitted a claim for an increased rating for his right medial epicondylitis (right elbow disability). In January 2015, the Veteran’s 10 percent rating for his elbow disability was continued by the RO. The Veteran appealed this decision. The Veteran’s right elbow disability is currently assigned a 10 percent rating under DC 5099-5024. Hyphenated diagnostic codes are used when a rating under one diagnostic code requires use of an additional diagnostic code to identify the basis for the assigned rating; the additional code is shown after the hyphen. The provisions of 38 C.F.R. § 4.27 provide that unlisted disabilities requiring rating by analogy will be coded with the first two numbers of the schedule provisions for the most closely related body part and 99. 38 C.F.R. § 4.27. Here, the hyphenated diagnostic code indicates that an unlisted musculoskeletal condition (DC 5099) is rated under the criteria for tenosynovitis (DC 5024). See 38 C.F.R. § 4.20. DC 5024 provides that such diseases will be rated on limitation of motion of affected parts. Limitation of motion of the elbow is rated under DC 5206. Under DC 5206, major forearm flexion limited to 100 degrees warrants a 10 percent evaluation, flexion limited to 90 degrees warrants a 20 percent evaluation, flexion limited to 70 degrees warrants a 30 percent evaluation, flexion limited to 55 degrees warrants a 40 percent evaluation, and limitation of flexion of the major forearm to 45 degrees warrants a 50 percent rating. 38 C.F.R. § 4.71a, DC 5206. The Board will also consider other diagnostic codes that contemplate limitation of motion of the elbow. Under DC 5207, major forearm extension limited to 75 degrees warrants a 20 percent evaluation, extension limited to 90 degrees warrants a 30 rating, limitation of extension to 100 degrees warrants a 40 percent rating, and limitation of extension to 110 degrees warrants a 50 percent rating. 38 C.F.R. § 4.71a, DC 5207. DC 5208 provides a 20 percent rating for limitation of forearm flexion to 100 degrees with extension to 45 degrees. DC 5209 provides a 20 percent rating for joint fracture, with marked cubitus varus or cubitus valgus deformity or with ununited fracture of head of radius. A 60 percent rating is provided for other impairment of flail joint. Under DC 5210, nonunion of the radius and ulna with flail false joint warrants a 50 percent rating. Under DC 5211, impairment of the ulna of the arm with malunion and bad alignment warrants a 10 percent rating; with nonunion in lower half warrants a 20 percent rating; with nonunion in upper half with false movement without loss of bone substance or deformity warrants a 30 percent rating; and nonunion in upper half with false movement with loss of bone substance (1 inch (2.5 cm.) or more) and marked deformity warrants a 40 percent rating. Under DC 5212, impairment of the radius with malunion and bad alignment warrants a 10 percent rating; with nonunion in upper half warrants a 20 percent rating; without loss of bone substance or deformity warrants a 30 percent rating; with loss of bone substance (1 inch (2.5 cm.) or more) and marked deformity warrants a 40 percent rating. Under 38 C.F.R. § 4.71a, Plate I, normal flexion of the elbow is 0 to 145 degrees, normal forearm pronation is 0 to 80 degrees, and normal forearm supination is 0 to 80 degrees. 38 C.F.R. § 4.71, Plate I (2017). The Veteran was provided an examination of his right elbow disability in January 2015. During the January 2015 examination, the Veteran reported that his right elbow pain started in 1980. He indicated that his pain was related to frequently working on a computer. He stated that he still has pain, but not often maybe twice per month. The pain will last a day or so. The examiner noted that the Veteran’s right arm was his dominant extremity. The examiner stated that range of motion testing was as follows: flexion from 0 to 145 degrees without objective evidence of painful motion; extension from 145 to 0 degrees without objective evidence of painful motion; right forearm supination was from 0 to 85 degrees without objective evidence of painful motion; and right forearm pronation was from 0 to 85 degrees without objective evidence of painful motion. No additional limitation was shown on repetitive motion testing. The Veteran was not shown to have flail joint, joint fracture, or impairment of supination or pronation. The examiner stated that the Veteran’s condition caused functional loss that included pain on movement of flexion that would result in 5 degrees of additional range of motion loss. The examiner also stated that the Veteran’s condition would limit his ability to lift or carry 40 pounds at work after multiple attempts. The Board concludes, after review of the competent evidence of record, that the criteria for a rating in excess of 10 percent for the Veteran’s right elbow disability have not been meet or approximated. In that regard, although the evidence indicates that the Veteran experiences loss of motion of the right elbow during his episodes of pain that occur twice per month, even with the complaints of pain, the evidence does not demonstrate limitation of flexion to 90 degrees or limitation of extension to 75 degrees, which would warrant the assignment of a 20 percent rating under DCs 5206 or 5207, or limitation of flexion to 100 degrees with extension to 45 degrees under DC 5208. 38 C.F.R. § 4.71a. The Board also notes that a rating in excess of 20 percent for the Veteran’s right elbow disability is not warranted under DC 5209, as there has been no current documentation of fracture, deformity, or flail joint. The Board notes the Veteran’s competent, credible reports of pain that result from his condition on a recurrent basis; however, the 2015 examiner considered these statements when the opinion that the Veteran’s condition would cause functional loss from pain on movement that would result in an additional loss of 5 degrees of flexion of the right elbow. Rather, if the ranges of right elbow motion noted above were strictly rated under range of motion diagnostic codes, the Veteran’s right elbow disability would be rated as 0 percent (noncompensably) disabling. In that regard, the Veteran’s functional loss due to pain is adequately covered by the 10 percent rating currently assigned. See 38 C.F.R. §§ 4.40, 4.45, 4.59; see DeLuca v. Brown. Further, the Veteran has not identified, nor does the competent medical evidence show, any functional limitation, which would warrant a higher rating under the applicable rating criteria. Although the Board is required to consider the effect of the Veteran’s pain when making a rating determination, and has done so in this case, the Rating Schedule does not provide for a separate rating for pain. The Board finds that the preponderance of the evidence reflects that the Veteran’s right elbow disability is no more than 10 percent disabling; therefore, the benefit-of-the-doubt rule does not apply and the claim for a rating in excess of 10 percent must be denied. 38 C.F.R. §§ 4.3, 4.7. Entitlement to a compensable rating for loss of teeth (22 and 12) The Veteran’s service-connected loss of teeth (22 and 12) is rated under 38 C.F.R. § 4.150, DC 9913. Under DC 9913, a noncompensable rating is warranted where the loss of masticatory surface can be restored by suitable prothesis. A ten percent rating is warranted where the lost masticatory surface cannot be restored by suitable prothesis for all upper and lower teeth on one side missing; or all lower anterior teeth missing; or all upper anterior teeth missing. In this case, the Veteran lost two teeth number 22 and number 12 due to loss of teeth due to loss of substance of body of maxilla or mandible without loss of continuity. See December 2014 VA Examination. While the 2014 examiner indicated that these surfaces could not be restored by a suitable prosthesis, the only reported missing teeth are 22 and 12. The Board notes that compensable ratings are warranted where the lost masticatory surface cannot be restored by suitable prothesis for missing all upper and lower teeth on one side, missing all lower anterior teeth, or missing all upper anterior teeth. While the Board is sympathetic to the Veteran’s claim, the Board does not find that missing two teeth (22 and 12) more nearly approximates missing one of these groups of teeth; accordingly, the Board finds that a compensable rating for loss of teeth (22 and 12) is not warranted. 38 C.F.R. §§ 4.3, 4.14, 4.150, DC 9913 (2017). The Board notes that the functional impairment that results from the Veteran’s loss of bone of the mandible and loss of bone of the maxilla are contemplated under his separately assigned ratings for maxilla, postoperative residuals of inter-maxillary fixation and reduction (DC 9915) and mandible, postoperative residuals of inter-maxillary fixation and reduction (DC 9904-9905). As the preponderance of the evidence of the evidence is against the Veteran’s claim for an initial compensable rating for loss of teeth (22 and 12), the benefit-of-the-doubt rule does not apply and the claim must be denied. 38 C.F.R. §§ 4.3, 4.7. Entitlement to a rating in excess of 40 percent for Maxilla Entitlement to a rating in excess of 30 percent for Mandible In August 2014, the Veteran submitted a claim for an increased rating for his post-operative mandible condition. As discussed above, a January 2015 rating decision granted a 40 percent rating for post-operative residuals, intermaxillary fixation and reduction of mandible. The Veteran filed an NOD with the assigned rating in March 2015. Subsequently, the Veteran was granted a separate evaluation of 30 percent for mandible, postoperative residuals of inter-maxillary fixation and reduction (mandible disability) from the Veteran’s 40 percent rating, which was characterized as maxilla, postoperative residuals of inter-maxillary fixation and reduction (maxilla disability). Unfortunately, the Board finds that the evidence of record does not support a higher rating for either condition. The Veteran’s maxilla disability is currently rated 40 percent disabling under 38 C.F.R. § 4.150, DC 9915 for loss of half or less of the maxilla. Under DC 9915, a 40 percent rating is warranted when there is loss of 25 to 50 percent of the maxilla not replaceable by prosthesis. No higher rating is available under the rating schedule for a disability manifested by loss of half or less of the maxilla. Higher ratings are available for loss of more than half of the maxilla under Diagnostic Code 9914. 38 C.F.R. § 4.150, DC 9914. The evidence demonstrates that the Veteran previously underwent surgery on the maxilla and mandible that resulted in intermaxillary fixation and reduction of mandible. In December 2014, the Veteran’s condition was evaluated by a VA examiner. The examiner reported that the Veteran’s condition resulted in loss of 25 percent to 50 percent of the maxilla, and that the loss was not replaceable by prosthesis. None of the competent evidence of record supports a finding that the Veteran’s maxilla disability has resulted in loss of more than 50 percent of the maxilla. Further, the Veteran (and his representative) have not argued that the Veteran’s maxilla disability has resulted in loss of more than 50 percent of the maxilla, and the Veteran has not explained why he feels that a rating in excess of 40 percent is warranted for the Veteran’s maxilla disability. The Board finds that the preponderance of the evidence reflects that the Veteran’s maxilla disability has not resulted in loss of more than 50 percent of the maxilla; therefore, the benefit-of-the-doubt rule does not apply and the claim for a rating in excess of 40 percent must be denied. 38 C.F.R. §§ 4.3, 4.7, 4.150, DC 9915. The Veteran’s service-connected mandible disability is currently rated 30 percent disabling under hyphenated diagnostic code 9904-9905. The hyphenated diagnostic code indicates that the Veteran’s malunion of the mandible (DC 9904) is rated under the diagnostic code for limitation of motion of temporomandibular articulation (DC 9905). Under DC 9905, a rating of 10 percent is warranted for limitation of lateral excursion from 0 to 4 millimeters (mm) or limitation of inter-incisal range from 31 to 40 mm. 38 C.F.R. § 4.150, DC 9905. A rating of 20 percent is warranted where inter-incisal range is from 21 to 30 mm. A rating of 30 percent is warranted where inter-incisal range is from 11 to 20 mm; and a rating of 40 percent is warranted where inter-incisal range is from 0 to 10 mm. Id. Ratings for limited inter-incisal movement shall not be combined with ratings for limited lateral excursion. 38 C.F.R. § 4.150, DC 9905, Note. During the Veteran’s December 2014 examination, the Veteran reported temporomandibular discomfort with opening and closing his jaw. On examination, the Veteran was noted to have loss of bone of the mandible. The examiner noted that the Veteran has loss of less than half of the substance of the mandibular ramus, not involving loss of continuity involving both sides of his mandible. The Veteran reported that speech required for his line of work and talking for long periods of time result in pain. The examiner reported loss of motion of TMJ articulation. The inter-incisal range of motion was from 0 to 22 mm, but after repetitive use testing inter-incisal range of motion was limited to between 11 to 20 mm. Range of lateral excursion was from 0 to 4 mm. The Veteran reported flare-ups that cause his jaw to lock up when he sleeps on one side. The examiner stated that functional ability was limited during flare-ups due to pain, weakness, fatiguability, and incoordination. The Veteran indicated that flare-ups cause lateral movement to be limited to less than 4 mm. Treatment records from the Madigan Army Medical Center report that the Veteran sought treatment for right ear pain that was diagnosed as likely temporomandibular joint dysfunction in May 2015. No measurements of inter-incisal range of motion were provided. The Board concludes, after review of the competent evidence of record, that the criteria for a rating in excess of 30 percent for the Veteran’s mandible disability have not been meet or approximated. The evidence of record indicates mandible disability has resulted in loss of less than half of the substance of the mandibular ramus, which limits his temporomandibular articulation. The evidence indicates that the Veteran’s temporomandibular articulation is limited at most to between 11 to 20 mm, even when considering functional limitations after repetitive use and during flare-ups. While the 2014 examiner opined that the Veteran had limited functional ability during flare-ups due to pain, weakness, fatiguability, and incoordination, it was indicated that these symptoms did not limit inter-incisal range of motion to less than 11 mm. The Board notes that the Veteran has not contended that his limitation of inter-incisal range of motion is less than 11 mm or that the December 2014 examination did not properly assess his range of temporomandibular articulation. Additionally, none of the medical evidence of record indicates that the Veteran has inter-incisal range of motion to less than 11 mm, including his treatment records from the Madigan Army Medical Center and the American Lake VA Medical Center. As the preponderance of the evidence reflects that the Veteran’s mandible disability has not resulted in inter-incisal range of motion to less than 11 mm, the Board finds that a rating in excess of 30 percent is not warranted under DC 9905. See 38 C.F.R. §§ 4.3, 4.7, 4.150, DC 9905. While the Veteran has documented lateral excursion limited to less than 4 mm, a separate rating would constitute impermissible pyramiding. See 38 C.F.R. §§ 4.14, 4.150, DC 9905, Note. The Board has considered other applicable diagnostic codes; however, none of the applicable diagnostic codes afford the Veteran a higher rating for his mandible disability under the rating criteria. The evidence does not indicate that the Veteran has loss of one half or more of the mandible; accordingly, a higher evaluation is not available under DCs 9901 or 9902. Further, the evidence of record does not indicate that the Veteran had loss whole or part of the ramus. Rather, the 2014 examiner indicated that the Veteran had lost less than half of the substance of the mandibular ramus and did not report loss whole or part of the ramus; accordingly, a higher evaluation is not warranted under DC 9906. In sum, the Board finds that the preponderance of the evidence is against the Veteran’s claim for a higher rating for either his 40 percent maxilla disability or his 30 percent mandible disability. As the preponderance of the evidence is against the Veteran’s claims for an increased rating, the benefit-of-the-doubt rule does not apply and the claims must be denied. 38 C.F.R. §§ 4.3, 4.7. Duties to Notify and Assist Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the appellant, if any, of any information and medical or lay evidence that is necessary to substantiate the claim. The Board finds that evidence of record indicates that the duty to notify has been satisfied. 38 U.S.C. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.326(a) (2017). The Board also finds that the duty to assist has been satisfied. The Veteran’s service treatment records, VA and private treatment records, and VA examinations have been associated with the claims file. The Board finds the medical examinations of record are adequate to resolve the Veteran’s claims for a higher rating decided on appeal. The Board finds these examinations, in combination with the treatment records associated with the claims file, to be comprehensive and sufficient in addressing the severity of the Veteran’s symptoms and resulting functional impairment caused by the Veteran’s right elbow disability, his loss of teeth (22 and 12), his maxilla disability, and his mandible disability during the appeal period. In this regard, it is noted that these examinations were provided following review of the claims file, physical examination of the Veteran, and interview of the Veteran. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). The Veteran has not identified any outstanding records that are relevant to his claims for a higher rating decided on appeal. The Board finds that the duty to assist has, therefore, been satisfied and there is no reasonable possibility that further assistance would be capable of substantiating the claims decided on appeal. 38 U.S.C. § 5103A (a)(2) (2012). REASONS FOR REMAND Entitlement to a rating in excess of 30 percent for vascular headaches is remanded. In claims for an increase in rating, it is first and foremost a priority to ensure that the most current assessment of the service-connected disability picture is of record. See Green v. Derwinski, 1 Vet. App. 121, 124 (1991). With regard to the Veteran’s service-connected vascular headaches, the evidence of record indicates that the Veteran’s condition may have worsened since his most recent VA examination in January 2015. Records from the Madigan Army Medical Center in June 2016 indicate that the Veteran is suffering from increased symptoms due to his headaches and the Veteran submitted an April 2016 residual functional capacity evaluation indicating that the Veteran’s headaches, in part, were interfering with his ability to work. As the evidence suggests a worsening of the Veteran’s service-connected vascular headaches that could allow for a higher rating, the Board finds that a new, comprehensive VA examination, addressing the severity of his service-connected disability should be afforded. Entitlement to a rating in excess of 10 percent for a cervical strain is remanded. In January 2015, the Veteran underwent a VA examination to evaluate the severity of the Veteran’s current cervical disability. The Board finds that this examination is inadequate to resolve the issue on appeal as it does not address pertinent facts of record and appears to demonstrate internally inconsistent findings. First, the medical records of the Veteran’s treatment at the Madigan Army Medical Center indicates that the Veteran has received intermittent cervical traction (ICT) to treat his neck disability during the appeal period. This treatment was not discussed by the 2015 VA examiner, and the Board finds that the new examination should discuss the duration and frequency of this treatment. Additionally, the examiner stated that the Veteran had flexion of his neck to from 0 to 35 degrees, with objective evidence of painful motion at 0 degrees. The examiner, however, stated in the flare-up portion of the examination that the Veteran would have an additional 5 degrees of limitation of flexion during flare-ups due to painful motion. This assessment and the examiner’s report of where painful motion begins appears to be in conflict. The examiner also indicated that objective evidence of painful motion was present at 0 degrees of extension and lateral rotation, but only reported additional limitations of range of motion with regard to flexion during flare-ups. The Board finds that a new examination should be provided to address these discrepancies. Entitlement to a TDIU is remanded. The Board finds that the issue of entitlement to TDIU is inextricably intertwined with the issues of entitlement to an increased rating being remanded; accordingly, it should also be remanded. Entitlement to the following: a compensable rating for exostosis, right third metacarpal; a rating in excess of 10 percent for thoracic strain with DDD of L4-5; a rating in excess of 10 percent for bilateral foot pain with stress reactions; a rating in excess of 10 percent for conjunctivitis; a rating in excess of 10 percent for left inguinal hernia; a compensable rating for laceration, left eyebrow; a rating in excess of 10 percent for left zygoma fracture; service connection for sleep apnea; service connection for hypertension; service connection for GERD; service connection for PTSD; and service connection for insomnia are remanded. Lastly, the January 2015 rating decision denied many issues including: a compensable rating for exostosis, right third metacarpal; a rating in excess of 10 percent for thoracic strain with DDD of L4-5; a rating in excess of 10 percent for bilateral foot pain with stress reactions; a rating in excess of 10 percent for conjunctivitis; a rating in excess of 10 percent for left inguinal hernia; a compensable rating for laceration, left eyebrow; a rating in excess of 10 percent for left zygoma fracture; service connection for sleep apnea; service connection for hypertension; service connection for GERD; service connection for PTSD; and service connection for insomnia. In March 2015, the Veteran submitted a notice of disagreement regarding all of these issues, however, the Statement of the Case (SOC) issued in August 2016 only addressed issues listed on the first two pages of the NOD. The Veteran’s representative has repeatedly requested that a SOC be issued for these issues; however, no SOC has been issued with regard to these issues. Because the Veteran has filed a notice of disagreement with regard to the above issues, the issuance of a statement of the case is required. 38 C.F.R. § 19.9 (c) (2017); Manlincon v. West, 12 Vet. App. 238, 240-41 (1999). The matters are REMANDED for the following action: 1. The Veteran must be afforded the appropriate VA examination to determine the current severity of his service-connected vascular headache disability. The claims file, including all electronic records must be made available to the examiner. Any indicated diagnostic tests and studies must be accomplished. All pertinent symptomatology and findings should be reported in detail. The examiner must provide a detailed rationale for any opinions rendered. 2. The Veteran must be afforded the appropriate VA examination to determine the current severity of his service-connected cervical spine disability. The examiner is asked to specifically discuss where objective evidence of painful motion of the neck is demonstrated during range of motion, whether range of motion is additionally limited during periods of flare-ups, and to discuss the Veteran’s treatment with intermittent cervical traction at the Madigan Army Medical Center during the appeal period. The claims file, including all electronic records must be made available to the examiner. Any indicated diagnostic tests and studies must be accomplished. All pertinent symptomatology and findings should be reported in detail. The examiner must provide a detailed rationale for any opinions rendered. 3. Issue a Statement of the Case to the Veteran addressing the issues of entitlement to a compensable rating for exostosis, right third metacarpal; a rating in excess of 10 percent for thoracic strain with DDD of L4-5; a rating in excess of 10 percent for bilateral foot pain with stress reactions; a rating in excess of 10 percent for conjunctivitis; a rating in excess of 10 percent for left inguinal hernia; a compensable rating for laceration, left eyebrow; a rating in excess of 10 percent for left zygoma fracture; service connection for sleep apnea; service connection for hypertension; service connection for GERD; service connection for PTSD; and service connection for insomnia. The Veteran must be advised of the time limit in which he may file a substantive appeal. See 38 C.F.R. § 20.302 (b). If, and only if, the appeals are perfected by a timely filed substantive appeal, these issues should be certified to the Board. 4. Then, readjudicate the claims. If the benefits sought on appeal are not granted, the Veteran should be furnished an SSOC and be afforded a reasonable opportunity to respond before the record is returned to the Board for further review. K. PARAKKAL Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD P.M. Johnson, Counsel