Citation Nr: 19106988 Decision Date: 01/29/19 Archive Date: 01/29/19 DOCKET NO. 15-46 249 DATE: January 29, 2019 ORDER Entitlement to an increased rating higher than 30 percent for posttraumatic stress disorder (PTSD) for purposes of accrued benefits and/or substitution is denied. Entitlement to an effective date earlier than March 21, 2011 for the grant of service connection for PTSD for purposes of accrued benefits and/or substitution is denied. A rating reduction from 100 percent to 40 percent, effective October 1, 2014, for prostate cancer for purposes of accrued benefits and/or substitution was proper. Entitlement to an increased rating higher than 40 percent for prostate cancer for purposes of accrued benefits and/or substitution, effective October 1, 2014 to October 9, 2015, is denied. Entitlement to an increased rating of 100 percent for prostate cancer for purposes of accrued benefits and/or substitution, effective October 10, 2015, is granted, subject to the rules governing the payment of monetary benefits. REMANDED Entitlement to service connection for hypertension for purposes of accrued benefits and/or substitution is remanded. Entitlement to service connection for nerve damage to fingers for purposes of accrued benefits and/or substitution is remanded. FINDINGS OF FACT 1. The Veteran’s PTSD was manifested by occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although generally functioning satisfactorily, with normal routine behavior, self-care, and conversation. 2. The Veteran’s service connection claim for anxiety neurosis with depression was denied in a June 1971 rating decision. The Veteran did not appeal this decision; nor did he, or the appellant assert clear and unmistakable error in this decision. 3. The Veteran’s service connection claim for PTSD was received by the RO on March 21, 2011. 4. Effective October 1, 2014 to October 9, 2015, the Veteran’s service-connected prostate cancer demonstrated actual material improvement that is reasonably certain to be maintained under the ordinary conditions of life and work. 5. Effective October 1, 2014 to October 9, 2015, the Veteran’s prostate cancer was in remission and manifested by daytime voiding interval of less than one hour, or awakening to void more than five times per night. 6. Effective October 10, 2015, the Veteran’s prostate cancer was active; and the Veteran later died from metastatic pancreatic cancer with contributing cause of prostate cancer in June 2016. CONCLUSIONS OF LAW 1. The criteria for an evaluation higher than 30 percent for PTSD, for purposes of accrued benefits and/or substitution, have not been met. 38 U.S.C. § 1155; 38 C.F.R. § 4.130, Diagnostic Code 9411. 2. The June 1971 rating decision denying service connection for anxiety neurosis with depression is final. 38 U.S.C. § 7105; 38 C.F.R. §§ 3.104, 3.156(c), 20.1103. 3. The criteria for an effective date prior to March 21, 2011, for the grant of service connection for PTSD for purposes of accrued benefits and/or substitution have not been met. 38 U.S.C. §§ 5107, 5110; 38 C.F.R. § 3.400. 4. The rating reduction from 100 percent to 40 percent effective from October 1, 2014, for the Veteran’s service-connected prostate cancer was proper. 38 U.S.C. §§ 1155, 5103(a), 5103A, 5107, 5112; 38 C.F.R. §§ 3.105(e), 3.344, 4.2, 4.115a, 4.115b, Diagnostic Code 7528. 5. The criteria for an increased rating higher than 40 percent for prostate cancer, for purposes of accrued benefits and/or substitution, have not been met, effective October 1, 2014 to October 9, 2015. 38 U.S.C. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.321, 4.115a, 4.115b, Diagnostic Code 7828. 6. The criteria for an increased rating of 100 percent for prostate cancer, for purposes of accrued benefits and/or substitution, have been met, effective October 10, 2015. 38 U.S.C. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.321, 4.115a, 4.115b, Diagnostic Code 7828. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran, who served on active duty in the United States Army from April 1968 to November 1969, died in May 2016. The Veteran’s surviving spouse has been properly substituted as the appellant in this case. 1. Entitlement to an increased rating higher than 30 percent for posttraumatic stress disorder (PTSD) The appellant contends that the Veteran’s PTSD was more severe than represented by the currently assigned 30 percent rating. The Board concludes that the Veteran’s PTSD did not warrant a rating higher than 30 percent. Disability ratings are based on the average impairment of earning capacity resulting from a disability. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. An evaluation of the level of disability present includes consideration of the functional impairment of the Veteran’s ability to engage in ordinary activities, including employment. 38 C.F.R. § 4.10. Separate diagnostic codes identify the various disabilities. Where there is a question as to which of two evaluations shall be applied, the higher evaluations will be assigned if the disability more closely approximates the criteria required for that rating. 38 C.F.R. § 4.7. Otherwise, the lower rating will be assigned. Id. The criteria for evaluating PTSD are found at 38 C.F.R. § 4.130, Diagnostic Code 9411. A 30 percent evaluation is assigned when there is occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, mild memory loss (such as forgetting names, directions, recent events). Id. A 50 percent evaluation is assigned when there is occupational and social impairment with reduced reliability and productivity due to such symptoms as flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short and long-term memory; impaired judgment; impaired abstract thinking; disturbance of motivation and mood; and difficultly in establishing and maintaining effective work and social relationships. Id. A 70 percent evaluation is warranted where there is occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a worklike setting); and inability to establish and maintain effective relationships. Id. A 100 percent evaluation requires total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; and memory loss for names of close relatives, own occupation, or own name. Id. Symptoms listed in the VA’s general rating formula for mental disorders serve as examples of the type and degree of the symptoms, or their effects, that would justify a particular rating, and are not intended to constitute an exhaustive list. See Mauerhan v. Principi, 16 Vet. App. 436, 442-44 (2002). The nomenclature employed in the rating formula is based upon the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, of the American Psychiatric Association (DSM-5). See 38 C.F.R. § 4.130. Effective August 4, 2014, VA amended the portion of its Schedule for Rating Disabilities that addressed mental disorders to remove outdated references to the DSM and to replace them with references to the recently updated DSM-5. The provisions of the interim final rule applied to all applications for benefits that are received by VA or that are pending before the agency of original jurisdiction on or after August 4, 2014. The Secretary did not intend for the provisions of the interim final rule to apply to claims that had been already certified for appeal to the Board, or that were pending before the Board, the United States Court of Appeals for Veterans Claims (Court), or the United States Court of Appeals for the Federal Circuit. See 79 Fed. Reg. 45,093, 45,094 (Aug. 4, 2014). The appellant’s substituted case was certified to the Board in May 2017. Thus, the DSM-5 applies to the present case. According to the applicable rating criteria, when evaluating a mental disorder, the frequency, severity, duration of psychiatric symptoms, length of remissions, and the veteran’s capacity for adjustment during periods of remission must be considered. See 38 C.F.R. § 4.126(a). In addition, the evaluation must be based on all the evidence of record that bears on occupational and social impairment, rather than solely on the examiner’s assessment of the level of disability at the moment of the examination. Id. Further, when evaluating the level of disability from a mental disorder, the extent of social impairment is considered, but the rating cannot be assigned solely on the basis of social impairment. See 38 C.F.R. § 4.126(b). The medical evidence does not support a rating higher than 30 percent for the Veteran’s PTSD. Overall, the Veteran was shown to have occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, mild memory loss (such as forgetting names, directions, recent events. A September 2012 VA examination report shows occupational and social impairment due to mild or transient symptoms, which decrease work efficiency and ability to perform occupational tasks only during periods of insignificant stress, or; symptoms controlled by medication. These findings actually represent a 10 percent rating under Diagnostic Code 9411. His symptoms included depressed mood, anxiety, and chronic sleep impairment, as well as disturbance of motivation and mood. The Veteran underwent another VA examination in November 2015, which showed that the Veteran had occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although generally functioning satisfactorily, with normal routine behavior, self-care, and conversation. These symptoms more closely meet the criteria for a 30 percent rating for PTSD. Occupationally, the Veteran was reportedly retired but still ran a consulting business. Socially, he was married and had a few friends. He noted that he almost got into a fight recently at a restaurant over politics. Based on these findings, which reflect occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although generally functioning satisfactorily, with normal routine behavior, self-care, and conversation, a rating higher than 30 percent is not warranted. The Board has also considered whether the Veteran’s PTSD presented an exceptional or unusual disability picture as to render impractical the application of the regular schedular standards such that an extraschedular rating is warranted, the threshold factor for extraschedular consideration. See 38 C.F.R. § 3.321(b)(1); Bagwell v. Brown, 9 Vet. App. 337, 338-39 (1996); see also Fisher v. Principi, 4 Vet. App. 57, 60 (1993) (“[R]ating schedule will apply unless there are ‘exceptional or unusual’ factors which render application of the schedule impractical.”). In the instant case, the Veteran had mild to moderate social and occupational functional impairment due to his symptoms of PTSD. However, this does not present an exceptional or unusual disability picture, and the assigned schedular evaluations are, therefore, adequate. See Thun, 22 Vet. App. at 115. The Veteran’s symptoms associated with his PTSD (i.e., occupational and social impairment with occasional decrease in work efficiency and intermittent inability to perform occupational tasks) were not shown to cause any impairment that is not already contemplated by the rating criteria. The 30 percent rating under Diagnostic Code 9411 specifically contemplates these symptoms. The Board finds that the rating criteria reasonably described the Veteran’s disability. For these reasons, referral for consideration of an extraschedular rating is not warranted for this claim. 2. Entitlement to an effective date earlier than March 21, 2011 for the grant of service connection for PTSD The Veteran asserted that service connection for PTSD should have been effectuated, August 1, 1972, as the medical evidence showed he spent six months in a VA hospital in Tuskegee, Alabama one year after he returned from Vietnam and was diagnosed with paranoid neurosis. See December 2012 notice of disagreement; and January 2014 statement. Generally, the effective date for an award of service connection is the day after service separation or the date entitlement arose, whichever is later, if the claim is received within one year of the date of separation from service. Otherwise, the effective date will be the date of receipt of the claim or the date entitlement arose, whichever is later. 38 U.S.C. § 5110 (b)(1); 38 C.F.R. § 3.400 (b)(2)(i). Where a claim for service connection is reopened and granted based upon new and material evidence, other than service records, received after the prior rating decision has become final, the effective date will be the date of receipt of claim to reopen or date entitlement arose, whichever is later. 38 C.F.R. § 3.400 (q). At any time after VA issues a decision on a claim, if VA receives or associates with the claims file relevant official service department records that existed and had not been associated with the claims record when VA first decided the claim, VA will reconsider the claim. Such records include, but are not limited to service records that are related to a claimed in-service event, injury, or disease, regardless of whether those records mention the Veteran by name and additional service records forwarded by the Department of Defense or the service department to VA any time after VA’s original request for service records. 38 C.F.R. § 3.156 (c). Just over one year after his November 1969 separation from service, the Veteran filed a service connection claim for nervousness in December 1970. The record showed that the Veteran had been hospitalized at a VA hospital from November 1970 to January 1971 and was diagnosed with anxiety neurosis with depression. The RO denied service connection for anxiety neurosis with depression in a June 1971 rating decision. It was noted that the Veteran’s service treatment records could not be obtained at that time and though there was evidence of treatment for anxiety neurosis with features of depression in November 1970, with no service clinical records, there was no evidence of any type of nervous disorder during service. The June 1971 rating decision was not appealed, and it is final. 38 U.S.C. § 7105; 38 C.F.R. § 20.1103. The RO received the Veteran’s service connection claim for PTSD on March 21, 2011. Service treatment records were added to the file, which were negative for any psychiatric treatment. The Veteran submitted a stressor statement noting stressors in Vietnam of constant mortar fire and witnessing a comrade accidentally killed himself. He underwent a VA examination in September 2012, in which the VA examiner diagnosed the Veteran with PTSD related to his fear of hostile military or terrorist activity in service. In an October 2012 rating decision, the RO granted service connection for PTSD on the basis that the VA examiner diagnosed him with PTSD and linked it to his fear of hostile military action while in Vietnam. The effective date assigned was March 21, 2011. An effective date earlier than March 21, 2011 for the grant of service connection for PTSD is not warranted in this case. Even liberally reading the Veteran’s original December 1970 service connection claim for nervousness as a claim for an acquired psychiatric disability, which would have encompassed a claim for PTSD, had the service records been available at that time, they did not reflect any treatment for a mental health disorder during service, and by themselves do not show that the Veteran’s PTSD originated during service. Thus, even though the RO did not consider the Veteran’s service treatment records at the time of the original rating decision in June 1971 that denied service connection for anxiety neurosis, entitlement to service connection for PTSD did not arise based on the medical findings in the service treatment records. Entitlement to PTSD arose when the VA examiner determined in September 2012 that the Veteran had PTSD related to his fear of hostile military or terrorist activity in service. In such situations, the award of service connection while be effectuated as of the date entitlement arose or the date VA received the previously decided claim, whichever is later. 38 C.F.R. § 3.156 (c). In this case, though the Veteran’s original claim for service connection for a psychiatric disability was received in December 1970, service connection for PTSD was not shown to have originated during active service at that time, as the medical opinion linking the Veteran’s PTSD to his service in Vietnam was not provided until September 2012. This is the basis for the RO’s grant of service connection in the October 2012 rating decision. Further, it is worth noting that the regulation, 38 C.F.R. § 3.304 (f)(3), relating to a stressor based on fear of hostile military or terrorist activity, is not a liberalizing regulation. See Stressor Determinations for PTSD, 75 Fed. Reg. 39843 (July 13, 2010) (“The effective date of benefits awarded pursuant to this rule will be assigned in accordance with the facts found but will not be earlier than the date of claim. 38 U.S.C. 5110 (a). Although 38 U.S.C. 5110 (g) and 38 CFR 3.114 (a) authorize in some circumstances an effective date of benefits before the date of claim, those provisions are applicable to “administrative issue[s]” that liberalize the basis for benefit entitlement.... This regulation, however, governs procedural matters rather than creating a new basis for entitlement to service connection for PTSD because it merely relaxes under certain circumstances the evidentiary standard for establishing occurrence of a stressor. As a result, 38 U.S.C. 5110 (a), rather than 38 U.S.C. A. § 5110 (g), is applicable to awards under this rule”). Thus, 38 U.S.C.S. § 5110 (g) and 38 C.F.R. § 3.114 are not applicable. Therefore, the Board finds that the appropriate effective date for the award of service connection for PTSD is March 21, 2011, the date the RO received the Veteran’s claim. Accordingly, the Veteran’s claim of entitlement to an earlier effective date for the grant of service connection for PTSD must be denied. 3. Whether a rating reduction from 100 percent to 40 percent, effective October 1, 2014, for prostate cancer was proper Initially, it is noted that where a reduction in an evaluation of a service-connected disability is considered warranted and the lower evaluation would result in a reduction or discontinuance of compensation payments currently being made, a rating proposing the reduction or discontinuance must be prepared setting forth all material facts and reasons. VA must also notify the Veteran that he has 60 days to present additional evidence showing that compensation should be continued at the present level. 38 C.F.R. § 3.105(e). In this case, the reduction of the Veteran’s prostate cancer resulted in a reduction of compensation payments. Specifically, his combined disability rating went from 100 percent, effective October 23, 2012, to 40 percent, effective October 1, 2014. Therefore, the notice provisions of 38 C.F.R. § 3.105(e) apply. An August 2013 rating decision noted that the Veteran’s prostate cancer was proposed to be reduced from 100 percent to 20 percent, on the basis that the Veteran’s prostate cancer treatment was completed in 2012. The Veteran was notified that he had 60 days to submit additional evidence showing that his compensation should be continued at the 100 percent rating. Based on review of the file, the notice provisions of 38 C.F.R. § 3.105(e) have been satisfied. Regarding rating reductions, the law provides that, when a rating has continued for a long period at the same level (i.e., five years or more), a reduction may be accomplished when the rating agency determines that evidence makes it reasonably certain that the improvement will be maintained under the ordinary conditions of life. 38 C.F.R. § 3.344(a). However, where a rating has been in effect for less than five years, the regulatory requirements under 38 C.F.R. § 3.344(a) and (b) are inapplicable, as set forth in 38 C.F.R. § 3.344 (c). In such cases, an adequate reexamination that discloses improvement in the condition will warrant reduction in rating. See 38 C.F.R. § 3.344 (c); 3.343(a). In the present case, the 100 percent rating for the Veteran’s prostate cancer had been in effect since October 23, 2012; i.e., for less than five years. Thus, the provisions of 38 C.F.R. § 3.344(c); 3.343(a) apply, and an adequate reexamination that discloses improvement in the condition will warrant reduction in rating. The Court has held that several general regulations are applicable to all rating reduction cases, without regard for how long a particular rating has been in effect. Certain regulations “impose a clear requirement that VA rating reductions, as with all VA rating decisions, be based upon a review of the entire history of the veteran’s disability.” Brown v. Brown, 5 Vet. App. 413, 420 (1993) (referring to 38 C.F.R. §§ 4.1, 4.2, 4.13). VA cannot reduce a Veteran’s disability evaluation without first finding, inter alia, that that an improvement has actually occurred in the Veteran’s service-connected disability and it has improved to the point that he or she is now better able to function under the ordinary conditions of life and work. See Murphy v. Shinseki, 26 Vet. App. 510, 517 (2014); Brown, 5 Vet. App. at 421. Care must be taken to ensure that a change in an examiner’s evaluation reflects an actual change in the Veteran’s condition, and not merely a difference in the thoroughness of the examination or in descriptive terms, when viewed in relation to the prior disability history. See 38 C.F.R. §§ 4.1, 4.2, 4.13; see also Brown, 5 Vet. App. at 420-22. Significantly, in a rating reduction case, VA has the burden of establishing that the disability has improved. This is in stark contrast to a case involving a claim for an increased (i.e., higher) rating, in which it is the Veteran’s responsibility to show the disability has worsened. A rating reduction case focuses on the propriety of the reduction and is not the same as an increased rating issue. See Peyton v. Derwinski, 1 Vet. App. 282, 286 (1991). In considering the propriety of a reduction, the Board must focus on the evidence available to the RO at the time the reduction was effectuated, although post-reduction medical evidence may be considered in the context of evaluating whether the condition had demonstrated actual improvement. Cf. Dofflemyer v. Derwinski, 2 Vet. App. 277, 281-282 (1992). The question of whether a disability has improved involves consideration of the applicable rating criteria. Disability ratings are based on the average impairment of earning capacity resulting from a disability. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. An evaluation of the level of disability present includes consideration of the functional impairment of the Veteran’s ability to engage in ordinary activities, including employment. 38 C.F.R. § 4.10. Separate diagnostic codes identify the various disabilities. Where there is a question as to which of two evaluations shall be applied, the higher evaluations will be assigned if the disability more closely approximates the criteria required for that rating. 38 C.F.R. § 4.7. Otherwise, the lower rating will be assigned. Id. As noted, the RO decreased the Veteran’s prostate cancer from 100 percent to 40 percent, effective October 1, 2014. The 100 percent disability rating had been in effect since October 23, 2012; i.e., less than five years. Therefore, a single reexamination disclosing improvement in the disability is sufficient to warrant reduction in a rating. See 38 C.F.R. § 3.344(c). The Veteran’s prostate cancer is rated under 38 C.F.R. § 4.115b, Diagnostic Code 7528 for malignant neoplasms of the genitourinary system. A 100 percent rating is assigned following surgical, x-ray, antineo-plastic chemotherapy or other therapeutic procedure, the rating of 100 percent shall continue with a mandatory VA examination at the expiration of six months. Any change in evaluation based upon that or any subsequent examination shall be subject to the provisions of § 3.105(e) of this chapter. If there has been no local reoccurrence or metastasis, rate on residuals as voiding dysfunction or renal dysfunction, whichever is predominant. An April 2013 VA examination report noted that the Veteran’s prostate cancer was in remission. He had a voiding dysfunction with urine leakage, but he did not require the use of absorbent materials. It was noted that the treatment was completed and he was currently in watchful, waiting status. The Veteran reportedly had voiding dysfunction, which caused increased urinary frequency of daytime voiding interval between two and three hours, and nighttime awakening to void three to four times. It was noted that there was borderline anemia, which might need further evaluation, and trace proteinuria, which also might need further evaluation. In a September 2013 statement, the Veteran disputed the RO’s proposed rating to 20 percent and noted that he had daytime voiding every 30 to 40 minutes, and nighttime voiding five to seven times. On the basis of the April 2013 VA examination, the RO initially assigned a 20 percent rating for the Veteran’s prostate cancer, effective October 1, 2014. An October 2013 VA treatment record noted that the Veteran had to get up to void six to seven times per night. He reported had daytime voiding interval of less than one hour. He also had nighttime awakening to void five or more times. He underwent another VA examination in October 2015, which demonstrated that the Veteran’s prostate cancer was active. However, a later VA examination in October 2015 noted that the Veteran’s prostate cancer was in remission. He reportedly required the use of absorbent materials, which must be changed less than two times per day. He had daytime voiding with an interval between one and two hours; and nighttime awakening to void three to four times. Based on the medical evidence, the RO increased the Veteran’s prostate cancer rating to 40 percent, effective October 1, 2014. Under the provisions of 38 C.F.R. § 4.115a, daytime voiding interval of less than one hour, or awakening to void more than five times per night warrants a 40 percent rating. Based on the VA examinations in April 2013 and October 2015 demonstrating that the Veteran’s prostate cancer was in remission and manifested by daytime voiding interval of less than one hour, or awakening to void more than five times per night, VA has met the burden of showing that there was improvement in the Veteran’s prostate cancer. Thus, a reduction in rating from 100 percent was proper, effective October 1, 2014. With respect to the VA examination which showed that the Veteran’s prostate cancer was active in October 2015, this matter is addressed in the increased rating section below. 4. Entitlement to an increased rating higher than 40 percent for prostate cancer As noted above, the Veteran’s prostate cancer was rated as 40 percent disabling from October 1, 2014. Disability ratings are based on the average impairment of earning capacity resulting from a disability. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. An evaluation of the level of disability present includes consideration of the functional impairment of the Veteran’s ability to engage in ordinary activities, including employment. 38 C.F.R. § 4.10. Separate diagnostic codes identify the various disabilities. Where there is a question as to which of two evaluations shall be applied, the higher evaluations will be assigned if the disability more closely approximates the criteria required for that rating. 38 C.F.R. § 4.7. Otherwise, the lower rating will be assigned. Id. The appellant contends that the prostate cancer symptoms were more severe than warranted for a 40 percent rating. The Board concludes that the Veteran’s prostate cancer disability did not warrant a rating higher than 40 percent, effective October 1, 2014 to October 9, 2015. However, effective October 10, 2015, a 100 percent rating for prostate cancer was warranted. As noted above, the Veteran’s prostate cancer is rated under 38 C.F.R. § 4.115b, Diagnostic Code 7528 for malignant neoplasms of the genitourinary system. A 100 percent rating is assigned following surgical, x-ray, antineo-plastic chemotherapy or other therapeutic procedure, the rating of 100 percent shall continue with a mandatory VA examination at the expiration of six months. If there has been no local reoccurrence or metastasis, rate on residuals as voiding dysfunction or renal dysfunction, whichever is predominant. In this case, the Veteran’s voiding dysfunction and particularly, urinary frequency, is predominant. An April 2013 VA examination report noted that the Veteran’s prostate cancer was in remission. He had a voiding dysfunction with urine leakage, but he did not require the use of absorbent materials. It was noted that the treatment was completed and he was currently in watchful, waiting status. The Veteran reportedly had voiding dysfunction, which caused increased urinary frequency of daytime voiding interval between two and three hours, and nighttime awakening to void three to four times. It was noted that there was borderline anemia, which might need further evaluation, and trace proteinuria, which also might need further evaluation. In a September 2013 statement, the Veteran disputed the RO’s proposed rating to 20 percent and noted that he had daytime voiding every 30 to 40 minutes, and nighttime voiding five to seven times. An October 2013 VA treatment record noted that the Veteran had to get up to void six to seven times per night. He reported had daytime voiding interval of less than one hour. He also had nighttime awakening to void five or more times. Under the provisions of 38 C.F.R. § 4.115a, daytime voiding with an interval less than one hour, or awakening to void five or more times per night warrants a 40 percent rating. Effective October 1, 2014 to October 10, 2015, there is no evidence of requiring the use of appliance or wearing absorbent materials that must be changed more than four times per day that would warrant a higher rating under the specified rating criteria for such symptomatology. See 38 C.F.R. § 4.115a. He underwent another VA examination on October 10, 2015, which demonstrated that the Veteran’s prostate cancer was active. Although a later VA examination in October 2015 noted that the Veteran’s prostate cancer was in remission, the record shows that the Veteran eventually died in June 2016 from metastatic pancreatic cancer with prostate cancer as a contributing factor. Resolving all doubt in the appellant’s favor, a 100 percent rating for prostate cancer was warranted, effective October 10, 2015, for active disease. For all the foregoing reasons, the Board finds that a rating higher than 40 percent is not warranted for the prostate cancer, effective October 1, 2014 to October 9, 2015; but a 100 percent rating is warranted, effective October 10, 2015. There are no objective medical findings that would support the assignment of a higher rating. See Hart v. Mansfield, 21 Vet. App. 505 (2007). The Board has also considered whether the Veteran’s prostate cancer presents an exceptional or unusual disability picture as to render impractical the application of the regular schedular standards such that an extraschedular rating is warranted, the threshold factor for extraschedular consideration. See 38 C.F.R. § 3.321(b)(1); Bagwell v. Brown, 9 Vet. App. 337, 338-39 (1996); see also Fisher v. Principi, 4 Vet. App. 57, 60 (1993) (“[R]ating schedule will apply unless there are ‘exceptional or unusual’ factors which render application of the schedule impractical.”). In the instant case, effective October 1, 2014 to October 9, 2015, the Veteran’s prostate cancer was in remission and he had voiding dysfunction manifested by daytime voiding interval of less than an hour, and waking five or more times per night. Effective October 10, 2015, his prostate cancer was in active disease. This does not present an exceptional or unusual disability picture, and the assigned schedular evaluation is, therefore, adequate. See Thun, 22 Vet. App. at 115. The symptoms associated with the Veteran’s prostate cancer (i.e., voiding dysfunction) are not shown to cause any impairment that is not already contemplated by the rating criteria. The 40 percent rating assigned under Diagnostic Code 5237, 38 C.F.R. § 4.115a specifically contemplates these symptoms. REASONS FOR REMAND 1. Entitlement to service connection for hypertension for purposes of accrued benefits and/or substitution is remanded. 2. Entitlement to service connection for nerve damage to the fingers for purposes of accrued benefits and/or substitution is remanded. The Board cannot make a fully-informed decision on the issue of service connection for hypertension and/or nerve damage to the fingers because no VA examiner has opined whether these disability first manifested in service, or were related to the Veteran’s presumed exposure to herbicides on a direct basis. The matter is REMANDED for the following action: Arrange for a medical opinion to be provided by an appropriate clinician to determine the nature and etiology of the Veteran’s hypertension and any nerve damage to the fingers. The examiner must opine whether any hypertension or nerve damage to the fingers at least as likely as not (1) began during active service, (2) manifested within a year after discharge from service, or (3) was noted during service with continuity of the same symptomatology since service. The examiner also should state whether either disease was at least as likely as not related to in-service herbicide agent exposure. S. L. Kennedy Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD Sarah B. Richmond