Citation Nr: 20009743 Decision Date: 02/05/20 Archive Date: 02/05/20 DOCKET NO. 08-23 254A DATE: February 5, 2020 ORDER Entitlement to a disability rating more than 10 percent for tinnitus is denied. Entitlement to a disability rating more than 10 percent for a bilateral hearing loss disability is denied. Entitlement to a disability rating more than 10 percent for carpal tunnel syndrome of the right upper extremity prior to November 27, 2013 is denied. Entitlement to a disability rating more than 50 percent for carpal tunnel syndrome of the right upper extremity from November 27, 2013 to October 31, 2015 is denied. Entitlement to a disability rating more than 30 percent for carpal tunnel syndrome of the right upper extremity from November 1, 2015 is denied. Entitlement to a disability rating more than 10 percent for carpal tunnel syndrome of the left upper extremity prior to November 27, 2013 is denied. Entitlement to a disability rating more than 40 percent for carpal tunnel syndrome of the left upper extremity from November 27, 2013 to October 31, 2015 is denied. Entitlement to a disability rating more than 20 percent for carpal tunnel syndrome of the left upper extremity from November 1, 2015 is denied. Entitlement to a disability rating more than 10 percent for right leg varicose veins is denied. Entitlement to a rating more than 40 percent for a combined rating effective September 29, 2011 is denied. FINDINGS OF FACT 1. The Veteran’s service-connected tinnitus is assigned a 10 percent rating, the maximum rating authorized under Diagnostic Code 6260. 2. The Veteran’s bilateral hearing loss disability is currently manifested by no more than level II hearing impairment in the right ear and level XI hearing impairment in the left ear. 3. Prior to November 27, 2013, the Veteran’s right carpal tunnel syndrome was manifested by no more than mild incomplete nerve paralysis. 4. From November 27, 2013 to October 31, 2015, the Veteran’s right carpal tunnel syndrome was manifested by no more than severe incomplete nerve paralysis. 5. From November 27, 2013, the Veteran’s right carpal tunnel syndrome is manifested by no more than moderate incomplete nerve paralysis. 6. Prior to November 27, 2013, the Veteran’s left carpal tunnel syndrome was manifested by no more than mild incomplete nerve paralysis. 7. From November 27, 2013 to October 31, 2015, the Veteran’s left carpal tunnel syndrome was manifested by no more than severe incomplete nerve paralysis. 8. From November 27, 2013, the Veteran’s left carpal tunnel syndrome is manifested by no more than moderate incomplete nerve paralysis. 9. The Veteran's right leg varicose veins disability is manifested by no greater than intermittent edema of the extremity or aching and fatigue in the leg after prolonged standing or walking, with symptoms relieved by elevation of the extremity or compression hosiery. 10. VA has determined that the Veteran's service-connected disability evaluations combine to an overall 40 percent rating under the Combined Ratings Table effective September 29, 2011. CONCLUSIONS OF LAW 1. There is no legal basis for the assignment of an evaluation in excess of 10 percent for tinnitus. 38 U.S.C. § 1155 (2012); 38 C.F.R. § 4.87, Diagnostic Code 6260 (2018). 2. The criteria for the assignment of a disability rating more than 10 percent for the service-connected bilateral hearing loss disability are not met. See 38 U.S.C. § 1155 (2012); 38 C.F.R. §§ 4.85, Diagnostic Code 6100, 4.86 (2018). 3. Prior to November 27, 2013, the criteria for a disability rating more than 10 percent for right carpal tunnel syndrome have not been met. 38 U.S.C. § 1155 (2012); 38 C.F.R. § 4.124a, Diagnostic Code 8515 (2018). 4. From November 27, 2013 to October 31, 2015, the criteria for a disability rating more than 50 percent for right carpal tunnel syndrome have not been met. 38 U.S.C. § 1155 (2012); 38 C.F.R. § 4.124a, Diagnostic Code 8515 (2018). 5. From November 1, 2015, the criteria for a disability rating more than 30 percent for right carpal tunnel syndrome have not been met. 38 U.S.C. § 1155 (2012); 38 C.F.R. § 4.124a, Diagnostic Code 8515 (2018). 6. Prior to November 27, 2013, the criteria for a disability rating more than 10 percent for left carpal tunnel syndrome have not been met. 38 U.S.C. § 1155 (2012); 38 C.F.R. § 4.124a, Diagnostic Code 8515 (2018). 7. From November 27, 2013 to October 31, 2015, the criteria for a disability rating more than 40 percent for left carpal tunnel syndrome have not been met. 38 U.S.C. § 1155 (2012); 38 C.F.R. § 4.124a, Diagnostic Code 8515 (2018). 8. From November 1, 2015, the criteria for a disability rating more than 20 percent for left carpal tunnel syndrome have not been met. 38 U.S.C. § 1155 (2012); 38 C.F.R. § 4.124a, Diagnostic Code 8515 (2018). 9. The criteria for a rating more than 10 percent for right leg varicose veins have not been met. 38 U.S.C. § 1155 (2012); 38 C.F.R. § 4.104, Diagnostic Code 7120 (2018). 10. The Veteran's overall disability rating effective September 29, 2011 is properly calculated using the Combined Ratings Table. 38 U.S.C. §§ 1155, 1157 (2012); 38 C.F.R. § 4.25 (2018). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from October 1962 to June 1984. These matters come to the Board of Veterans’ Appeals (Board) on appeal from rating decisions rendered by the Regional Office (RO) of the Department of Veterans Affairs (VA). With regard to the increased rating claims for right and left carpal tunnel syndrome and right leg varicose veins, the Veteran requested a videoconference hearing in his October 2008 VA Form 9. However, in November 2019, he informed VA that he would like to cancel the hearing request. Accordingly, his request for a hearing is considered withdrawn. The Board remanded the Veteran’s claims on appeal in July 2017. The Veteran’s claims folder has returned to the Board for further appellate proceedings. Increased Rating Pertinent legal criteria Disability evaluations are determined by comparing a Veteran’s present symptomatology with criteria set forth in VA’s Schedule for Rating Disabilities, which is based on average impairment in earning capacity. 38 U.S.C. § 1155; 38 C.F.R. Part 4. When a question arises as to which of two ratings apply under a particular diagnostic code, the higher evaluation is assigned if the disability more closely approximates the criteria for the higher rating. 38 C.F.R. § 4.7. In view of the number of atypical instances it is not expected, especially with the more fully described grades of disabilities, that all cases will show all the findings specified. Findings sufficiently characteristic to identify the disease and the disability therefrom, and above all, coordination of rating with impairment of function will, however, be expected in all instances. 38 C.F.R. § 4.21 (2018). After careful consideration of the evidence, any reasonable doubt remaining is resolved in favor of the Veteran. 38 U.S.C. § 5107(b) (2012); 38 C.F.R. § 4.3 (2018). The Veteran’s entire history is reviewed when making disability evaluations. Schafrath v. Derwinski, 1 Vet. App. 589 (1991); 38 C.F.R. § 4.1. Where the question for consideration is propriety of the initial evaluation assigned, evaluation of the medical evidence since the grant of service connection and consideration of the appropriateness of “staged rating” is required. Fenderson v. West, 12 Vet. App. 119, 126 (1999). When a disability has undergone varying and distinct levels of severity during the appeal, it is appropriate to apply staged ratings. See Hart v. Mansfield, 21 Vet. App. 505 (2007). Tinnitus Tinnitus is evaluated under Diagnostic Code 6260, which was revised effective June 13, 2003, to clarify existing VA practice that only a single 10 percent evaluation is assigned for tinnitus, whether the sound is perceived as being in one ear, both ears, or in the head. 38 C.F.R. § 4.87, Diagnostic Code 6260, note 2 (2018). In Smith v. Nicholson, 19 Vet. App. 63 (2005), the United States Court of Appeals for Veterans Claims (Court) held that the pre-1999 and pre-June 13, 2003 versions of Diagnostic Code 6260 required the assignment of dual ratings for bilateral tinnitus. VA appealed this decision to the United States Court of Appeals for the Federal Circuit (Federal Circuit) and stayed the adjudication of tinnitus rating cases affected by the Smith decision. In Smith v. Nicholson, 451 F.3d 1344 (Fed. Cir. 2006), the Federal Circuit concluded that the Court erred in not deferring to the VA’s interpretation of its own regulations, 38 C.F.R. § 4.25(b) and 38 C.F.R. § 4.87, Diagnostic Code 6260, which limits a veteran to a single schedular disability rating for tinnitus, regardless of whether the tinnitus is unilateral or bilateral. Subsequently, the stay of adjudication of tinnitus rating cases was lifted. The maximum schedular rating available for tinnitus is 10 percent. 38 C.F.R. § 4.87, Diagnostic Code 6260. See 38 U.S.C. § 1155 (2012). No arguments have been raised, nor evidence submitted or otherwise obtained, which raises the issue of entitlement to an extraschedular rating. As there is no legal basis upon which to award a higher schedular rating, or separate schedular ratings for tinnitus in each ear, the Veteran’s appeal must be denied. Sabonis v. Brown, 6 Vet. App. 426 (1994). Bilateral hearing loss disability In evaluating service-connected hearing loss, disability ratings are derived by a mechanical application of the rating schedule to the numeric designations assigned after audiometric evaluations are performed. See Lendenmann v. Principi, 3 Vet. App. 345, 349 (1992). Hearing loss disability evaluations range from noncompensable to 100 percent based on organic impairment of hearing acuity, as measured by controlled speech discrimination tests in conjunction with the average hearing threshold and as measured by puretone audiometric tests in the frequencies 1000, 2000, 3000, and 4000 cycles per second. The rating schedule establishes 11 auditory acuity levels designated from Level I for essentially normal hearing acuity, through Level XI for profound deafness. VA audiometric examinations are conducted using a controlled speech discrimination test (Maryland CNC) together with the results of a puretone audiometry test. The vertical lines in Table VI (38 C.F.R. § 4.85) represent nine categories of the percentage of discrimination based on the controlled speech discrimination test. The horizontal columns in Table VI represent nine categories of decibel (dB) loss based on the puretone audiometry test. The numeric designation of impaired hearing (Levels I through XI) is determined for each ear by intersecting the vertical row appropriate for the percentage of discrimination and the horizontal column appropriate to the puretone dB loss. The percentage evaluation is found from Table VII (38 C.F.R. § 4.85) by intersecting the vertical column appropriate for the numeric designation for the ear having the better hearing acuity and the horizontal row appropriate to the numeric designation level for the ear having the poorer hearing acuity. For example, if the better ear has a numeric designation Level of “V” and the poorer ear has a numeric designation Level of “VII,” the percentage evaluation is 30 percent. See 38 C.F.R. § 4.85 (2018). The provisions of 38 C.F.R. § 4.86(a) provide that when the puretone thresholds at each of the four specified frequencies (1000, 2000, 3000, and 4000 Hertz) is 55 decibels or more, the rating specialist will determine the Roman numeral designation for hearing impairment from either Table VI or Table VIA, whichever results in the higher numeral. Each ear will be evaluated separately. The provisions of 38 C.F.R. § 4.86(b) provide that when the puretone threshold is 30 dB or less at 1000 hertz, and 70 dB or more at 2000 hertz, the rating specialist will determine the Roman numeral designation for hearing impairment from either Table VI or Table VIA, whichever results in the higher numeral. That numeral will then be elevated to the next higher Roman numeral. Each ear will be evaluated separately. The Veteran seeks entitlement to a higher rating for his bilateral hearing loss disability, which is currently evaluated as 10 percent disabling under 38 C.F.R. § 4.85 (2018). As was explained in the law and regulations section above, the resolution of this issue involves determining the level of hearing acuity in each ear. The Veteran was afforded a VA audiological examination in January 2012. He reported difficulty hearing in particular from the left ear. The January 2012 VA audiological examination report revealed the following: HERTZ 1000 2000 3000 4000 Average RIGHT 25 40 55 65 46.25 LEFT 80 85 95 105 91.25 Speech audiometry revealed speech recognition ability on the Maryland CNC word list of 86 percent for the right ear and 20 percent for the left ear. The examination yielded a numerical designation of II in the right ear (42-49 percent average puretone decibel hearing loss, with between 84 and 90 percent speech discrimination) and also a numerical designation of XI for the left ear (90-97 percent average puretone threshold, with between 0 and 34 percent speech discrimination). Entering the category designations into Table VII, a disability percentage evaluation of 10 percent is for assignment under Diagnostic Code 6100. The Board has considered the alternative rating scheme for exceptional patterns of hearing impairment and while § 4.86(b) is not applicable, § 4.86(a) is applicable. However, application of § 4.86(a) also results in a disability percentage evaluation of 10 percent for the Veteran’s bilateral hearing loss disability. A February 2012 VA audiological evaluation revealed the following: HERTZ 1000 2000 3000 4000 Average RIGHT 35 45 60 70 50 LEFT 90 85 90 110 93.75 Speech audiometry revealed speech recognition ability on the Maryland CNC word list of 96 percent for the right ear and 42 percent for the left ear. The examination yielded a numerical designation of II in the right ear (50-57 percent average puretone decibel hearing loss, with between 92 and 100 percent speech discrimination) and also a numerical designation of XI for the left ear (90-97 percent average puretone threshold, with between 36 and 42 percent speech discrimination). Entering the category designations into Table VII, a disability percentage evaluation of 10 percent is for assignment under Diagnostic Code 6100. The Board has considered the alternative rating scheme for exceptional patterns of hearing impairment and while § 4.86(b) is not applicable, § 4.86(a) is applicable. However, application of § 4.86(a) also results in a disability percentage evaluation of 10 percent for the Veteran’s bilateral hearing loss disability. The Veteran was afforded a VA audiological examination in December 2013. He reported noise exposure from working with a printing press.   The December 2013 VA audiological examination report revealed the following: HERTZ 1000 2000 3000 4000 Average RIGHT 40 45 60 75 55 LEFT 100 100 105+ 105+ 102.5 Speech audiometry revealed speech recognition ability on the Maryland CNC word list of 84 percent for the right ear and zero percent for the left ear. The examination yielded a numerical designation of II in the right ear (50-57 percent average puretone decibel hearing loss, with between 84 and 90 percent speech discrimination) and also a numerical designation of XI for the left ear (98+ percent average puretone threshold, with between 0 and 34 percent speech discrimination). Entering the category designations into Table VII, a disability percentage evaluation of 10 percent is for assignment under Diagnostic Code 6100. The Board has considered the alternative rating scheme for exceptional patterns of hearing impairment and while § 4.86(b) is not applicable, § 4.86(a) is applicable. However, application of § 4.86(a) also results in a disability percentage evaluation of 10 percent for the Veteran’s bilateral hearing loss disability. The Veteran was afforded a VA audiological examination in November 2016. He reported continued noise exposure.   The November 2016 VA audiological examination report revealed the following: HERTZ 1000 2000 3000 4000 Average RIGHT 35 55 60 80 57.5 LEFT 95 105 105+ 105+ 102.5 Speech audiometry revealed speech recognition ability on the Maryland CNC word list of 100 percent for the right ear and the left ear could not be tested. The examination yielded a numerical designation of II in the right ear (58-65 percent average puretone decibel hearing loss, with between 92 and 100 percent speech discrimination). Although speech discrimination could not be tested for the left ear, even if the score was zero percent, a 10 percent evaluation would continue for the Veteran’s bilateral hearing loss disability based upon use of Table VII under Diagnostic Code 6100. The Board has considered the alternative rating scheme for exceptional patterns of hearing impairment and while § 4.86(b) is not applicable, § 4.86(a) is applicable. However, application of § 4.86(a) also results in a disability percentage evaluation of 10 percent for the Veteran’s bilateral hearing loss disability.   The Board also notes that a private audiological report date September 2011 from Marion Downs Hearing Center revealed the following: HERTZ 1000 2000 3000 4000 Average RIGHT 20 40 55 60 43.75 LEFT 100 100 115 120 108.75 Speech audiometry revealed speech recognition ability revealed 100 percent for the right ear and the left ear could not be tested. However, it is unclear whether the Maryland CNC word list was used. If it was used, then the examination yielded a numerical designation of I in the right ear (42-49 percent average puretone decibel hearing loss, with between 92 and 100 percent speech discrimination). Although speech discrimination could not be tested for the left ear, even if the score was zero percent, a 10 percent evaluation would continue for the Veteran’s bilateral hearing loss disability based upon use of Table VII under Diagnostic Code 6100. The Board has considered the alternative rating scheme for exceptional patterns of hearing impairment and while § 4.86(b) is not applicable, § 4.86(a) is applicable. However, application of § 4.86(a) also results in a disability percentage evaluation of 10 percent for the Veteran’s bilateral hearing loss disability. In Martinak v. Nicholson, 21 Vet. App. 447 (2007), the Court noted that VA had revised its hearing examination worksheets to include the effect of the Veteran’s hearing loss disability on occupational functioning and daily activities. See Revised Disability Examination Worksheets, Fast Letter 07-10 (Dep’t of Veterans Affairs Veterans Apr. 24, 2007); see also 38 C.F.R. § 4.10. The Court also noted, however, that even if an audiologist’s description of the functional effects of the Veteran’s hearing disability was somehow defective, the Veteran bears the burden of demonstrating any prejudice caused by a deficiency in the examination, and here the Veteran has not presented any evidence that the examination was defective or that there was any prejudice caused by any deficiency in the examination. Indeed, the Veteran has reported that he has difficulty hearing other people. See, e.g., the January 2012 VA examination report. The Board has considered the statements made by the Veteran regarding his hearing loss. The schedular criteria, however, are specific, and the Veteran’s hearing loss is simply not of such severity to warrant a disability rating more than 10 percent based on audiological testing results of record. See Lendenmann, 3 Vet. App. at 349. Therefore, the Veteran’s claim for a disability rating more than 10 percent for a bilateral hearing loss disability is denied. Right and left carpal tunnel syndrome The Veteran's service-connected right and left carpal tunnel syndrome have been rated under 38 C.F.R. § 4.124a, Diagnostic Code 8515. Right carpal tunnel syndrome is assigned a 10 percent disability rating prior to November 27, 2013; a 50 percent rating from November 27, 2013 to October 31, 2015; and a 30 percent rating thereafter. Left carpal tunnel syndrome has been assigned a 10 percent rating prior to November 27, 2013; a 40 percent rating from November 27, 2013 to October 31, 2015; and a 20 percent rating thereafter. The Board notes that the Veteran is right-hand dominant (major hand). See, e.g., the February 2007 VA examination report. Diagnostic Code 8515 relates to impairment of the median nerve and provides that a 10 percent disability evaluation is assigned for mild, incomplete paralysis of the median nerve of the minor or major hand. Moderate incomplete paralysis of the major hand warrants a 30 percent evaluation. Moderate incomplete paralysis of the minor hand warrants a 20 percent evaluation. Severe incomplete paralysis of the major hand warrants a 50 percent evaluation. Severe incomplete paralysis of the minor hand warrants a 30 percent evaluation. Complete paralysis of the major hand warrants a 70 percent evaluation. Complete paralysis of the minor hand warrants a 60 percent evaluation. 38 C.F.R. § 4.124a, Diagnostic Code 8515. In rating peripheral nerve injuries and their residuals, attention should be given to the site and character of the injury, the relative impairment and motor function, atrophic changes, or sensory disturbances. 38 C.F.R. § 4.120. Under 38 C.F.R. § 4.124a, disability from neurological disorders is rated from 10 to 100 percent in proportion to the impairment of motor, sensory, or mental function. With partial loss of use of one or more extremities from neurological lesions, rating is to be by comparison with mild, moderate, severe, or complete paralysis of the peripheral nerves. The term 'incomplete paralysis' indicates a degree of lost or impaired function substantially less than the type of picture for complete paralysis given with each nerve, whether due to varied level of the nerve lesion or to partial regeneration. When the involvement is only sensory, the rating should be for the mild, or at most, the moderate degree. In rating peripheral nerve disability, neuritis, characterized by loss of reflexes, muscle atrophy, sensory disturbances, and constant pain, at times excruciating, is to be rated on the scale provided for injury of the nerve involved, with a maximum equal to severe, incomplete paralysis. The maximum rating to be assigned for neuritis not characterized by organic changes referred to in this section will be that for moderate incomplete paralysis, or with sciatic nerve involvement, for moderately severe incomplete paralysis. 38 C.F.R. § 4.123. Neuralgia, cranial or peripheral, characterized usually by a dull and intermittent pain, of typical distribution so as to identify the nerve, is to be rated on the same scale, with a maximum equal to moderate incomplete paralysis. 38 C.F.R. § 4.124 (2018). The Veteran was afforded a VA examination in February 2007. He complained of some swelling in his hands and some generalized diminished sensation over the palmar aspects bilaterally. He had pain through his fingers, especially with repetitive motion. There was no lack of coordination. Upon examination, the VA examiner reported that the wrists revealed no swelling and no significant point tenderness. There was no atrophy visible in either forearm, wrist, or hand. Muscle bulk was symmetrical. Motor tone was 5/5 on hand grip and finger abduction and adduction. The hands were warm, and circulation was normal. Sensation was intact over all aspects of the palmar and dorsal aspects of the hands and wrists to monofilament testing. He had a negative Tinel’s and Phalen’s signs. The examiner reported no significant symptoms consistent with carpal tunnel syndrome. A VA examination report dated July 2014 noted the Veteran’s report of impairment due to the bilateral carpal tunnel syndrome which consisted of daily pain, numbness, and weakness. The examiner documented no constant pain; severe intermittent pain in the right upper extremity and moderate intermittent pain in the left upper extremity; severe paresthesias and/or dysthesias of the upper extremities; and moderate numbness of the upper extremities. Muscle strength testing was 5/5 with the exception of grip strength which was 4/5. The examiner indicated some muscle atrophy. Reflex testing was normal, although there was decreased sensation in the hand/fingers. Tinel’s and Phalen’s testing was positive. The examiner noted incomplete paralysis of the median nerves. The Veteran was provided another VA examination in March 2015. He reported pain on a daily basis that was aggravated by doing chores around the house or in his yard. He used braces on both wrists for pain relief. He had a tendency to lose his grip frequently. The examiner documented mild constant pain, no intermittent pain, moderate paresthesias and/or dysesthesias, and moderate numbness in both extremities. Upon examination, muscle strength testing was normal with no muscle atrophy. Reflex and sensory testing was normal. There was no evidence of diminished feeling in the thumb, although all five digits on the palmar side had less sensation than on the dorsum at the radial dermatome. Also, the palmar aspect of the hands was less sensitive than the volar forearm above the wrist. There were no trophic changes. Tinel’s and Phalen’s testing was positive. The examiner specifically reported moderate incomplete paralysis of the median nerves. The Board also notes that VA treatment records document treatment for the Veteran’s bilateral carpal tunnel syndrome and essentially reveal normal findings with the exception of a September 2014 VA evaluation noting 2/4 strength testing of the left upper extremity. Based on the evidence of record, the Board finds that higher ratings are not warranted for the Veteran’s right and left carpal tunnel syndrome during any period under consideration. In this regard, prior to November 27, 2013, ratings higher than 10 percent are not warranted as the evidence does not demonstrate at least moderate impairment of the right and left median nerve. As discussed above, the February 2007 VA examination documented essentially normal findings. There are no objective findings to the contrary prior to November 27, 2013. Therefore, ratings more than 10 percent are not warranted prior to November 27, 2013. From November 27, 2013 to October 31, 2015, ratings higher than 50 percent for right carpal tunnel syndrome and 40 percent for left carpal tunnel syndrome are not warranted as the evidence during this period does not show paralysis of either nerve which is required for a 70 percent (right) and 60 percent (left). The VA examiner specifically noted in his March 2015 report moderate incomplete paralysis of the median nerves, and the evidence addressed in the July 2014 and March 2015 VA examination reports as well as VA treatment records noting treatment for the Veteran’s bilateral carpal tunnel syndrome during this period do not support a finding of complete nerve paralysis in either median nerve. Notably, the VA examiner reported incomplete paralysis of the median nerves and there are no medical findings to the contrary. As such, the Board finds that increased ratings are not warranted for the Veteran’s right and left carpal tunnel syndrome from November 27, 2013 to October 31, 2015. Finally, from November 1, 2015, the Board finds that a rating higher than 30 percent for right carpal tunnel syndrome and 20 percent for left carpal tunnel syndrome under Diagnostic Code 8515 are not warranted. Specifically, there are no objective findings consistent with at least severe incomplete nerve paralysis which is required for a higher 50 percent (right) and 40 percent (left) rating. Indeed, there are no neurological findings recorded in VA treatment records or statements from the Veteran that indicate such. The Board has considered other potentially applicable Diagnostic Codes. Schafrath v. Derwinski, 1 Vet. App. at 595. However, there are no other Diagnostic Codes pertaining to the Veteran's symptoms that offer a higher disability rating for the symptoms described in the record. Accordingly, the Board finds that ratings higher than 10 percent are not warranted for the Veteran’s right and left carpal tunnel syndrome prior to November 27, 2013; a rating higher than 50 percent for right carpal tunnel syndrome and 40 percent for left carpal tunnel syndrome is not warranted from November 27, 2013 to October 31, 2015; and a rating higher than 30 percent for right carpal tunnel syndrome and 20 percent for left carpal tunnel syndrome are not warranted from November 1, 2015. Right leg varicose veins The Veteran’s right leg varicose veins disability is rated 10 percent disabling pursuant to 38 C.F.R. § 4.104, Diagnostic Code 7120 (varicose veins). Varicose veins, with intermittent edema of an extremity or aching and fatigue in the leg after prolonged standing or walking, with symptoms relieved by elevation of extremity or compression hosiery, is assigned a 10 percent rating. When there is persistent edema, incompletely relieved by elevation of the extremity, with or without beginning stasis pigmentation or eczema, a 20 percent rating is assigned. Varicose veins, with persistent edema and stasis pigmentation or eczema, with or without intermittent ulcerations, will be rated as 40 percent disabling. When there is persistent edema or subcutaneous induration, stasis pigmentation or eczema, and persistent ulceration, a 60 percent rating will be assigned. A 100 percent rating is warranted with the following findings attributed to the effects of varicose veins: massive board-like edema with constant pain at rest. On February 2007 VA examination, the Veteran reported occasional swelling in his right calf but no significant discomfort. He occasionally wore a compression stocking. There was no significant restriction upon walking or standing, just the swelling. Upon examination, the VA examiner reported that the Veteran’s right calf was nontender and had normal coloration and temperature. There was no abnormality of gait. However, the right calf measured 39.5 cm in circumference and the left calf measured 37.5 cm in circumference. On July 2014 VA examination, the Veteran reported soreness and swelling in his right calf and ankle as well as occasional use of a compression hose. He did not report any blood clots. The examiner documented symptoms of aching and fatigue in the leg after prolonged standing or walking, symptoms relieved by elevation of extremity, symptoms relieved by compression hosiery, and intermittent edema of extremity. Based on the foregoing, the Board finds that a disability rating greater than 10 percent for the Veteran’s right leg varicose veins is not warranted. As discussed above, a higher 20 percent rating is warranted when the varicose veins disability is manifested by persistent edema, incompletely relieved by elevation of extremity, with or without beginning stasis pigmentation or eczema. Such criteria are not met here. As discussed above, the July 2014 VA examination report in particular indicates that the Veteran does not evidence persistent edema, and symptoms attributable to the right leg varicose veins were relieved by elevation of the extremity or compression hosiery. There are no findings contrary to the July 2014 VA examination during the period under consideration. Accordingly, the criteria for a disability rating higher than 10 percent for the Veteran’s right leg varicose veins are not met, and his claim is denied. Combined evaluation of more than 40 percent effective September 29, 2011 Effective September 29, 2011, the Veteran was in receipt of a combined disability rating of 40 percent. In accordance with the applicable VA regulations, his service-connected disabilities were evaluated according to the Rating Schedule and the evaluations were then combined under the Combined Ratings Table set forth at 38 C.F.R. § 4.25. See 38 U.S.C. §§ 1155 and 1157 (2012). The law directs the Secretary to provide for ratings based on the combination of evaluations for veterans suffering from multiple service-connected disabilities. See 38 U.S.C. § 1157. The Secretary has prescribed a table for combined ratings in 38 C.F.R. § 4.25. Combined ratings result from the consideration of the efficiency of the individual as affected first by the most disabling condition, then by the less disabling condition, then by other less disabling conditions, if any, in the order of severity. Id. In this case, effective September 29, 2011, the Veteran was service connected for right carpal tunnel syndrome, evaluated 10 percent disabling; left carpal tunnel syndrome, evaluated 10 percent disabling; tinnitus, evaluated 10 percent disabling; bilateral hearing loss disability, evaluated 10 percent disabling; right leg varicose veins, evaluated 10 percent disabling; recurrent bilateral plantar warts, evaluated noncompensable; and lipoma of the right arm, evaluated noncompensable. Rather than adding each 10 percent disability rating resulting in a 50 percent disability evaluation, the Combined Ratings Table requires VA to combine the first two 10 percent ratings to make 19 percent then calculate each 10 percent rating thereafter which results in an increase disability evaluation of 41. As 38 C.F.R. § 4.25 requires that combined rating be converted to the nearest degree divisible by ten, the overall disability of the conditions would be 40 percent rather than 50 percent. As noted above, VA is directed by law to provide for evaluations based on the combination of ratings for multiple service-connected disabilities by use of the Combined Ratings Table at 38 C.F.R. § 4.25. The Board is bound by applicable statutes, regulations of the Department of Veterans Affairs, and precedent opinions of the General Counsel of the Department of Veterans Affairs, and is without authority to revise them. 38 C.F.R. § 19.5. Therefore, the Board does not have any authority to calculate the Veteran's overall disability rating utilizing any method other than the Combined Ratings Table and 38 C.F.R. § 4.25. The Board finds that the claim for a higher overall rating on a basis other than use of the Combined Rating Table effective September 29, 2011 has no legal merit and is denied. H. N. SCHWARTZ Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Arif Syed, Counsel The Board’s decision in this case is binding only with respect to the instant matter decided. This decision is not precedential, and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.