Citation Nr: 21064699 Decision Date: 10/21/21 Archive Date: 10/21/21 DOCKET NO. 17-11 419 DATE: October 21, 2021 ORDER Entitlement to service connection for bilateral hearing loss is denied. Entitlement to an initial rating higher than 10 percent for painful left hand laceration residual scar is denied. Entitlement to an initial rating higher than 10 percent for left hand laceration between the second and long fingers, with long finger weakness, is denied. Entitlement to an initial rating higher than 10 percent for left hand laceration between the second and long fingers, with index finger weakness, is denied. Entitlement to an initial rating of 10 percent, but no higher, for left hand laceration causing pain and weakness in the thumb, ring finger, and little finger, is granted. REFERRED The issue of entitlement to service connection for an upper extremity peripheral nerve disorder was raised by the Veteran at the May 2021 VA examination. This issue is referred to the Agency of Original Jurisdiction in order to provide the Veteran with the proper form to submit a claim, if he so wishes. FINDINGS OF FACT 1. There is no probative evidence indicating that the Veteran has a current hearing loss disability for VA compensation purposes. 2. The Veteran's left hand laceration is painful, but it is not unstable or covering an area of at least 39 square centimeters (cm.). 3. The Veteran has pain and weakness in his left index finger, with a gap of 10 cm. between the fingertip and the proximal transverse crease of the palm. 4. The Veteran has pain and weakness in his left long finger, with a gap of 12 cm. between the fingertip and the proximal transverse crease of the palm. 5. The probative medical evidence indicates that the Veteran's left hand laceration has caused pain, limited motion, and weakness in his thumb, ring finger, and little finger. CONCLUSIONS OF LAW 1. The criteria for service connection for bilateral hearing loss have not been met. 38 U.S.C. §§ 1131, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304, 3.307, 3.309. 2. The criteria for an initial rating higher than 10 percent for painful left hand laceration residual scar have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.118, Diagnostic Code 7804. 3. The criteria for an initial rating higher than 10 percent for left hand laceration between the second and long fingers, with long finger weakness, have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.3, 4.10, 4.40, 4.45, 4.71a, Diagnostic Code 5229. 4. The criteria for an initial rating higher than 10 percent for left hand laceration between the second and long fingers, with index finger weakness, have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.3, 4.10, 4.40, 4.45, 4.71a, Diagnostic Code 5229. 5. The criteria for an initial rating of 10 percent, but no higher, for left hand laceration causing pain and weakness in the thumb, ring finger, and little finger, have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.3, 4.10, 4.40, 4.45, 4.71a, Diagnostic Codes 5228, 5230. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from October 1979 to October 1982. This case comes to the Board of Veterans' Appeals (Board) from August 2016 and September 2016 rating decisions of the Department of Veterans Appeals (VA) Regional Office. This case was remanded by the Board for additional development in July 2020. It appears that the Board's previous July 2020 remand erroneously included the issue of entitlement to an initial rating higher than 10 percent for right ear scars, as this issue was not appealed by the Veteran in his February 2017 Form 9. Furthermore, in a June 2021 rating decision, the Veteran was granted an increased initial evaluation of 30 percent for a right ear scar, effective March 20, 2016. This was a full grant of the 30 percent rating requested by the Veteran in his November 2016 Notice of Disagreement, and the rating decision specifically stated that this was a full grant of the benefit sought. The Board finds that this constitutes a full grant of the benefit sought. The Veteran has not disagreed with that decision, and this issue is not part of the current appeal. The June 2021 rating decision also granted a separate initial 10 percent rating for a left hand laceration scar, effective November 1, 2016. In a June 2021 rating decision, the Veteran was assigned additional, separate 10 percent ratings for laceration with weakness of the index finger, and for laceration with weakness of the long finger, effective March 30, 2016. As these grants did not assign the maximum possible rating or the ratings requested by the Veteran, these issues remain on appeal. Because the Veteran has now been assigned compensable initial ratings for his left hand scars and right ear scar, the Veteran no longer has two or more separate service-connected disabilities which are rated as noncompensably disabling (0 percent), and the claim for entitlement to a 10 percent evaluation based upon multiple, noncompensable service-connected disabilities is rendered moot. See 38 C.F.R. § 3.324; Butts v. Brown, 5 Vet. App. 532, 541 (1993). Bilateral Hearing Loss The Veteran contends that he has a current bilateral hearing loss disability that was related to either the laceration of his right ear in service or to hazardous noise exposure in service. The Veteran has written that he has difficulty hearing people when they are talking, especially if there is other noise present, and that he has to ask people to repeat themselves. Service connection may be granted for a disability resulting from disease or injury incurred coincident with or aggravated by service. 38 U.S.C. § 1131; 38 C.F.R. § 3.303(a). Service connection requires evidence satisfying three criteria: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship ("nexus") between the present disability and the disease or injury incurred or aggravated during service. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Sensorineural hearing loss may be presumed to have been incurred in service if the respective disorder was compensably disabling within a year of a veteran's separation from active duty. 38 U.S.C. §§ 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.307, 3.309. For the purposes of applying the laws administered by VA, impaired hearing will be considered to be a disability when the auditory threshold in any of the frequencies at 500, 1000, 2000, 3000, or 4000 Hertz is 40 decibels or greater; or when the auditory thresholds for at least three of the frequencies at 500, 1000, 2000, 3000, or 4000 Hertz are 26 decibels or greater; or when speech recognition scores using the Maryland CNC Test are less than 94 percent. 38 C.F.R. § 3.385. In this case, the Board has reviewed all of the evidence of record, and there is no evidence indicating that the Veteran has a current hearing loss disability for VA compensation purposes. The Veteran's service treatment records do not show any audiological test results that indicate a hearing loss disability. While the Veteran was treated for a laceration behind the right ear in November 1979, and for perforation of the left tympanic membrane in July 1981, there is no indication in the record that these injuries resulted in any damage to his hearing. None of the Veteran's hearing tests showed hearing levels that would qualify as a disability for VA purposes under 38 C.F.R. § 3.385. The Veteran attended a VA examination in August 2016. The Veteran reported that he had a hard time hearing conversations and needed the TV to be loud. The examiner was not able to test the Veteran's hearing thresholds, because the subjective pure tone results were not consistent or repeatable, and the results were not consistent with speech reception threshold results. He wrote that the speech discrimination scores were 56 percent in the right ear and 76 percent in the left ear, but the use of speech discrimination scores was not appropriate, because of language difficulties, cognitive problems, or inconsistent word recognition scores. Because the Veteran's actual hearing levels were not able to be tested in August 2016, in the July 2020 remand, the Board gave the Veteran another opportunity to attend a VA audiological examination and to comply with the testing instructions. The Veteran attended a VA examination in November 2020. Unfortunately, this examiner was also not able to obtain any pure tone threshold results. She wrote that non-organic, exaggerated hearing loss was suspected, and the test results were invalid. She wrote that there was a positive Stenger pure tone threshold/speech recognition threshold mismatch, and inconsistent pure tone and speech response. She wrote that the Veteran was reinstructed throughout the examination, and was told to respond at the softest sound he could hear. Speech discrimination testing found right ear results of 84 percent, and left ear results of 78 percent, but the examiner marked that the use of these scores was not appropriate, because of language difficulties, cognitive problems, or inconsistent word recognition scores. She wrote that the Veteran provided no responses in the right ear, which would indicate a profound hearing loss, but he had little to no difficulty to case history questions outside of the booth, and directions presented at 70 decibels inside of the booth over insert earphones were understood. His pure tone responses for the left ear were inconsistent, and retesting provided no improvement. The Board therefore finds that the Veteran has been provided with two separate opportunities to have his hearing levels tested and evaluated, but his unwillingness to comply with the examiners' instructions has resulted in test results that are invalid, and cannot be used to determine whether he has a current hearing loss disability. There are no indications that the two VA examiners did not perform their duties correctly, and the Veteran has not asserted that they erred in any way. There is no other evidence indicating that the Veteran has a current hearing loss disability. The Veteran has not reported that he was diagnosed with right or left ear hearing loss at any time, nor has he indicated that he has received any treatment for his hearing, either through a private provider or VA. The Veteran's VA treatment records and private treatment records show no reports of difficulty hearing or treatment for hearing loss. There is no other evidence in any of the Veteran's past medical records that he has ever had, at any time, a hearing loss disability under 38 C.F.R. § 3.385 in either ear. VA regulation specifically defines the parameters of a hearing loss disability for compensation purposes, and the Veteran in this case does not meet the criteria for establishing a current disability. Id. Congress specifically limits entitlement for service-connected disease or injury to cases where such incidents have resulted in a disability. In the absence of proof of present disability, there can be no valid claim. Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992); see also McClain v. Nicholson, 21 Vet. App. 319, 321 (2007). As there is no evidence that the Veteran has a hearing loss disability in either the right or the left ear for VA purposes, service connection is not warranted. The Board acknowledges that the Veteran is competent to describe experiencing loud noise exposure during service and any symptomatology regarding perceived hearing loss, including having difficulty hearing when there is background noise and needing to ask people to repeat themselves. See Layno v. Brown, 6 Vet. App. 465, 470 (1994). However, as a lay person, his opinion as to the degree of hearing loss is not a competent medical opinion. See Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). Determining the actual degree of hearing loss requires audiological examination and testing by a qualified professional. See 38 C.F.R. §§ 3.385, 4.85. For the foregoing reasons, the Board finds that the preponderance of the evidence does not demonstrate that the Veteran's bilateral hearing ability has, at any time, been shown to meet the criteria for a hearing loss disability for VA purposes. The claim for service connection must therefore be denied. In reaching this decision the Board considered the doctrine of reasonable doubt; however, as the preponderance of the evidence is against the appellant's claim, the doctrine is not for application. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Left Hand Laceration Painful Scar The Veteran contends that his left hand scar is unstable and painful, and that it is excessively sensitive and uncomfortable when he uses his left hand. He has also written that it makes activities, such as cooking, cleaning, and shaving more difficult, because his has difficulty with the movement of his fingers and because he has so much pain and discomfort. Disability evaluations are determined by the application of a schedule of ratings which is based, as far as can practically be determined, on the average impairment of earning capacity. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. 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. The Board notes that VA amended the criteria for rating skin disabilities effective from August 13, 2018. However, Diagnostic Code 7804 was not substantively changed by the August 13, 2018, amendments. Under Diagnostic Code 7804, one or two scars that are unstable or painful scars warrants a 10 percent rating. Three or four scars that are unstable or painful scars warrants a 20 percent rating. 38 C.F.R. § 4.118, Diagnostic Code 7804. Note 1 to Diagnostic Code 7804 instructs that an unstable scar is one where, for any reason, there is frequent loss of covering of skin over the scar. Id. If a scar is both painful and unstable, an additional 10 percent can be assigned. 38 C.F.R. § 4.118, Diagnostic Code 7804, Note 2. The Board notes that separate rating criteria can be applied when the scarred area is at least 39 square cm., or they cause functional impairment. See 38 C.F.R. § 4.118, Diagnostic Codes 7801, 7802, 7805. In this case, there is no indication that the Veteran's left hand scar has ever been close to 39 square cm., and that criteria therefore does not apply. The functional impairment caused by the Veteran's scar will be addressed separately. At an August 2016 VA hand examination, the Veteran was found to have a scar that was 2 cm. by 0.1 cm., and it was not painful or unstable. At a September 2016 VA examination, the Veteran was found to have a 4.5 cm. linear scar on his left palm extending to the webspace between the index and middle finger. The scar was not painful or unstable. At a May 2021 VA examination, the Veteran was found to have one painful scar on the left hand. He reported that it was tender and painful, like something was "stuck in there." The scar was not unstable, and it did not have frequent loss of covering of the skin. The scar was 4 cm. by 0.1 cm. The Board is also unable to assign a rating higher than 10 percent for a painful left hand laceration residual scar at this time. The Veteran has reported having pain in his left hand scar, and this allows for a 10 percent rating under 38 C.F.R. § 4.118, Diagnostic Code 7804. The Veteran is also service-connected for a scar by his right ear, but this scar has already been separately rated under 38 C.F.R. § 4.118, Diagnostic Code 7800, and assigned a 30 percent rating. The Veteran's left hand scar has never been found to be unstable. While the Veteran has written that he believes his scar is unstable, the Board finds his assertions to be less probative than the findings of competent VA medical examiners. See Jandreau, 492 F.3d at 1376-77. At no time has any medical professional found his scar to be unstable, to have had any loss of change in the skin integrity, or to have any loss of the skin covering. The Board therefore finds that the Veteran has a painful scar on his left palm, the 10 percent initial rating that has been assigned is appropriate, and a higher initial rating is not warranted. The Veteran's functional impairment related to his left hand scar has been assigned separate ratings, and will be discussed below. Left Hand Laceration Scars and Finger Weakness The Veteran contends that higher initial ratings are warranted for the functional impairment caused by his left palm residual scar. He has written that it causes weakness and pain, which makes it hard for him to cook, clean, and shave, and that it has affected the function of his fingers. Any disabling effects caused by a scar are to be evaluated under the appropriate diagnostic code for those effects. 38 C.F.R. § 4.118, Diagnostic Code 7805. Here, the Veteran has been found to have pain and weakness affecting the function and movement of his index and long fingers that are associated with his scar. 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. It is essential that the examination on which ratings are based adequately portrays the anatomical damage, and the functional loss, with respect to these elements. The intent of the schedule is to recognize painful motion with joint or periarticular pathology as productive of disability. It is the intention to recognize actually painful, unstable, or malaligned joints, due to healed injury, as entitled to at least the minimum compensable rating for the joint. 38 C.F.R. § 4.59. When evaluating musculoskeletal disability es based on limitation of motion, 38 C.F.R. § 4.40 requires consideration of functional loss caused by pain or other factors listed in that section that could occur during flare-ups or after repeated use. 38 C.F.R. § 4.45 requires consideration also be given to less movement than normal, more movement than normal, weakened movement, excess fatigability, incoordination, and pain on movement. See DeLuca v. Brown, 8 Vet. App. 202 (1995); see also Mitchell v. Shinseki, 25 Vet. App. 32, 44 (2011). Nonetheless, even when the background factors listed in § 4.40 or 4.45 are relevant when evaluating a disability, the rating is assigned based on the extent to which motion is limited, pursuant to 38 C.F.R. § 4.71a; a separate or higher rating under § 4.40 or 4.45 itself is not appropriate. See Thompson v. McDonald, 815 F.3d 781, 785 (Fed. Cir. 2016). The Veteran has been assigned a 10 percent evaluation for repair with sutures and weakness of the left index finger, and a 10 percent rating for repair with sutures and weakness of the left long finger, under § 4.40 and § 4.45, because he has painful motion in his index finger. The Veteran was not found to have amputation of any finger, ankylosis of any finger, or limited motion of the thumb such that there was a gap of more than 2 inches between the pad and the fingers. The medical evidence indicates that the Veteran is right-handed, and therefore his left hand is his "minor" extremity. The rating criteria for musculoskeletal disorders under 38 C.F.R. § 4.71a were amended, effective February 7, 2021 [Schedule for Rating Disabilities: Musculoskeletal System and Muscle Injuries, 85 Fed. Reg. 76453-69 (November 30, 2020)]. The amendments did not alter the rating criteria for evaluating the hand and fingers. The rating criteria pertaining to the hands and fingers allow for a 10 percent rating when the index finger or long finger have ankylosis. 38 C.F.R. § 4.71a, Diagnostic Codes 5225, 5226. Ankylosis of the ring of little finger, either favorable or unfavorable, is assigned a 0 percent rating. 38 C.F.R. § 4.71a, Diagnostic Code 5227. When both the index and long finger are in unfavorable ankylosis, on the minor hand, a 20 percent rating is assigned. 38 C.F.R. § 4.71a, Diagnostic Code 5219. Additional ratings are assignable for other combinations of ankylosed fingers under 38 C.F.R. § 4.71a, Diagnostic Codes 5216-5223. When rating limitation of motion in the individual digits, a 10 percent rating is assigned for limitation of motion in the long finger or the index finger with a gap of one inch or more between the fingertip and the proximal transverse crease of the palm, with the finger flexed to the extent possible, or; with extension limited by more than 30 degrees. 38 C.F.R. § 4.71a, Diagnostic Code 5229. This is the highest rating available for these digits. Any limitation of motion in the ring of little finger is assigned a 0 percent rating. 38 C.F.R. § 4.71a, Diagnostic Code 5229. 38 C.F.R. § 4.71a, Diagnostic Code 5230. Limitation of motion in the thumb is assigned a 10 percent rating when there is a gap of one to two inches between the thumb pad and the fingers, with the thumb attempting to oppose the fingers, and a 20 percent rating with a gap of more than two inches between the thumb pad and the fingers, with the thumb attempting to oppose the fingers. 38 C.F.R. § 4.71a, Diagnostic Code 5228. When evaluating ankylosis in the fingers, if both the metacarpophalangeal and proximal interphalangeal joints of a digit are ankylosed, and either is in extension or full flexion, or there is rotation or angulation of a bone, it is rated as amputation without metacarpal resection. Amputation of the minor arm long or index finger is assigned a 20 percent rating when there is metacarpal resection (more than one-half the bone lost), and a 10 percent rating without metacarpal resection. 38 C.F.R. § 4.71a, Diagnostic Codes 5153, 5154. The Veteran attended a VA examination in August 2016. The Veteran's dominant hand was his right hand. He did not report any flare ups. Range of motion testing in the left hand was all normal. There was no gap between the finger and proximal transverse crease of the hand, and no gap between the pad of the thumb and the fingers. There was no evidence of pain with use of the hand or localized tenderness. The Veteran could perform repetitive use testing with no further loss of motion. He was being examined immediately after repetitive use over time, and pain, weakness, fatigability, and incoordination did not significantly limit functional ability with repeated use over time. Muscle strength was normal, and there was no ankylosis. The Veteran also attended a VA hand and fingers examination in May 2021. The Veteran reported having left hand pain that was constant and was aggravated by use. He reported flare ups that occurred a few times a week, lasted for minutes, and caused sharp pain. The examination was conducted during a flare up. He reported that his hand disorder impacted his ability to hold things with his hand or use his hand, including getting dressed or fixing things around the house. The examiner wrote that the Veteran had difficulty grasping objects. Range of motion testing, both active and passive, found that the Veteran had significantly limited flexion in all digits, but did maintain at least 30 degrees of metacarpophalangeal (MCP) joint flexion in all digits. The Veteran also had extension to 0 degrees in all joints of each finger. There was an index finger gap of 10 cm. and a long finger gap of 12 cm. between these fingers and the proximal transverse crease of the hand. There was no gap between the pad of the thumb and the fingers. There was pain in all fingers, and pain precluded repetitive use of the hand. There was no loss of range of motion after three repetitions. There was no ankylosis in any finger. She wrote that the condition was severe, but the Veteran did not have functional impairment such that no effective use remained other than that which would be equally well served by amputation with prosthesis. A June 2021 addendum opinion was requested. The examiner wrote that the treatment records showed that the Veteran was right-hand dominant. She wrote that she believed that the Veteran's prior statements were meant to indicate a relative loss of use of his left hand, not that he was left-handed in the past. She wrote that the Veteran's condition was chronic and had intermittent flare ups. She also indicated that the Veteran had a left upper extremity nerve condition that was likely secondary to his service-connected left hand disorder. After reviewing all of the evidence of record, the Board finds that regarding the awards of 10 percent assigned for the impact of the Veteran's laceration scar on his index finger and long finger, no higher ratings can be assigned. The Veteran has not had any ankylosis in these fingers, but he has been found to have significant limitation of motion. This allows for a maximum rating of 10 percent for each finger, which the Veteran has already been assigned. See 38 C.F.R. § 4.71a, Diagnostic Code 5229. The Veteran has not been found to have loss of use of the fingers or the equivalent of amputation. There is no other basis for any higher ratings to be assigned for the index and long fingers. The Board does find, however, that the Veteran's disability has worsened during the appeal period, and as was found by the May 2021 VA examiner, his left hand laceration now affects all of the fingers on his left hand. The Board therefore accepts that a separate service connection is warranted for left hand laceration causing pain and weakness in the thumb, ring finger, and little finger, and a separate 10 percent initial rating can be assigned. The Veteran has limitation of motion, pain, and weakness in the thumb, ring finger, and little finger. The Veteran has not been found to have a gap of one to two inches between the thumb pad and the fingers, and therefore a compensable rating cannot be assigned for his limitation of motion in the thumb under the criteria set forth in 38 C.F.R. § 4.71a, Diagnostic Code 5228. He does, however, have painful limitation of motion, and the Board therefore can assign him a 10 percent rating based on painful motion, as actually painful joints can be entitled to at least the minimum compensable rating for the joint. See 38 C.F.R. § 4.59. The Board does not find, however, that additional, separate compensable ratings should be assigned for the Veteran's pain and limitation of motion in the ring finger and little finger. While the Veteran has pain and limited motion in these fingers, the maximum compensable ratings for limitation of motion in these digits is 0 percent. 38 C.F.R. § 4.71a, Diagnostic Code 5230. Even if these fingers were completely ankylosed, and thus immovable, they would only be assigned a rating of 0 percent. 38 C.F.R. § 4.71a, Diagnostic Code 5227. Only with amputation of these fingers would a compensable rating be warranted, and the Board finds no evidence indicating that the Veteran's disability to his little and ring fingers is of such severity that it is the equivalent of amputation. The May 2021 VA examiner specifically indicated that there was no loss of use such that no effective function remained other than which would be equally well served by amputation with prosthesis. The Board has considered the Veteran's lay statements, including his reports of pain, weakness, and having difficulty with activities that require the use of his left hand and fingers. The Board has taken the Veteran's reports of pain into consideration in assigning these ratings. See DeLuca, 8 Vet. App. 202. While the Board appreciates that he finds the pain in his fingers to be very uncomfortable, and makes it more difficult for him to perform activities that require extensive use of his fingers, the Veteran has already been assigned the maximum schedular rating for limitation of motion in the little, ring, long, and index fingers. His painful limited motion in his thumb is also the basis for the additional 10 percent rating that has not been assigned. There is no other indication that pain or weakness related to this disability has caused such impairment to the function of his hand that higher ratings should be assigned. In sum, the Board finds that ratings higher than 10 percent for both the long finger weakness and the index finger weakness, due to left hand laceration, are not warranted. A separate rating of 10 percent, but no higher, can be assigned for left hand laceration causing pain and weakness in the thumb, ring finger, and little finger. The Board has again considered the benefit of the doubt doctrine regarding the ratings assigned for the Veteran's painful scar and functional impairment in his fingers from his scar, but the preponderance of the evidence is against assigning any higher ratings. See 38 U.S.C. § 5107(b). Extraschedular Consideration The Board notes that the prior remand characterized the Veteran's left hand functional impairment issues as including consideration of both schedular and extraschedular ratings, although no referral was made regarding consideration of an extraschedular rating. After reviewing all of the evidence of record, the Board finds that this characterization was included in error, and there is no indication that referral for extraschedular consideration is warranted. The United States Court of Appeals for Veterans Claims (Court) has clarified that there is a three-step inquiry for determining whether a veteran is entitled to an extraschedular rating. Thun v. Peake, 22 Vet. App. 111, 115 (2008). Initially, the Board must determine whether the evidence presents such an exceptional disability picture that the available schedular ratings for the service-connected disability are inadequate. See Yancy v. McDonald, 27 Vet. App. 484 (2016); Doucette v. Shulkin, 28 Vet. App. 366 (2017) (holding that either the veteran must assert that a schedular rating is inadequate or the evidence must present exceptional or unusual circumstances); Sowers v. McDonald, 27 Vet. App. 472, 478 (2016) ("[t]he rating schedule must be deemed inadequate before extraschedular consideration is warranted"). Second, if the schedular rating does not contemplate the veteran's level of disability and symptomatology and is found inadequate, the Board must determine whether the veteran's disability picture exhibits other related factors such as marked interference with employment and frequent periods of hospitalization. Thun, 22 Vet. App. at 116. Third, if the first two Thun elements have been satisfied, then the case must be referred to the Under Secretary for Benefits or the Director of the Compensation and Pension Service to determine whether, to accord justice, the veteran's disability picture requires the assignment of an extraschedular rating. Thun, 22 Vet. App. at 116. In other words, the first element of Thun compares a veteran's symptoms to the rating criteria, while the second element considers the resulting effects of those symptoms; if either prong is not met, then referral for extraschedular consideration is not appropriate. Yancy, 27 Vet. App. at 494-95. With respect to the first prong of Thun, the evidence does not establish such an exceptional disability picture as to render the schedular criteria inadequate. The schedular rating criteria include ratings for both scars, including the impact of pain from scars, and for limitation of motion in the fingers. The Veteran's assertions have been that he has both pain and functional impairment from his left hand laceration. Now that the Veteran has been assigned separate ratings both under the criteria for scars and under the criteria for limitation of motion of the fingers, all the Veteran's symptoms and their functional impact are contemplated by the schedular rating criteria. Accordingly, the Board finds that the Veteran's reported symptoms and the findings on VA examinations are contemplated in the regulations and schedular rating criteria. There are no other additional expressly or reasonably raised issues presented on the record. Absent any exceptional factors, the Board finds that the criteria for referral for consideration of an extraschedular rating pursuant to 38 C.F.R. § 3.321(b)(1) are not met. See Bagwell v. Brown, 9 Vet. App. 337 (1996). JENNIFER HWA Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Mary E. Rude, 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.