Citation Nr: 21012421 Decision Date: 03/04/21 Archive Date: 03/04/21 DOCKET NO. 14-11 080 DATE: March 4, 2021 ORDER Entitlement to a rating in excess of 10 percent for a left wrist disability for the period prior to July 6, 2011 is denied. Entitlement to a rating in excess of 10 percent for a left wrist disability for the period from November 1, 2011, to April 25, 2013 is denied. Entitlement to a rating in excess of 20 percent for a left wrist disability for the period from July 1, 2013 to March 13, 2020 is denied. Entitlement to a rating in excess of 70 percent for a left wrist disability for the period since March 14, 2020 is denied. REMANDED Entitlement to an extension beyond June 30, 2013, for a temporary total evaluation based on the service-connected left wrist disability requiring a period of convalescence is remanded. FINDINGS OF FACT 1. For the periods prior to July 6, 2011 and from November 1, 2011, to April 25, 2013, the Veteran’s left wrist disability was manifested by limitation of motion and painful motion; and was not productive of malunion, nonunion, loss of bone substance, marked deformity, or ankylosis. 2. For the period from July 1, 2013 to March 13, 2020 is the Veteran’s left wrist was shown to have favorable ankylosis in 20 degrees to 30 degrees of dorsiflexion, but not ankylosis of the wrist in any other position except favorable. 3. For the rating period beginning March 14, 2020, the Veteran is in receipt of the highest allowable rating for loss of use of the left hand. CONCLUSIONS OF LAW 1. The criteria for a rating in excess of 10 percent for a left wrist disability for the period prior to July 6, 2011 have not been met. 38 U.S.C. § 1155 (2012); 38 C.F.R. §§ 4.7, 4.71a, Diagnostic Codes 5010-5212 (2020). 2. The criteria for a rating in excess of 10 percent for a left wrist disability for the period from November 1, 2011, to April 25, 2013 have not been met. 38 U.S.C. § 1155 (2012); 38 C.F.R. §§ 4.7, 4.71a, Diagnostic Codes 5010-5212 (2020). 3. The criteria for a rating in excess of 20 percent for a left wrist disability for the period from July 1, 2013 to March 13, 2020 have not been met. 38 U.S.C. § 1155 (2012); 38 C.F.R. §§ 4.7, 4.71a, Diagnostic Codes 5214-5125 (2020). 4. The criteria for entitlement to a rating in excess of 70 percent for a left wrist disability for the period since March 14, 2020 have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. § 4.71a, Diagnostic Code 5125 (2020). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active service from June 1991 to September 1991 and from September 1992 to July 1993. This case comes to the Board of Veterans’ Appeals (Board) on appeal from a September 2011 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO). In April 2017, the Veteran testified at a videoconference hearing held before the undersigned Veterans Law Judge. A transcript of the hearing has been associated with the electronic record. In December 2017 and September 2020, the Board remanded these issues for additional development. Notably, in a June 2020 rating decision, the RO granted an increased 70 percent evaluation for the Veteran’s service-connected left wrist disability for the period since March 14, 2020 under Diagnostic Codes 5214-5125. The June 2020 rating decision also granted entitlement to special monthly compensation (SMC) based on the loss of use of the left hand effective March 14, 2020 and granted service connection for peripheral neuropathy of the left hand status post-surgery at an initial 30 percent evaluation, effective March 14, 2020. However, the Veteran has not disagreed with the initial 30 percent disability evaluation for peripheral neuropathy of the left-hand status post-surgery. Accordingly, this issue is not before the Board. Increased Ratings Laws and Regulations The Board must assess the credibility and weight of all evidence, including the medical evidence, to determine its probative value, accounting for evidence which it finds to be persuasive or unpersuasive, and providing reasons for rejecting any evidence favorable to the claimant. Equal weight is not accorded to each piece of evidence contained in the record; every item of evidence does not have the same probative value. When all the evidence is assembled, VA is responsible for determining whether the evidence supports the claims or is in relative equipoise, with the Veteran prevailing in either event, or whether a preponderance of the evidence is against the claims, in which case, the claims are denied. See Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Disability evaluations are determined by evaluating the extent to which a Veteran’s service-connected disability adversely affects his or her ability to function under the ordinary conditions of daily life, including employment, by comparing his or her symptomatology with the criteria set forth in the Schedule for Rating Disabilities. The percentage ratings represent as far as can practicably be determined the average impairment in earning capacity resulting from such diseases and injuries and the residual conditions in civilian occupations. Generally, the degree of disabilities specified are considered adequate to compensate for considerable loss of working time from exacerbation or illness proportionate to the severity of the several grades of disability. 38 U.S.C. § 1155; 38 C.F.R. § 4.1 (2012). Separate diagnostic codes identify the various disabilities and the criteria for specific ratings. If two disability evaluations are potentially applicable, the higher evaluation will be assigned to the disability picture that more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7 (2020). Any reasonable doubt regarding the degree of disability will be resolved in favor of the Veteran. 38 C.F.R. § 4.3 (2020). The Veteran’s entire history is reviewed when making a disability determination. See 38 C.F.R. § 4.1 (2020). Where service connection has already been established, and increase in the disability rating is at issue, it is the present level of the disability that is of primary concern. See Francisco v. Brown, 7 Vet. App. 55 (1994). However, in Fenderson v. West, 12 Vet. App. 119 (1999), it was held that evidence to be considered in the appeal of an initial assignment of a disability rating was not limited to that reflecting the then current severity of the disorder. The Court also discussed the concept of the “staging” of ratings, finding that, in cases where an initially assigned disability evaluation has been disagreed with, it was possible for a veteran to be awarded separate percentage evaluations for separate periods based on the facts found during the appeal period. See also Hart v. Mansfield, 21 Vet. App. 505 (2008). Where there is a question as to which of two ratings shall be applied, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7 (2020). In this case, the Veteran is competent to testify on factual matters of which he has first-hand knowledge. Washington v. Nicholson, 19 Vet. App. 362 (2005). He is also competent to report symptoms of his left wrist disability. Layno v. Brown, 6 Vet. App. 465, 469-71 (1994). The Veteran is competent to describe his symptoms and their effects on employment or daily activities. 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. 38 C.F.R. § 4.40. Functional loss may be due to pain, supported by adequate pathology and evidenced by the visible behavior in undertaking the motion. 38 C.F.R. § 4.59 (discussing facial expressions such as wincing, muscle spasm, crepitation, etc.). Weakness is as important as limitation of motion, and a part that becomes painful on use must be regarded as seriously disabled. Excess fatigability and incoordination should be taken into account in addition to more movement than normal, less movement than normal, and weakened movement. 38 C.F.R. § 4.45. 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. See 38 C.F.R. § 4.59. Although the first sentence of 38 C.F.R. § 4.59 refers only to arthritis, the regulation applies to joint conditions other than arthritis. Burton v. Shinseki, 25 Vet. App. 1, 3-5 (2011). In evaluating disabilities of the musculoskeletal system, it is necessary to consider, along with the schedular criteria, functional loss due to flare-ups of pain, fatigability, incoordination, pain on movement, and weakness. DeLuca v. Brown, 8 Vet. App. 202 (1995). Although pain may cause functional loss, pain itself does not constitute functional loss. Rather, pain must affect some aspect of “the normal working movements of the body,” such as “excursion, strength, speed, coordination, and endurance,” in order to constitute functional loss. Mitchell v. Shinseki, 25 Vet. App. 32, 38-43 (2011) (quoting 38 C.F.R. § 4.40). The Veteran’s left wrist disability is currently rated under Diagnostic Codes 5010-5212 and 5214-5125. While portions of the rating schedule addressing the musculoskeletal system were revised effective February 7, 2021, these diagnostic codes were not changed. The Veteran filed a claim for an increased rating that was received by VA on March 7, 2011. The Veteran currently has a 10 percent rating for a left wrist disability for the periods prior to July 6, 2011 and from November 1, 2011, to April 25, 2013 under Diagnostic Codes 5010-5212. The Veteran currently has a 20 percent rating for a left wrist disability for the period for the period from July 1, 2013 to March 13, 2020 under Diagnostic Codes 5214-5125. Notably, in a June 2020 rating decision, the RO granted an increased 70 percent evaluation for the Veteran’s service-connected left wrist disability for the period since March 14, 2020 under Diagnostic Codes 5214-5125. Hyphenated diagnostic codes are used when a rating under one code requires use of an additional code to identify the basis for the evaluation assigned. 38 C.F.R. § 4.27 (2020). Diagnostic Code 5010 applies to traumatic arthritis, which is to be rated as degenerative arthritis under diagnostic code 5003. Diagnostic code 5212 applies to impairment of the radius. Degenerative arthritis is rated under Diagnostic Code 5003. Under this code, arthritis substantiated by x-ray findings is rated either on limitation of motion of the affected joint under the appropriate diagnostic code or, if only a noncompensable limitation of motion is found, a 10 percent rating will be assigned for each affected major joint or group of minor joints. 38 C.F.R. § 4.71a. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. Id. In the absence of limitation of motion, a 10 percent rating is warranted if there is x-ray evidence of involvement of two or more major joints or two or more minor joint groups and a 20 percent rating is warranted if there is x-ray evidence of involvement of two or more major joints or two or more minor joint groups and there are occasional incapacitating exacerbations. Id. Under 38 C.F.R. § 4.71a, Diagnostic Code 5212, malunion of the radius with bad alignment is rated at 10 percent. Nonunion in the upper half of the radius is rated at 20 percent. Nonunion in the lower half of the radius with false movement but without loss of bone substance or deformity is rated at 30 percent in the dominant extremity and at 20 percent in the nondominant extremity. Nonunion in the lower half of the radius with false movement, loss of an inch or more of bone substance, and marked deformity is rated at 40 percent in the dominant extremity and at 30 percent in the nondominant extremity. Diagnostic Codes 5214 and 5215 assign disability ratings for the wrist. Diagnostic Code 5215 provides for a maximum rating of 10 percent for limitation of motion of the wrist for either the dominant or non-dominant hand when dorsiflexion is less than 15 degrees or when palmer flexion is limited in line with the forearm. 38 C.F.R. § 4.71a (2020). A 10 percent rating is the maximum rating available under Diagnostic Code 5215. Higher ratings are available under Diagnostic Code 5214 for ankylosis of the wrist. Under Diagnostic Code 5214, a disability rating of 30 percent for dominant and 20 percent for nondominant is assigned when the wrist manifests favorable ankylosis with a dorsiflexion between 20 and 30 degrees, and a disability rating of 40 percent for dominant and 30 percent for nondominant is assigned when the wrist manifests ankylosis in any position except favorable. A disability rating of 50 percent for dominant and 40 percent for nondominant is assigned when the Veteran’s wrist manifests unfavorable ankylosis in any degree of palmar flexion or with ulnar or radial deviation. Ankylosis is immobility and consolidation of a joint due to disease, injury, or surgical procedure. Dorland’s Illustrated Medical Dictionary 94 (31st ed. 2007). Finally, extremely unfavorable ankylosis will be rated under Diagnostic Code 5125. Under Diagnostic Code 5125, a disability rating of 60 percent is assigned for the loss of use of the nondominant hand with a disability rating of 70 percent for the loss of use of the dominant hand. 38 C.F.R. § 4.71a, Diagnostic Code 5125. Normal range of motion for the wrist is 70 degrees of dorsiflexion (extension) and 80 degrees of palmar flexion. 38 C.F.R. § 4.71, Plate I. Normal ulnar deviation is 45 degrees, while normal radiation deviation is 20 degrees. Id. It is noted that the assignment of a particular Diagnostic Code is “completely dependent on the facts of a particular case.” Butts v. Brown, 5 Vet. App. 532, 538 (1993). One Diagnostic Code may be more appropriate than another based on such factors as an individual’s relevant medical history, the diagnosis, and demonstrated symptomatology. Any change in a Diagnostic Code by a VA adjudicator must be specifically explained. Pernorio v. Derwinski, 2 Vet. App. 625, 629 (1992). The Board must also consider whether another rating code is “more appropriate” than the one used by the RO. See Tedeschi v. Brown, 7 Vet. App. 411, 414 (1995). Factual Background The Veteran underwent a VA examination in May 2011. The examiner noted that the Veteran was ambidextrous. The Veteran presented with complaints of constant left wrist pain that was 8/10 in intensity. He had swelling, locking and instability of the joints. He worked as a cook at Waffle House and his ability to do this job was impacted by his left wrist as he had difficulty with repetitive motions and movements. He denied problems with activities of daily living and denied flare-ups as he stated that his symptoms were always present and always worse with any activity. He used a brace for his left wrist. On examination, the Veteran’s left wrist flexion was from 0 to 35 degrees, extension was from 0 to 40 degrees, radial deviation was from 0 to 17 degrees and ulnar deviation was from 0 to 12 degrees. Pain did not additionally limit range of motion following repetitive use. He had tenderness to palpation and slight swelling of the left wrist but no warmth or redness. The diagnoses were a left wrist fracture that was repaired but resulted in degenerative arthritis and a left wrist ulnar styloid fracture. A VA treatment note indicated that the Veteran was undergoing surgery in July 2011 and that the convalescence period for this surgery would be 12 weeks. The Veteran underwent a VA examination in August 2012. The Veteran had a left carpal navicular fracture status post carpectomy with posttraumatic arthritis. The Veteran reported very little use of his left hand as he had severe weakness, severe throbbing and stabbing pain. He also complained of intermittent numbness in his left fingertips. He used Percocet every 6 hours which cut his pain in half. He also wore a soft wrist brace that helped sometimes. He also reported intermittent swelling. The examiner indicated that the Veteran was right hand dominant. The Veteran reported flare-ups as he had limited use of his left hand as he stated that he could not pick up his 40-pound son with his left arm. He also reported that he could not lift light things and that he could not use his left hand to drive. On examination, left wrist palmar flexion was from 0 to 40 degrees with pain beginning at 20 degrees. Left wrist dorsiflexion was from 0 to 30 degrees with pain beginning at 15 degrees. He was able to perform repetitive use testing and there was no additional loss of range of motion after 3 repetitions. The Veteran had functional loss of the left wrist as he had less movement than normal, weakened movement, excess fatigability and pain on movement. There was no localized pain on palpation. Muscle strength testing was normal and there was no ankylosis. He had pain, weakness and limited motion as a result of his left wrist surgery. The Veteran’s left wrist impacted his ability to work as he had limited use of his left hand. A February 2013 treatment note from a private physician noted that the Veteran had undergone a left proximal row carpectomy but that his pain and range of motion had not improved much. He still had increased pain and decreased motion with activities. Wrist extension was from 0 to 5 degrees and flexion was also from 0 to 5 degrees. He had full pronation and supination of the left wrist. An April 2013 treatment note from a private physician noted that the Veteran wanted to proceed with his left wrist arthrodesis surgery. On April 26, 2013, the Veteran underwent left wrist arthrodesis surgery without complications. A May 2013 treatment note from a private treatment provider noted that the Veteran was under his care and would be on convalescent leave for 5 months. Another May 2013 treatment note from a private physician indicated that the Veteran’s hand was well healed and his sutures were removed that day. He had discomfort in the dorsal aspect of his hand as he was regaining more extension and flexion. A June 2013 private treatment note reported interval improvement although the Veteran still had intermittent discomfort over the dorsal aspect of his hand. He had full active extension and full composite flexion. He also had full pronation and supination. The Veteran underwent a VA examination in October 2013. The diagnosis was traumatic arthritis of the left wrist. The examiner indicated that the Veteran was ambidextrous. The Veteran reported flare-ups as the weather and trying to use his left wrist caused his pain to flare. Left wrist palmar flexion and dorsiflexion were from 0 degrees and there was no objective evidence of painful motion. There was no additional loss of range of motion after repetitive use testing. He had functional loss as he had less movement than normal, weakened movement, incoordination and pain on movement. There was localized tenderness. Muscle strength testing was normal and there was no ankylosis. Residuals of his surgeries included multiple scars and “basically no movement of the left wrist since the fusion was performed”. The Veteran’s left wrist disability impacted his ability to work as he could not use the left wrist muscle at all and he had difficulty picking up things with his left hand. The Veteran underwent a VA examination in February 2015. The examiner indicated that the Veteran was right-handed. The Veteran did not report flare-ups of his left wrist but had functional loss as the Veteran’s wrist was fused and was unable to bend. On examination, no pain was noted but palmar flexion, dorsiflexion, ulnar deviation and radial deviation were all 0 to 0 degrees. There was no tenderness. Right wrist range of motion was normal. The Veteran was unable to perform repetitive use testing of the left wrist because the wrist was fused. The examiner was unable to say without resorting to mere speculation whether pain, weakness, fatigability or incoordination significantly limited functional ability when used over a period of time or with flare-ups. Muscle strength testing was reduced as the Veteran had no muscle movement (0/5). There was no muscle atrophy. The left wrist had favorable ankylosis in 20 degrees to 30 degrees dorsiflexion. Ankylosis was a residual of his surgery. The Veteran’s left wrist disability impacted his ability to work as it negatively affected his ability to “lift, carry, hammer, etc. with his left hand”. The condition may also affect the Veteran’s ability to perform fine motor skills with his left hand as they may be required or sedentary work. The Veteran underwent a VA examination in March 2020. The examiner noted that the Veteran continued to have pain in his left wrist and he could no longer hold anything. The examiner indicated that the Veteran was ambidextrous. He had flare-ups of his left wrist which occurred to weather, trying to pick anything up, hanging his left arm down and when motioning his hand. He could not bend his wrist or use it for anything as it was fused. On examination, no pain was noted but palmar flexion, dorsiflexion, ulnar deviation and radial deviation were all 0 to 0 degrees. There was tenderness and pain that caused functional loss. Right wrist range of motion was normal. The Veteran was unable to perform repetitive use testing of the left wrist because the wrist was fused. Pain, weakness, fatigability or incoordination significantly limited functional ability when used over a period of time or with flare-ups. Muscle strength testing of the left wrist revealed active movement against some resistance (4/5). There was no muscle atrophy. There was extremely unfavorable ankylosis as the left wrist joint was fused and there was no movement. The Veteran had left wrist fusion surgery in 2016 with residuals including pain, and an inability to use his left wrist and hand. The Veteran regularly used a cane. The Veteran’s left wrist disability impacted his ability to work as he was unable to do anything with his left hand due to fusion surgery. His associated dull ache and neuropathic pain reduced functional capacity would negatively impact his ability to work. The Veteran underwent a peripheral nerves examination in March 2020. The Veteran had left hand peripheral neuropathy. The examiner noted that the Veteran had 5 wrist surgeries with the last surgery a left wrist fusion surgery in 2016. He had been having numbness and tingling in his first and second fingers since this time. He had no feelings in these two fingers but no anatomical deformity and all motions were still possible. The examiner indicated that the Veteran was left-handed. The Veteran had mild paresthesias of the left and right upper extremity and moderate numbness of the left and right upper extremity. Muscle strength testing was normal and there was no muscle atrophy. Reflexes were normal. The sensory examination revealed decreased sensation in the left hand/finger (C6-8). The examiner found that the Veteran had moderate incomplete paralysis of the radial nerve on the left. The Veteran’s left peripheral neuropathy disability impacted his ability to work. Per the September 2020 Board remand instructions, a VA examiner provided an addendum opinion in November 2020. The examiner noted that there was conflicting information regarding the hand dominance of the Veteran. The Veteran claimed under oath at a hearing that he was left-handed but on his 1992 entrance examination he indicated that he was right-handed. His orthopedic surgeon indicated that he was right-handed in his preoperative and physical. The examiner noted that the Veteran claimed right handedness prior to his injury and documentation at the time of the injury/treatment confirmed his righthandedness. As a result, the examiner opined that it was more likely than not that the Veteran is right hand dominant. Analysis Initially, the Board notes that the record contains conflicting evidence throughout as to whether the Veteran has a particular hand that is dominant. Notably, in its December 2017 remand, the Board found that because”[t]here is conflicting evidence on whether the Veteran is right-handed, left-handed, or ambidextrous a new VA examination was necessary to determine whether the Veteran had a dominant hand. Per the December 2017 and September 2020 Board remand instructions, a VA examiner provided an addendum opinion in November 2020 to specifically address whether the Veteran is right-handed, left-handed, or ambidextrous. As reflected above, the examiner concluded that it was more likely than not that the Veteran is right hand dominant. In making this conclusion, the examiner noted that while there was conflicting information regarding the hand dominance of the Veteran, on his 1992 entrance examination he indicated that he was right-handed and his orthopedic surgeon indicated that he was right-handed in his preoperative and physical. The examiner noted that the Veteran claimed right handedness prior to his injury and documentation at the time of the injury/treatment confirmed his righthandedness. The Board finds the November 2020 opinions to be highly probative, as it was based on a thorough review of the Veteran’s medical records, cited to relevant medical principles and specifically addressed the Veteran’s contentions. The opinion is also consistent with the other evidence of record and is supported by a detailed rationale. See Prejean v. West, 13 Vet. App. 444, 448-9 (2000) (noting that factors for assessing the probative value of a medical opinion are the physician’s access to the claims file and the thoroughness and detail of the opinion.). As a result and based on the opinion of the November 2020 VA examiner, the Veteran’s service-connected left wrist disability will be addressed for his non-dominant left hand. Period prior to July 6, 2011 and from November 1, 2011, to April 25, 2013 The Veteran currently has a 10 percent rating for a left wrist disability for the periods prior to July 6, 2011 and from November 1, 2011, to April 25, 2013 under Diagnostic Codes 5010-5212. Considering the pertinent facts in light of applicable rating criteria, the Board finds that an evaluation in excess of 10 percent is not warranted for the Veteran’s service-connected left wrist disability for the periods prior to July 6, 2011 and from November 1, 2011, to April 25, 2013. In order to warrant a higher rating than the currently assigned 10 percent for a left wrist disability under Diagnostic Code 5212, there must be nonunion in the upper half of the radius, nonunion in the lower half of the radius with false movement but without loss of bone substance or deformity or nonunion in the lower half of the radius with false movement, loss of an inch or more of bone substance, and marked deformity. However, there is no evidence of record showing that the Veteran has nonunion in his wrist, loss of bone substance, or marked deformity for the periods prior to July 6, 2011 and from November 1, 2011, to April 25, 2013. For this time period, the Veteran reported increased pain on extended use of his left wrist, but that limitation of function was contemplated by the examiner when reporting limitation of motion. Further, the Veteran’s painful motion was contemplated when he was assigned the current 10 percent rating. As noted above, in evaluating any disability on the basis of limitation of motion, VA must consider the actual degree of functional impairment imposed by pain, incoordination, weakness, fatigue, and lack of endurance with repetitive motion. 38 C.F.R. §§ 4.40, 4.45, 4.59; DeLuca v. Brown, 8 Vet. App. 202 (1995). A review of the record therefore demonstrates that the Veteran experiences functional loss and limitation of motion due to his left wrist disability, however, ankylosis of the left wrist is not shown for the periods prior to July 6, 2011 and from November 1, 2011, to April 25, 2013. As a result, while higher disabilities ratings are contemplated for ankylosis of the wrist under Diagnostic Code 5214, the evidence does not show that the Veteran’s left wrist had been manifested by symptoms consistent with ankylosis at any time during the course of the appeal, even upon consideration of the actual degree of functional impairment due to factors such as pain, weakness, fatigability, incoordination, and lack of endurance. 38 C.F.R. § 4.45; DeLuca v. Brown, 8 Vet. App. 202 (1995). Therefore, a rating in excess of 10 percent for the left wrist disability is not warranted. 38 C.F.R. §§ 4.59, 4.71a, Diagnostic Codes 5010-5212 (2020). The Board has also considered whether a higher rating should be assigned under a different diagnostic code pertaining to the wrist. However, there is no evidence that the Veteran has malunion, nonunion, loss of bone substance, significant limitation of motion, bone fusion, or ankylosis. Therefore, the Board finds that there is no basis for assignment of a higher rating under another diagnostic code. 38 C.F.R. § 4.71a, Diagnostic Codes 5211, 5214, 5215. Accordingly, as the preponderance of the evidence is against the claim for a rating in excess of 10 percent for service-connected left wrist disability for the periods prior to July 6, 2011 and from November 1, 2011, to April 25, 2013, the benefit-of-the-doubt rule does not apply, and the claims must be denied. 38 U.S.C. § 5107(b) (2012); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Period from July 1, 2013 to March 13, 2020 The Veteran currently has a 20 percent rating for a left wrist disability for the period for the period from July 1, 2013 to March 13, 2020 under Diagnostic Codes 5214-5125. Considering the pertinent facts in light of applicable rating criteria, the Board finds that an evaluation in excess of 20 percent is not warranted for the Veteran’s service-connected left wrist disability for the period from July 1, 2013 to March 13, 2020. In order to warrant a higher rating than the currently assigned 20 percent for a left wrist disability under Diagnostic Codes 5214-5125, there must be unfavorable ankylosis. The medical evidence for the period from July 1, 2013 to March 13, 2020 shows that while the Veteran had ankylosis in the left wrist, it was in the favorable position, i.e., at 0 degrees. Notably, the October 2013 and February 2015 VA examinations indicated that palmar flexion, dorsiflexion, ulnar deviation and radial deviation were all 0 to 0 degrees as the Veteran’s wrist was fused. The February 2015 VA examiner specifically indicated that the left wrist had favorable ankylosis in 20 degrees to 30 degrees dorsiflexion which warrants the current 20 percent evaluation for a nondominant hand under Diagnostic Code 5214. 38 U.S.C. § 5107 (b); 38 C.F.R. §§ 3.102, 4.3, 4.7, 4.71a, Diagnostic Code 5214. The evidence does not show that the Veteran’s wrist had been ankylosed in an unfavorable position (i.e., fixed in a position other than 0 degrees) at any point during the period from July 1, 2013 to March 13, 2020. Accordingly, a higher rating is not warranted. Diagnostic Code 5214 also contains a note that states extremely unfavorable ankylosis should be rated pursuant to Diagnostic Code 5125 for loss of use of the hand. 38 C.F.R. § 4.71a, Diagnostic Codes 5125 and 5214. The Board has considered this option based on the medical and lay evidence of record and additionally as pursuant to Deluca and Mitchell but finds that in this case such a rating is not warranted. DeLuca, 8 Vet. App. at 205-06; Mitchell, 25 Vet. App. at 39-42. In this regard, the medical evidence again does not indicate that his left wrist has extremely unfavorable ankylosis for this time period and that loss of use had not been demonstrated. In sum, the Board finds that the Veteran’s left wrist does not approximate extremely unfavorable ankylosis and therefore a higher rating for loss of use of hand pursuant to 5215 is not warranted. 38 U.S.C. § 5107 (b); 38 C.F.R. §§ 3.102, 4.3, 4.7, 4.71a, Diagnostic Codes 5125 and 5214. Accordingly, as the preponderance of the evidence is against the claim for a rating in excess of 20 percent for service-connected left wrist disability for the period from July 1, 2013 to March 13, 2020, the benefit-of-the-doubt rule does not apply, and the claims must be denied. 38 U.S.C. § 5107(b) (2012); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Period from March 14, 2020 In a June 2020 rating decision, the RO granted the Veteran a 70 percent rating effective March 14, 2020 for loss of use of the left wrist due to unfavorable ankylosis under Diagnostic Code 5125. This 70 percent rating is the maximum allowable rating under Diagnostic Code 5125. Moreover, the RO also granted a special monthly compensation based on loss of use of the left hand. A 70 percent rating is the highest rating that a veteran can receive under Diagnostic Code 5125 for the loss of use of a dominant hand. As noted above, it has been determined that the Veteran’s left hand is his non-dominant hand but the Board will not disturb the maximum 70 percent rating for the loss of use of a dominant hand for the Veteran’s left wrist disability for the period from March 14, 2020. No higher rating would be available to him under any of the other Diagnostic Codes applicable to disabilities of the hands or wrist, as he receives the highest rating possible under Diagnostic Code 5125. Under the “amputation rule,” the combined rating for disabilities of an extremity shall not exceed the rating for the amputation at that elective level, were amputation to be performed. Amputation or loss of use of the hand warrants a rating of 70 percent under Diagnostic Code 5125, which constitutes the schedular maximum rating for all disabilities affecting the Veteran’s left hand. Thus, pursuant to the amputation rule, a 70 percent rating for the Veteran’s left wrist is the maximum rating available. Accordingly, the award of any increase over this amount is subject to the amputation rule, 38 C.F.R. § 4.68. Therefore, a rating higher than 70 percent is not warranted. For the foregoing reasons, the preponderance of the evidence is against assignment of a rating in excess of 70 percent for the Veteran’s left wrist disability for the period since March 14, 2020. There is no reasonable doubt to be resolved as to this issue. 38 U.S.C. § 5107 (b); 38 C.F.R. §§ 3.102, 4.3. See Gilbert v. Derwinski, 1 Vet. App. 49 (1990). REASONS FOR REMAND The Board finds that more development is necessary prior to final adjudication of the claim remaining on appeal. An August 2013 rating decision granted the Veteran a temporary total 100 percent disability rating for his left disability, effective from April 26, 2013 through May 31, 2013. The previously assigned 10 percent disability rating was resumed, effective June 1, 2013. A September 2013 granted a 1-month extension for the Veteran’s temporary total 100 percent disability rating for his left disability, effective from April 26, 2013 through June 30, 2013. A 20 percent disability rating was assigned, effective July 1, 2013. In his appeal, the Veteran argues that the temporary total 100 percent disability rating was discontinued prematurely after his April 26, 2013 surgery. 38 C.F.R. § 4.30 provides for the assignment of a total disability rating, effective from the date of hospital admission or outpatient treatment and continuing for a period of 1, 2, or 3 months from the first day of the month following hospital discharge or outpatient release, if the treatment of a service-connected disability resulted in: (1) surgery necessitating at least one month of convalescence; (2) surgery with severe postoperative residuals such as incompletely healed surgical wounds, stumps of recent amputations, therapeutic immobilization of one major joint or more, application of a body cast, or the necessity for house confinement, or the necessity for continued use of wheelchair or crutches (regular weight-bearing prohibited); or (3) immobilization by cast, without surgery, of one major joint or more. Under 38 C.F.R. § 4.30 (b)(1), extension of an additional 1, 2, or 3 months beyond the initial three month period may be made, subject to the guiding provisions under 38 C.F.R. § 4.30 (a)(1)-(3), which are outlined above. Additionally, 38 C.F.R. § 4.30 (b)(2) provides that an extension of 1 or more months up to 6 months beyond the initial 6 months period may be made, subject again to the guiding provisions under 38 C.F.R. § 4.30 (a)(2) and (3). The regulation provides expressly, however, that such extension beyond the initial 6-month period is granted upon approval of the Veterans Service Center Manager. Subject to the foregoing regulations, the facts and information contained in the VA treatment records following the Veteran’s April 23, 2013 surgery to date indicate that the Veteran experienced worsening musculoskeletal and neurological symptoms after the surgery. Notably, a May 2013 treatment note from a private treatment provider noted that the Veteran was under his care and would be on convalescent leave for 5 months. In an August 2013 correspondence, the private physician who performed the April 2013 surgery noted that the Veteran would require a “5 to 6 month” convalescence period to recover from the operative treatment. Overall, the evidence contains sufficient facts and evidence to conclude that it is plausible that the Veteran may be entitled to an extension of his temporary total disability benefits beyond June 30, 2013. Under the circumstances, this matter must be referred to the Veterans Service Center Manager in order to consider whether an extension of the Veteran’s temporary total disability benefits is warranted beyond the initial 4-month period following the Veteran’s left wrist surgery on April 26, 2013. The matters are REMANDED for the following action: 1. Refer the Veteran’s claim for an extension of a temporary total disability rating for surgery necessitating convalescence, effective currently from April 26, 2013through June 30, 2013, to the Veterans Service Center Manager for consideration under 38 C.F.R. § 4.40 (b)(2), as to whether an extension of temporary total disability benefits beyond the initial 3 month period is warranted. 2. Thereafter, readjudicate the issue on appeal. If any benefit sought on appeal remains denied, the Veteran and his representative should be provided with a Supplemental Statement of the Case and be afforded a reasonable opportunity to respond. The case should then be returned to the Board for further appellate review, if otherwise in order. MICHAEL LANE Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board James A. DeFrank, 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.