Citation Nr: 1043110 Decision Date: 11/16/10 Archive Date: 11/24/10 DOCKET NO. 03-36 244 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Paul, Minnesota THE ISSUES 1. Entitlement to an initial schedular evaluation in excess of 40 percent for fibromyalgia with headaches, sleeplessness, fatigue, and diffuse multiple joint pain, to include whether separate ratings for individual joint disabilities are warranted. 2. Entitlement to an extraschedular evaluation for fibromyalgia with headaches, sleeplessness, fatigue, and diffuse multiple joint pain. REPRESENTATION Appellant represented by: Dennis L. Peterson, Attorney ATTORNEY FOR THE BOARD P. Olson, Counsel INTRODUCTION The Veteran had active military service from February 1984 to February 1987; November 1990 to May 1991; and March 1994 to March 2001. This matter is before the Board of Veterans' Appeals (Board) following Board Remands in July 2009 and January 2010. This matter came back before the Board of Veterans' Appeals (Board) on Remand from the United States Court of Appeals for Veterans Claims (Court) regarding a Board decision rendered in March 2007. This matter is originally on appeal from a October 2002 rating decision which granted service connection for fibromyalgia like symptoms and assigned a 20 percent evaluation effective March 13, 2001, and a November 2003 Decision Review Officer Decision which increased the Veteran's service-connected fibromyalgia to 40 percent effective March 13, 2001. The issue of entitlement to an extraschedular evaluation for fibromyalgia with headaches, sleeplessness, fatigue, and diffuse multiple joint pain is addressed in the REMAND portion of the decision below and is REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. FINDINGS OF FACT 1. The 40 percent rating currently assigned for the Veteran's service-connected fibromyalgia is the maximum schedular rating provided for such disability 2. Separate ratings for the Veteran's various joint pain is not warranted. CONCLUSION OF LAW 1. The criteria for an initial schedular evaluation in excess of 40 percent for fibromyalgia have not been met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 4.1, 4.7, 4.71(a), Diagnostic Code 5025 (2010). 2. The criteria for separate ratings for the Veteran's various joint pain have not been met. 38 C.F.R. § 4.14. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Preliminary Matters The Board has thoroughly reviewed all the evidence in the Veteran's claims folders. Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, the extensive evidence submitted by the Veteran or on his behalf. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (the Board must review the entire record, but does not have to discuss each piece of evidence). The analysis below focuses on the most salient and relevant evidence and on what this evidence shows, or fails to show, on the claim. The Veteran must not assume that the Board has overlooked pieces of evidence that are not explicitly discussed herein. See Timberlake v. Gober, 14 Vet. App. 122 (2000) (the law requires only that the Board address its reasons for rejecting evidence favorable to the Veteran). Pursuant to the Board's July 2009 and January 2010 Remands, the RO scheduled a VA examination and obtained a VA medical opinion assessing the severity of the Veteran's fibromyalgia, determining the existence and etiology of any separate knee and/or elbow disability, and providing a description of the effects that the Veteran's fibromyalgia has on his ability to work, and issued a Supplemental Statement of the Case. Based on the foregoing actions, the Board finds that there has been compliance with the Board's July 2009 and January 2010 Remands. Stegall v. West, 11 Vet. App. 268 (1998). Veterans Claims Assistance Act of 2000 As provided for by the Veterans Claims Assistance Act of 2000 (VCAA), the United States Department of Veterans Affairs (VA) has a duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002); 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a) (2010). Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant and his or her representative, if any, of any information, and any medical or lay evidence, that is necessary to substantiate the claim. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b); Quartuccio v. Principi, 16 Vet. App. 183 (2002). Proper notice from VA must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. With respect to service connection claims, the U.S. Court of Appeals for Veterans Claims held that, upon receipt of an application for a service-connection claim, 38 U.S.C. § 5103(a) and 38 C.F.R. § 3.159(b) require VA to review the information and the evidence presented with the claim and to provide the claimant with notice of what information and evidence not previously provided, if any, will assist in substantiating, or is necessary to substantiate, each of the five elements of the claim, including notice of what is required to establish service connection and that a disability rating and an effective date for the award of benefits will be assigned if service connection is awarded. Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). With respect increased rating claims, In Vazquez-Flores v. Peake, 22 Vet. App. 37 (2008), the United States Court of Appeals for Veterans Claims held that, pursuant to 38 U.S.C. § 5103(a) (2008) (currently at 38 U.S.C. § 5103(a)(1)), a VCAA notice for an increased rating claim must include the following information: (1) the VA must notify the Veteran that in order to substantiate a claim, he or she must provide (or ask the VA to obtain) medical or lay evidence demonstrating that his or her disability has worsened or increased in severity and the effect the worsening has had on his or her employment and daily life; (2) if the Veteran's current diagnostic code "contains criteria necessary for entitlement to a higher disability rating that would not be satisfied" by providing the evidence described above-the example provided was where a "specific measurement or test result" would be required-then the VA must give "at least general notice" of that requirement; (3) the VA must tell the Veteran that if he or she is assigned a higher rating, that rating will be determined by applying relevant diagnostic codes, which generally provide for disability ratings between 0-100%, "based on the nature of the symptoms of the condition for which disability compensation is being sought, their severity and duration, and their impact upon employment and daily life"; and (4) the notice must also provide examples of the types of medical and lay evidence-such as job application rejections-that the Veteran may submit (or ask the VA to obtain) "that are relevant to establishing [her or] his entitlement to increased compensation." The United States Court of Appeals for the Federal Circuit issued a decision on appeal that vacated and remanded the decision of the Veterans Claims Court in Vazquez-Flores. See Vazquez-Flores v. Shinseki, 580 F.3d 1270 (Fed. Cir. Sept. 4, 2009). In view of some potentially qualifying language included in the Federal Circuit's decision in vacating the CAVC's decision ("insofar as"), it appears that only the generic first, third, and fourth elements [contained in the CAVC's decision] are in fact required under the Federal Circuit's decision. The Board notes that the issue on appeal arises from a notice of disagreement as to the initial rating assigned to the Veteran's fibromyalgia, and as such, represent a "downstream" issue as referenced in VAOPGCPREC 8-2003 (December 22, 2003), summary published at 69 Fed. Reg. 25,180 (May 5, 2004), a precedent opinion of VA's General Counsel that is binding on the Board (see 38 U.S.C.A. 7104(c); 38 C.F.R. § 14.507). The opinion states that if, in response to notice of its decision on a claim for which VA has already given the 38 U.S.C. § 5103(a) notice, VA receives a notice of disagreement that raises a new issue, 38 U.S.C. § 7105(d) requires VA to take proper action and issue a statement of the case if the disagreement is not resolved, but section 5103(a) does not require VA to provide notice of the information and evidence necessary to substantiate the newly- raised issue. With regard to the instant case, the Board finds that adequate 38 U.S.C. § 5103(a) notice was provided as to the original claim) for service connection in June 2001, and as such, the rating assignment issue on appeal falls within the exception for the applicability of 38 U.S.C.A. § 5103(a). VA has met all statutory and regulatory notice and duty to assist provisions. Letters dated in June 2001 and August 2009 fully satisfied the duty to notify provisions. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b)(1); Quartuccio, 6 Vet. App. at 183, Dingess, 19 Vet. App. at 473. Together, the letters informed the appellant of what evidence was required to substantiate the claim and of the appellant's and VA's respective duties for obtaining evidence, as well as how VA determines disability ratings and effective dates. Ideally, the notice required by 38 U.S.C.A. § 5103(a) should be provided to a claimant before the initial unfavorable agency of original jurisdiction (AOJ) decision on a claim. Pelegrini v. Principi, 18 Vet. App. 112 (2004); see also Mayfield v. Nicholson, 19 Vet. App. 103 (2005). Although that was not done in this case, the Board finds that this error was not prejudicial to the appellant because the actions taken by VA after providing the notice have essentially cured the error in the timing of notice. Not only has the appellant been afforded a meaningful opportunity to participate effectively in the processing of his claim and given ample time to respond, but the AOJ also readjudicated the case after the notice was provided. See Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006) (where notice was not provided prior to the AOJ's initial adjudication, this timing problem can be cured by the Board remanding for the issuance of a VCAA notice followed by readjudication of the claim by the AOJ). For these reasons, it is not prejudicial to the appellant for the Board to proceed to finally decide this appeal as the timing error did not affect the essential fairness of the adjudication. The Veteran's service treatment records and post-service medical treatment records have been obtained, to the extent available. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. There is no indication in the record that any additional evidence, relevant to the issues decided herein, is available and not part of the claims file. The duty to assist also includes providing a medical examination or obtaining a medical opinion when such is necessary to make a decision on the claim, as defined by law. The Veteran was accorded VA examinations in September 2002 and May 2005, and September 2009. 38 C.F.R. § 3.159(c)(4). In February 2010, the RO obtained a medical opinion with regard to the severity of the Veteran's fibromyalgia including activity limitations. There is no objective evidence indicating that there has been a material change in the severity of the Veteran's service-connected fibromyalgia since he was last examined. 38 C.F.R. § 3.327(a). The duty to assist does not require that a claim be remanded solely because of the passage of time since an otherwise adequate VA examination was conducted. VAOPGCPREC 11-95. The February 2010 VA medical report is thorough and supported by VA outpatient treatment records. The examinations in this case are adequate upon which to base a decision. The Board notes that the Veteran is represented by counsel; and there has been no assertion of any failure to provide appropriate notice. As there is no indication that any failure on the part of VA to provide additional notice or assistance reasonably affects the outcome of this case, the Board finds that any such failure is harmless. See Mayfield v. Nicholson, 19 Vet. App. 103 (2005), rev'd on other grounds, 444 F.3d 1328 (Fed. Cir. 2006). Increased rating Historically, in March 2001, the Veteran filed his application for compensation seeking service connection for fibromyalgia, bilateral shoulder conditions, headaches, degenerative joint disease bilateral knees, atypical chest pain, joint swelling and aching, memory loss, low back problems, hearing loss, and tinnitus. In October 2002, service connection was established for fibromyalgia-like symptoms (polyarthralgia without active synovitis and negative labs) claimed as bilateral knee condition, degenerative joint disease, bilateral shoulder condition, headaches, chest pain, questionable arthritis (aches and swelling joints), and low back condition. A 20 percent evaluation was assigned effective March 13, 2001. The Veteran appealed this decision; and in November 2003, the RO increased the disability evaluation to 40 percent effective March 13, 2001. In a decision promulgated in March 2007, the Board denied, inter alia, an initial evaluation in excess of 40 percent for the Veteran's service-connected fibromyalgia with headaches, sleeplessness, fatigue, and diffuse multiple joint pain, to include whether separate ratings for individual joint disabilities are warranted. The Veteran appealed the Board's March 2007 decision to the United States Court of Appeals for Veterans Claims (CAVC). In a September 2008 Memorandum Decision, the CAVC set aside the March 2007 decision with respect to the issue of entitlement to an initial evaluation in excess of 40 percent for service- connected fibromyalgia and remanded the matter for further development and adjudication. The CAVC noted that before the Board, the Veteran argued that he was entitled to separate disability ratings for his bilateral elbow and knee conditions but that the Board denied the Veteran's claim after concluding that the medical evidence showed that all of the Veteran's symptoms were "part and parcel" of his fibromyalgia, "as opposed to representing an independent and separate disability, or a symptom of a different condition." The CAVC noted that the Board stated that there was "no evidence of current chronic disease which exist separately and independently from the currently diagnosed and already service- connected fibromyalgia." The CAVC also noted that the Veteran argued that in reaching this conclusion, the Board ignored medical evidence that shows that the Veteran was diagnosed with bilateral epicondylitis of the elbows and a bilateral knee condition in additional to fibromyalgia. The CAVC noted that it agreed with the Veteran that there was medical evidence that suggested that he had multiple disorders affecting his elbows and knees and that despite this evidence, the Board failed to discuss or provide an analysis of probative value of this evidence. The CAVC also noted that medical evidence of record in this case was inadequate. Although there is some evidence that suggests that the appellant may suffer from additional knee and elbow disorders, the record in this case does not contain sufficient information regarding the exact nature of the disorders involving the Veteran's elbows and knees, the extent to which these are separate and apart from fibromyalgia, and the relationship, if any, of these additional disorders to service. The CAVC noted that on remand, the Board should obtain a new medical examination of the appellant that addresses the exact nature of the conditions that affect his knees and elbows, that the medical examiner should provide a complete diagnosis of the disorders affecting the Veteran's elbows and knees, and that if the medical examiner determined that the appellant suffers from fibromyalgia and any other disorder involving the elbows or knees, that the examiner should identify the symptomatology that is attributed to each disease, and that the medical examiner should state whether any diagnosed disorder, other than fibromyalgia, had its onset in service or was incurred or aggravated in service or by his service-connected fibromyalgia. In addition, with respect to entitlement to an extraschedular rating, the CAVC agreed that the record was inadequate and noted that although the 2002 VA medical examination included an assessment regarding the functional limitations associated with the Veteran's fibromyalgia, he alleged that his condition had worsened since that examination was conducted. In July 2009, and then again in January 2010, the Board remanded the case for additional development in compliance with the September 2008 Memorandum Decision including scheduling the Veteran for a VA examination to determine the severity of his fibromyalgia, determining the existence and etiology of any separate knee and/or elbow disability, and determining the effects of the Veteran's fibromyalgia on his ability to work and on activities of daily living. Disability ratings are determined by applying the criteria set forth in the VA's Schedule for Rating Disabilities, which is based on the average impairment of earning capacity. Individual disabilities are assigned separate diagnostic codes. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. If two evaluations are potentially applicable, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating; otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. The Veteran is appealing the original assignments of disability evaluations following an award of service connection for fibromyalgia-like symptoms. As such, it is not the present level of disability which is of primary importance, but rather the entire period is to be considered to ensure that consideration is given to the possibility of staged ratings; that is, separate ratings for separate periods of time based on the facts found. Fenderson v. West, 12 Vet. App. 119 (1999). The Veteran's service-connected fibromyalgia (polyarthralgia without active synovitis and negative labs) claimed as bilateral knee condition, degenerative joint disease, bilateral shoulder condition, headaches, chest pain, questionable arthritis (aches and swelling joints), and low back condition has been rated as 40 percent disabling pursuant to 38 C.F.R. § 4.71a, Diagnostic Code 5025 for fibromyalgia. Fibromyalgia (fibrositis, primary fibromyalgia syndrome) with widespread musculoskeletal pain and tender points, with or without associated fatigue, sleep disturbance, stiffness, paresthesias, headache, irritable bowel symptoms, depression, anxiety, or Raynaud's-like symptoms: provides a 10 percent rating for symptoms that require continuous medication for control, a 20 percent rating for symptoms that are episodic, with exacerbations often precipitated by environmental or emotional stress or by overexertion, but that are present more than one-third of the time, and a 40 percent rating for symptoms that are constant, or nearly so, and refractory to therapy. 38 C.F.R. § 4.71a, Diagnostic Code 5025. The current 40 percent rating is the maximum evaluation allowed pursuant to 38 C.F.R. § 4.71a, Diagnostic Code 5025 for fibromyalgia. As the Veteran is already receiving the highest evaluation for this disability, a schedular increase is not warranted. In addition, as the 40 percent rating has been assigned effective the day following the Veteran's service discharge in March 2001, staged ratings for this disability are not warranted. Fenderson v. West, 12 Vet. App. 119 (1999). The Board notes that the Veteran, through his representative, argues that separate ratings should be assigned for "at least some of the claimed conditions" or at least support an extraschedular rating for fibromyalgia. The Board notes that the evaluation of the same disability under various diagnoses is to be avoided. That is to say that the evaluation of the same manifestation under different diagnoses, a practice known as "pyramiding," is to be avoided. See 38 C.F.R. § 4.14. The critical inquiry in making a determination to separately service connect any of the Veteran's claimed conditions is whether any of the symptomatology is duplicative or overlapping as the Veteran is only entitled to a combined rating where the symptomatology is distinct and separate. See Esteban v. Brown, 6 Vet. App. 259 (1994). Thus, in order to grant separate ratings for "at least some of the claimed conditions", the record must include competent medical evidence that the "claimed condition" is a currently diagnosed disability independent of the fibromyalgia with distinct and separate symptomatology and that it was incurred in or aggravated by the Veteran's military service. The Board notes that the September 2008 Memorandum Decision noted that in 2003 and 2005, the Veteran's treating VA physician diagnosed him with fibromyalgia, bilateral chondromalacia of the knees, bilateral knee disability of unknown etiology, and epicondylitis of the elbows. The September 2008 Memorandum Decision noted that the Board denied the Veteran's claim after concluding that the medical evidence showed that all of the Veteran's symptoms were "part and parcel" of his fibromyalgia, "as opposed to representing an independent and separate disability, or a symptoms of a different condition" and that the Board stated that there was "no evidence of current chronic disease which exists separately and independently from the currently diagnosed and already service-connected fibromyalgia." The September 2008 Memorandum Decision noted that the CAVC agreed that there was medical evidence that suggested that the Veteran had multiple disorders affecting his elbows and knees such as bilateral knee arthritis, bilateral chondromalacia of the knees, bilateral knee disability of unknown etiology, and epicondylitis of the elbows and that a 2005 x-ray report of the Veteran's elbows showed "early degenerative changes of the distal triceps, tendonopathy on the right" elbow. The Veteran's service treatment records indicate that x-rays of the left elbow in May 1984 showed no bony or soft tissue abnormalities. X-rays of the knees in December 1990 showed no significant abnormality. On a February 1998 Report of Medical History, the examiner noted that the Veteran was told by VA hospital that he had arthritis in every joint of body. X-rays in June 2000 showed normally mineralized and minor narrowing of the medial compartment bilaterally, otherwise normal. A bone scan done in October 2000 showed slight increased radiotracer uptake is distribution of right tibial tuberosity which may represent area of prior trauma or possible musculotendinous strain and that the remainder of the examination was unremarkable. In July 2001, the Veteran presented to establish care and to obtain medications for fibromyalgia. Physical examination conducted by Dr. Martin demonstrated knees appeared symmetrical without gross bony abnormality, no heat induration or rubor, slight right crepitus, negative McMurray's sign, negative anterior drawer sign, full and symmetrical range of motion with passive range of motion, ankles without heat, induration, and nontender to passive range of motion. There was an absence of trigger point on the occipital, scapular, and shoulder regions. There was no tenderness of the epicondyle bilaterally or of the wrist. The chest wall, the knees and the ankles were nontender to palpation. Motor strength was 5/5 in all extremities and nontender. Sensory revealed light tough, proprioception intact. Deep tendon reflexes, biceps patellar trace bilaterally, and brachioradialis negative bilaterally. Assessment included, inter alia, history of fibromyalgia, history of bilateral knee arthritis, lumbosacral strain, no evidence of ankle pathology. It was Dr. Martin's opinion that the Veteran did not meet the diagnostic criteria for fibromyalgia and that although he may have myalgias, there was no evidence of muscle weakness. Dr. Martin noted that the neck examination revealed full, symmetrical, and nontender range of motion. Dr. Martin noted that she suspected that part of the frontal headaches that the Veteran was experiencing was due to sinus disorder and that there was an absence of trigger point and an absence of chest wall discomfort. Dr. Martin also assessed history of bilateral knee arthritis and noted that there was very minimal crepitus of the right knee but that the left knee was entirely normal on physical examination. A January 2002 ambulatory care note lists bilateral knee degenerative joint disease as an active health problem and notes that the Veteran has knee pain if he stands greater than an hour and when he ascends or descends stairs, has recurrent popping of the knees and ankles, gets ankle/feet swelling, and takes Tylenol 500 mg 4 pills at a time before going to work. In April 2002, the Veteran presented for unscheduled visit for an episode of dizziness and chest pain. Physical examination demonstrated, inter alia, no joint swelling, redness, or tenderness to palpation noted in bilateral knees, shoulders, hands, wrists, ankles; no crepitus was noted in bilateral knees, shoulders, ankles; slight joint popping in bilateral wrists with rotational movement; full range of motion without pain in bilateral knees, shoulders, hands, wrists, and ankles. Assessment included, inter alia, fibromyalgia and knee pain. It was noted that the Veteran had been seen in Sioux Falls in July 2001 and that it was felt at that time that he did not meet the diagnostic criteria for fibromyalgia, there was no objective evidence of muscle weakness, and no trigger points were found. The Veteran presented in July 2002 with history of same aches and pain and his knees hurting a lot. Physical examination demonstrated full range of motion, strength 5/5 and no joint stiffness or warmth. Assessment included, inter alia, myalgia/arthralgia generalized using Tylenol Extra Strength. Labs and rheumatology consultation were ordered. The Veteran underwent VA general medical examination in September 2002. The examiner noted that the onset of fibromyalgia symptoms of joint pains all over the body began around 1996 to 1997. The examiner, Dr. Sarva, noted that the Veteran's service medical records documented multiple visits from October 1997 to December 2000 for symptoms of multiple joint arthralgias including shoulders, elbows, neck, lower back, hips, knees, and ankles, chronic fatigue, chronic headaches, and sleep problems. Dr. Sarva noted that record review revealed that the Veteran had multiple evaluations with extensive lab studies which were normal and that the diagnoses of lupus or systemic collagen disease were ruled out. Dr. Sarva noted that the Veteran was treated with non-steroidal anti-inflammatory drugs, Elavil for sleep. The Veteran reported that he had a Gulf War physical examination done in 1991 after returning from the Gulf, that he was evaluated by orthopedic surgeon and rheumatologist around December 2000 for multiple arthralgias and chronic fatigue syndrome and headaches, and that it was finally concluded that he had fibromyalgia (poly- arthralgias without active synovitis and negative lab studies). Dr. Sarva noted that the Veteran had a medical evaluation board done in December 2000 since he was unable to perform his duties. The Veteran reported that he still experienced pain in all of the joints but that he did not seek any medical evaluation until June 2002 at VA clinic. Dr. Sarva noted that July 2002 lab studies revealed a sed rate of 7 and a negative ANNA, rheumatoid factor, chemistry panel, UA, CBC, C-reactive protein and x-rays of the shoulders and knees. The examiner noted that the Veteran was on Motrin and had not received any steroid treatment for the joint pains. The Veteran reported that he started getting knee pain, right worse than left since 1996 from physical training. Dr. Sarva noted that the Veteran's service medical records documented visits for knee pain treated with light duty and naproxen but indicated that knee x-rays from 1990 were reported as negative, however, knee x-rays from 2000 reported degenerative joint disease changes. Dr. Sarva noted that the Veteran was finally evaluated by orthopedic surgeon for the joint pain in 2000, that he had a bone scan which was reported as normal, and that he did not seek any evaluation or treatment since he separated from the service for knee pain. The Veteran complained of knee pain from prolonged standing over several hours at work, that his knees ached, and that he had to take Tylenol for the pain. The Veteran denied swelling, heat, redness, locking, instability, the use of a knee brace, crutches, or orthotics, and impairment of daily activity. The Veteran complained of symptoms of shoulder pain and stiffness and popping with movement which began since 1997 without swelling, redness, or heat. Dr. Sarva noted that the service medical records documented visits for shoulder pain along with the other joints as well as the diagnosis of cellulitis of the right elbow in 2000, hospitalized and treated with antibiotics with recovery, and no recurrence of symptoms since that time. The Veteran claimed that he still had shoulder discomfort and stiffness but that he did not seek any treatment since separation from the military. He denied heat, redness, swelling, dislocation of the shoulder, surgery, acute flare-ups, and exacerbations. Dr. Sarva noted that the Veteran was evaluated as part of his fibromyalgia symptoms for chronic headaches and sleep disturbance and multiple joint arthralgias. Dr. Sarva noted that the Veteran had a negative CT scan of the sinuses and it was felt that the headaches were part of the fibromyalgia syndrome symptoms. The Veteran reported that he was only treated with Motrin for the headaches and claimed that he had a nagging headache all of the time over the frontal area and the back of the head without nausea, vomiting, and scotoma. There was no history of aura, no sound or light sensitivity, and no known aggravating factors. Dr. Sarva noted that Tylenol seemed to relieve the headaches. Dr. Sarva noted that service medical records documented visits for low back pain, diagnosed as low back strain, treated with light duty and non-steroidal anti-inflammatory drugs. The Veteran was also seen for low back pain along with other joint pains. There were no surgeries, hospitalizations, acute flare ups, or exacerbations. Dr. Sarva noted that as reported earlier, the Veteran had symptoms of multiple joint arthralgias including shoulders, neck, elbows, hands, ankles, feet, knees, hips, and back since 1998 and that he had not sought any treatment since his separation from service in 2000. The Veteran reported no injury, surgery, hospitalizations, or the use of a brace, cane, or crutches. The Veteran reported no acute flare ups or exacerbations or limitation of daily activity or functional loss. The Veteran reported that the pain in the joints was a pain level of 3-4/10 at that time and that the pain seemed to get better with activity and moving the joints and stretching. Dr. Sarva noted that the Veteran complained of chest pain and soreness over the sternal area along with other joint pains in the year 2000 and that it was thought that the retrosternal pain was part of the fibromyalgia syndrome. The Veteran claimed that he felt the soreness right under the sternum averaging once or twice a week, lasting from eight to nine hours, and resolving spontaneously without any medication or treatment. The Veteran claimed that stress seemed to aggravate the chest and that there were no relieving factors. The Veteran reported that he had an acute onset of left substernal chest pain, radiating to the neck and left arm with palpitations and dizziness in April 2002, that he was seen in the emergency room and had a normal EKG and echocardiogram, and that his blood sugar was low at 49. Dr. Sarva noted that the Veteran was seen at the VA in June 2002 with similar symptoms of left side chest pain, radiating into the left arm and neck pain and dizziness. At that time, his blood sugar was 129 and it was felt that the symptoms were secondary to interaction with some of the medications that he was taking, Tagamet and naproxen, etc. The medications were changed to half a tablet of Pepcid a day and Motrin for arthritic pain. The Veteran reported no recurrence of symptoms since June 2002. Physical examination revealed no heat, redness, or swelling of any major joints. The joints were nontender on palpation. There were no trigger points on palpation of the upper back, scapular area, and the trapezius areas. There was full range of motion in all major joints. Strength in the upper and lower extremities was 5/5 bilaterally, deep tendon reflexes were 2+ symmetrically bilateral, balance was intact, and gait was normal. Physical examination of the knees revealed mild valgus deformity. There was no swelling, redness, heat, or effusion. Knees were nontender on palpation. There was negative crepitus, negative laxity, McMurray and anterior drawer signs were negative. Range of motion in flexion of the bilateral knee was zero to 135 degrees and extension was zero to 180 degrees without pain. Physical examination of the shoulders revealed no deformity, good shoulder girdle musculature, no definite tenderness on palpation and no heat, redness, or crepitus. There was full range of motion in bilateral shoulders. Physical examination of the lumbar spine and back revealed good posture without scoliosis or deformity, negative tenderness of palpation of the lumbosacral spine, and full range of motion of the lumbosacral spine without pain. X-rays of bilateral knees, chest, and lumbosacral spine were negative. Rheumatology labs were normal. Final diagnoses included fibromyalgia like symptoms (polyarthralgia without active synovitis and negative labs), bilateral knee pain secondary to fibromyalgia like symptoms, bilateral shoulder pain part of fibromyalgia like symptoms, headaches, part of fibromyalgia like symptoms, arthralgias and low back pain, secondary to part of fibromyalgia like symptoms, and atypical chest pain, part of fibromyalgia like symptoms. On March 11, 2003, the Veteran was seen for evaluation of fibromyalgia. The Veteran complained of widespread pain but most severe in the legs after prolonged standing and walking, no swollen joints, lab evaluations that were all normal. Physical examination demonstrated full range of motion of shoulders, hands, knees, and ankles and crepitus both knees but no effusions in any peripheral joints. Dr. Fanciullo noted that the Veteran had all fibromyalgia tender points. Impression was fibromyalgia and patelofemoral pain syndrome. In June 2003, the Veteran presented for fibromyalgia. Physical examination demonstrated multiple fibromyalgia tender points. Impression was fibromyalgia stable. In September 2003, the Veteran was seen by Dr. Fanciullo in Rheumatology. The Veteran complained of forearm aches and generalized achiness. Physical examination demonstrated very tender lateral epicondyles both arms and multiple fibromyalgia tender points. Impression was fibromyalgia and epicondylitis. On February 19, 2004, Mr. Peters, Physician's Assistant noted that the Veteran gave a history of significant arthritis and noted that he was trying to update his disability rating and was having some problems with this. Mr. Peters noted plain lumbar spine films, CT of lumbar spine, and right knee x-rays, none having an impression of arthritis. On March 23 2004, the Veteran presented for labs. It was noted that he had fibromyalgia, that both elbows bothered him, that he experienced numbness/tingling worse at work as a food safety inspector, and that he had "steroid" injections to relieve the fibromyalgia pain. On March 8, 2005, the Veteran presented for follow up and was complaining of significant widespread pain, aching in forearms, pain over the lateral epicondyle related to activity, swelling in elbows, pain and swelling in knees with prolonged standing. Physical examination demonstrated multiple fibromyalgia tender points including anterior chest wall, trapezius, brachioradialis, medial aspect of the knees. Dr. Fanciullo noted that there was no swelling of the elbow joint but that the Veteran did have some prominence and tenderness over the lateral epicondyles consistent with probable lateral epicondylitis and that he had full range of motion of the elbow joints with no effusion, warmth, or redness. Wrists and hands looked normal and no knee joint effusions or swelling were noted. Impression was chronic pain syndrome, lateral epicondylitis both elbows, and chronic knee pain of undetermined etiology. Dr. Fanciullo noted that the chronic pain syndrome most likely represented fibromyalgia with chronic widespread pain and multiple tender points and that the epicondylitis could be aggravated by repetitive activity. Dr. Fanciullo noted that the Veteran had never had any abnormalities on his knee x-rays and that he had never observed any actual effusions or swelling of the knees or of any other joints and that he did not think that there was a primary inflammatory arthropathy present as an etiology of the Veteran's pain. Dr. Fanciullo stated that he planned to take plain film x-rays of the elbows mostly to see if there were any abnormal calcifications in the tendons, around the elbow and forearm to suggest calcific tendonitis. X-rays of the elbows showed early degenerative changes of distal triceps tendonopathy of the right but no radiographic evidence of right or left elbow joint effusion or fractures or an inflammatory arthropathy. X-rays of the knees showed no abnormality. The Veteran underwent VA examination in May 2005. Physical examination revealed normal tone, strength and coordination of the extremities. The examiner noted that there was no tenderness to any of the trigger points. The examiner noted that at the end of the examination, the Veteran was asked to stand upright, his feet supinated. The examiner noted that the Veteran had flat which was probably a major contributing factor to the knee pain for which no radiologic explanation had been reached. Diagnoses included fibromyalgia (by history), cephalalgia (by history), GERD, epicondylitis (by history), sleep disorder (patient's history), pes planus, and arthralgia (bilateral knees). The examiner opined that the flat feet may very well give rise to knee and hip pain and that epicondylitis is usually a result of repetitive work such as using a screwdriver, and that the Veteran used a knife in his occupation for cutting and this, if not the cause of the epicondylitis, might very well ensure its chronicity. The examiner stated that the Veteran had many complaints or conditions of which only the GERD could be confirmed objectively. Private chiropractor records from August 2005 to September 2009 assess the Veteran with lumbosacral, thoracic, and cervical segmental dysfunction. In September 2009, the Veteran underwent VA examination. The Veteran reported fatigue, tiredness, and soreness from head to toe. The Veteran reported pain in his anterior chest, hips, knees and shoulders and constant headache. He said pain level has been 3 to 9/10 depending on aggravation. He said that he had a bone scan which reported degenerative joint disease. The Veteran reported that it is aggravated when the weather changes and any physical activity and alleviated by medication such as Tylenol, Tramadol, or Ibuprofen. The examiner noted that on examination, there was no tenderness under the lower sternocleidomastoid muscle. There was no pain or tenderness noted at the insertions of the subocciptal muscle. There was no pain of the mid upper trapezius muscles on either side. No muscle pain was noted and no trigger points were found on the origin of the supraspinatus. No pain or discomfort was noted near the second costochondral junction. There was no pain at the prominence of the greater trochanter bilaterally, at medial fat pads of both knees, at upper outer quadrants of the buttocks. However, there was pain and tenderness to the lateral 2 centimeters distal to the lateral epicondyle bilaterally consistent with fibromyalgia. The Veteran's muscle strength was 5+5 to flexion and extension at the elbow and at the knee. Palpation of the joint line of the knee demonstrated no swelling, redness, tenderness, and no effusion. Elbow flexion was from zero to 135 degrees with muscle against forearm bilaterally, pronation and supination from zero to 90 degrees. Multiple repetitions of motion times three revealed no further disability due to pain, weakness, fatigue, or lack of endurance. No muscle atrophy was noted in the upper or lower extremities. Deep tendon reflexes were 2+/4 at the biceps and triceps. Sensation to light touch, pinprick, and vibratory sense were intact at the distal fingers. Radial pulse was 2+/4. X-rays of both elbows were read as normal. Assessment was lateral epicondylitis consistent with complaints of fibromyalgia and fibromyalgia tender points as note per Up to Date. No joint abnormality noted. Physical examination of the knees demonstrated extension to zero degrees, flexion to 134 degrees bilaterally with calf against thigh being the limiting area. Negative Lachman's, negative McMurray's. Medial collateral and lateral collateral ligaments were intact and without pain noted at 30 degrees. No crepitus was noted on either kneecap. Multiple repetitions of motion times three revealed no further disability due to pain, weakness, fatigue or lack of endurance. X-rays showed normal bilateral knees. The examiner noted that the diagnosis for the Veteran's elbows was bilateral lateral epicondylitis but that there was no joint abnormality. In addition, the examiner noted that, with respect to the Veteran's knees, he had subjective complaints of pain with a normal examination. The examiner noted that were no findings of the elbows or knees that were unrelated to the fibromyalgia. In February 2010, the Veteran claims file was reviewed by Dr. Whittle. Dr. Whittle opined that the Veteran did have the diagnosis of fibromyalgia, confirmed by rheumatology evaluations. Dr. Whittle explained that fibromyalgia is a clinical diagnosis consisting of symptoms of multiple arthralgias/myalgias, sleep disturbance, depression, and the finding of at least 11 out of 18 tender points throughout the spine and extremities. Dr. Whittle opined that there was no evidence to suggest that the Veteran's elbow and knee pain were related to any other diagnosis as clinical and radiographic findings were minimal. Dr. Whittle stated that he felt that the Veteran's knee and elbow pain were related to fibromyalgia and not a separate disease entity. Dr. Whittle also noted that in terms of activity limitations, patients with fibromyalgia were usually restricted to light work activities to include no heavy lifting and restricted repetitive bending/stooping/kneeling/crawling. Dr. Whittle noted that patients with fibromyalgia are encouraged to engage in aerobic exercises and that standing and walking should not be limited. With respect to the Veteran's knees, Dr. Martin assessed a history of bilateral knee arthritis and noted that there was very minimal crepitus of the right knee but that the left knee was entirely normal on physical examination. In January 2002, VA listed degenerative joint disease bilateral knees as an active health problem. In addition, a March 2003 Rheumatology Note authored by Dr. Fanciullo indicates an impression of patelofemoral pain syndrome. However, a March 2005 Rheumatology Note authored by Dr. Fanciullo, indicated an impression of chronic knee pain of undetermined etiology and noted that the Veteran had never had any abnormalities on his knee x-rays and that he had never observed any actual effusions or swelling of the knees and opined that he did not think that there was a primary inflammatory arthropathy present as an etiology of the Veteran's pain. In April 2002, physical examination demonstrated no joint swelling, redness, tenderness to palpation, or crepitus in bilateral knees and full range of motion without; and assessment was knee pain. In September 2002, Dr. Sarva diagnosed bilateral knee pain secondary to fibromyalgia like symptoms. In May 2005, the examiner noted that the Veteran had flat feet which were probably a major contributing factor to the knee pain for which no radiologic explanation had been reached. The September 2009 VA examiner stated that the Veteran had subjective complaints of pain with a normal examination. In January 2010, Dr. Whittle opined that there was no evidence to suggest that the Veteran's knee pain was related to any other diagnosis as clinical and radiographic findings were minimal and that he felt that the Veteran's knee pain was related to fibromyalgia and not a separate disease entity. With respect to the Veteran's elbows, as noted above, in March 2005, the Veteran complained of pain over the lateral epicondyle related to activity and swelling in elbows, and Dr. Fanciullo noted that there was no swelling of the elbow joint but that the Veteran did have some prominence and tenderness over the lateral epicondyles consistent with probable lateral epicondylitis and that he had full range of motion of the elbow joints with no effusion, warmth, or redness. Impression included lateral epicondylitis both elbows, and Dr. Fanciullo noted that the epicondylitis could be aggravated by repetitive activity. X-rays of the elbows showed early degenerative changes of distal triceps tendonopathy of the right but no radiographic evidence of right or left elbow joint effusion or fractures or an inflammatory arthropathy. However, in May 2005, the diagnosis included epicondylitis (by history) and the VA examiner explained that epicondylitis is usually a result of repetitive work such as using a screwdriver, and that the Veteran used a knife in his occupation for cutting meat and this, if not the cause of the epicondylitis, might very well ensure its chronicity. In September 2009, the Veteran demonstrated pain and tenderness to the lateral 2 centimeters distal to the lateral epicondyle bilaterally consistent with fibromyalgia, elbow flexion was from zero to 135 degrees, and x- rays of both elbows were read as normal. The examiner noted that the diagnosis for the Veteran's elbows was bilateral lateral epicondylitis but that there was no joint abnormality. In February 2010, Dr. Whittle opined that there was no evidence to suggest that the Veteran's elbow pain was related to any other diagnosis as clinical and radiographic findings were minimal and that he felt that the Veteran's elbow pain was related to fibromyalgia and not a separate disease entity. With respect to the Veteran's shoulders, the September 2002 VA examiner diagnosed bilateral shoulder pain, part of fibromyalgia like symptoms. With respect to the Veteran's low back, in July 1001, Dr. Martin assessed lumbosacral strain. Private chiropractor records from August 2005 to September 2009 assessed the Veteran with lumbosacral, thoracic, and cervical segmental dysfunction. However, in September 2002, Dr. Sarva noted that service medical records documented visits for low back pain, diagnosed as low back strain, treated with light duty and non-steroidal anti- inflammatory drugs and that he was also seen for low back pain along with other joint pains. X-rays of lumbosacral spine were negative. Dr. Sarva diagnosed arthralgias and low back pain, secondary to part of fibromyalgia like symptoms. In February 2004, plain lumbar spine films and CT of lumbar spine showed no arthritis. With respect to chest pain, Dr. Sarva noted that the Veteran complained of chest pain and soreness over the sternal area along with other joint pains in the year 2000 and that it was thought that the retrosternal pain was part of the fibromyalgia syndrome. X-rays of the chest were negative. Dr. Sarva diagnosed atypical chest pain, part of fibromyalgia like symptoms. With respect to headaches, in July 2001, Dr. Martin noted that she suspected that part of the frontal headaches that the Veteran was experiencing was due to sinus disorder. However, in September 2002, Dr. Sarva noted that the Veteran had a negative CT scan of the sinuses and it was felt that the headaches were part of the fibromyalgia syndrome symptoms. She noted that the Veteran reported that he was only treated with Motrin for the headaches and claimed that he had a nagging headache all of the time over the frontal area and the back of the head without nausea, vomiting, and scotoma and that there was no history of aura, no sound or light sensitivity, and no known aggravating factors. Dr. Sarva diagnosed headaches, part of fibromyalgia like symptoms. With respect to the Veteran's shoulder and chest pain, the evidence suggests that these are part of the Veteran's fibromyalgia; and there is no evidence to the contrary. With respect to the Veteran's knees, elbows, low back, and headache pain, the Board notes that there is a difference of opinion among the medical professionals. In deciding whether the Veteran's has a knee, elbow, low back or headache diagnosis with distinct and separate symptoms from the Veteran's fibromyalgia, it is the responsibility of the Board to weigh the evidence and decide where to give credit and where to withhold the same and, in so doing, accept certain medical opinions over others. Evans v. West, 12 Vet. App. 22, 30 (1998). That responsibility is particularly onerous where medical opinions diverge. At the same time, the Board is mindful that it cannot make its own independent medical determinations and that there must be plausible reasons for favoring one medical opinion over another. Id. There are post-service diagnoses of history of bilateral knee arthritis, degenerative joint disease bilateral knees, patelofemoral pain syndrome, lateral epicondyle, lumbosacral strain, lumbosacral, thoracic, and cervical segmental dysfunction, headache due to sinus disorder suggesting distinct knee, elbow, low back, and headache diagnoses. However, there is evidence which contradicts that the Veteran has distinct knee, elbow, low back, and headache diagnoses and that these problems are part and parcel of the Veteran's fibromyalgia. With regard to medical evidence, an assessment or opinion by a health care provider is never conclusive and is not entitled to absolute deference. Indeed, the courts have provided guidance for weighing medical evidence. They have held, for example, that a post-service reference to injuries sustained in service, without a review of service medical records, is not competent medical evidence. Grover v. West, 12 Vet. App. 109, 112 (1999). Further, a bare conclusion, even one reached by a health care professional, is not probative without a factual predicate in the record. Miller v. West, 11 Vet. App. 345, 348 (1998). In addition, an examination that does not take into account the records of prior medical treatment is neither thorough nor fully informed. Green v. Derwinski, 1 Vet. App. 121, 124 (1991). A bare transcription of lay history, unenhanced by additional comment by the transcriber, is not competent medical evidence merely because the transcriber is a health care professional. LeShore v. Brown, 8 Vet. App. 406, 409 (1995). Moreover, a medical professional is not competent to opine as to matters outside the scope of his expertise. Id. citing Layno v. Brown, 6 Vet. App. 465, 469 (1994). A medical opinion based on speculation, without supporting clinical data or other rationale, does not provide the required degree of medical certainty. Bloom v. West, 12 Vet. App. 185, 187 (1999). Also, a medical opinion is inadequate when unsupported by clinical evidence. Black v. Brown, 5 Vet. App. 177, 180 (1995). Finally, a medical opinion based on an inaccurate factual premise is not probative. Reonal v. Brown, 5 Vet. App. 458, 461 (1993). In sum, the weight to be accorded the various items of medical evidence in this case must be determined by the quality of the evidence and not necessarily by its quantity or source. With respect to the Veteran's knees, although the Veteran's service medical records note bilateral knee arthritis, VA medical records list bilateral knee arthritis as an active problem, and Dr. Martin assessed a history of bilateral knee arthritis, Dr. Fanciullo, indicated an impression of chronic knee pain of undetermined etiology and noted that the Veteran had never had any abnormalities on his knee x-rays and that he had never observed any actual effusions or swelling of the knees and opined that he did not think that there was a primary inflammatory arthropathy present as an etiology of the Veteran's pain. In addition, x-rays of the knees in 2002 were negative and x-rays of the knees in 2009 were normal. The Board assigns higher weight to the post-service opinions that the Veteran does not have bilateral knee arthritis as these opinions were provided after taking into account the records of prior medical treatment. In fact, in July 2001, Dr. Martin who assessed a history of bilateral knee arthritis also noted that the Veteran was to provide records so that it could be assessed what his prior radiographs have indicated. With respect to the Veteran's elbows, although post-service medical records indicate a diagnosis of epicondylitis by numerous medical providers, there is also strong evidence that the Veteran's elbow pain is part and parcel of his fibromyalgia. In this case, even assuming a separate disability for epicondylitis, no competent medical evidence has been provided that epicondylitis was caused by or aggravated by the Veteran's active duty service. In fact, the May 2005 VA examiner noted that if the Veteran's occupation as a meat cutter did not cause the epicondylitis, it likely ensured its chronicity. With respect to the Veteran's low back, diagnoses of lumbosacral strain and lumbosacral segmental dysfunction have been rendered. With respect to the lumbosacral strain, the Board cannot conclude that this is a "chronic" condition. That an injury occurred is not enough; there must be chronic disability resulting from that injury. With respect to the diagnosis of lumbosacral segmental dysfunction, the Board assigns higher weight to the post-service opinions that the Veteran's back pain is part of the Veteran's fibromyalgia as these opinions were provided after taking into account the records of prior medical treatment. Similarly, with respect to headaches, the Board assigns higher weight to the post-service opinions that the Veteran's headaches are part of the Veteran's fibromyalgia. In fact, although Dr. Martin noted that she suspected that part of the frontal headaches that the Veteran was experiencing was due to sinus disorder, she noted that she would obtain a sinus CT to better delineate any evidence of sinus disorder. In September 2002, Dr. Sarva noted that the Veteran had a negative CT scan of the sinuses and it was felt that the headaches were part of the fibromyalgia syndrome symptoms. Although post-service medical records include diagnoses of bilateral lateral epicondylitis, bilateral knee degenerative joint disease, and patelofemoral pain syndrome, lumbosacral segmental dysfunction, and sinus headaches, the preponderance of the evidence indicates that the Veteran's multiple arthralgias/ myalgias, including the Veteran's knee and elbow pain, are manifestations of the fibromyalgia. However, as noted above, even assuming the Veteran's elbow pain is caused by epicondylitis, there is no competent medical evidence that relates such diagnosis to the Veteran's active duty service. Rather it has been related to his post-service occupation as a meat cutter. In addition, even assuming for the sake of argument that the Veteran's knee, elbow, back, and headache pain were in part due to a separate disease entity, as noted above, the critical inquiry in making a determination to separately service connect any of the Veteran's claimed conditions is whether any of the symptomatology is duplicative or overlapping as the Veteran is only entitled to a combined rating where the symptomatology is distinct and separate. Esteban, 6 Vet. App. at 259. In this case, as the Veteran's knees, elbows, back, and head conditions are manifested by pain, these symptoms duplicate the fibromyalgia symptoms of pain of the knees, elbows, back, and head. With respect to the consideration of functional loss due to pain, the Board notes that fibromyalgia has been determined to be a "nonarticular" rheumatic disease, and that objective impairment of the musculoskeletal function, including limitation of joints, is not considered to be present, in contrast to the usual findings in "articular" rheumatic diseases. The rating criteria are not based on evaluations of individual joints or other specific parts of the musculoskeletal system; rather, they are based on pain and whether symptoms are constant or episodic. Consequently, additional or separate ratings would not be assigned based on 38 C.F.R. §§ 4.40 or 4.45. See 64 Fed. Reg. 32410-32411 (June 17, 1999). In addition, as the Veteran is receiving the maximum schedular rating available under DC 5025, no additional higher rating is available for functional loss due to pain. Johnston v. Brown, 10 Vet. App. 80 (1997). Although the Veteran contends that he has separate disabilities manifested by multiple joint pain that are related to his service apart from his fibromyalgia, as a layman he is not competent to offer opinions on medical causation and, moreover, the Board may not accept unsupported lay speculation with regard to medical issues. Espiritu v. Derwinski, 2 Vet. App. 492, 494-95 (1992). Accordingly, the Board concludes that the preponderance of the evidence is against the claim, and the benefit of the doubt rule enunciated in 38 U.S.C.A. § 5107(b) is not for application. ORDER Entitlement to an initial schedular evaluation in excess of 40 percent for fibromyalgia with headaches, sleeplessness, fatigue, and diffuse multiple joint pain is denied. Entitlement to separate ratings for individual joint disabilities is denied. REMAND The Board is aware that an extraschedular rating is a component of an increased rating claim. Barringer v. Peake, 22 Vet. App. 242 (2008); see Bagwell v. Brown, 9 Vet. App. 337, 338-39 (1996). The threshold factor for extraschedular consideration is a finding on the part of the RO or the Board that the evidence presents such an exceptional disability picture that the available schedular evaluations for the service-connected disability at issue are inadequate. Thun v. Peake, 22 Vet. App. 111 (2008); see Fisher v. Principi, 4 Vet. App. 57, 60 (1993); 38 C.F.R. § 3.321(b)(1). If so, factors for consideration in determining whether referral for an extraschedular rating is warranted include marked interference with employment or frequent periods of hospitalization that indicate that application of the regular schedular standards would be impracticable. Thun, citing 38 C.F.R. § 3.321(b)(1) (2010). The Board acknowledges the judicial holding in Rice v. Shinseki, 22 Vet. App. 447, 453-54 (2009). In that decision, the Court held that a request for a total rating based on individual unemployability (TDIU), whether expressly raised by the Veteran or reasonably raised by the record, is not a separate 'claim' for benefits, but rather, can be part of a claim for increased compensation. In other words, if the claimant or the evidence of record reasonably raises the question of whether the Veteran is unemployable due to a disability for which an increased rating is sought, then part and parcel with the increased rating claim is the issue whether a TDIU is warranted as a result of that disability. In January 2010, the Board remanded the case for a VA physician to provide a full description of the effects of the Veteran's service-connected fibromyalgia on his ability to work and on activities of daily living. The Board requested that the physician discuss any "limitation of activity" imposed by the Veteran's fibromyalgia. This was not done. The Veteran claims file was reviewed by Dr. Whittle who noted that in terms of activity limitations, patients with fibromyalgia were usually restricted to light work activities to include no heavy lifting and restricted repetitive bending/stooping/ kneeling/crawling. Dr. Whittle noted that patients with fibromyalgia are encouraged to engage in aerobic exercises and that standing and walking should not be limited. Further development is, therefore, needed in light of this Stegall violation. In March 2010, the RO requested consideration of an extraschedular grant of individual unemployability from March 13, 2001. In June 2010, the Director of Compensation and Pension Service opined, "Our review of the evidence in this claim does not disclose the Veteran is unemployed and unemployable due to service connected disability. The Veteran completed VA Form 21- 4192, received in VA on May 20, 2005, indicating the employer would not complete the form. A "sticky note" attached to the form indicates: [The Veteran] has resigned from our agency on his own. ... The evidence supports neither an extra-schedular evaluation for fibromyalgia-like syndrome in excess of the schedular 40 percent evaluation assigned fibromyalgia nor an extra-schedular total disability evaluation based on unemployability." As the February 2010 VA examination report did not provide the opinion requested, pertinent facts were neither identified nor evaluated and weighed in the extraschedular consideration. The Board, therefore, concludes that an additional VA examination is needed to determine whether the Veteran's fibromyalgia causes marked interference with employment, necessitates frequent periods of hospitalization, or renders the Veteran unable to follow a substantially gainful employment. Accordingly, the case is REMANDED for the following action: 1. Development contemplated by the VCAA should be undertaken, including, but not limited to, informing the Veteran of the information and evidence not of record (1) that is necessary to substantiate the claim for an extraschedular evaluation under 38 C.F.R. § 3.321(b)(1). The Veteran should be asked to furnish records verifying that he experiences marked interference with employment, that he has had frequent periods of hospitalization, or that he is unable to follow a substantially gainful employment due to fibromyalgia with headaches, sleeplessness, fatigue, and diffuse multiple joint pain. This evidence may include any correspondence from an employer or physician that would verify his contentions, and/or medical records showing periods of hospitalization. 2. The Veteran should be afforded the appropriate VA examination by a rheumatologist. The claims file must be made available to and reviewed by the rheumatologist in conjunction with the examination, and the examination report should reflect that such a review was made. All pertinent symptomatology and findings should be reported in detail. Any indicated diagnostic tests and studies should be accomplished. The examiner is requested to provide functional limitations associated with the Veteran's fibromyalgia and render an opinion as to whether it is at least as likely as not that the Veteran's fibromyalgia with headaches, sleeplessness, fatigue, and diffuse multiple joint pain causes marked interference with his employment, necessitates frequent periods of hospitalization, or renders the Veteran unable to follow a substantially gainful employment. It would be helpful if the examiner would use the following language, as may be appropriate: "more likely than not" (meaning likelihood greater than 50%), "at least as likely as not" (meaning likelihood of at least 50%), or "less likely than not" or "unlikely" (meaning that there is a less than 50% likelihood). The term "at least as likely as not" does not mean "within the realm of medical possibility." Rather, it means that the weight of medical evidence both for and against a conclusion is so evenly divided that it is as medically sound to find in favor of that conclusion as it is to find against it. The examiner should provide a complete rationale for any opinion provided. 3. The RO must ensure that all requested actions have been accomplished (to the extent possible) in compliance with this REMAND. If any action is not undertaken, or is taken in a deficient manner, appropriate corrective action should be undertaken. 4. The claim should then be referred to the either the Under Secretary for Benefits, or the Director of Compensation and Pension Service for consideration of an extraschedular evaluation under the provisions of 38 C.F.R. § 3.321(b)(1). 5. The case should be reviewed on the basis of the additional evidence. If the benefit sought is not granted in full, the Veteran should be furnished a Supplemental Statement of the Case and be afforded a reasonable opportunity to respond before the record is returned to the Board for further review. No action is required of the appellant until further notice. However, the Board takes this opportunity to advise the appellant that the conduct of the efforts as directed in this remand, as well as any other development deemed necessary, is needed for a comprehensive and correct adjudication of his claim. His cooperation in VA's efforts to develop his claim, including reporting for any scheduled VA examination, is both critical and appreciated. The appellant is also advised that failure to report for any scheduled examination may result in the denial of a claim. 38 C.F.R. § 3.655. The appellant has the right to submit additional evidence and argument on the matter or matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2009). ______________________________________________ MILO H. HAWLEY Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs