Citation Nr: 1608746 Decision Date: 03/04/16 Archive Date: 03/09/16 DOCKET NO. 13-13 844 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Atlanta, Georgia THE ISSUES 1. Entitlement to an earlier effective date for the grant of service connection for bronchitis. 2. Entitlement to an initial compensable evaluation for a respiratory disability manifested by recurrent bronchitis and upper respiratory infection. 3. Entitlement to an increased evaluation for migraine headaches, currently evaluated as 30 percent disabling. 4. Entitlement to a total disability rating based on individual unemployability due to service-connected disabilities (TDIU). 5. Entitlement to an increased evaluation for posttraumatic stress disorder (PTSD), currently evaluated as 50 percent disabling. 6. Whether new and material evidence has been received sufficient to reopen a claim for service connection for chronic fatigue syndrome. REPRESENTATION Veteran represented by: Douglas E. Sullivan, Attorney WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD Roya Bahrami, Associate Counsel INTRODUCTION The Veteran had active service from December 1988 to December 1992. These matters come before the Board of Veterans' Appeals (Board) on appeal from January 2011 and May 2012 rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in Atlanta, Georgia. The Veteran testified at a videoconference hearing before the undersigned Veterans Law Judge (VLJ) in December 2015; a copy of the hearing transcript is of record. The Board has recharacterized the respiratory disability claim to better reflect the Veteran's current diagnoses. The issues of entitlement to an increased evaluation for PTSD, entitlement to a TDIU, and whether new and material evidence has been received sufficient to reopen a claim for service connection for chronic fatigue syndrome are addressed in the REMAND portion of the decision below and are REMANDED to the Agency of Original Jurisdiction (AOJ). FINDINGS OF FACT 1. During the December 2015 Board hearing, the Veteran expressed her desire to withdraw her appeal as to the issue of entitlement to an earlier effective date for the grant of service connection for bronchitis. 2. The Veteran's respiratory disability has resulted in near constant findings of cough with purulent sputum associated with unexplained weight loss and hemoptysis, requiring antibiotic usage almost continuously. 3. The Veteran's migraine headache disability is manifested by very frequent completely prostrating and prolonged attacks that are productive of severe economic inadaptability. CONCLUSIONS OF LAW 1. The criteria for withdrawal of an appeal by the Veteran are met with respect to the claim for an earlier effective date for the grant of service connection for bronchitis. 38 U.S.C.A. § 7105 (West 2015); 38 C.F.R. § 20.204 (2015). 2. The criteria for a disability rating of 60 percent for the Veteran's respiratory disability are met for the entire period on appeal. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107, 7104 (West 2015); 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.3, 4.7, 4.10, 4.124a, Diagnostic Code 6601 (2015). 3. The criteria for a disability rating of 50 percent for migraine headaches are met for the entire period on appeal. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107, 7104 (West 2015); 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.3, 4.7, 4.10, 4.124a, Diagnostic Code 8100 (2015). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Dismissal The Veteran's perfected appeal included the issue of entitlement to an earlier effective date for the grant of service connection for bronchitis, but the Veteran and her representative expressly withdrew the appeal of that issue on the record at the beginning of the Board hearing. See December 2015 Board Hearing Transcript (Tr.) at 2. Under 38 U.S.C.A. § 7105, the Board may dismiss any appeal which fails to allege specific error of fact or law in the determination being appealed. An appeal may be withdrawn in writing at any time before the Board promulgates a decision. 38 C.F.R. § 20.204. Withdrawal may be made in writing or on the record at a hearing by the appellant or by an authorized representative. Id. Inasmuch as the Veteran has withdrawn her appeal for earlier effective date for the grant of service connection for bronchitis, there is no allegation of error of fact or law in the matter remaining before the Board. Hence, the Board does not have jurisdiction to consider an appeal in the matter, and the appeal seeking an earlier effective date for the grant of service connection for bronchitis must be dismissed. II. Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA), Pub. L. No. 106-475, 114 Stat. 2096 (2000) (codified as amended at 38 U.S.C. §§ 5100, 5102, 5103, 5103A, 5107 (West 2015), sets forth VA's duties to notify and assist claimants in substantiating claims for VA benefits. See 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2015). Under the VCAA, when VA receives a complete or substantially complete application for benefits, it is required to notify the claimant and his representative, if any, of any information and 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). In order to satisfy its duty to notify the claimant under the VCAA, the United States Court of Appeals for Veterans Claims (Court) held that 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. Quartuccio v. Principi, 16 Vet. App. 183, 187 (2002). For service connection claims, proper notice of what is necessary to substantiate the claim requires that the Veteran be informed of the following five elements: (1) veteran status; (2) existence of a disability; (3) a connection between the veteran's service and the disability; (4) degree of disability; and (5) effective date. Dingess/Hartman v. Nicholson, 19 Vet. App. 473, 484 (2006); Quartuccio, 16 Vet. App. at 187. In a claim for increase, the VCAA requirement is generic notice, that is, the type of evidence needed to substantiate the claim, namely, evidence demonstrating a worsening or increase in severity of the disability and the effect that worsening has on employment, as well as general notice regarding how disability ratings and effective dates are assigned. Vazquez-Flores v. Shinseki, 580 F.3d 1270 (Fed. Cir. 2009). The record reflects that the RO provided the Veteran with the requisite notice pertaining to service connection for a respiratory disability in April 2009, prior to the initial January 2011 rating decision. Service connection was subsequently granted, and the Veteran appealed the rating assigned. In cases such as this, where the claim has been granted and an initial disability rating and effective date have been assigned, the typical claim has been more than substantiated, it has been proven, thereby rendering 38 U.S.C.A. § 5103(a) notice no longer required because the purpose that the notice is intended to serve has been fulfilled. Dingess/Hartman, 19 Vet. App. at 490; Dunlap v. Nicholson, 21 Vet. App. 112 (2007). The Veteran bears the burden of demonstrating any prejudice from defective (or nonexistent) notice with respect to the downstream elements. Goodwin v. Peake, 22 Vet. App. 128, 137 (2008). That burden has not been met in this case, as neither the Veteran nor her attorney has alleged such prejudice. Additionally, the RO provided the Veteran with the requisite notice pertaining to increased evaluation for migraines in January 2012, prior to the May 2012 rating decision. Therefore, the Board finds that VA's duty to notify the Veteran has been satisfied. Regarding the duty to assist, the Board finds that all relevant facts have been properly developed and that all evidence necessary for equitable resolution of the issues herein decided has been obtained in accordance with 38 U.S.C.A. § 5103A and 38 C.F.R. § 3.159(c). All identified and available post-service treatment records have been obtained. The Veteran's disabilities were evaluated in December 2010 and May 2015. The examination reports have been reviewed and found to be collectively adequate to make a determination on the claims. See Barr v. Nicholson, 21 Vet. App. 303, 311 (2007); Stefl v. Nicholson, 21 Vet. App. 120, 124-25 (2007). Additionally, the Veteran was afforded the opportunity to give testimony before the undersigned in December 2015. At the hearing, the undersigned identified the issues on appeal and discussed the Veteran's history and her current complaints. The undersigned sought to identify any pertinent evidence not currently associated with the record that might have been overlooked or was outstanding that might substantiate her claim. As such, the Board finds that, consistent with Bryant v. Shinseki, 23 Vet. App. 488 (2010), the undersigned complied with the duties set forth in 38 C.F.R. § 3.103(c)(2). Neither the Veteran nor her attorney alleges otherwise. In light of the foregoing, the Board finds that VA's duties to notify and assist have been satisfied and, thus, appellate review may proceed without prejudice to the Veteran. See Bernard v. Brown, 4 Vet. App. 384, 394 (1993). III. Law and Regulations - Increased Ratings Disability evaluations are determined by application of the criteria set forth in the VA's Schedule for Rating Disabilities, which is based on average impairment in earning capacity. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4. An evaluation of the level of disability present must also include consideration of the functional impairment of the Veteran's ability to engage in ordinary activities, including employment. 38 C.F.R. § 4.10. When a question arises as to which of two ratings apply under a particular diagnostic code, the higher evaluation is assigned if the disability more closely approximates the criteria for the higher rating. 38 C.F.R. § 4.7. After careful consideration of the evidence, any reasonable doubt remaining is resolved in favor of the Veteran. 38 C.F.R. § 4.3. The Veteran's entire history is to be considered when making disability evaluations. See generally 38 C.F.R. § 4.1; Schafrath v. Derwinski, 1 Vet. App. 589 (1995). Where service connection has already been established and an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. Francisco v. Brown, 7 Vet. App. 55 (1994). The Court has held that "staged" ratings are appropriate for any rating claim when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. See Hart v. Mansfield, 21 Vet. App. 505 (2007); Fenderson v. West, 12 Vet. App 119 (1999). IV. Respiratory disability The Veteran's respiratory disability has been assigned a 0 percent rating under Diagnostic Code (DC) 6600, for bronchitis. Under DC 6600, a 10 percent rating is warranted when the FEV1 is 71 to 80 percent predicted, or; FEV1/FVC is 71 to 80 percent predicted, or; DLCO (SB) of 66 to 80 percent predicted. A 30 percent rating is assigned when the FEV1 is 56 to 70 percent predicted, or; FEV1/FVC is 56 to 70 percent predicted, or; DLCO (SB) of 56 to 65 percent predicted. A 60 percent rating is assigned when the FEV1 is 40 to 55 percent predicted, or; FEV1/FVC is 40 to 55 percent predicted, or; DLCO (SB) of 40 to 55 percent predicted, or with maximum oxygen consumption of 15 to 20 ml/kg/min (with cardiorespiratory limit). A maximum 100 percent rating is awarded for FEV-1 less than 40 percent of predicted value; or the ratio of FEV-1/FVC is less than 40 percent; or DLCO (SB) less than 40 percent predicted; or maximum exercise capacity less than 15 ml/kg/min oxygen consumption (with cardiac or respiratory limitation); or cor pulmonale (right heart failure); or right ventricular hypertrophy; or pulmonary hypertension (shown by Echo or cardiac catheterization); or episode(s) of acute respiratory failure; or requires outpatient oxygen therapy. 38 C.F.R. § 4.97, DC 6600 (2015). As discussed below in further detail, the record reflects that the Veteran also has a history of recurrent upper respiratory infections (URIs); thus, consideration of additional diagnostic codes related to respiratory disabilities is warranted. Under DC 6601, for bronchiectasis, a 10 percent rating is warranted for symptoms of an intermittent productive cough with acute infection requiring a course of antibiotics at least twice a year. A 30 percent rating is warranted for incapacitating episodes of infection of two to four weeks total duration per year, or daily productive cough with sputum that is at times purulent or blood-tinged and that requires prolonged (lasting four to six weeks) antibiotic usage more than twice a year. A 60 percent rating is warranted for incapacitating episodes of infection of four to six weeks total duration per year, or near continuous findings of cough with purulent sputum associated with anorexia, weight loss, and frank hemoptysis requiring antibiotic use almost continuously. Incapacitating episodes are defined as episodes requiring bedrest and treatment by a physician. 38 C.F.R. § 4.97, DC 6601. DC 6602, for asthma, assigns a 30 percent evaluation with a FEV-1 of 56 to 70 percent predicted, or; FEV-1/FVC of 56 to 70 percent, or; daily inhalational or oral bronchodilator therapy, or; inhalational anti-inflammatory medication. A 60 percent evaluation is assigned with a FEV-1 of 40 to 55 percent predicted, or; FEV- 1/FVC of 40 to 55 percent, or; at least monthly visits to a physician for required care of exacerbations, or; intermittent (at least three per year) courses of systemic (oral or parenteral) corticosteroids. A 100 percent evaluation is assigned with a FEV-1 of less than 40 percent predicted, or; FEV-1/FVC of less than 40 percent, or; more than one attack per week with episodes of respiratory failure, or; bronchial asthma requiring daily use of high dose corticosteroids or immunosuppressive medications. A note to DC 6602 states that in the absence of clinical findings of asthma at the time of examination, a verified history of asthmatic attacks must be of record. 38 C.F.R. § 4.97, DC 6602 (2015). By way of background, a January 2011 rating decision granted service connection for bronchitis and assigned a noncompensable evaluation effective January 30, 2009, the date the RO reopened the Veteran's claim for chronic respiratory disease. Turning to the relevant evidence of record, a March 2009 VA treatment record indicated that the Veteran complained of recurrent URIs since returning from Iraq. She had a history of multiple courses of antibiotics and reported no allergies. Her URI onset about 4 to 5 days previously. She reported fever/chills at night and coughing up greenish colored and blood tinged mucus. The examiner prescribed antibiotics and advised the Veteran to follow up with her primary care provider for a more extensive evaluation of her respiratory symptoms. A September 2010 VA treatment record noted complaints of cough productive of green sputum for over a week. The examining physician prescribed the Veteran a z-pack (antibiotic). An October 2010 VA treatment record indicated that the Veteran complained of a URI. She experienced 1 week of nasal congestion, productive cough of green sputum, some blood tinged, ears feel full, headache, fever at night, and myalgia. Three weeks previously, she had taken a full course of antibiotics. She had improved for 1 week, but then had similar symptoms the following week. The examiner assessed URI and prescribed antibiotics. The examiner also suspected bronchitis, and prescribed moxifloxacin if the URI did not resolve in 7 to 10 days. The examiner, a physician, also prescribed rest, fluids, and hand hygiene. A November 2010 VA treatment record noted that a URI started 3 days previously, with symptoms of fever/chills, green productive cough, left ear pain, retro orbital headache, and myalgias. The examining physician assessed viral URI vs early bronchitis. Given her history of bronchitis, the examiner prescribed antibiotics, rest, and fluids. On December 2010 VA QTC (contract) examination, the Veteran reported that due to her respiratory condition, she has a loss of appetite, hemoptysis (coughing up blood), a cough with purulent sputum, fevers, night sweats, chills and shortness of breath at rest. She contracted infection easily from her respiratory condition, which required antibiotics about 5 times per year, each time lasting for 2 weeks. The infections required bed rest and treatment by a physician as often as 1 time per month, each time lasting for 2 and a half weeks. She had no episodes of respiratory failure requiring respiration assistance from a machine. She was taking Azithromycin (an antibiotic) for the previous 8 days, and the response had been minimal. Side effects of the antibiotic included occasional dry skin and hair loss with constant use. She also took Guaifenesin (an expectorant). Side effects of the expectorant included a little dizziness and lightheadedness. Due to her respiratory disability, her activities must be performed in small increments. She had an inability to exercise because of shortness of breath, with the exception of limited stretching and short walks. She was previously on bronchial inhalers for treatment for at least 2 years. Pulmonary function test (PFT) showed FVC of 96 percent predicted and FEV-1 of 96 percent predicted, pre-bronchodilator. The post-bronchodilator test was not performed because the pre-bronchodilator test was within normal limits. Diffusion capacity of the lung for carbon monoxide by the single breath method (DLCO) was not measured as the PFT results were sufficient to evaluate the pulmonary status of the Veteran. The chest x-ray results were within normal limits. The examiner did not diagnose recurrent bronchitis because the Veteran had no complications such as cor pulmonale, right ventricular hypertrophy, pulmonary hypertension or chronic respiratory failure with carbon dioxide retention. In November 2011, the Veteran presented with complaints of cough productive of green-brown sputum, and pain in left lung. She mentioned wheezing and shortness of breath as well. She had pain with coughing. The examiner assessed URI, likely viral. The examiner prescribed rest, fluids, hand hygiene, ibuprofen, and an expectorant. A December 2011 VA treatment record noted that the Veteran presented with a bad URI. She had fever, cough with dark green phlegm with blood. She had swollen glands and hives, pain in her lungs and ears. The symptoms she had in November had never dissipated. Symptomatic medications did not help. The examiner assessed URI and prescribed antibiotics and Robitussin. A January 2012 VA treatment record noted that a cough started 3 days prior, productive of green mucus. She felt sweaty and had a feeling of fluid in left ear. She had mostly chest congestion, not much in head. The examiner assessed viral URI and prescribed fluids, steam, Guaifenesin (expectorant), and Robitussin. An April 2012 disability benefits questionnaire (DBQ) indicates that the Veteran had exacerbations of chronic bronchitis at least 3 times per month, which required urgent care or treatment by her VA physician. Her respiratory condition required continuous low dose corticosteroids and intermittent inhalational bronchodilator therapy. PFTs showed FEV-1 to 84 percent predicted and FVC to 82 percent predicted, pre-bronchodilator. FEV-1 most accurately reflected the Veteran's pulmonary function. Post-bronchodilator tests were not completed because pre-bronchodilator tests were normal. DLCO testing was not completed because it was not indicated for the Veteran's condition. Her respiratory disability did not impact her ability to work because it was well-controlled by her corticosteroid inhaler with her use of bronchodilation inhaler for rescue as needed. A May 2012 VA nursing note indicated that the Veteran complained of sore throat and chest congestion. She had been coughing up blood-tinged green mucous for 2 weeks. The sore throat and chest congestion had worsened over the previous few days. She stated it was very painful to breathe. A strep throat test was negative. The examiner assessed prolonged URI and prescribed a z-pack and Asmanex (a corticosteroid inhaler) daily. An October 2014 VA pulmonary clinic note indicated that the Veteran's dyspnea had improved since a previous visit when she had an active URI. She had been given a z-pack and her symptoms improved. She still had occasional chest wall pain, a sore throat, and occasional cough with yellow-green sputum. A December 2014 VA treatment record noted that the Veteran had frequent respiratory illness. Inhalers controlled symptoms for the most part, but she needed to take Albuterol (bronchodilator) daily. The examiner noted a current URI, with 2 weeks of cough productive of blood tinged green sputum. There had been no improvement. She also had night sweats and fever. A March 2015 VA pulmonary clinic note indicated that the Veteran had been having cough with purulent sputum and fevers for the previous 4 weeks. On May 2015 VA examination, the examiner noted that the Veteran's respiratory condition required use of intermittent inhalational bronchodilator therapy and daily inhalational and anti-inflammatory medication. The Veteran was unable to perform PFTs adequately due to her abdominal pain from recent abdominal surgery. Chest x-rays were normal. The examiner noted that bronchitis had resolved. During the December 2015 Board hearing, the Veteran testified that she has chronic bronchitis and periods of viral infections. She took daily corticosteroid inhalers and a bronchodilator. She had exacerbations about 5 to 8 times per year, when she is "out" for a week to three weeks at a time. She had 4 viral infections this year. She stated that her doctors tell her to stay in bed. Based on the foregoing, the Board finds that a 60 percent rating is warranted under DC 6601. The medical evidence, as well as the Veteran's lay testimony, indicates that over the course of the appeal period, the Veteran's respiratory disability manifested with near constant findings of cough with purulent sputum associated with unexplained weight loss and hemoptysis, requiring antibiotic usage almost continuously. A higher, 100 percent rating is not warranted unless there is evidenced of incapacitating episodes of infection of at least six weeks total duration per year. As noted above, an incapacitating episode requires bedrest and treatment by a physician. While the Veteran has testified that she has experienced such episodes 5 to 8 times per year (lasting for a week to 3 weeks each time, with doctors advising her to stay in bed), and has reported similar episodes during her VA examinations, the Board affords more probative value to her treatment records, which indicate that she was only advised to "rest" on three occasions by her treating clinicians during the appeal period (in October 2010, November 2010, and November 2011), which spans over seven years. These findings do not equate to incapacitating episodes of at least six weeks total duration per year. Accordingly, a 60 percent rating, but no higher, is warranted under DC 6601. A higher rating is not warranted under any other diagnostic code. The Veteran's respiratory disability has not manifested in a FEV-1, FEV-1/FVC, or DLCO (SB) of less than 40 percent of predicted value. There is no evidence of maximum exercise capacity less than 15 ml/kg/min oxygen consumption (with cardiac or respiratory limitation), right heart failure, right ventricular hypertrophy, pulmonary hypertension, episodes of acute respiratory failure, or a requirement of outpatient oxygen therapy. Additionally, there is no evidence of asthma attacks more than once per week or bronchial asthma requiring daily use of high dose corticosteroids or immunosuppressive medications. Specifically, the April 2012 DBQ noted that the Veteran did not have asthma attacks and that her respiratory condition required low dose corticosteroids. Thus, a higher, 100 percent rating is not warranted under DC 6600 or DC 6602. V. Migraine headaches A July 2002 rating decision granted service connection for migraines and assigned a 30 percent evaluation effective May 15, 2001. In December 2011, the Veteran submitted a claim for increased rating, asserting that her migraine disability more closely approximated the criteria for a 50 percent evaluation. The increased rating period on appeal includes evidence within one year prior to the date of her claim for an increased rating, which is December 2010. See 38 C.F.R. § 3.400(o)(2). Under DC 8100, migraine headaches warrant a 50 percent rating when there are very frequent completely prostrating and prolonged attacks that are productive of severe economic inadaptability; a 30 percent rating is warranted with characteristic prostrating attacks occurring on an average once a month over the last several months. 38 C.F.R. § 4.124a, DC 8100. Turning to the evidence of record, a December 2010 VA psychiatry note indicated that the Veteran experienced migraine headaches about 5 to 6 times per month. An August 2011 VA progress note indicated that the Veteran had 4 migraines per month, and was taking prescribed Imitrex. A December 2011 DBQ notes that the Veteran's migraine symptoms included nausea, lightheadedness, and dizziness, which last up to 12 hours. Headache pain was described as pulsating or throbbing, localized to one side of the head, and worsened with physical activity. She also experienced sensitivity to light and sound, changes in vision, sensory changes, and watery eyes. Typical head pain was less than 1 day. Head pain was located on the left side of the head. Attacks occurred more frequently than once per month. The examiner found that the Veteran had very frequent prostrating and prolonged attacks of migraine headache pain. Her headache condition impacted her ability to work because she has to stop what she is doing and wait until the symptoms subside. She has missed work due to migraines. A January 2012 VA treatment record indicated that the frequency of the Veteran's migraines had increased to 5 per month. A February 2012 DBQ noted that the Veteran had been diagnosed with migraine headaches. Symptoms include pulsating or throbbing head pain localized to left side of the head, worse with physical activity. Other symptoms included nausea, vomiting, sensitivity to light and sound, changes in vision, sensory changes, and watery eyes. Head pain lasted less than 1 day. Prostrating attacks of migraine headache pain occurred more frequently than once per month. The Veteran's headache condition impacted her ability to work because, whenever she gets a migraine, she has to stop what she is doing and wait until the symptoms subside. She has missed work because of them. A December 2014 VA treatment record noted that the Veteran reported getting 3 to 4 migraines per month. She reported seeing spots hours before the pain started. A January 2015 DBQ indicated that the Veteran had prostrating attacks of migraine headaches 3 to 4 times per month. Her headache pain was described as pulsating or throbbing, localized to one side of the head, and worsened with physical activity. She also experienced nausea, vomiting, sensitivity to light and sound, changes in vision, and sensory changes in the entire left side of the body. Duration of typical head pain was 1 to 2 days. Location in the left side of head. The physician opined that the Veteran's headache condition impacts her ability to work, such that the Veteran is unable to work during headache attacks. A March 2015 nursing note indicated that the Veteran reported experiencing migraine headaches with a pain level of 5 out of 10. On May 2015 VA examination, the Veteran reported headaches located from frontal to left side, throbbing in nature with a 8 to 10 out of 10 pain level. They are often associated with nausea, photophobia, and phonophobia. She takes migraine prophylactic medication, including Metoprolol daily and Imitrex for headache abortive therapy. Prostrating attacks occurred more frequently than once per month. The examiner noted that the headache condition did not impact her ability to work. During the December 2015 Board hearing, the Veteran testified that she has a minimum of 3 migraines a month, and sometimes 4 or 5 times per month. Her migraines are extremely debilitating. She is sensitive to light and sound. Usually, she stays in her bedroom with her head under the covers. She is on 2 medications for the migraines; one she takes regularly which has side effects of dizziness, nausea, and numbness in the left side of her body; the other she takes with the onset of a migraine. She wears dark sunglasses anytime she goes out. Any sort of sound is amplified. The frequency of her headaches increases whenever she runs out of medication. Based on the foregoing, the Board finds that a higher 50 percent rating is warranted during the entire appeal period. The medical evidence shows that the Veteran has consistently experienced between 3 and 6 migraines per month during the appeal period. Her migraines have severe symptomatology, which has caused her to miss work and ultimately stop working. Moreover, the December 2011, February 2012 and January 2015 DBQs note that the Veteran had frequent completely prostrating and prolonged attacks that are productive of severe economic inadaptability. Although the Board recognizes that the May 2015 VA examiner opined that the Veteran did not have frequent completely prostrating and prolonged attacks and that the headaches did not affect her occupational functioning, the Board notes that the DBQs are more consistent with the medical treatment of record and the Veteran's testimony. Further, the May 2015 examiner did not explain why the Veteran's headaches did not affect her occupational functioning. Accordingly, the Board finds the DBQs to be more probative. With resolution of all reasonable doubt in the Veteran's favor, the Board finds that a 50 percent rating for migraine headaches is warranted. A 50 percent rating is the maximum rating available under the rating schedule. Therefore no higher schedular rating is warranted. VI. Extraschedular Consideration In Thun v. Peake, 22 Vet. App. 111 (2008), the Court held that the determination of whether a claimant is entitled to an extra-schedular rating is a three-step inquiry. In Anderson v. Shinseki, 22 Vet. App. 423, 427 (2008), the Court clarified that the Thun steps are, in fact, "elements." The first step (or element) is a finding of whether the evidence before VA presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. Therefore, initially, there must be a comparison between the level of severity and symptomatology of the claimant's service-connected disability with the established criteria found in the rating schedule for that disability. Id. This task is to be performed by the RO or the Board. Id. The second step is a determination of whether the claimant's exceptional disability picture exhibits other related factors such as those provided by the regulation as "governing norms." Id. Such factors include "marked interference with employment" and "frequent periods of hospitalization." Id. If these two elements are met, the case must be referred to the Under Secretary for Benefits or the Director of Compensation and Pension Service for completion of the third step or element--a determination of whether, to accord justice, the claimant's disability picture requires the assignment of an extra-schedular rating. Id. Neither the RO nor the Board is permitted to assign an extra-schedular rating; rather the matter must initially be referred to those officials who possess the delegated authority to assign such a rating. The Board finds that the schedular rating criteria contemplate the symptomatology and severity of the Veteran's respiratory disability and migraine headaches. The Veteran's respiratory symptoms include shortness of breath, unexplained weight loss, chronic cough productive of sputum that is at times blood-tinged, requiring the use of antibiotics, corticosteroids, and bronchodilators. Her headache disability is manifested by very frequent and completely prostrating and prolonged attacks. The schedular criteria specifically provide for ratings based on the presence of such symptoms. Moreover, the schedular criteria specifically contemplate severe economic impact of symptoms related to headaches. Such factors are explicitly part of the schedular rating criteria. Because the schedular rating criteria are adequate to rate the disability, there is no exceptional or unusual disability picture to render impractical the application of the regular schedular standards. For these reasons, the Board finds that the criteria for referral for extraschedular rating have not been met for either claimed disability. 38 C.F.R. § 3.321(b)(1). Finally, the Board need not address whether referral for extraschedular consideration is warranted for the Veteran's disabilities on a collective basis, as that issue has not been reasonably raised by the Veteran or the record. See Yancy v. McDonald, No. 14-3390 (February 26, 2016). ORDER The appeal for an earlier effective date for the grant of service connection for bronchitis is dismissed. A 60 percent disability evaluation, but no higher, for respiratory disability is granted for the entire appeal period. A 50 percent disability evaluation for migraine headaches is granted for the entire appeal period. REMAND Regarding the issue of entitlement to increased evaluation for PTSD, a May 2015 rating decision continued a 50 percent evaluation. In June 2015, the Veteran submitted a notice of disagreement with the evaluation and effective date assigned. In addition, a June 2011 rating decision denied the Veteran's petition to reopen a formerly denied claim of entitlement to service connection for chronic fatigue syndrome. In December 2011, the Veteran submitted a timely notice of disagreement. It does not appear that the RO has issued a statement of case addressing either issue. Therefore, the appropriate Board action is to remand that issue for issuance of a statement of the case. Manlincon v. West, 12 Vet. App. 238 (1999). Regarding the claim for a TDIU, the Board notes that while the ultimate question of whether a veteran is capable of substantial gainful employment is not a medical one, (see 38 C.F.R. § 4.16(a); Geib v. Shinseki, 733 F.3d 1350, 1354 (Fed. Cir. 2013)), the Board finds that the Veteran should be afforded a VA Social Industrial Survey that provides a full description of the effects of her service-connected disabilities on her ordinary activities, to include his employability. 38 C.F.R. § 4.10; Floore v. Shinseki, 26 Vet. App. 376, 381 (2013). Updated treatment records should also be secured on remand. Accordingly, the case is REMANDED for the following action: 1. Obtain all updated VA treatment records. 2. Issue a statement of the case that addresses the issues of: (a) entitlement to an increased evaluation and earlier effective date for the assignment of a 50 percent evaluation for PTSD; and (b) whether new and material evidence has been received sufficient to reopen a claim for service connection for chronic fatigue syndrome. Inform the Veteran of her appeal rights and that she must file a timely substantive appeal if she desires appellate review. 3. Then schedule the Veteran for a Social Industrial Survey to ascertain the impact of her service-connected disabilities (PTSD, migraine headaches, respiratory disorder) on her ordinary activities, to include her employability. All indicated tests and studies shall be conducted. The examiner must review the claims file and should note that review in the report. The VA Social Industrial surveyor is requested to describe the Veteran's employment history, and provide a full description of the effects, to include all associated limitations, of her service-connected disabilities on her ordinary activities, to include her employability, taking into consideration her level of education, special training, and previous work experience, but not her age or any impairment caused by nonservice-connected disabilities. A complete rationale should accompany any opinion provided. 4. The readjudicate the TDIU claim, and issue a Supplemental Statement of the Case, as appropriate. The Veteran has the right to submit additional evidence and argument on the 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 2014). ____________________________________________ S. BUSH Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs