Citation Nr: 0813828 Decision Date: 04/25/08 Archive Date: 05/01/08 DOCKET NO. 98-05 134A ) DATE ) ) On appeal from the Department of Veterans Affairs (VA) Regional Office (RO) in Boston, Massachusetts THE ISSUES 1. Entitlement to service connection for fibrocystic adenosis. 2. Entitlement to an initial rating in excess of 10 percent for mitral valve prolapse, prior to January 12, 1998. 3. Entitlement to a rating in excess of 30 percent for mitral valve prolapse since January 12, 1998. 4. Entitlement to an initial rating in excess of 10 percent for a low back disability, prior to March 10, 2005. 5. Entitlement to a rating in excess of 20 percent for a low back disability, since March 10, 2005. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD M. Donovan, Associate Counsel INTRODUCTION The veteran served on active duty from May 1980 to April 1997. These matters come before the Board of Veterans' Appeals (Board) on appeal from a December 1997 RO rating decision that, inter alia, denied service connection for positive tuberculosis (TB) test, epiglottis, bilateral knee pain, recurrent gastritis, and recurrent fibrocystic adenosis, and granted service connection and assigned 10 percent disability ratings for mitral valve prolapse and low back pain, effective June 12, 1997. The appellant filed a Notice of Disagreement (NOD) in regard to the denials of service connection and assigned disability ratings in March 1998, and the RO issued a Statement of the Case (SOC) in the same month. The appellant filed a VA Form 9 (Appeal to the Board of Veterans' Appeals) in April 1998. A December 1998 rating decision granted service connection for recurrent gastritis and acid reflux with irritable bowel/h. pylori and granted an earlier effective date of May 1, 1997 for the grants of service connection. A January 2000 rating decision granted service connection for recurrent epiglottis. These rating decisions constitute full grants of the benefits sought regarding the claims for service connection for recurrent gastritis and recurrent epiglottis. In August 2001, the Board denied entitlement to service connection for a positive TB test and remanded the matters remaining on appeal to the RO for further action. In a July 2004 rating decision, the RO in Los Angeles, California, inter alia, granted service connection for degenerative joint disease of the right and left knees, each evaluated as 10 percent disabling, and a higher rating of 30 percent for the veteran's mitral valve prolapse, effective January 12, 1998 (the date of revision of the pertinent rating criteria). The July 2004 rating decision constitutes full grants of the benefits sought regarding the right and left knee. The RO continued the denial of service connection for fibrocystic adenosis and increased initial ratings (as reflected in a July 2004 supplemental SOC (SSOC)). A November 2005 rating decision granted a higher rating of 20 percent for the veteran's service-connected low back disability, effective March 10, 2005. As the claims on appeal involve requests for higher initial ratings following the grants of service connection, the Board has characterized the issues on appeal in light of the distinction noted in Fenderson v. West, 12 Vet. App. 119, 126 (1999) (distinguishing initial rating claims from claims for increased ratings for disabilities already service- connected). Moreover, although higher ratings for mitral valve prolapse and the service-connected low back disability have been assigned, effective January 12, 1998 and March 10, 2005, respectively, as higher ratings for these disabilities are available before and after those dates, and the veteran is presumed to be seeking the maximum available benefit, the Board has recharacterized the appeal as encompassing the matters set forth on the title page. See A.B. v. Brown, 6 Vet. App. 35, 38 (1993). The Board's decision addressing the claims for an initial rating in excess of 10 percent for mitral valve prolapse prior to January 12, 1998, and the claims for entitlement to an initial rating in excess of 10 percent for a low back disability, prior to March 10, 2005, and entitlement to a rating in excess of 20 percent for a low back disability, since March 10, 2005, is set forth below. The claim for service connection for fibrocystic adenosis and the claim for a rating in excess of 30 percent for mitral valve prolapse since January 12, 1998 are addressed in the remand following the order; these matters are being remanded to the RO via the Appeals Management Center (AMC), in Washington, DC. VA will notify the appellant when further action, on her part, is required. As a final preliminary matter, the Board notes that, in a March 2005 statement, the veteran's representative indicated that the veteran believed that her left knee disability met the criteria for a "moderate" rating under Diagnostic Code 5257. In addition, in a May 2007 statement, the veteran described increasing bilateral knee pain. As there is no indication in the record that claims for increased ratings for degenerative joint disease of the right and left knees has yet been addressed by the RO, these matters are not properly before the Board; hence, they are referred to the RO for appropriate action. FINDINGS OF FACT 1. All notification and development actions needed to fairly adjudicate the claims herein decided have been accomplished. 2. From May 1, 1997, the effective date of the grant of service connection, through January 11, 1998, mitral valve prolapse was manifested by complaints of chest pain, palpitations, dyspnea on exertion and lightheadedness, with no medical evidence of diastolic murmur or a definitely enlarged heart. 3. Resolving all doubt in favor of the veteran, from May 1, 1997, the effective date of the grant of service connection, the service-connected low back disability has been manifested by full flexion to 90 degrees, with pain, weakness, and incoordination on range of motion; there is no evidence of severe intervertebral disc syndrome (IVDS), with recurring attacks with intermittent relief, or of any separately compensable neurological manifestations or incapacitating episodes of IVDS. CONCLUSIONS OF LAW 1. The criteria for an initial rating in excess of 10 percent for mitral valve prolapse, for the period prior to January 12, 1998, are not met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.3, 4.20, 4.27 (2007); 38 C.F.R. § 4.104, Diagnostic Code 7000 (1997). 2. The criteria for an initial rating of 20 percent for the service-connected low back disability are met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.159, 4.1, 4.3, 4.7, 4.40, 4.45, 4.71a, Diagnostic Codes (DCs) 5292, 5295 (as in effect prior to September 26, 2003). 3. The criteria for an initial rating in excess of 20 percent for the service-connected low back disability are not met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.159, 4.1, 4.3, 4.7, 4.40, 4.45, 4.71a, Diagnostic Codes (DC) 5292, 5295 (as in effect prior to September 26, 2003); General Rating Formula for Diseases and Injuries of the Spine (as in effect since September 26, 2003). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA), Pub. L. No. 106-475, 114 Stat. 2096 (Nov. 9, 2000) (codified at 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, and 5126 (West 2002 & Supp. 2007)) includes enhanced duties to notify and assist claimants for VA benefits. VA regulations implementing the VCAA have been codified, as amended at 38 C.F.R. §§ 3.102, 3.156(a), 3.159, and 3.326(a) (2007). Notice requirements under the VCAA essentially require VA to notify a claimant of any evidence that is necessary to substantiate the claim(s), as well as the evidence that VA will attempt to obtain and which evidence he or she is responsible for providing. See, e.g., Quartuccio v. Principi, 16 Vet. App. 183 (2002) (addressing the duties imposed by 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b)). As delineated in Pelegrini v. Principi, 18 Vet. App. 112 (2004), after a substantially complete application for benefits is received, proper VCAA notice must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim(s); (2) that VA will seek to provide; (3) that the claimant is expected to provide; and (4) must ask the claimant to provide any evidence in her or his possession that pertains to the claim(s), in accordance with 38 C.F.R. § 3.159(b)(1). In rating cases, a claimant must be provided with information pertaining to assignment of disability ratings (to include the rating criteria for all higher ratings for a disability), as well as information regarding the effective date that may be assigned. Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). The Court has also held that, in rating cases, VA must notify the claimant that, to substantiate a claim for an increased rating: (1) the claimant must provide, or ask VA to obtain, medical or lay evidence demonstrating a worsening or increase in severity of the disability and the effect that worsening has on the claimant's employment and daily life; (2) if the diagnostic code under which the claimant is rated contains criteria necessary for entitlement to a higher disability rating that would not be satisfied by the claimant demonstrating a noticeable worsening or increase in severity of the disability and the effect of that worsening on the claimant's employment and daily life (such as a specific measurement or test result), the Secretary must provide at least general notice of that requirement to the claimant; (3) the claimant must be notified that, should an increase in disability be found, a disability rating will be determined by applying relevant diagnostic codes; and (4) the notice must also provide examples of the types of medical and lay evidence that the claimant may submit (or ask VA to obtain) that are relevant to establishing entitlement to increased compensation. See Vazquez-Flores v. Peake, 22 Vet. App. 37 (2008). VCAA-compliant notice must be provided to a claimant before the initial unfavorable decision on a claim for VA benefits by the agency of original jurisdiction (in this case, the RO). Id.; Pelegrini, 18 Vet. App. at 112. See also Disabled American Veterans v. Secretary of Veterans Affairs, 327 F.3d 1339 (Fed. Cir. 2003). However, the VCAA notice requirements may, nonetheless, be satisfied if any errors in the timing or content of such notice are not prejudicial to the claimant. Id. In this appeal, a March 2002 post-rating letter provided notice to the veteran regarding what information and evidence was needed to substantiate the claims for higher ratings for her low back disability and mitral valve prolapse, as well as what information and evidence must be submitted by the veteran and what information and evidence would be obtained by VA. While the veteran has not explicitly been advised to provide any evidence in her possession that pertains to these claims, the claims file reflects that the veteran has submitted evidence in support of her claims. Given that fact, as well as the RO's instructions to her, the Board finds that the veteran has, effectively, been put on notice to provide any evidence in her possession that pertains to the claims on appeal. Accordingly, on these facts, the RO's omission is harmless. See Mayfield v. Nicholson, 20 Vet. App. 537, 543 (2006) (rejecting the argument that the Board lacks authority to consider harmless error). The Board notes that the VCAA letter was sent after the initial rating decision, which, in this case, makes sense, as the December 1997 rating action on appeal preceded enactment of the VCAA by a number of years. Moreover, after issuance of the March 2002 letter, and opportunity for the veteran to respond, the July 2004, December 2006 and June 2007 SSOCs reflect readjudication of the claims. Hence, the veteran is not shown to be prejudiced by the timing of VCAA-compliant notice. See Mayfield v. Nicholson, 20 Vet. App. 537, 543 (2006); see also Prickett v. Nicholson, 20 Vet. App. 370, 376 (2006) (the issuance of a fully compliant VCAA notification followed by readjudication of the claim, such as in a statement of the SOC or SSOC, is sufficient to cure a timing defect). The Board notes that the veteran was provided notice of the criteria for higher ratings for mitral valve prolapse and her low back disability in the March 1998 SOC and January 2000 and July 2004 SSOCs, which suffices for Dingess/Hartman. A November 2007 letter generally informed the veteran how disability ratings and effective dates are assigned and the type of evidence that impacts those determinations. While the November 2007 letter was not followed by readjudication of the claims, the timing of this notice is not shown to prejudice the veteran. As discussed below, the Board has determined that the veteran is entitled to an increased initial rating of 20 percent for her service-connected low back disability from the date of the grant of service connection. As this is the earliest possible effective date for the increased rating, the veteran is not prejudiced by any timing deficiency regarding the notice regarding effective dates. To the extent that Vazquez-Flores applies to claims for increased initial ratings, the Board finds that, taken together, the March 2002 VCAA letter, which informed the veteran of the information and evidence necessary to substantiate her claims for increased ratings, the March 1998 SOC and January 2000 and July 2004 SSOCs, which included the pertinent rating criteria, and the November 2007 letter, which explained how disability ratings are determined, satisfy the notice requirements of Vazquez-Flores. As discussed above, the veteran's claims for higher ratings were not readjudicated following issuance of the November 2007 letter, which provided notice of how disability ratings are determined. After issuance of the letter, the veteran was afforded the opportunity to respond regarding this notice, however, the veteran did not respond. Hence, the Board finds that the veteran has received sufficient notice compliant with Vazquez-Flores, and has been afforded ample opportunity to respond to this notice. As such, the veteran is not prejudiced by any timing deficiency in this notice. See Mayfield, 20 Vet. App. at 543; see also Dunlap v. Nicholson, 21 Vet. App. 112 (2007) (holding that notice deficiencies are not prejudicial if they did not render the claimant without a meaningful opportunity to participate effectively in the processing of his or her claim). The Board also points out that neither the veteran nor her representative has contended that any notification deficiencies, either with respect to timing or content, have resulted in prejudice to the veteran. The record also reflects that VA has made reasonable efforts to obtain or to assist in obtaining all relevant records pertinent to the matters on appeal. Pertinent medical evidence associated with the claims file consists of the veteran's service medical records, VA and private treatment records, and the reports of September 1997, October 1997, January 2003, and May 2005 VA examinations. Also of record are various written statements provided by the veteran, as well as by her representative, on her behalf. As will be discussed below, a June 2006 record of VA treatment references a February 2006 private MRI of the lumbar spine. The report of this MRI has not been associated with the claims file. However, as the findings of that MRI are included in the VA treatment record, the Board finds that remand to obtain the private MRI report would impose unnecessary additional burdens on adjudication resources, with no benefit flowing to the veteran, and is thus not appropriate. See Soyini v. Derwinski, 1 Vet. App. 540, 546 (1991). In summary, the duties imposed by the VCAA have been considered and satisfied. Through various notices of the RO, the veteran has been notified and made aware of the evidence needed to substantiate these claims, the avenues through which she might obtain such evidence, and the allocation of responsibilities between herself and VA in obtaining such evidence. There is no additional notice that should be provided, nor is there any indication that there is additional existing evidence to obtain or development required to create any additional evidence to be considered in connection with the claim. Consequently, any error in the sequence of events or content of the notice is not shown to prejudice the veteran or to have any effect on the appeal. Any such error is deemed harmless and does not preclude appellate consideration of the matters on appeal, at this juncture. See Mayfield, 20 Vet. App. at 543 (rejecting the argument that the Board lacks authority to consider harmless error). See also ATD Corp. v. Lydall, Inc., 159 F.3d 534, 549 (Fed. Cir. 1998). II. Analysis Disability evaluations are determined by the application of VA's Schedule for Rating Disabilities, which assigns ratings based on average impairment of earning capacity resulting from a service-connected disability. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4. Where there is a question as to which of two ratings shall be applied, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. 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 entitlement to compensation already has been established and an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). However, where the question for consideration is entitlement to a higher initial rating since the grant of service connection, evaluation of the medical evidence since the grant of service connection to consider the appropriateness of "staged rating" (assignment of different ratings for distinct periods of time, based on the facts found) is required. Fenderson, 12 Vet. App. at 126. A. Mitral Valve Prolapse Prior to January 12, 1998 The December 1997 rating decision granted service connection and assigned an initial 10 percent rating for mitral valve prolapse, under the provisions of 38 C.F.R. § 4.104, Diagnostic Code 7099-7000, effective June 12, 1997, indicating that the veteran's mitral valve prolapse was being evaluated, by analogy, to rheumatic heart disease. See 38 C.F.R. §§ 4.20 and 4.27. As noted above, the December 1998 rating decision granted an earlier effective date of May 1, 1997 for the grant of service connection. Initially, the Board notes that, effective January 12, 1998, VA revised the criteria for rating diseases of the heart, including rheumatic heart disease. See 62 Fed. Reg. 65207- 65224 (1997). As there is no indication that the revised criteria are intended to have a retroactive effect, the Board has the duty to adjudicate the claim only under the former criteria for any period prior to the effective date of the new Diagnostic Codes, and to consider the revised criteria for the period beginning on the effective date of the new provisions. See Wanner v. Principi, 17 Vet. App. 4, 9 (2003); DeSouza v. Gober, 10 Vet. App. 461, 467 (1997). See also VAOPGCPREC 3- 2000 (2000) and 7-2003 (2003). Under the rating criteria in effect prior to January 12, 1998, Diagnostic Code 7000 provides that a 10 percent rating is warranted for rheumatic heart disease with identifiable valvular lesion, slight, if any dyspnea, the heart not enlarged; following established active rheumatic heart disease. A 30 percent rating is warranted from the termination of an established service episode of rheumatic fever, or, its subsequent recurrence, with cardiac manifestations, during the episode of recurrence, for 3 years, or diastolic murmur with characteristic EKG manifestations or definitely enlarged heart. A 60 percent rating is warranted for rheumatic heart disease with heart definitely enlarged; severe dyspnea on exertion, elevation of systolic blood pressure, or such arrhythmias as paroxysmal auricular fibrillation or flutter or paroxysmal tachycardia; more than light manual labor is precluded. A 100 percent rating is warranted for active disease, and, with ascertainable cardiac manifestation, for a period of 6 months, or for inactive disease with definite enlargement of the heart confirmed by roentgenogram and clinically; dyspnea on slight exertion; rales, pretibial pitting and end of day or other definite signs of beginning congestive failure; more than sedentary employment is precluded. 38 C.F.R. § 4.104, Diagnostic Code 7000 (1997). Considering the pertinent evidence in light of the criteria (as in effect prior to January 12, 1998), the Board finds that a rating in excess of 10 percent for the veteran's service-connected mitral valve prolapse, for the period prior to January 12, 1998, is not warranted. On VA heart disease examination in September 1997, the veteran reported a history of noting chest pains, palpitations, and shortness of breath after developing a bad sinus infection in 1986. Since that time, she noted intermittent bouts of chest pain and palpitations, which seemed to be associated with fevers. Her current complaints included occasional atypical chest pain when she had a temperature and two flight dyspnea on exertion, with no paroxysmal nocturnal dyspnea or orthopnea. She noted occasional light-headedness with palpitations, but had not experienced syncope. On examination, blood pressure was 125/80. There was no venous distention or adenopathy of the neck. Carotid pulse contour appeared normal and no bruits were audible. The chest was clear to percussion and ausculatation and the heart did not appear to be enlarged. Rhythm was regular. No murmur was heard in the supine position, but a grade I/VI systolic murmur was heard in the sitting position. The impression was mitral valve prolapse, ventricular irritability by history, on treatment. On VA General Medical examination in October 1997, the veteran reported that, since developing sinusitis in 1985, she had noted recurrent episodes of chest pain and light- headedness. Her current complaints included light- headedness. The impression included questionable mitral valve prolapse. The Board finds that the medical evidence as noted above does not show symptoms that warrant a rating in excess of 10 percent prior to January 12, 1998. In this regard, although VA heart examination revealed a systolic murmur, no diastolic murmur was noted, and the heart did not appear to be enlarged. As such, an initial rating in excess of 10 percent under Diagnostic Code 7000, as in effect prior to January 12, 1998, is not warranted. 38 C.F.R. § 4.104, Diagnostic Code 7000 (1997). Based on the foregoing, the Board finds that the record presents no basis for assignment of more than a 10 percent schedular rating for mitral valve prolapse from the May 1, 1997 effective date of the grant of service connection through January 11, 1998. B. Low Back Disability The December 1997 rating decision granted service connection and assigned an initial 10 percent rating for low back pain, under the provisions of 38 C.F.R. § 4.71a, Diagnostic Code 5295, effective June 12, 1997. As noted above, the December 1998 rating decision granted an earlier effective date of May 1, 1997 for the grant of service connection. Initially, the Board notes that, effective September 26, 2003, VA revised the criteria for rating all disabilities of the spine, including IVDS. As there is no indication that the revised criteria are intended to have a retroactive effect, the Board has the duty to adjudicate the claim only under the former criteria for any period prior to the effective date of the new DCs, and to consider the revised criteria for the period beginning on the effective date of the new provisions. See Wanner, 17 Vet. App. at 9; DeSouza, 10 Vet. App. at 467 (1997). See also VAOPGCPREC 3- 2000 (2000) and 7-2003 (2003). In this case, the RO has considered the claim under both the former and revised applicable criteria, and has given the appellant notice of both criteria in the March 1998 SOC, and January 2000 and July 2004 SSOCs. Hence, there is no due process bar to the Board also considering the claim in light of the former and revised applicable rating criteria, as appropriate. 2. Prior to September 26, 2003 Under the rating criteria in effect prior to September 26, 2003, former DC 5295 provides that lumbosacral strain with characteristic pain on motion warrants a 10 percent rating. A 20 percent rating is assignable for lumbosacral strain with muscle spasm on extreme forward bending and unilateral loss of lateral spine motion in a standing position. A 40 percent rating requires severe lumbosacral strain with listing of the whole spine to the opposite side, a positive Goldthwaite's sign, marked limitation of motion with osteoarthritic changes, or narrowing or irregularity of joint space, or some of the above with abnormal mobility on forced motion. 38 C.F.R. § 4.71a, Diagnostic Code 5295 (2003). Alternatively, the veteran's low back disability could be evaluated under DC 5292, rating limitation of motion of the lumbar spine. Former DC 5292 provides a 10 percent rating for slight limitation of motion of the lumbar spine, while a 20 percent rating is assignable for moderate limitation of motion, and a 40 percent rating requires severe limitation of motion. 38 C.F.R. § 4.71a, DC 5292 (2003). The terms "mild," "moderate," and "severe" are not defined in the rating schedule; rather than applying a mechanical formula, VA must evaluate all the evidence to the end that its decisions are equitable and just. 38 C.F.R. § 4.6. Considering the pertinent evidence in light of the above- noted criteria, the Board finds that an initial rating of 20 percent for the veteran's service-connected low back disability is warranted. On VA general medical examination in October 1997, the veteran reported a history of experiencing severe back pain in 1981 thought to be a "ruptured disc." She was treated with bedrest and Valium for 6 weeks. She reported that, in September 1997, she had again been found to have a ruptured disc in the same area, for which she was treated with Motrin. The history given at this examination also notes that the veteran was found to have scoliosis with low back pain in 1981. The impression included low back pain and scoliosis. Records of private treatment from February to June 1998 include a February 1998 CT scan of the lumbar spine, which revealed rotary scoliosis convexity to the left, a generalized disc bulge at L3-4, L4-5 considerably narrowed with gas in the degenerated disc, and L5-S1 disc intact. Treatment in June 1998 included a finding of chronic low back pain. In a January 1999 statement, the veteran indicated that she was having more problems with back pain, especially with any type of movement, and she reported that her low back pain was radiating down the sides of both legs. On VA joints examination in January 2003, the veteran described daily back pain, which she described as a 3/10, with exacerbations of pain to 7/10 about twice a week, when she would have to take Levoxine and Motrin. She localized the pain to the mid portion of the lower back, but added that the pain was sometimes paraspinal on either the right or left side. She added that her pain was worsened with any type of increased activity. She denied radicular pain, although she admitted to persistent right leg weakness since 1993, which she indicated had been attributed to multiple sclerosis at different times. On examination, range of motion of the lumbar spine revealed flexion to 90 degrees, extension to 15 degrees with pain, right bending to 20 degrees with pain, left bending to 30 degrees with pain, right rotation to 45 degrees with pain, and left rotation to 45 degrees without pain. On forward bending, the veteran had a notable left lumbar scoliotic curvature and right thoracic curvature. There was no other deformity and no defect noted in the spine. Motor examination revealed 5/5 motor strength throughout the left lower extremity, while the right lower extremity had 4/5 motor strength in hip flexion and knee extension strength and 5/5 hip abduction and adduction and ankle dorsiflexion. Sensory examination was intact to sharp versus dull throughout L1-S1 bilaterally, although it was decreased in a stocking glove pattern subjectively bilaterally. Straight leg raise was negative for radiculopathy. Deep tendon reflexes were brisk and symmetric at L4 and S1 bilaterally. Review of X-rays of the lumbar spine confirmed scoliotic curvature measuring 23 degrees of left lumbar curvature and 23 degrees of right thoracic curvature, as well as degenerative disc disease of the lumbar spine. MRI of the lumbar spine revealed diffuse mild degenerative disc disease in the lumbar spine with severe degenerative disc disease at the L4-L5 level. There was no focal neurologic impingement noted on MRI. The assessment included scoliotic deformity as noted of the thoracic and lumbar spine and mechanical low back pain with a component of degenerative disk disease. The examiner noted that there was evidence of low back pain with range of motion, as well as weakness and incoordination. The examiner opined that the veteran would experience functional loss due to pain and incoordination associated with the lumbar spine. Regarding the extent of this functional loss, the examiner opined that the veteran would not be able to do any heavy lifting or activities requiring prolonged standing longer than 15 minutes, or walking farther than 3 blocks. The examiner added that the neurological lfindings, specifically weakness of the right lower extremity, could not be directly explained from the clinical or radiographic findings, specifically as the MRI revealed no neurological involvement of the spinal cord in the lumbar region. The examiner added that this weakness in the right lower extremity had previously been attributed to central nervous system symptoms. The Board finds that the medical evidence as noted above does not show symptoms that warrant a rating in excess of 10 percent prior to September 26, 2003 under former DC 5295. In this regard, the medical evidence does not include findings of muscle spasm on extreme forward bending or loss of lateral spine motion, unilateral, in standing position, as required for a higher rating of 20 percent for lumbosacral strain. See 38 C.F.R. § 4.71a, DC 5295 (2003). The Board finds that a rating in excess of 10 percent is also not warranted under former DC 5292, as the veteran had full flexion to 90 degrees, with no notation of pain on flexion, on VA examination in January 2003. While extension was limited to 15 degrees, and right bending was limited to 20 degrees, the veteran, nevertheless, had left bending and bilateral rotation to 30 degrees or more. Thus, even considering some limitation in extension and right lateral flexion demonstrated on examination, the veteran's limitation of motion of the lumbar spine for the period in question can be characterized as no more than slight. See 38 C.F.R. § 4.71a, DC 5292 (2003). However, when evaluating musculoskeletal disabilities, VA may, in addition to applying the schedular criteria, consider granting a higher rating in cases in which the claimant experiences additional functional loss due to pain, weakness, excess fatigability, or incoordination, to include with repeated use during flare-ups, and those factors are not contemplated in the relevant rating criteria. See 38 C.F.R. §§ 4.40, 4.45 (2003); DeLuca v. Brown, 8 Vet. App. 202, 204- 7 (1995). The provisions of 38 C.F.R. §§ 4.40 and 4.45 are to be considered in conjunction with the DCs predicated on limitation of motion. See Johnson v. Brown, 9 Vet. App. 7 (1996). The August 2001 remand indicated that the veteran should be afforded a VA examination to evaluate her low back disability. The examiner was asked to indicate whether there was objective evidence of pain on motion, weakness, excess fatigability, and/or incoordination associated with the service-connected back disorder. The remand further instructed that the physician should indicate whether, and to what extent, the veteran experienced likely functional loss due to pain and/or any of the other symptoms listed above during flare-ups and/or with repeated use. The remand further indicated that, to the extent possible, the examiner should express any such additional functional loss in terms of additional degrees of limited motion. While the January 2003 VA examiner noted that the veteran did experience functional loss in that she had low back pain, weakness, and incoordination during range of motion testing, he did not express the veteran's functional loss in terms of additional degrees of limited motion. However, the examiner did express an opinion regarding the extent of the veteran's functional loss, by stating that she would not be able to do heavy lifting, stand for more than 15 minutes, or walk farther than 3 blocks. Based on the foregoing findings regarding functional impairment, the Board finds that the veteran's low back disability more nearly approximates the criteria for the next higher, 20 percent, rating, under Diagnostic Code 5292. Resolving all reasonable doubt in the veteran's favor, and considering her March 1998 statement that she had an increase in mid and low back pain, and her January 1999 statement that she had more problems with the pain in her back, especially with any type of movement or trying to lift anything, the Board finds that the functional impairment resulting from the veteran's service-connected low back disability has more nearly approximated the criteria for a 20 percent rating since the grant of service connection. Given the MRI evidence of degenerative disc disease noted during the January 2003 VA examination, the Board has considered whether rating the veteran's low back disability under the criteria for IVDS would benefit the veteran. Prior to September 26, 2003, IVDS was rated under former DC 5293 (changed to DC 5243 on September 26, 2003). Prior to September 23, 2002, a 10 percent rating was warranted for mild IVDS, a 20 percent rating was warranted for moderate IVDS with recurring attacks, a 40 percent rating was warranted for severe IVDS with recurring attacks with intermittent relief, and a 60 percent rating was warranted for pronounced IVDS, with persistent symptoms compatible with sciatic neuropathy with characteristic pain and demonstrable muscle spasm, absent ankle jerk, or other neurological findings appropriate to the site of the diseased disc, with little intermittent relief. See 38 C.F.R. § 4.71a, DC 5293 (2002). There is no evidence prior to September 23, 2002 that the veteran's service-connected low back disability was manifested by severe IVDS with recurring attacks with intermittent relief, as required for a rating in excess of 20 percent. Rather, the February 1998 CT scan merely noted that the L4-5 disc was considerably narrowed with gas in the degenerated disc. As of September 23, 2002, IVDS could be evaluated on either the total duration of incapacitating episodes over the past 12 months, or by combining under 38 C.F.R. § 4.25 separate ratings of its chronic orthopedic and neurological manifestations, along with evaluations of all other disabilities, whichever results in the higher rating. For purposes of evaluation under former DC 5293, an incapacitating episode is a period of acute signs and symptoms due to IVDS that requires bed rest prescribed by a physician, and chronic orthopedic and neurological manifestations mean orthopedic and neurological signs and symptoms resulting from IVDS that are present constantly, or nearly so. 38 C.F.R. § 4.71a, DC 5293, Note (1) (2003). The medical evidence during the period in question does not indicate any bed rest prescribed by a physician, let alone for a total period of at least four weeks in the last 12 months, as required for higher rating of 40 percent. While the veteran reported pain radiating down the sides of both legs in January 1999, she denied any radicular pain on VA examination in January 2003. Although she described persistent right leg weakness, the examiner specifically noted that this had been previously attributed to central nervous system symptoms, and that MRI revealed no neurological involvement of the spinal cord in the lumbar region. In light of the findings of the January 2003 VA examiner regarding neurological manifestations of the service-connected low back disability, combining the ratings for separate orthopedic and neurological manifestations would not result in a rating greater than 20 percent. The record also presents no basis for assignment of any higher rating under any alternative diagnostic code, during the period in question. While, under the former criteria, as in effect prior to September 26, 2003, residuals of fracture of the vertebrae, ankylosis of the spine, or ankylosis of the lumbar spine may warrant a rating in excess of 20 percent, here, the service-connected low back disability has not been shown to involve any of the above. See 38 C.F.R. § 4.71a, DCs 5285, 5286, 5289 (2003). 2. Since September 26, 2003 Effective September 26, 2003, the criteria for rating all spine disabilities, to include IVDS, are now set forth in a General Rating Formula for Diseases and Injuries of the Spine. Under the General Rating Formula, a 10 percent rating is assignable for forward flexion of the thoracolumbar spine greater than 60 degrees but not greater than 85 degrees. A rating of 20 percent is assignable for forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees, or, the combined range of motion of the thoracolumbar spine not greater than 120 degrees, or muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. A 40 percent rating is assignable where forward flexion of the thoracolumbar spine is 30 degrees or less, or there is favorable ankylosis of the entire thoracolumbar spine. A 50 percent rating is assignable for unfavorable ankylosis of the entire thoracolumbar spine. A 100 percent rating is assignable for unfavorable ankylosis of the entire spine. These criteria are applied with and without symptoms such as pain (whether or not it radiates), stiffness, or aching in the area of the spine affected by residuals of injury or disease. 38 C.F.R. § 4.71a, General Rating Formula for DCs 5235- 5243 (2007). Under the revised rating criteria, forward flexion to 90 degrees, and extension, lateral flexion, and rotation to 30 degrees, each, are considered normal range of motion of the thoracolumbar spine. 38 C.F.R. § 4.71a, Plate V. As noted above, the RO granted an increased rating of 20 percent for the veteran's service-connected low back disability effective March 10, 2005, based on the findings of a VA examination conducted on that date. As the Board has granted entitlement to an increased initial evaluation of 20 percent, under the rating criteria in effect prior to September 26, 2003, the Board will now consider entitlement to a rating in excess of 20 percent under the revised rating criteria. Considering the pertinent evidence in light of the criteria (as in effect since September 26, 2003), the Board finds that a rating in excess of 20 percent for the veteran's service- connected low back disability, for the period since September 26, 2003, is not warranted. On VA joints examination in May 2005, the veteran reported that she used Motrin and Robaxin to treat her back pain, and that she had a supply of Ultram for times when the pain in her back got particularly bad. She added that inserts in her shoes had greatly reduced the episodes of back pain and, as a result, she had not had to use Ultram more than three or four times since receiving her shoe inserts about eight months earlier. She described her pain as mostly in the low back, although she reported that, if she was up and walking for more than about 20 minutes, her right foot would begin to drag as a result of "right radiculopathy." The veteran reported that, when she developed back pain, she would have to lie down for about 20 minutes, and could then get up and work about another hour. She did not use a cane or a back brace. She reported that she was able to stand or walk for about one hour, but would then have to stop and, if possible, lie down. On examination, there was hyperlordosis of 45 degrees with a compensatory increased kyphosis to 50 degrees. When the veteran would bend forward, which the examiner noted she could do to a full 90 degrees, the lordosis was reduced to 0, but not reversed, and her kyphosis actually did not increase. She was able to extend to 40 degrees, lateral flexion was to 45 degrees, bilaterally, and rotation was to 60 degrees, bilaterally. Range of motion testing was repeated several times, with no change in range of motion with several repetitions, although the level of discomfort increased with each repetition. Straight-leg raising was positive at 60 degrees on the left. On neurologic examination, sensation was intact to pin and light touch throughout the lower extremities. There was no specific spasm palpable either in the lumbar lordosis or in the dorsal spine. The pertinent assessment was musculoskeletal back pain. The examiner added that all range of motion testing was repeated both actively and passively several times, with no change in degree of motion, and only increase in discomfort in the dorsal and lumbar spine. Records of VA treatment from May 2004 to May 2007 include complaints regarding and treatment for low back pain. In June 2006, the physician reviewed a private MRI performed in February 2006, which revealed hypertrophy at L3-4 without nerve root compression and left lateral disc herniation at L5-S1 without clear nerve root compression. In August 2006, the veteran complained of low back pain radiating to the lower extremities. On examination, there was increased lumbar lordosis. Range of motion was almost full, with extension limited to 10 degrees. Straight-leg raising was negative. Sensory examination was intact, with deep tendon reflexes positive and symmetrical. The assessment was chronic low back pain with degenerative disc disease of the lumbosacral spine. Records of private treatment from November 2004 to January 2006 also include complaints regarding low back pain. The Board finds that the medical evidence as noted above does not show symptoms that warrant a rating in excess of 20 percent since September 26, 2003. In this regard, there is no medical evidence of forward flexion of the thoracolumbar spine 30 degrees or less, or favorable ankylosis of the thoracolumbar spine. Rather, the veteran had full forward flexion to 90 degrees on VA examination in May 2005, and the record of VA treatment from August 2006 noted almost full range of motion, and only indicated that extension was limited to 10 degrees. The Board has also considered entitlement to a rating in excess of 20 percent based on functional impairment; however, although the veteran had increased discomfort on repetitive motion during the May 2005 VA examination, the examiner specifically noted that all range of motion testing was repeated both actively and passively several times, with no change in degree of motion,. The Board notes that the revised criteria contemplate symptoms such as pain, stiffness, aching, etc., if present, thus, evaluations based on pain alone are not appropriate, unless there is specific nerve root pain, for example, that could be evaluated under the sections of the rating schedule for evaluating neurological disabilities. See 68 Fed. Reg. 51,455 (Aug. 27, 2003). Thus, consideration of 38 C.F.R. §§ 4.40, 4.45 and DeLuca, 8 Vet. App. at 204-7, provides no basis for a higher rating. While, under Note (1) of the General Rating Formula, VA must also consider whether combining ratings for orthopedic and neurological manifestations would result in a higher rating for the veteran's service-connected low back disability, such would not be the case here, as, despite the veteran's reports of "right radiculopathy" on VA examination in May 2005, nuerological testing revealed sensation to be intact in the bilateral lower extremities. Further, the June 2006 record of VA treatment specifically indicated that the MRI performed in February 2006, revealed hypertrophy at L3-4 without nerve root compression and left lateral disc herniation at L5-S1 without clear nerve root compression. Sensory examination was again intact, with deep tendon reflexes positive and symmetrical, during VA treatment in August 2006. Further, there is no medical evidence that the veteran's service-connected low back disability would warrant a higher rating if rated on the basis of incapacitating episodes. While, during the May 2005 VA examination, the veteran reported that the low back disability required that she lie down, there simply is no objective evidence of incapacitating episodes having a total duration of at least four weeks during the previous 12-month period, which is required for a 40 percent rating under the Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes. See 38 C.F.R. § 4.71a, DC 5243 (2007). Under these circumstances, the Board finds that the record presents no basis for assignment of a higher schedular rating under the applicable rating criteria during the period in question. C. All Claims Decided The above determinations are based on consideration of applicable provisions of VA's rating schedule, the Board finds that there is no showing that, under any period under consideration, the veteran's service-connected mitral valve prolapse or low back disability have reflected so exceptional or so unusual a disability picture as to warrant the assignment of any higher rating on an extra-schedular basis. See 38 C.F.R. § 3.321(b) (cited in the March 1998 SOC and January 2000 SSOC). In this regard, the Board notes that the disabilities have not objectively been shown to markedly interfere with employment (i.e., beyond that contemplated in any assigned rating). Although the record reflects that the veteran is not currently working, there is no showing that these disabilities have resulted in marked interference with employment (i.e., beyond that contemplated in any assigned rating). Rather, in a March 2005 claim for increased compensation based on unemployability, the veteran reported that she stopped working because of cardiac chest pain and knee pain. In addition, there is no evidence of record indicating that these disabilities have necessitated frequent periods of hospitalization, or otherwise rendered inadequate the regular schedular standards. In the absence of evidence of any of the factors outlined above, the criteria for invoking the procedures set forth in 38 C.F.R. § 3.321(b)(1) have not been met. See Bagwell v. Brown, 9 Vet. App. 337, 338-9 (1996); Floyd v. Brown, 9 Vet. App. 88, 96 (1996); Shipwash v. Brown, 8 Vet. App. 218, 227 (1995). The Board has also considered the applicability of the benefit-of-the doubt doctrine, but finds that, while the doctrine is favorable for application in the award of an initial 20 percent rating for the veteran's service-connected low back disability, the preponderance of the evidence is against assignment of a rating an initial rating in excess of 10 percent for mitral valve prolapse prior to January 12, 1998 or for a rating in excess of 20 percent for the service- connected low back disability. See 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). ORDER An initial rating in excess of 10 percent for mitral valve prolapse, prior to January 12, 1998, is denied. An initial rating of 20 percent for a low back disability is granted. A rating in excess of 20 percent for a low back disability is denied. REMAND Unfortunately, the Board finds that additional RO action on the claim for service connection for fibrocystic adenosis and the claim for a rating in excess of 30 percent for mitral valve prolapse since January 12, 1998 is warranted, even though it will, regrettably, further delay an appellate decision on these matters. A remand by the Board confers on the veteran, as a matter of law, the right to compliance with the remand instructions, and imposes upon VA a concomitant duty to ensure compliance with the terms of the remand. See Stegall v. West, 11 Vet. App. 268, 271 (1998). In the Board's February 2007 remand, the Board directed the RO to obtain a VA examination for evaluation of any fibrocystic adenosis currently present. The remand noted that a November 1979 pre-induction examination report noted the veteran's history of chronic cystic mastitis of the left breast, with no evidence of malignancy, and that the service medical records indicated that the veteran underwent several bilateral breast biopsies in service. The remand specifically asked that the examiner render an opinion as to whether it is at least as likely as not that any currently found fibrocystic adenosis was incurred in or aggravated during the veteran's active military service. The remand also noted that it was imperative that the physician designated to examine the veteran review the evidence in her claims files, including a copy of the remand. The veteran was afforded a VA examination in December 2002. The examiner noted that the veteran developed palpable lesions in both breasts in 1986, which were biopsied, with a diagnosis of intraductal papillomatosis of the right and left breasts. Examination revealed scars on the breasts. The pertinent diagnosis was intraductal papillomatosis, right and left breasts. A handwritten note on the examination report states that the claims file was reviewed. The veteran was afforded another VA examination in August 2003. The examiner indicated that review of the medical records revealed that the veteran had five breast biopsies, all benign, with the initial biopsy in April 1986. Breast examination revealed multiple surgical scars and no discrete mass. The examiner concluded that the veteran clearly had a diagnosis of fibrocystic breast disease, which was initially made in 1985 while in the service. The veteran's breasts were again evaluated during VA examination in May 2005. The examiner noted the history of five breast biopsies in service, all of which were benign, showing intraductal papillomatosis or fibroadenoma. The veteran gave a history of noting non-tender breast lumps around 1984, for which biopsies were done. Following examination, the pertinent diagnosis was history of multiple benign breast biopsies, most consistent with a diagnosis of fibrocystic change of the breasts. The Board notes that, while the August 2003 VA examiner concluded that the veteran's diagnosis of fibrocystic breast disease was initially made in the service, the examiner did not consider the notation on the November 1979 examination of chronic cystic mastitis of the left breast. In addition, this examiner did not acknowledge review of the claims files, but only "review of the medical records" and the conclusion that fibrocystic breast disease was initially diagnosed in service suggests that the November 1979 examination report was not reviewed. Under these circumstances, another remand of this matter, for the RO to obtain a supplemental medical opinion from the August 2003 VA examiner, if available, is warranted. In rendering the supplemental opinion, the examiner should specifically consider and address the November 1979 examination report, noting chronic cystic mastitis of the left breast. The RO should arrange for the veteran to undergo VA examination only if the August 2003 VA examiner is not available, or the designated physician is unable to provide the requested opinion without examining the veteran. Since January 12, 1998, mitral valve prolapse has been rated as 30 percent disabling under Diagnostic Code 7000. Under this diagnostic code, valvular heart disease with workload of greater than 5 METs but not greater than 7 METs results in dyspnea, fatigue, angina, dizziness, or syncope, or; evidence of cardiac hypertrophy or dilation on electro-cardiogram, echocardiogram, or X-ray warrants a 30 percent rating. The next higher rating of 60 percent requires more than one episode of acute congestive heart failure in the past year, or; workload of greater than 3 METs but not greater than 5 METs results in dyspnea, fatigue, angina, dizziness, or syncope, or; left ventricular dysfunction with an ejection fraction of 30 to 50 percent. 38 C.F.R. § 4.104, Diagnostic Code 7000. The Board notes that the August 2001 remand instructed that the veteran be afforded a VA cardiovascular examination. The remand instructed that all indicated special tests and studies should be accomplished, including a laboratory determination of METs by exercise testing, an electro- cardiogram, echocardiogram, and x-ray study. With regard to MET testing, the examiner was asked document the level of METs at which dyspnea, fatigue, angina, dizziness or syncope develops. If a laboratory determination of METs by exercise testing could not be done for medical reasons, the remand indicated that an estimation by a medical examiner of the level of activity (expressed in METs and supported by specific examples, such as slow stair climbing or shoveling snow) that results in dyspnea, fatigue, angina, dizziness, or syncope could be used. The veteran was afforded VA examinations to evaluate her mitral valve prolapse in January 2003 and April 2005. The January 2003 VA examination noted that the veteran's activity was limited mainly by knee and back pain to about two blocks, which would be a MET level of about 7. A November 2002 echocardiogram revealed normal left ventricular size and function with an ejection fraction of 65 percent. The assessment included mild mitral valve regurgitation. On VA examination in April 2005, the examiner noted that the veteran had an ultrasound at a private facility in December 2004, which revealed a normal ejection fraction, and a sestamibi study which revealed normal function of the left ventricle with a calculated ejection fraction of 70 percent. The examiner opined that there had not been a substantial change in the veteran's valvular heart disease, rated as 30 percent disabling. The examiner added that, as the veteran had not established that there had been a progression of this service-connected problem, he did not feel there was any reason to change the percentage of service connection. While the January 2003 VA examination included an estimate of MET level, and discussed the November 2002 echocardiogram, the veteran has not been afforded a VA examination which includes exercise testing, an electro-cardiogram, and X-ray as instructed in the August 2001 remand. Further, neither VA examination report indicates the level of METs at which dyspnea, fatigue, angina, dizziness or syncope develops, or states that determination of METs by exercise testing could not be done for medical reasons. In addition, the Board notes that the medical evidence since April 2005 reflects a worsening of mitral valve prolapse. In this regard, during VA treatment in April 2006, the veteran reported a history of increased frequency of palpitations for about one year, with chest pain and some shortness of breath. The veteran indicated that she was currently experiencing almost unremitting palpitations with lightheadedness and dizziness. A January 2006 echocardiogram revealed an ejection fraction greater than 55 percent. The assessment was 54 year old female with longstanding palpitations, increased frequency/severity with new symptoms in recent months, improved on increased Inderal, with a very reassuring Holter and echo. To ensure compliance with the August 2001 remand, and to ensure that the record accurately reflects the current severity of the disability under consideration, the Board finds that a more contemporaneous examination-with clear findings responsive to the applicable rating criteria-is needed to properly evaluate the service-connected mitral valve prolapse. See 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. Accordingly, the RO should arrange for the veteran to undergo VA cardiovascular examination, by an appropriate physician, at a VA medical facility. The veteran is hereby notified that failure to report to any scheduled examination(s), without good cause, may result in a denial of the claim(s) (as adjudication will be based on the evidence of record). See 38 C.F.R. § 3.655. Examples of good cause include, but are not limited to, the illness or hospitalization of the claimant and death of an immediate family member. If the veteran fails to report to the scheduled examinations, the RO should obtain and associate with the claims file (a) copy(ies) of the notice(s) of the examinations sent to her by the pertinent VA medical facility. Prior to arranging for the veteran to undergo further examination(s), the RO should obtain and associate with the claims file all outstanding VA medical records. The claims file currently includes outpatient treatment records from the Boston VA Medical Center (VAMC) dated from May 2004 to August 2006 and from the Loma Linda VAMC dated from December 2006 to May 2007. The Board emphasizes that records generated by VA facilities that may have an impact on the adjudication of a claim are considered constructively in the possession of VA adjudicators during the consideration of a claim, regardless of whether those records are physically on file. See Dunn v. West, 11 Vet. App. 462, 466-67 (1998); Bell v. Derwinski, 2 Vet. App. 611, 613 (1992). Hence, the RO must obtain all outstanding pertinent treatment records from the Boston and Loma Linda VAMCs, since August 2006 and May 2007, respectively, following the current procedures prescribed in 38 C.F.R. § 3.159 as regards requests for records from Federal facilities. To ensure that all due process requirements are met, the RO should also give the veteran another opportunity to present information and/or evidence pertinent to the claims remaining on appeal. The RO's notice letter to the veteran should explain that she has a full one-year period for response. See 38 U.S.C.A § 5103(b)(1) (West 2002); but see 38 U.S.C.A. § 5103(b)(3) (West Supp. 2007) (amending the relevant statute to clarify that VA may make a decision on a claim before the expiration of the one-year notice period). The RO should invite the veteran to submit all pertinent evidence in her possession (not previously requested) and ensure that its notice to the veteran meets the requirements of Vazquez- Flores v. Peake, 22 Vet. App. 37 (2008), as regards the claim for an increased rating, as appropriate. After providing the appropriate notice, the RO should attempt to obtain any additional evidence for which the veteran provides sufficient information, and, if needed, authorization, following the current procedures prescribed in 38 C.F.R. § 3.159. The actions identified herein are consistent with the duties imposed by the VCAA. See 38 U.S.C.A. §§ 5103, 5103A; 38 C.F.R. § 3.159. However, identification of specific actions requested on remand does not relieve the RO of the responsibility to ensure full compliance with the VCAA and its implementing regulations. Hence, in addition to the actions requested above, the RO should also undertake any other development and/or notification action deemed warranted by the VCAA prior to adjudicating the claims remaining on appeal. The RO's adjudication of the claim for a higher rating for mitral valve prolapse since January 12, 1998 should include consideration of whether "staged rating" (assignment of different ratings for different periods of time, based on the facts found), pursuant to Fenderson, is warranted. Accordingly, these matters are hereby REMANDED to the RO, via the AMC, for the following action: 1. The RO should obtain all records of evaluation and/or treatment of the veteran's fibrocystic adenosis or mitral valve prolapse from the Boston and Loma Linda VAMCs since August 2006 and May 2007, respectively. The RO must follow the procedures set forth in 38 C.F.R. § 3.159(c) as regards requesting records from Federal facilities. All records and/or responses received should be associated with the claims file. 2. The RO should send to the veteran and her representative a letter requesting that the veteran provide sufficient information, and if necessary, authorization to enable it to obtain any additional evidence pertinent to the claims remaining on appeal that is not currently of record. The RO should ensure that its letter meets the requirements of Vazquez-Flores (cited to above), as appropriate, and the RO should clearly explain to the veteran that she has a full one-year period to respond (although VA may decide the claim within the one-year period). 3. If the veteran responds, the RO should assist her in obtaining any additional evidence identified by following the current procedures set forth in 38 C.F.R. § 3.159. All records/responses received should be associated with the claims file. If any records sought are not obtained, the RO should notify her and her representative of the records that were not obtained, explain the efforts taken to obtain them, and describe further action to be taken. 4. After all available records and/or responses from each contacted entity are associated with the claims file, the RO should forward the claims file to the examiner that examined the veteran in August 2003, if available. The examiner should provide an opinion as whether it is at least as likely as not (i.e., there is a 50 percent or greater probability) that the veteran has current fibrocystic adenosis that was incurred in or aggravated by service. The examiner should specifically address whether any current fibrocystic adenosis (a) pre- existed service; and, if so (b) was aggravated (i.e., permanently worsened) beyond the natural progression during or as a result of service; and, if not (c) is otherwise medically related to the veteran's service. In providing the requested opinion, the examiner should consider and address the November 1979 examination report noting chronic cystic mastitis of the left breast. The physician should set forth all findings, along with the complete rationale for the conclusions reached, in a printed (typewritten) report. If further examination of the veteran is deemed necessary, the RO should arrange for the veteran to undergo examination, by a physician, to obtain the above-noted opinion. The entire claims file, to include a complete copy of this REMAND, must be made available to the physician designated to examine the veteran, and the examination report should include discussion of the veteran's documented medical history and assertions. All indicated tests and studies should be accomplished (with all findings made available to the requesting physician prior to the completion of his or her report), and all clinical findings should be reported in detail. 5. Regarding the claim for a rating in excess of 30 percent for mitral valve prolapse, since January 12, 1998, the RO should also arrange for the veteran to undergo VA cardiovascular examination, by an appropriate physician, at a VA medical facility. The entire claims file, to include a complete copy of the REMAND, must be made available to the physician designated to examine the veteran, and the report of examination should include discussion of the veteran's documented medical history and assertions. All appropriate tests and studies should be accomplished (with all results made available to the examining physician prior to the completion of his or her report), and all clinical findings should be reported in detail. All indicated special tests and studies should be accomplished, including a laboratory determination of METs by exercise testing, an electro-cardiogram, echocardiogram, and x-ray study. With regard to MET testing, the examiner should document the level of METs at which dyspnea, fatigue, angina, dizziness or syncope develops. If a laboratory determination of METs by exercise testing cannot be done for medical reasons, an estimation by a medical examiner of the level of activity (expressed in METs and supported by specific examples, such as slow stair climbing or shoveling snow) that results in dyspnea, fatigue, angina, dizziness, or syncope may be used. All manifestations of the veteran's mitral valve prolapse should be documented by the examiner. The physician should set forth all examination findings, along with complete rationale for the conclusions reached, in a printed (typewritten) report. If the veteran fails to report to any scheduled examination(s), the RO must obtain and associate with the claims file (a) copy(ies) of any notice(s) of the date and time of the examination(s) sent to the veteran by the pertinent VA medical facility. 6. To help avoid future remand, 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. Stegall v. West, 11 Vet. App. 268 (1998). 7. After completing the requested actions, and any additional notification and/or development deemed warranted, the RO should adjudicate the claims remaining on appeal in light of all pertinent evidence and legal authority. The RO's adjudication of the claims for higher rating for mitral valve prolapse should include consideration of whether "staged rating", pursuant to Fenderson (cited to above), is warranted 98 If any benefit sought on appeal remains denied, the RO must furnish to the veteran and her representative an appropriate supplemental SOC that clear reasons and bases for all determinations, and afford them the appropriate time period for response before the claims file is returned to the Board for further appellate consideration. The purpose of this REMAND is to afford due process; it is not the Board's intent to imply whether the benefits requested should be granted or denied. The veteran need take no action until otherwise notified, but he may furnish additional evidence and/or argument during the appropriate time frame. See Kutscherousky v. West, 12 Vet. App. 369 (1999); Colon v. Brown, 9 Vet. App. 104, 108 (1996); Booth v. Brown, 8 Vet. App. 109 (1995); Quarles v. Derwinski, 3 Vet. App. 129, 141 (1992). This REMAND 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. 2007). ______________________________________________ JACQUELINE E. MONROE Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs