Citation Nr: 1125865 Decision Date: 07/11/11 Archive Date: 07/19/11 DOCKET NO. 05-22 934 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUES 1. Whether new and material evidence has been presented to reopen a claim of service connection for migraine headaches to include as secondary to thrombotic thrombocytopenic purpura (TTP). 2. Whether new and material evidence has been presented to reopen a claim of service connection for sinusitis. 3. Entitlement to service connection for weight gain to include as secondary to TTP. 4. Entitlement to service connection for swelling of the feet and hands to include as secondary to TTP. 5. Entitlement to service connection for glycosuria to include as secondary to TTP. 6. Entitlement to service connection for hives to include as secondary to TTP. 7. Entitlement to service connection for hair loss to include as secondary to TTP. 8. Entitlement to service connection for gastroesophageal reflux disease to include as secondary to TTP. 9. Entitlement to service connection for aseptic necrosis of the left hip to include as secondary to TTP. 10. Entitlement to service connection for shortness of breath to include as secondary to TTP and anemia. 11. Entitlement to service connection for peripheral neuropathy of the upper extremities to include as secondary to TTP and anemia. 12. Entitlement to service connection for peripheral neuropathy of the lower extremities to include as secondary to TTP and anemia. 13. Entitlement to service connection for a cervical spine disability to include as secondary to TTP. 14. Entitlement to service connection for a lumbosacral spine disability to include as secondary to TTP. 15. Entitlement to a rating higher than 30 percent for TTP. 16. Entitlement to an initial rating higher than 30 percent for depression. 17. Entitlement to an initial compensable rating for anemia. 18. Entitlement to an effective date prior to September 8, 2006, for the grant of service connection for anemia. REPRESENTATION Veteran represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL Veteran ATTORNEY FOR THE BOARD Debbie A. Breitbeil, Counsel INTRODUCTION The Veteran, who is the appellant, served on active duty from July 1985 to September 1993, with a prior period of active duty for training from March 22, 1984, to August 9, 1984. This matter is before the Board of Veterans' Appeals (Board) on appeal of rating decisions in October 2004, August 2007, February 2008, and January 2009 of Department of Veterans Affairs (VA) Regional Offices (RO or an Agency of Original Jurisdiction). In March 2010, the Veteran appeared at a hearing before the undersigned Veterans Law Judge. A transcript of that hearing has been associated with the Veteran's file. At the hearing and in March 2010, the Veteran submitted additional evidence to the Board, which was accompanied by a waiver of the right to have the RO initially consider the evidence. 38 C.F.R. § 20.1304. The claims of service connection for eustachian tube dysfunction and vertigo and for rheumatoid arthritis (of all joints - feet, ankles, knee, elbows, wrists, hands, shoulder, hips, and entire spine) have been raised by the Veteran in March 2010 and are referred to an Agency of Original Jurisdiction for appropriate action. The reopened claims of service connection for migraine headaches and sinusitis, the claims for a higher rating for TTP and anemia, the claims of service connection for weight gain, swelling of the hands and feet, glycosuria, hives, hair loss, gastroesophageal reflux disease, shortness of breath, and peripheral neuropathy of the extremities, and the claim for an earlier effective date for the grant of service connection for anemia, are REMANDED to the RO via the Appeals Management Center in Washington, DC. FINDINGS OF FACT 1. In rating decisions in December 1994 and June 1999, the RO denied the claim of service connection for migraine headaches on a direct and secondary basis, respectively; after the Veteran was notified of the adverse determination and of his procedural and appellate rights in December 1994 and June 1999, she did not appeal the rating decisions and the rating decisions became final by operation of law based on the evidence of record at the time. 2. The additional evidence presented since the rating decisions in December 1994 and June 1999 by the RO, denying service connection for migraine headaches on a direct and secondary basis, relates to an unestablished fact necessary to substantiate the claim of service connection. 3. In rating decisions in December 1994 and June 1999, the RO denied the claim of service connection for sinusitis on a direct and secondary basis, respectively; after the Veteran was notified of the adverse determination and of her procedural and appellate rights in December 1994 and June 1999, he did not appeal the rating decisions and the rating decisions became final by operation of law based on the evidence of record at the time. 4. The additional evidence presented since the rating decisions in December 1994 and June 1999 by the RO, denying service connection for migraine headaches on a direct and secondary basis, relates to an unestablished fact necessary to substantiate the claim of service connection. 5. There is no competent medical evidence of current aseptic necrosis of the left hip. 6. A cervical spine disability was not affirmatively shown to have had onset during service; and a cervical spine disability, first diagnosed after service, is not shown to be related to a disease, an injury, or an event of service origin and is not shown to be related to a service-connected disability. 7. A lumbosacral spine disability was not affirmatively shown to have had onset during service; and a lumbosacral spine disability, first diagnosed after service, is not shown to be related to a disease, an injury, or an event of service origin and is not shown to be related to a service-connected disability. 8. Since the effective date of service connection, depression is shown to be productive of a disability picture that equates to occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to various symptoms; her disability picture is without evidence of occupational and social impairment with reduced reliability and productivity, due to such symptoms as flattened affect, circumstantial, circumlocutory, or stereotyped speech, difficulty in understanding complex commands, impairment of long-term memory, impaired judgment, impaired abstract thinking, and difficulty in establishing and maintaining effective work relationships. CONCLUSIONS OF LAW 1. New and material evidence has been presented to reopen the claim of service connection for migraine headaches. 38 U.S.C.A. §§ 5108, 7105(c) (West 2002); 38 C.F.R. §§ 3.104, 3.156 (2010). 2. New and material evidence has been presented to reopen the claim of service connection for sinusitis. 38 U.S.C.A. §§ 5108, 7105(c) (West 2002); 38 C.F.R. §§ 3.104, 3.156 (2010). 3. Aseptic necrosis of the left hip was not due to disease or injury incurred in or aggravated by active service, and aseptic necrosis of the left hip is not proximately due to or aggravated by any service-connected disability. 38 U.S.C.A. §§ 1110, 1131, 5107(b) (West 2002); 38 C.F.R. §§ 3.303, 3.310 (2010). 4. A cervical spine disability was not due to disease or injury incurred in or aggravated by active service; a cervical spine disability, degenerative disc disease, as a chronic disease may not be presumed to have been incurred in service; and a cervical spine disability is not proximately due to or aggravated by any service-connected disability. 38 U.S.C.A. §§ 1110, 1131, 5107(b) (West 2002); 38 C.F.R. §§ 3.303, 3.307, 3.309, 3.310 (2010). 5. A lumbosacral spine disability was not due to disease or injury incurred in or aggravated by active service, a lumbosacral spine disability, degenerative disc disease, as a chronic disease may not be presumed to have been incurred in service; and a lumbosacral spine disability is not proximately due to or aggravated by any service-connected disability. 38 U.S.C.A. §§ 1110, 1131, 5107(b) (West 2002); 38 C.F.R. §§ 3.303, 3.307, 3.309, 3.310 (2010). 6. The criteria for an initial rating higher than 30 percent for depression have not been met. 38 U.S.C.A. §§ 1155, 5107(b) (West 2002); 38 C.F.R. § 4.7, 4.130, Diagnostic Code 9434 (2010). The Veterans Claims Assistance Act of 2000 (VCAA) The VCAA, codified in part at 38 U.S.C.A. §§ 5103, 5103A, and implemented in part at 38 C.F.R § 3.159, amended VA's duties to notify and to assist a claimant in developing information and evidence necessary to substantiate a claim. As the applications to reopen the claims of service connection for migraine headaches and for sinusitis are favorable to the Veteran, no further action is required to comply with the VCAA. Duty to Notify Under 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b), when VA receives a complete or substantially complete application for benefits, it will notify the claimant of the following: (1) any information and medical or lay evidence that is necessary to substantiate the claim, (2) what portion of the information and evidence VA will obtain, and (3) what portion of the information and evidence the claimant is to provide. Also, the VCAA notice requirements apply to all five elements of a service connection claim. The five elements are: (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 of the disability. Dingess v. Nicholson, 19 Vet. App. 473 (2006). The VCAA notice must be provided to a claimant before the initial unfavorable adjudication by the RO. Pelegrini v. Principi, 18 Vet. App. 112 (2004). On the claims of service connection for aseptic necrosis of the left hip, degenerative joint disease of the cervical spine, and lumbosacral strain, the RO provided pre-adjudication VCAA notice by letters, dated in January 2007 (lumbosacral strain), October 2007 (left hip), and September 2008 (cervical spine). The Veteran was notified of the evidence needed to substantiate the claims of service connection, namely, evidence of an injury or disease or event, causing an injury or disease, during service; evidence of current disability; and evidence of a relationship between the current disability and the injury or disease or event, causing an injury or disease, during service. The Veteran was notified that VA would obtain service records, VA records, and records of other Federal agencies, and that she could submit other records not in the custody of a Federal agency, such as private medical records, or with her authorization VA would obtain any such records on her behalf. The VCAA notice included the provisions for the effective date of a claim and for the degree of disability assignable. As for content of the VCAA notice, the documents substantially complied with the specificity requirements of Quartuccio v. Principi, 16 Vet. App. 183 (2002) (identifying evidence to substantiate a claim and the relative duties of VA and the claimant to obtain evidence), of Charles v. Principi, 16 Vet. App. 370 (2002) (identifying the document that satisfies VCAA notice); of Pelegrini v. Principi, 18 Vet. App. 112 (2004) (to the extent of pre-adjudication VCAA notice ); and of Dingess v. Nicholson, 19 Vet. App. 473 (notice of the elements of service connection claim). On the claim for an initial rating higher than 30 percent for depression, whereas here service connection has been granted and an initial disability rating and effective date have been assigned, the service connection 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. Therefore, further VCAA notice under 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b)(1) is no longer applicable in the claim for initial higher rating following the initial grant of service connection. Dingess, 19 Vet. App. 473; Dunlap v. Nicholson, 21 Vet. App. 112, 116- 117 (2007); Goodwin v. Peake, 22 Vet. App. 128 (2008). Duty to Assist Under 38 U.S.C.A. § 5103A, VA must make reasonable efforts to assist the claimant in obtaining evidence necessary to substantiate a claim. VA has obtained service treatment records, VA records, and private medical records such as those from Eglin Air Force Base, Moncrief Army Community Hospital, Sumter Neurology and Pain, and Northeast Psychiatry. The Veteran too has submitted numerous private medical records. The Social Security Administration responded to an RO request for records, indicating in November 2007 that it had no records on file. Further, VA has conducted necessary medical inquiry in an effort to substantiate the claim of service connection for lumbosacral strain. 38 U.S.C.A. § 5103A(d). The Veteran was afforded a VA examination in July 2007 with an addendum in September 2007. As the report of the VA examination was based on consideration of the prior medical history and described the disability in sufficient detail so that the Board's review of the claim is a fully informed one, the medical examination and the medical opinion rendered are adequate. Stefl v. Nicholoson, 21 Vet. App. 120, 123 (2007). On the claims of service connection for aseptic necrosis of the left hip and degenerative joint disease of the cervical spine, VA has not conducted medical inquiry in the form of a VA compensation examination in an effort to substantiate the claims, but further development is not required because there is no record of the conditions or complaint relative thereto during service. Additionally, there is no credible evidence of persistent or recurrent symptoms. As the evidence of record does not indicate that aseptic necrosis of the left hip and degenerative joint disease of the cervical spine may be associated with service or a service-connected disability, a medical examination or medical opinion is not required under the duty to assist. 38 C.F.R. § 3.159(c)(4); McLendon v. Nicholson, 20 Vet. App. 79 (2006). On the claim for an initial rating higher than 30 percent for depression, the Veteran was afforded a VA examination in August 2007, and the evidence of record is adequate to rate the disability. There is no evidence in the record dated subsequent to the VA examination that shows a material change in the condition to warrant a reexamination. 38 C.F.R. § 3.327(a). As there is no indication of the existence of additional evidence to substantiate the claims, the Board concludes that no further assistance to the Veteran in developing the facts pertinent to the claims is required to comply with the duty to assist. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. New and Material Evidence to Reopen Claims Procedural History and Evidence Previously Considered In a decision in December 1994, the RO denied service connection for migraine headaches and sinusitis on a direct basis, concluding that although there was a record of treatment for the conditions during service, there was no service treatment evidence that the conditions were chronic and there was no evidence of the conditions following service. In a decision in June 1999, the RO denied service connection for migraine headaches and sinusitis on a secondary basis, concluding that there was no evidence to establish that there was a relationship between the conditions and the Veteran's service-connected TTP. In letters, dated in December 1994 and June 1999, the RO notified the Veteran of the adverse determinations and of her procedural and appellate rights. The notices included the Veteran's right to appeal the adverse determination by notifying the RO of her intention within one year from the date of the letter. The Veteran initiated an appeal of the June 1999 RO rating decision, and was issued a statement of the case with regard to those issues in August 1999, but she did not perfect (or complete) her appeal to the Board with the filing of a substantive appeal. Thus, the rating decisions by the RO in December 1994 and June 1999 became final by operation of law, except the claims may be reopened if new and material evidence is presented. 38 U.S.C.A. § 7105(c); 38 C.F.R. §§ 3.104, 3.156. The evidence of record at the time of the rating decision in December 1994 is summarized as follows. The service records show that the Veteran served on active duty from July 1985 to September 1993, with a prior period of active duty for training from March 22, 1984, to August 9, 1984. The service treatment records show that the Veteran was hospitalized for a severe headaches in August 1989, diagnosed as tension headaches. The Veteran was also diagnosed and treated for sinusitis in July 1991 and February 1993, and left maxillary and ethmoid sinusitis in March 1993. After service, the Veteran was diagnosed with history of headaches at the time of a VA examination in October 1993. At the time of a VA examination in May 1994, she had edema of the nasal mucus membranes, diagnosed as acute upper respiratory infection with a history for allergic rhinitis. On another VA examination in May 1994, the examiner noted that she had had two episodes of probable common migraine that appeared to be isolated incidents and not a recurring condition. Also, the examiner noted that the Veteran she had probably episodic, tension type headaches that were intermittent and could be incapacitating when they occurred. The evidence of record at the time of the rating decision in June 1999, including that evidence previously discussed above, is summarized as follows. Private medical evidence shows ongoing monitoring of TTP (including treatment for an acute exacerbation in September 1995) and for upper respiratory infection in December 1995. In an October 1998 statement, S.M., M.D., noted that the Veteran had TTP that was manifested by intermittent exacerbations of thrombocytopenia as well as ongoing visual problems and headaches. A VA examination report of April 1999 reflected an evaluation of her TTP condition, and noted that whenever the Veteran's platelet count dropped below a certain threshold she began having headaches and dizziness. Current Claims to Reopen As the unappealed rating decisions in December 1994 and June 1999 by the RO became final based on the evidence then of record, new and material evidence is required to reopen the claims. 38 U.S.C.A. § 5108. Where, as here, a claim of service connection has previously been denied, a subsequent claim of service connection for the same disability may not be considered on the merits unless new and material evidence has been presented. And whether or not the RO reopened a claim is not dispositive, as it is the Board's jurisdiction responsibility to consider whether it is proper for a claim to be reopened. Jackson v. Principi, 265 F.3d 1366 (Fed. Cir. 2001) (reopening after a prior unappealed RO denial). As the Veteran's application to reopen the claims was received in September 2006 (for headaches) and in October 2008 (for sinusitis), the current regulatory definition of new and material evidence applies. "New evidence" means existing evidence not previously submitted to agency decision makers; "material evidence" means existing evidence that, by itself or when considered with previous evidence of record, relates to an unestablished fact necessary to substantiate the claim. "New and material evidence" can be neither cumulative nor redundant of the evidence of record at the time of the last prior final denial of the claim sought to be reopened, and must raise a reasonable possibility of substantiating the claim. 38 C.F.R. § 3.156(a). For the purpose of establishing whether new and material evidence has been submitted, the credibility of the evidence, although not its weight, is to be presumed. Justus v. Principi, 3 Vet. App. 510, 513 (1992). The presumption of credibility is rebuttable when the evidentiary assertion is inherently incredible or when the fact asserted is beyond the competence of the person making the assertion. King v. Brown, 5 Vet. App. 19, 21 (1993). In order that the additional evidence may be considered new and material, the evidence must relate to the basis for the prior denial of the claim. Analysis The additional evidence added to the file since the December 1994 and June 1999 rating decisions includes private and VA medical evidence of current treatment for headaches and sinusitis. Of particular note is an October 2007 statement from S.M., M.D., indicating that due to long-term difficulties with TTP, the Veteran has had problems with chronic headaches. The same physician, in an August 2008 statement, noted that the Veteran had current problems with headaches secondary to her anemia (which is a condition for which service connection has been established, as well as TTP). Moreover, the evidence includes a private MRI of the brain in March 2008, which showed paranasal sinus disease, and a VA outpatient record in December 2009 diagnosing chronic sinusitis, for which she was advised to continue taking medication through her private provider. The evidence is new and material because it relates to the unestablished fact necessary to substantiate the headache and sinusitis claims. That is, the evidence appears to link a headache condition to service-connected disabilities of both TTP and anemia. There was not previously of record a medical nexus between headaches and anemia. Also, regarding both headaches and sinusitis, the evidence shows continuing pathology for the conditions and appears to show that the conditions are of a chronic nature. The absence of such facts was the basis for the prior denials of the claims. Moreover, the Veteran's testimony in March 2010, to the effect that she had headaches and sinusitis recurrently since service is also important for providing evidence of continuity of symptomatology of the claimed conditions after service. Such was not known by the RO when it previously considered her claims. To that end, it is noted that for the purpose of establishing whether new and material evidence has been submitted, the credibility of the evidence, although not its weight, is to be presumed. Justus v. Principi, 3 Vet. App. 510, 513 (1992). As the evidence is new and material, the claims of service connection for migraine headaches and sinusitis are reopened. II. Service Connection Legal Criteria Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active duty. 38 U.S.C.A. §§ 1110, 1131. Where a veteran served 90 days or more of continuous, active military service and a chronic disease, such as arthritis, becomes manifest to a degree of 10 percent within one year from date of separation from service, the disease shall be presumed to have been incurred in service even though there is no evidence of such disease during the period of service. 38 U.S.C.A. §§ 1112, 1137; 38 C.F.R. §§ 3.307, 3.309. Service connection means that the facts, shown by evidence, establish that a particular injury or disease resulting in disability was incurred in service. This may be accomplished by affirmatively showing inception during service. 38 C.F.R. § 3.303(a). For the showing of chronic disease in service, there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time, as distinguished from merely isolated findings or a diagnosis including the word "chronic." Continuity of symptomatology is required only where the condition noted during service is not, in fact, shown to be chronic or where the diagnosis of chronicity may be legitimately questioned. When the fact of chronicity in service is not adequately supported, then a showing of continuity after discharge is required to support the claim. 38 C.F.R. § 3.303(b). Service connection may be granted for disability shown after service, when all of the evidence, including that pertinent to service, shows that it was incurred in service. 38 C.F.R. § 3.303(d). Service connection may also be warranted for disability proximately due to or the result of a service-connected disorder and where aggravation of a nonservice-connected disorder is proximately due to or the result of a service-connected disability. 38 C.F.R. § 3.310(a). Secondary service connection includes the concept of aggravation of a nonservice-connected disability by a service-connected disability. Allen v. Brown, 7 Vet. App. 439 (1995). Evidentiary Standards VA must give due consideration to all pertinent medical and lay evidence in a case where a veteran is seeking service connection. 38 U.S.C.A. § 1154(a). The Veteran does not argue, and the record does not show, that the claimed disabilities were the result of participation in combat with the enemy. Competency is a legal concept in determining whether medical or lay evidence may be considered, in other words, whether the evidence is admissible as distinguished from weight and credibility, a factual determination going to the probative value of the evidence, that is, does the evidence tend to prove a fact, once the evidence has been admitted. Rucker v. Brown, 10 Vet. App. 67, 74 (1997). Competent lay evidence means any evidence not requiring that the proponent have specialized education, training, or experience. Lay evidence is competent if it is provided by a person who has knowledge of facts or circumstances and conveys matters that can be observed and described by a lay person. 38 C.F.R. § 3.159. Competent medical evidence means evidence provided by a person who is qualified through education, training, or experience to offer a medical diagnosis, statement, or opinion. 38 C.F.R. § 3.159. The Board, as fact finder, must determine the probative value or weight of the admissible evidence. Washington v. Nicholson, 19 Vet. App. 362, 369 (2005) (citing Elkins v. Gober, 229 F.3d 1369, 1377 (Fed. Cir. 2000) ("Fact-finding in veterans cases is to be done by the Board")). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the Veteran. 38 U.S.C.A. § 5107(b). Facts and Analysis Aseptic Necrosis of the Left Hip In September 2007, the Veteran filed a claim of service connection for aseptic necrosis of the left hip. In a February 2010 statement, she did not refer to necrosis of her hip but indicated that she had arthritis in her hips. At a March 2010 hearing, she testified that both of her hips hurt. In reference to her left hip, she indicated that it began to give her problems about three or four years previously. She noted that a recent VA X-ray showed arthritis. The Veteran served on active duty from July 1985 to September 1993, with a prior period of active duty for training from March 22, 1984, to August 9, 1984. There is no in-service documentation of any complaints, treatment, or diagnosis of left hip disability. After service, private and VA records do not show complaints or treatment of a left hip condition for many years. In 2010, the Veteran testified that she first began having problems with her left hip about three or four years previously. Records from Moncrief Army Community Hospital indicate that in September 2007 the Veteran complained of some radiating pain into the hip. There were no abnormal clinical findings on evaluation of the hips. VA X-rays of the hips in December 2009 show joint spaces were maintained and femoral head contours were unremarkable. The only finding was some degenerative change at the sacroiliac joints. A review of the foregoing records shows that there was no objective evidence of left hip necrosis at any time after service. As there is no competent medical evidence of record showing that the Veteran actually has necrosis of the left hip, as claimed, service connection under any theory of entitlement cannot be granted in the absence of a present disability of hip disability. That a condition or injury may have occurred or be shown in service alone is not enough; there must be a current disability resulting from that condition or injury. Chelte v. Brown, 10 Vet. App. 268, 271 (1997). In the absence of proof of a present left hip necrosis disability, there can be no valid claim. Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). To the extent that X-rays showed some degenerative change associated with sacroiliac joints, which are in the same anatomical region as the hips, the Board notes that such finding is reserved for initial consideration by the RO, in relation to a claim of service connection for arthritis of the joints referred to the RO in the Introduction of this decision. The Veteran as a lay person may establish a diagnosis of a simple medical condition, a contemporaneous medical diagnosis, or symptoms that later support a diagnosis by a medical professional. Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). And in certain circumstances, the Veteran as a lay person is competent to offer an opinion on a simple medical condition. Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009) (citing Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007)). Competent lay evidence means any evidence not requiring that the proponent have specialized education, training, or experience; lay evidence is competent if it is provided by a person who has knowledge of facts or circumstances and conveys matters that can be observed and described by a lay person); Layno v. Brown, 6 Vet. App. 465, 469 (1994) (A witness must have personal knowledge in order to be competent to testify to a matter; personal knowledge is that which comes to the witness through the use of the senses.). Competency is a question of fact, which is to be addressed by the Board. Jandreau at 1377. Although a lay person is competent to describe symptoms, aseptic necrosis of the left hip is not a condition under case law that has been found to be capable of lay observation, and therefore the determination as to the presence or diagnosis of such a disability is medical in nature, that is, not capable of lay observation, and competent medical evidence is required to substantiate the claim. Savage v. Gober, 10 Vet. App. 488, 498 (1997) (On the question of whether the veteran has a chronic condition since service, the evidence must be medical unless it relates to a condition as to which, under case law, lay observation is competent); Barr v. Nicholson, 21 Vet. App. 303 (2007) (Lay testimony is competent to establish the presence of observable symptomatology, where the determination is not medical in nature and is capable of lay observation). The presence or diagnosis of aseptic necrosis of the left hip cannot be made by the Veteran based own personal observation as such a disability cannot be perceived through the use of the senses, for example, by visual observation, and therefore such a disability is not a simple medical condition. And no factual foundation has been established to show that the Veteran is otherwise qualified through specialized education, training, or experience to diagnose aseptic necrosis of the left hip. For these reasons, the Veteran's lay statements are not competent evidence on the question of the presence or diagnosis of aseptic necrosis of the left hip, since service or currently, and the lay statements are excluded, that is, not to be considered as evidence favorable to the claim. To the extent lay evidence may relate to a contemporaneous medical diagnosis or symptoms that later support a diagnosis by a medical professional, there is no competent medical evidence of current aseptic necrosis of the left hip. To the extent, the Veteran's lay statements are offered as proof that the claimed disability is related to the service-connected TTP, as previously noted the Veteran as a lay person is competent to offer an opinion on a simple medical condition. However, a lay opinion is limited to inferences that are rationally based on a lay persons' perception and does not require specialized education, training, or experience. An opinion on causation in this case requires competent evidence provided by a person who is qualified through education, training, or experience to offer a medical diagnosis, statement, or opinion. 38 C.F.R. § 3.159. And as no factual foundation has been established to show that the Veteran is qualified through specialized education, training, or experience to offer such an opinion on causation, the Veteran's lay opinion is not competent evidence and are not to be considered as favorable evidence in support of the claim of service connection, including due to the service-connected TTP. And in the absence of competent evidence suggesting the presence of necrosis of the left hip or an association between the claimed disability and TTP, and in the absence of credible evidence of continuity of symptomatology, there is no possible association with service, and VA is not required to further develop the claim by affording the Veteran a VA examination or by obtaining a VA medical opinion under the duty to assist. 38 U.S.C.A. § 5103A(d)(2); 38 C.F.R. § 3.159(c)(4); McLendon v. Nicholson, 20 Vet. App. 79 (2006). In the absence of proof of present aseptic necrosis of the left hip, there can be no valid claim. Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). It is the Veteran's general evidentiary burden to establish all elements of the claim, including evidence of a current disability. 38 U.S.C.A. § 5107(a); Fagan v. Shinseki, 573 F.3d. 182, 1287 (Fed. Cir. 2009). As there is no favorable competent evidence of current aseptic necrosis of the left hip, the preponderance of the evidence is against the claim, and the benefit-of-the-doubt standard of proof does not apply. 38 U.S.C.A. § 5107(b). Disabilities of the Cervical and Lumbosacral Spine In January 2007, the Veteran filed a claim of service connection for low back pain, which she indicated was osteoporosis from TTP medication (prednisone) usage over a prolonged period (over 13 years). In an August 2008 statement, the Veteran asserted that MRIs of her lumbosacral spine showed degenerative joint disease, spondylosis, and bulging disks, all due to over 15 years of prednisone usage. She also claimed that degenerative joint disease of the cervical spine was due to her long time usage of prednisone. In March 2010, she testified that she had had problems with her neck for about five or six years and was diagnosed with arthritis. She stated that problems with her lumbar spine began long before that, dating probably after service. She contended that the cervical and lumbar problems were attributable to the medication and treatment for TTP. The service treatment records do not show a complaint, diagnosis, finding, history or treatment of a cervical spine disability or a lumbosacral spine disability. On the basis of the service treatment records, degenerative joint disease of the cervical and lumbosacral spine, and lumbosacral strain, were not affirmatively shown to have had onset during service, and service connection under 38 U.S.C.A. §§ 1110, 1131 and 38 C.F.R. § 3.303(a) is not established. After service, records show that the Veteran underwent a VA examination in July 2007 specifically to determine whether the effects of medication were causing her lower back pain condition. The Veteran also wondered whether a spinal tap from diagnostic testing in service was the cause of low back pain and muscle spasms. X-rays of the lumbosacral spine were negative. The diagnosis was chronic lumbosacral strain. The examiner provided an addendum opinion in September 2007, concluding that there was no supporting evidence in the file connecting prednisone treatments with chronic lumbosacral strain and that research of the medical literature did not uncover a link between chronic prednisone use and lumbosacral strain. Private medical records show that beginning in September 2007 the Veteran complained of low back pain and muscle spasms. She denied a history of injury. The diagnosis was sciatica. In February 2008, a private bone mineral density examination of the lumbar spine was within normal range. On a visit to Sumter Neurology in March 2008, the Veteran complained of a history of back aches. M.W., M.D., ordered MRIs of the cervical spine and lumbar spine. In March 2008 a cervical spine MRI was generally unremarkable, although there was minimal degenerative disc disease noted with minor disc bulging. A lumbar spine MRI was abnormal due to shallow disc herniations at L4-5 and L5-S1, which created a moderate central canal stenosis and lateral recess stenosis. As there is no competent evidence during service or since service that a cervical spine disability or a lumbosacral spine disability was noted, that is, observed during service, the principles of service connection pertaining to chronicity and continuity of symptomatology under 38 C.F.R. § 3.303(b) do not apply. Savage v. Gober, 10 Vet. App. 488, 495-96 (1997). It is the Veteran's general contention that her spinal disabilities are related to her service-connected TTP and its medication. Also, she has testified that her difficulties with the cervical spine and lumbosacral spine began after service, and many years after service in the case of the cervical spine. As for service connection based on the initial diagnosis after service under 38 C.F.R. § 3.303(d), there is no competent evidence that links the current cervical spine disability, diagnosed as minimal degenerative disc disease, and the current lumbosacral spine disability, diagnosed as strain and subsequently as degenerative disc disease from disc herniations at L4-5 and L5-S1, to an injury or disease or event in service. Although the Veteran is competent to describe symptoms such as pain in the cervical and lumbosacral spine regions, see Layno v. Brown, 6 Vet. App. 465, 469 (1994), degenerative disc disease of the cervical and lumbosacral spine and lumbosacral strain are not conditions under case law that have been found to be capable of lay observation, and the determination as to the presence or diagnosis of such disabilities therefore is medical in nature. Savage v. Gober, 10 Vet. App. 488, 498 (1997). The Veteran as a lay person is competent to identify a simple medical condition, a contemporaneous medical diagnosis, or symptoms that later support a diagnosis by a medical professional. Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). Also, the Veteran as a lay person is competent to offer an opinion on a simple medical condition. Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009) (citing Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007)). Competency is a question of fact, which is to be addressed by the Board. Jandreau at 1377. As the presence or diagnosis of degenerative disc disease of the cervical and lumbosacral spine and of lumbosacral strain cannot be made by the Veteran as a lay person based on mere personal observation, that is, perceived by visual observation or by any other of the senses, the cervical and lumbosacral spine disabilities are not a simple medical conditions that the Veteran is competent to identify. And it is not argued or shown that the Veteran is otherwise qualified through specialized education, training, or experience to offer diagnoses of such disabilities. Where, as here, there is a question of the presence or a diagnosis of cervical and lumbosacral spine disabilities, not capable of lay observation by case law, and cervical and lumbosacral spine disabilities are not a simple medical conditions under Jandreau for the reason previously expressed, to the extent the Veteran's statements are offered as proof of the presence of such disabilities in service, the Veteran's statements are not competent evidence, and the statements are excluded, that is, not admissible as evidence, and the statements are not to be considered as competent evidence favorable to claims. As for the Veteran describing a contemporaneous medical diagnosis, there is no diagnosis of cervical and lumbosacral spine degenerative disc disease or of lumbosacral strain before 2007, and no health-care professional diagnosed the disabilities before 2007 based on symptoms described by the Veteran. And in the absence of credible evidence of persistent or recurrent symptoms since service or an equivocal medical nexus opinion about a cervical or lumbosacral spine disability and a possible association with an injury, disease, or event in service, or with a service-connected disability, a VA medical examination or medical opinion is not required to decide the claims under 38 C.F.R. § 3.159(c)(4); McLendon v. Nicholson, 20 Vet. App. 79 (2006). To the extent the Veteran has expressed the opinion that her cervical and lumbosacral spine disabilities are related to service-connected TTP, the Veteran's opinion as a lay person is limited to inferences that are rationally based on the Veteran's perception and does not require specialized education, training, or experience. Here the question of the relationship between cervical and lumbosacral spine disabilities and the service-connected TTP is not one that involves a simple medical condition as the Veteran as a lay person is not competent to declare either the presence or diagnosis of degenerative disc disease of the cervical and lumbosacral spine and lumbosacral strain based on personal observation, so that any inference based on what is not personally observable cannot be competent lay evidence. And it is not argued or shown that the Veteran is otherwise qualified through specialized education, training, or experience to offer an opinion on the relationship between her spinal disabilities and the service-connected TTP and it medication. As noted above, the disabilities of the spine were first documented many years after service, that is, well beyond the one-year presumptive period (following the date of separation from military service in September 1993) for such conditions as a chronic disease under 38 U.S.C.A. §§ 1112 and 1137 and 38 C.F.R. §§ 3.307, 3.309. In sum, the evidence shows that cervical spine and lumbosacral spine disabilities did not manifest until many years after separation from active service, and are not otherwise related to active service including to a service-connected disability, as particularly alleged. As a result, the Board finds that the preponderance of the evidence weighs against the Veteran's claims, and the benefit-of-the-doubt standard of proof does not apply. 38 U.S.C.A. § 5107(b). III. Rating Depression A disability rating is determined by the application of VA's Schedule for Rating Disabilities (Rating Schedule). The percentage ratings contained in the Rating Schedule represent, as far as can be practicably determined, the average impairment in earning capacity resulting from diseases and injuries incurred or aggravated during military service and their residual conditions in civil occupations. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4. Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating. Otherwise the lower rating will be assigned. 38 C.F.R. § 4.7. VA has a duty to acknowledge and consider all regulations that are potentially applicable through the assertions and issues raised in the record, and to explain the reasons and bases for its conclusions. Schafrath v. Derwinski, 1 Vet. App. 589, 592-93 (1991). The Board will consider whether separate ratings may be assigned for separate periods of time based on facts found, a practice known as "staged ratings," whether it is an initial rating case or not. Fenderson v. West, 12 Vet. App. 119, 126-27 (1999); Hart v. Mansfield, 21 Vet. App. 505, 510 (2007). When evaluating a mental disorder, the rating agency shall consider the frequency, severity, and duration of psychiatric symptoms, the length of remissions, and the veteran's capacity for adjustment during periods of remission. The rating agency shall assign an evaluation based on all the evidence of record that bears on occupational and social impairment rather than solely on the examiner's assessment of the level of disability at the moment of the examination. Further, when evaluating the level of disability from a mental disorder, the rating agency shall consider the extent of social impairment, but shall not assign an evaluation based solely on the basis of social impairment. The focus of the rating process is on industrial impairment from the service-connected psychiatric disorder, and social impairment is significant only insofar as it affects earning capacity. 38 C.F.R. §§ 4.126, 4.130. Depression is evaluated under 38 C.F.R. § 4.130, Diagnostic Code 9434, for major depressive disorder. Ratings are assigned according to the manifestation of particular symptoms. However, the use of the term "such as" in 38 C.F.R. § 4.130 demonstrates that the symptoms after that phrase are not intended to constitute an exhaustive list, but rather are to serve as examples of the type and degree of the symptoms, or their effects, that would justify a particular rating. Mauerhan v. Principi, 16 Vet. App. 436 (2002). Accordingly, the evidence considered in determining the level of impairment from depression under 38 C.F.R. § 4.130 is not restricted to the symptoms provided in Diagnostic Code 9434. Instead, VA must consider all symptoms of a claimant's condition that affect the level of occupational and social impairment, including, if applicable, those identified in the DSM-IV (American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders (4th ed. 1994)). The Veteran's depression has been rated as 30 percent disabling under 38 C.F.R. § 4.130, Diagnostic Code 9434, ever since service connection was established effective in September 2006. The criteria for Diagnostic Code 9434, for major depressive disorder, are as follows. The criteria for a 30 percent rating are occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, mild memory loss (such as forgetting names, directions, recent events). The criteria for the next higher rating, a 50 percent rating, are occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; and difficulty in establishing and maintaining effective work and social relationships. The Global Assessment of Functioning (GAF) score is a scale reflecting the "psychological, social, and occupational functioning in a hypothetical continuum of mental health-illness." DSM-IV at 32. GAF scores ranging from 61 to 70 reflect mild symptoms (e.g., depressed mood and mild insomnia) or some difficulty in social, or school functioning, but generally functioning pretty well, has some meaningful interpersonal relationships. Scores ranging from 51 to 60 reflect moderate symptoms (e.g., flat affect and circumstantial speech, occasional panic attacks) or moderate difficulty in social, occupational, or school functioning (e.g., few friends, conflicts with peers or co-workers). See Carpenter v. Brown, 8 Vet. App. 240, 242 (1995). In this case, as will be discussed, the Board has given consideration to the propriety of "staged ratings" for the depression over the period of time since service connection became effective in September 2006. See Fenderson v. West, 12 Vet. App. 119 (1999). The Board concludes that the evidence does not show the Veteran's disability approximating the criteria for an initial rating higher than 30 percent at any period considered in this appeal. The Veteran's claim for service connection for depression was received in September 2006. In a statement of January 2007, the Veteran claimed that she had depression, although she did not yet have a diagnosis of such a condition. She indicated that her disorder was manifested by anxiety, lack of sleep, and depression due to TTP. On VA examination in August 2007, the Veteran complained of a depressed mood and a loss of interest in the usual activities. She also experienced significant anxiety as to when her next episode of TTP would occur. She related poor sleep and an irritable mood. She said she was frequently tearful. She was not currently taking any medication for treatment of depressive symptoms. She denied suicidal and homicidal ideation. She complained of difficult with memory and concentration at work. She was employed. On mental status examination, the Veteran appeared appropriately dressed and groomed. Her speech was clear, coherent, and goal directed. She was alert and oriented to time, place, and person. There was no psychomotor agitation or retardation noted. Her short-term memory and concentration were somewhat impaired. Long-term memory was within normal limits. There was no evidence of any thought or perceptual disturbance. Insight and judgment were adequately developed. Her fund of information and level of intelligence were in the average to above average range. She was tearful at some points during the evaluation. Her affect was mood congruent. The diagnosis was depressive disorder due to general medical condition. The GAF score was 60. She was competent to manage her own benefits. The examiner found that the Veteran was currently experiencing a mild to, at times, moderate level of impairment in social and occupational functioning. Private medical records from Northeast Psychiatry show that the Veteran was referred there for anxiety. Her appearance was neat and cheerful. She was oriented. Speech was clear. Mood was anxious with anticipatory anxiety. Affect was congruent. There was no suicidal or homicidal ideation or auditory/visual hallucinations. As for depressive symptoms, there was occasional depression. Judgment and insight were good. Thought process was linear. Recall was intact. The diagnosis was major depression, related to medical problem. The GAF score was 65, denoting mild symptoms (as provided on a scale noted in the record). She was begun on a trial of medications. On a follow up visit later that month, the Veteran reported some relief from symptoms and having slept much better. She was to continue her medication therapy. VA records show that the Veteran was seen in December 2009 with a complaint of depression. She underwent a suicide risk assessment because she had been positive on a screen for feelings of hopelessness. It was noted that she had worked at VA RO for over three years. Mental status examination findings were similar to those noted on the VA examination. She also reported having panic attacks (palpitations, shortness of breath, and a warm feeling) two to three times a week, when she observed bruising or was concerned about her platelet count. The assessment was mood disorder due to a general medical condition. The GAF score was 65. Likewise, in February 2010, the GAF score was 65, when the Veteran was seen with findings consistent with those of previous VA evaluations. In March 2010, the Veteran testified that in terms of problems caused by depression at work, she experienced a lack of concentration. She also noted periods of sadness and tearfulness and irritability. She indicated that she did not socialize as much as she previously had. She also mentioned panic attacks. In reviewing the medical evidence, the Veteran's GAF scores ranged from 60 to 65, reflective of mild to moderate symptoms. On the basis of the report of the VA examination, the Veteran's social and occupational impairment from her depressive disorder is characterized as mild and at times moderate. The GAF scores in conjunction with the findings of VA and a private evaluation show that the Veteran's symptoms are encompassed in the criteria for the current 30 percent rating. That is, the service-connected depression is shown to be productive of a disability picture that equates to occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal). The disorder is shown to consistently be productive of the following criteria that are characteristic of the type and severity of a disorder for which a 30 percent disability rating is most appropriate: depressed mood, anxiety, suspiciousness, panic attacks (weekly), chronic sleep impairment, mild memory loss (such as forgetting names, directions, recent events). The disorder is not shown to consistently be productive of the following criteria that are characteristic of the type and severity of a disorder for which a 50 percent disability rating would be warranted: flattened affect; circumstantial, circumlocutory, or stereotyped speech; difficulty in understanding complex commands; impairment of long-term memory; impaired judgment; impaired abstract thinking; and difficulty in establishing and maintaining effective work and social relationships. Considering the psychiatric symptomatology that is generally characterized as mild, particularly short-term memory and concentration impairment, irritability, some sleep difficulty, and anxiety with panic attacks, the severity of the Veteran's depression is consistent with the assignment of a 30 percent disability rating. And the psychiatric symptomatology is not to a degree that more nearly approximates the schedular criteria for a 50 percent rating. For the reasons expressed, the symptomatology associated with the rating criteria under the General Rating Formula and symptomatology associated with the diagnosis of major depressive disorder under the DSM-IV do not more nearly approximate or equate to occupational and social impairment, resulting in reduced reliability and productivity for the next higher rating. As the preponderance of the evidence is against an initial disability rating higher than 30 percent for depression, the benefit-of-the-doubt standard of proof does not apply. 38 U.S.C.A. § 5107(b). Extraschedular Consideration Although the Board is precluded by regulation from assigning an extraschedular rating under 38 C.F.R. § 3.321(b)(1) in the first instance, the Board is not precluded from considering whether the case should be referred to the Director of VA's Compensation and Pension Service for a rating. The threshold factor for extraschedular consideration is a finding that the evidence presents such an exceptional disability picture that the available schedular ratings for the service-connected disability are inadequate. This is accomplished by comparing the level of severity and symptomatology of the service-connected disability with the established criteria. If the criteria reasonably describe a disability level and symptomatology, then the disability picture is contemplated by the Rating Schedule, and the assigned schedular rating is, therefore, adequate and referral for an extraschedular rating is not required. Thun v. Peake, 22 Vet. App. 111, 115 (2008). A review of the record indicates that the Veteran is gainfully employed. Further, as the symptoms of her depression are contemplated by the Rating Schedule, the assigned schedular rating is, therefore, adequate. Consequently, referral for extraschedular consideration is not required under 38 C.F.R. § 3.321(b)(1). ORDER As new and material evidence has been presented, the claim of service connection for migraine headaches to include as secondary to TTP is reopened, and to this extent only the appeal is granted. As new and material evidence has been presented, the claim of service connection for sinusitis is reopened, and to this extent only the appeal is granted. Service connection for aseptic necrosis of the left hip, for a cervical spine disability, and for a lumbosacral spine disability, to include as secondary to TTP, is denied. An initial rating higher than 30 percent for depression is denied. REMAND Prior to considering the claims of service connection for migraine headaches and sinusitis on the merits, under the duty to assist additional evidentiary development is needed, including a VA examination. 38 C.F.R. § 3.159(c)(4); McLendon v. Nicholson, 20 Vet. App. 79 (2006). On the claims for a higher rating for TTP and anemia, the evidence is not adequate to evaluate the disabilities. The most recent VA examination for TTP was in April 2004 and the Veteran's platelet counts and current medication regimen is not known (lab records from Moncrief Army Community Hospital show that the platelet count decreased from November to December 2009). Since the VA examination in 2004, service connection has been established for anemia secondary to TTP on the basis of a private medical opinion in October 2007 linking the two conditions. The Veteran's hemoglobin level was 11.1 gm. in October 2007, but an August 2008 record shows that it has since worsened to 8.9 gm. Further, the Veteran has complained of symptoms such as fatigability, headaches, and shortness of breath related to her disabilities. The Board notes that private medical records dated from 2008 to 2010 reflect that the Veteran was receiving treatment for vitamin B12 deficiency and the diagnosis was iron deficiency anemia, which is indicated to be a microcytic type of anemia. However, service treatment records noted treatment for hemolytic anemia and in a March 1995 report from Eglin Air Force Base, she was diagnosed with microcytic anemia that was not due to iron deficiency. In an August 2008 statement, S.M., M.D., noted that the Veteran has had anemia for as long as she has had TTP and that recently it has worsened and she required iron tablets. Thus, a VA examination is needed to clarify and distinguish what type of anemia is related to the Veteran's service-connected TTP and the manifestations and symptoms of such. On the claims of service connection for weight gain, swelling of the hands and feet, glycosuria, hives, hair loss, gastroesophageal reflux disease, shortness of breath, and peripheral neuropathy of the extremities, the evidence of record is insufficient to decide the claims, and a VA medical examination and a medical opinion are needed under the duty to assist. Each of these conditions is claimed to be associated with the service-connected TTP or anemia. In an October 2007 statement, S.M., M.D., appeared to relate the Veteran's swelling, neuropathy, hair loss, and fungal type skin infections to the longstanding TTP and its medications. There has been no medical statement related to whether any weight gain and high levels of glucose is a manifestation of the Veteran's disease (high levels of glucose in the blood has been documented, however). A VA examiner had earlier in July 2007 dissociated hives or urticaria and hair loss to TTP medication, but did not provide any opinion as to a fungal type skin infection. A VA examiner in October 2008 discounted a connection between gastroesophageal reflux disease and the Veteran's Prednisone use for TTP, but did not discuss side effects of other medication such as Persantine (also known for having gastrointestinal side effects). In an August 2008 statement, S.M., M.D., noted the Veteran's problems with dyspnea on exertion related to anemia. The same physician also noted in October 2007 that the Veteran's neuropathy was a complication of TTP and its medication, but subsequently a nerve conduction study was normal in March 2008 and a VA examiner in a November 2008 addendum report stated that a nerve conduction study showed only bilateral ulnar neuropathy at the elbows that was not related to any other diagnosis in the Veteran. In short, VA examinations are needed to clarify the current status of the Veteran's TTP, the type of anemia related to the TTP, and all of the symptom manifestations of the TTP and associated anemia. On the claim for an earlier effective date for the grant of service connection for anemia, in a rating decision in February 2008, the RO granted service connection for anemia, assigning the date of receipt of the claim on September 8, 2006, as the effective date of the award. In an August 2008 statement, which is construed as a notice of disagreement with the effective date, the Veteran indicated that it was error for the RO to assign the date of her claim when there was evidence of anemia dating back to military service. When there has been adjudication by the RO and a timely notice of disagreement has been filed, a statement of the case addressing the issue must be furnished to the Veteran. Manlincon v. West, 12 Vet. App. 238 (1999). Accordingly, the case is REMANDED for the following action: 1. Afford the Veteran a VA neurologic examination to determine whether it is more likely than not (probability greater than 50 percent), at least as likely as not (probability of 50 percent), less likely than not (probability less than 50 percent), or an opinion is not possible without resort to speculation, that the current headache condition is related to an injury, disease, or event in service or to the service-connected disabilities of TTP and/or anemia including medication for such disabilities. The VA examiner is asked to consider and comment as necessary on the clinical significance of the following. In testimony and statements, the Veteran indicated that she was treated for headaches during and ever since service (for which she is competent to state). Service treatment records show treatment for headaches during service in 1989, diagnosed as tension headaches. Post-service records show she is currently treated privately and through VA for headaches. In May 1994, a VA examiner diagnosed probable episodic, tension type headaches. In April 1999, a VA examiner noted that whenever the Veteran's platelet count dropped below a certain threshold she began having headaches. In private medical statements in October 1998, October 2007, and August 2008, S.M., M.D., linked the headaches to TTP and to anemia. If, however, after a review of the record, an opinion on causation is not possible without resort to speculation, the examiner is asked to clarify whether actual causation cannot be determined because an opinion on causation is beyond what may be reasonably concluded based on the evidence of record and current medical knowledge. The Veteran's file must be made available to the VA examiner for review. 2. Afford the Veteran a VA ear, nose, throat examination to determine whether it is more likely than not (probability greater than 50 percent), at least as likely as not (probability of 50 percent), less likely than not (probability less than 50 percent), or an opinion is not possible without resort to speculation, that the current sinusitis is related to an injury, disease, or event in service. The VA examiner is asked to consider and comment as necessary on the clinical significance of the following. In testimony and statements, the Veteran asserted that she was treated for sinusitis during and ever since service (for which she is competent to state). Service treatment records showing treatment for sinusitis during service in July 1991, February 1993, and March 1993. Post-service private and VA records show that the Veteran is treated currently for sinusitis (an MRI of the brain in March 2008 showed paranasal sinus disease). If, however, after a review of the record, an opinion on causation is not possible without resort to speculation, the examiner is asked to clarify whether actual causation cannot be determined because an opinion on causation is beyond what may be reasonably concluded based on the evidence of record and current medical knowledge. The Veteran's file must be made available to the VA examiner for review. 3. Afford the Veteran an appropriate VA examination to evaluate the level of impairment due to include all symptom manifestations of the disease and of the treatment for the disease. The examiner is requested to comment on the following: (a) Is the Veteran's TTP manifested by a platelet count that is between 20,000 and 70,000 or a platelet count that is less than 20,000; is there bleeding associated with the TTP; and does the TTP require treatment with medication and transfusions? (b) What type of anemia is associated with the Veteran's TTP or its medication? (c) Of the following claimed symptoms and conditions, which are manifestations of or aggravated by TTP or anemia related to the TTP, or medication taken for TTP or anemia: weight gain, swelling of the hands and feet, glycosuria or elevated blood sugar, hives or a skin disorder, hair loss, gastroesophageal reflux disease, shortness of breath, and peripheral neuropathy of the extremities. The Veteran's file must be made available to the VA examiner for review. 4. After the above development is completed, adjudicate the claims. If any benefit sought remains denied, furnish the Veteran and her representative a supplemental statement of the case and return the case to the Board. 5. Furnish the Veteran a statement of the case on the claim of an effective date prior to September 8, 2006, for the grant of service connection for anemia. In order to perfect an appeal of the claim to the Board, the Veteran must still timely file a substantive appeal after issuance of the statement of the case. 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 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. 2010). ______________________________________________ George E. Guido Jr. Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs