Citation Nr: 1202990 Decision Date: 01/27/12 Archive Date: 02/07/12 DOCKET NO. 09-38 934 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Montgomery, Alabama THE ISSUES 1. Entitlement to service connection for a lumbar spine disorder. 2. Entitlement to service connection for uterine fibroids and ovarian cysts. 3. Entitlement to service connection for a disorder resulting in vertigo, to include Meniere's disease. 4. Entitlement to an initial compensable evaluation for gastroesophageal reflux disease (GERD). 5. Entitlement to an initial compensable evaluation for bilateral carpal tunnel syndrome. REPRESENTATION Appellant represented by: The American Legion WITNESS AT HEARING ON APPEAL Veteran ATTORNEY FOR THE BOARD James G. Reinhart, Counsel INTRODUCTION The Veteran served on active duty from April 1999 to May 2006. This matter comes before the Board of Veterans' Appeals (Board) on appeal from an October 2007 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Montgomery, Alabama. In October 2011, the Veteran testified at a personal hearing before the undersigned Veterans Law Judge. A transcript of the hearing is associated with the claims file. The issue of entitlement to an initial compensable evaluation for bilateral carpal tunnel syndrome is addressed in the REMAND portion of the decision below and is REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. FINDINGS OF FACT 1. The Veteran's lumbar spine disorder was incurred in active service. 2. The Veteran's uterine fibroids and ovarian cysts were incurred in active service. 3. The Veteran's Meniere's disease was incurred in active service. 4. The Veteran's GERD results in reflux, regurgitation, epigastric pain, dysphagia, and dyspepsia but does not result in material weight loss, hematemesis, melena, or considerable or greater impairment of health. CONCLUSIONS OF LAW 1. The criteria for service connection for a lumbar spine disorder have been met. 38 U.S.C.A. §§ 1110 5107(b) (West 2002); 38 C.F.R. §§ 3.102, 3.303 (2011). 2. The criteria for service connection for Meniere's disease have been met. 38 U.S.C.A. §§ 1110, 5107(b) (West 2002); 38 C.F.R. §§ 3.102, 3.303 (2011). 3. The criteria for service connection for uterine fibroids and ovarian cysts have been met. 38 U.S.C.A. §§ 1110, 5107(b) (West 2002); 38 C.F.R. §§ 3.102, 3.303 (2011). 4. The criteria for a 10 percent disability evaluation, but no higher, for GERD, have been met for the entire appeal period. 38 U.S.C.A. §§ 1155, 5107(b) (West 2002); 38 C.F.R. §§ 4.1, 4.2, 4.7, 4.10, 4.20, 4.21, 4.114, Diagnostic Code 7346 (2011). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Duties to notify and assist As provided for by the Veterans Claims Assistance Act of 2000 (VCAA), VA has a duty to notify and assist claimants in substantiating claims for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2011); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2011). Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant and his or her representative, if any, of any information, and any medical or lay evidence, that is necessary to substantiate the claim. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b); Quartuccio v. Principi, 16 Vet. App. 183 (2002). Proper notice from VA must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. 38 C.F.R. § 3.159(b)(1). This notice must be provided prior to an initial unfavorable decision on a claim by the RO. Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004). For service-connection claims, this notice must address the downstream elements of a disability rating and an effective date. Dingess v. Nicholson, 19 Vet. App. 473 (2006). The claim that gave rise to the decision on appeal was received by VA in September 2006. VA's duty to notify was satisfied by way of letters sent to the Veteran in October 2006 and December 2006, prior to the initial adjudication of her claims by the RO. The letters informed the Veteran of what evidence was required to substantiate the claims and of her and VA's respective duties for obtaining evidence. The letters included notice as to what evidence is considered in determining assignment of disability ratings and effective dates. VA sent an additional notice letter to the Veteran in December 2007. VA has a duty to assist claimants in the development of claims. This duty includes assisting claimants in the procurement of service and other pertinent treatment records and providing examinations when necessary. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. The Board finds that all necessary development has been accomplished, and therefore appellate review may proceed without prejudice to the Veteran. See Bernard v. Brown, 4 Vet. App. 384 (1993). The RO has obtained service and VA treatment records. Either by submission by the Veteran or with VA assistance, all identified private treatment records have been associated with the claims file. As to the issues of entitlement to service connection, it is not necessary to address whether the duty to assist has been met. Assuming, without deciding, that there has been an error in the duty to assist, any such error would is harmless and does not warrant delaying adjudication of the claims for service connection in order to remand those claims for further assistance. This is because the Board in this document grants the appeal as to those issues. As the benefit sought with regard to those issues is granted, the purpose of VA's duty to assist has been achieved and any defect in VA's duty to assist is harmless error. VA afforded the Veteran examinations with regard to the GERD issue in July 2007 and April 2009, the latter through QTC Medical Services. The July 2007 examination report documents that the Veteran's claims file was not provided for review. The July 2007 examination report does include a history of the Veteran's GERD, apparently provided by the Veteran. There is no indication that the physician who examined the Veteran in April 2009 had the claims file for review. That examiner indicated that the history obtained was that related by the Veteran. In order to apply the rating schedule, both in the examination and the evaluation of a disability, the disability must be viewed in relation to its history. 38 C.F.R. § 4.1. However, the "absence of claims file review" by an examiner does not "categorically exclude the possibility that he is nevertheless informed of the relevant facts." Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 303 (2008). As to the July 2007 and April 2009 examinations, the histories provided by the Veteran to each examiner are not any less complete or detailed than relevant evidence of record at the time of each examination. At the time of the July 2007 examination the only evidence of record was that found in the service treatment records. Relevant evidence in the service treatment records was no more detailed than, for example, an October 2005 entry that the Veteran had reported heart burn off and on during the day of two weeks duration and a March 2006 entry that the Veteran was taking medication for heartburn. At the time of the April 2009 examination there also was no evidence associated with the claims file more detailed or different from what the Veteran reported to the examiner. The reports in VA treatment records were not more detailed than those found in July 2008 records noting that she had chest pressure/knot with GERD with nausea. Because the histories provided by the Veteran were as complete and detailed as any history of her GERD found in the claims file, the absence of review of the claims file by the examiners does not render either examination inadequate. Both examiners provided sufficient findings and considered the history of the Veteran's GERD. The examinations are adequate. Neither the Veteran nor her representative has identified, and the record does not otherwise indicate, any additional existing evidence that is necessary for a fair adjudication of the claims that has not been obtained. Hence, no further notice or assistance to the Veteran is required to fulfill VA's duty to assist under the VCAA. Smith v. Gober, 14 Vet. App. 227 (2000), aff'd 281 F.3d 1384 (Fed. Cir. 2002); Dela Cruz v. Principi, 15 Vet. App. 143 (2001); see also Quartuccio v. Principi, 16 Vet. App. 183 (2002). II. Service Connection Service connection may be granted for a disability resulting from a disease or injury incurred in or aggravated by active service. See 38 U.S.C.A. §§ 1110, 1131 (West 2002); 38 C.F.R. § 3.303(a) (2011). "To establish a right to compensation for a present disability, a Veteran must show: "(1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service"-the so-called "nexus" requirement." Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2010) (quoting Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). One way of establishing the nexus element is through evidence of continuity of symptomatology. 38 C.F.R. § 3.303(b) (2011). A showing of continuity of symptomatology requires evidence (1) that the condition was "noted" during service; (2) post-service evidence of the same symptomatology; and (3) medical or, in certain circumstances, lay evidence of a nexus between the present disability and the post-service symptomatology. Barr v. Nicholson, 21 Vet. App. 303, 307 (2007) (citing Savage v. Gober, 10 Vet.App. 488, 495-96 (1997)). "[S]ymptoms, not treatment, are the essence of any evidence of continuity of symptomatology." Savage, 10 Vet. App. at 496. The "noted" in service element requires only that the condition was noted at the time the veteran was in service but such noting need not be reflected in any written documentation contemporaneous to service. Id. In general, a claimant is competent to provide lay statements of observable symptoms of disability and continuity of such symptoms. See Jandreau v. Nicholson, 492 F.3d 1372, 1376 (Fed. Cir. 2007). The value of lay statements of symptoms and continuity of symptomatology, as with any evidence, depends in part on whether it is credible; the mere absence of corroborating contemporaneous medical evidence does not render the statements incredible. Buchanan v. Nicholson, 451 F.3d 1331, 1336-37 (Fed. Cir. 2008). II.A. Lumbar spine disorder During the hearing before the Board, the Veteran testified that she injured her back lifting an aircraft part during service in the U.S. Air Force. June 2003 service treatment records document that the Veteran sought treatment for low back pain with onset after lifting a heavy aircraft part. She was treated for low back pain through the latter half of 2005 and in December 2005 she was placed on physical profile, based in part on low back pain and L5-S1 disc bulge. Although November 2005 lumbosacral x-ray studies were normal, a January 2006 magnetic resonance imaging (MRI) study showed disc bulge at L5-S1 and L4-L5. The impression at that time was mild spondyloarthropathy. The Board finds this service treatment record evidence sufficient to establish that the Veteran had a chronic low back disorder during service. The chronicity is shown not only by the use of the work "chronic" but also by the repeated treatment for low back symptoms. Just 3 months prior to separation from service she continued to exhibit chronic low pain. The report of an acute exacerbation in February 2006 is evidence that this was not treatment for a new injury or disease but rather was part of her unresolved chronic low back disorder. The in-service injury element of a service connection claim is therefore met. She filed her claim for VA disability compensation several months after service and underwent a VA examination in July 2007 pursuant to that claim. Diagnosis was chronic lumbar strain. Although lumbar spine x-rays were requested, the x-ray study was not conducted, apparently through no error on VA's part. Private treatment records from Chastain Resurgens Orthopedics document that an MRI conducted in January 2008 showed L4-L5 disc desiccation with small herniation. In April 2009, the Veteran again underwent a medical examination at the direction of VA and provided through QTC Medical Services. Diagnosis was intervertebral disc syndrome most likely involving the right sciatic nerve. This medical evidence is sufficient for the Board to find that the Veteran has had a low back disorder since she filed her claim for compensation benefits, and therefore the present disability element of a service connection claim is met. This leaves only the nexus element. The preponderance of the evidence shows that this element has been met. In October 2011, the Veteran testified before the Board that her low back symptoms began in 2003 after lifting a heavy object, that the symptoms continued from that point on, and that her symptoms did not ever improve. October 2011 hearing transcript at 14-15. She acknowledged that she had been in an automobile accident after service but explained that her shoulder, not her lower back was affected by that accident. Id. at 15. This testimony is given considerable weight favorable to a finding that the nexus element has been met. The testimony is consistent with other facts of record. For example, she has essentially the same diagnosis now as she did during service. Moreover, the Board finds no evidence that she reinjured her back after service or that the injury during service ever resolved. Because the preponderance of the evidence shows that the Veteran's current lumbar spine disorder had onset with her injury during service, the appeal must be granted as to entitlement to service connection for a lumbar spine disorder. II.B. Uterine fibroids and ovarian cysts The Veteran contends that she has irregular menses, infertility, and hirsutism due to uterine fibroids and ovarian cyst diagnosed during active service. In November 2003 the Veteran sought treatment for amenorrhea and right lower quadrant pain. Radiology and ultrasound studies revealed right and left ovarian cysts and a uterine fibroid. There is a documented normal female examination from October 2005 but in March 2006 the Veteran reported that she was not having a regular cycle. There is thus evidence that she had the claimed condition during service and this evidence is sufficient to establish the in-service element of a service connection claim. August and September 2008 VA treatment notes document the Veteran's concerns about irregular menses, infertility, and hirsutism. The April 2009 examination includes the Veteran's report that she had irregular menses since 2002. Under a diagnosis heading in the examination report, the examiner provided the following: For the claimant's claimed condition of uterine fibroidspolycystic ovarian syndrome, ovarian cyst, the diagnosis is of uterine fibroidspolycystic ovarian syndrome, ovarian cyst. The subjective factors are her complaints of heavy periods, irregular cycle, inability to conceive, pain, and cramps. The objective factors are heavy irregular bleeding during menstruation, irregular cycle with prolonged bleeding during cycles, control with use of medication. [case and spelling corrected]. This is evidence of that the Veteran currently has the claimed condition. It is also evidence that the claimed condition is the same as the condition she had during service. This is because the diagnosis provided in the April 2009 examination report is essentially the same as the in-service diagnosis. This diagnosis along with the inherent nexus evidence is afforded significant probative weight because it was rendered by a medical professional following examination and review of the relevant medical history. The only unfavorable evidence as to this issue is the in-service normal findings from 2005. That isolated item of evidence, without any substantial supporting data or explanation, is afforded little weight. The preponderance of the evidence shows that the Veteran has disability due to the claimed ovarian cysts and uterine fibroid and the current ovarian cysts and uterine fibroid had onset during service. As all elements of a service connection claim have been met, her appeal as to this issue must be granted. II.C. Meniere's disease - vertigo The Veteran contends that she began experiencing vertigo during service and has continued to experience vertigo since service. She has also described her vertigo as dizziness and dizzy spells. Service treatment records include reports that the Veteran denied dizziness in March 2000, had a swollen ear canal in June 2000 but did not mention dizziness, denied dizziness in January 2001, reported dizzy spells and nausea in July 2002 and was assess with dizziness / vertigo of one week duration with a history of vertigo, reported occasional dizziness in December 2003, and denied dizziness in July 2005. The service treatment records provide evidence favorable and unfavorable to a finding that she had a chronic condition resulting in vertigo during service. The conflict is shown principally by the July 2005 report. The Veteran's testimony however is also evidence that she experienced symptoms continuously since service. The Board does not find the record to show that her statements are other than credible and she is competent to report her symptoms. Although the treatment records document that she denied dizziness in July 2005, the Veteran has not stated that her dizziness was constant. It is reasonable to view the July 2005 report as no providing no more than she was not experiencing dizziness at the particular time that she made the report. Weighing all of the relevant evidence as to this element, the Board finds that the Veteran did have dizziness continuously from 2002 through the remainder of her active service. The in-service element of a service connection claim is therefore met. The first relevant post-service evidence is a report of a VA medical examination conducted in July 2007. The examiner noted the Veteran's report that she experienced dizziness twice a day, that this began in 2002, that she was prescribed motion sickness pills which helped the symptoms, and noted the Veteran's description of her dizziness that it feels as if she is spinning. The examiner stated that there was insufficient evidence on examination and history to establish a diagnosis based on dizzy spells. An August 2007 treatment record from Tanner Medical Center documents that the Veteran reported dizziness and includes a diagnosis of vertigo. There is no explanation of a cause of the vertigo. VA treatment records show that she continued to report dizziness. In May 2010 she underwent another VA examination. The examination report includes an accurate history of her symptoms back to 2002. For a diagnosis the examiner listed recurrent vertigo based only on the Veteran's reported symptoms. There is what could be construed as a discrepancy in that the examiner noted that he had been asked to see the Veteran "regarding Meniere's disease which was diagnosed in 2002." There is no diagnosis of Meniere's disease recorded in 2002. That discrepancy is not significant because the relevance of the May 2010 evidence has to do with whether she has a present disability, not whether she was actually diagnosed with Meniere's disease in 2002. Also of record is a May 2010 data analysis report of relevant diagnostic testing. The examiner indicated that the test results were consistent with left unilateral vestibular weakness which is as likely as not associated with Meniere's disease. This diagnosis was rendered based on diagnostic testing conducted May 5, 2010 and provided in an addendum. The diagnosis of recurrent vertigo, supported only by the Veteran's report of dizziness is dated May 4, 2010 and was dictated May 17, 2010. Given that the diagnostic testing was conducted the day after the examination, and given the two different diagnoses, the Board does not find it important that the dictation of the first report took place later. Rather, the diagnosis associating the test results with Meniere's disease the Board finds to be the most probative evidence as to what condition the Veteran has. The Board concludes that the addendum is sufficient evidence to find that the Veteran has Meniere's disease. The present disability element of a service connection claim is therefore met. Diagnostic testing in May 2010 was conducted specifically in response to the Veteran's reports of dizzy spells. It thus follows logically, and does not require any medical opinion statement, that her dizzy spells are due to the Meneire's disease. As to a nexus between her Meniere's disease and the Veteran's in-service dizzy spells, her reports of continuous symptoms since onset in 2002 is sufficiently supported by the record and is sufficient for the Board to find that the nexus element is met. Because the preponderance of evidence supports a finding that the Veteran's Meniere's disease, resulting in vertigo, had onset during service, the appeal as to service connection for disability manifesting as vertigo must be granted. III. Disability evaluation - GERD The Veteran disagrees with the initial noncompensable evaluation assigned for disability due to GERD. Disability ratings are determined by applying the criteria set forth in the VA's Schedule for Rating Disabilities, which is based on the average impairment of earning capacity. Individual disabilities are assigned separate diagnostic codes. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. The basis of disability evaluations is the ability of the body as a whole, or of the psyche, or of a system or organ of the body to function under the ordinary conditions of daily life including employment. 38 C.F.R. § 4.10. In determining the severity of a disability, the Board is required to consider the potential application of various other provisions of the regulations governing VA benefits, whether or not they were raised by the Veteran, as well as the entire history of the Veteran's disability. 38 C.F.R. §§ 4.1, 4.2; Schafrath v. Derwinski, 1 Vet. App. 589, 595 (1991). If the disability more closely approximates the criteria for the higher of two ratings, the higher rating will be assigned; otherwise, the lower rating is assigned. 38 C.F.R. § 4.7. It is not expected that all cases will show all the findings specified; however, findings sufficiently characteristic to identify the disease and the disability therefrom and coordination of rating with impairment of function will be expected in all instances. 38 C.F.R. § 4.21. This appeal arises from the rating decision in which service connection was established for GERD. As such, the Board has considered whether different ratings for different periods of time, based on the facts found, are warranted. See Fenderson v. West, 12 Vet. App. 119 (1999). Such ratings are referred to as "staged ratings." Id. at 126. There is no specific diagnostic code that lists GERD. When an unlisted condition is encountered it is permissible to rate the disability under criteria for a closely related disease or injury, in which not only the function affected, but the anatomical localization and symptomatology are closely analogous. 38 C.F.R. § 4.20. The RO has evaluated disability due to the Veteran's GERD under the criteria found at 38 C.F.R. § 4.114, Diagnostic Code 7346, for hiatel hernia. The criteria at that diagnostic code is closely analogous to the localization and symptomatology of the Veteran's GERD as well as the function affected. The Board finds no more appropriate criteria. Under those criteria a 60 percent rating is assigned where there are symptoms of pain, vomiting, material weight loss and hematemesis or melena with moderate anemia; or other symptom combinations productive of severe impairment of health. 38 C.F.R. § 4.114 , Diagnostic Code 7346. A 30 percent rating is assigned for persistently recurrent epigastric distress with dysphagia, pyrosis, and regurgitation, accompanied by substernal or arm or shoulder pain, productive of considerable impairment of health. Id. A 10 percent rating is assigned when the disease exhibits two or more of the symptoms for the 30 percent evaluation of less severity. Id. In every instance where the rating schedule does not provide a zero percent rating for a diagnostic code, a zero percent rating shall be assigned when the requirements for a compensable rating are not met. 38 C.F.R. § 4.31 The July 2007 examination report includes that the Veteran reported treating her GERD with ranitidine and TUMS but that this did not help improve her symptoms. She reported dyspepsia, belching, occasional dysphagia, and reflux but denied gassiness and stomach pain or irregular bowel movements. Physical examination yielded no results favorable to assigning a compensable evaluation for GERD. During the April 2009 examination, the Veteran reported that she had dysphagia, heartburn, epigastric pain, scapular pain, reflux, and regurgitation of stomach contents. She did not have arm pain, hematemesis, passing of black tarry stools, nausea, or vomiting. She reported that the symptoms occurred all the time, mostly in the morning and at night but constantly. She treated the GERD with Nexium and Omeprazole and used antacids one or two times per day. She reported that when she has a bad episode the medication does not seem to help. She also reported that her symptoms cause her to lose her voice at times, and that her acid reflux wakes her up at night. As to any additional functional impairment she reported losing her voice and that she is hoarse at times. In a diagnosis section of the report, the examiner stated that the Veteran has heartburn, pressure under the lower breast bone, reflux and regurgitation of stomach contents, difficulty swallowing and pain above the stomach. The examiner stated that she has classic reflux symptom complains and that the condition does not cause significant anemia and there were no findings of malnutrition. This examination covered all of her claimed disabilities. In a remarks section the examiner stated that the effect of all her conditions on her usual occupation was moderate but caused fatigue from decreased sleep, chronic GI upset, loss of work time. In October 2011 the Veteran testified that she frequently has regurgitation. This report the Board finds to be consistent with her reports during the examination in April 2009. There is no evidence in the record, and the Veteran has not contended, that her GERD has worsened since the examination. There is no evidence of record showing that the Veteran's GERD has resulted in weight loss. None of the treatment records provide evidence more favorable than that provided by the examination reports and the Veteran's own statements. The Board finds that disability due to the Veteran's GERD approximates the criteria for a 10 percent rating because there is evidence sufficient to find that she has had at least two of the symptoms listed for the 30 percent criteria and that those symptoms are of less severity than indicated in the criteria for the 30 percent rating. The criteria for a schedular rating higher than 10 percent is not approximated because the preponderance of the evidence is against a finding that the Veteran's GERD symptoms are productive of considerable impairment of health. Impairment reported by the Veteran is that she loses her voice at times, is awaken at times from reflux, and is hoarse at times. The Board finds no other evidence showing any greater impairment. Additionally, the preponderance of the evidence shows that the criteria for a 60 percent rating is not approximated. The preponderance of the evidence shows that the Veteran's GERD has never resulted in hematemesis, material weight loss, melena, anemia, or any symptom combination productive of severe impairment of health. From review of all evidence of record, the Board concludes that the criteria for a rating higher than 10 percent for GERD is not approximated. Consistent with Fenderson, the Board has considered whether staged ratings are appropriate in this case. Review of all evidence of record does not disclose any facts that indicate that staged ratings are appropriate here. Hence, the criteria for a 10 percent rating is approximated for all periods of time on appeal but a rating higher than 10 percent is not approximated for any period of time on appeal. Also considered by the Board is whether referral is warranted for a rating outside of the schedule. To accord justice in an exceptional case where the scheduler standards are found to be inadequate, the field station is authorized to refer the case to the Chief Benefits Director or the Director, Compensation and Pension Service for assignment of an extraschedular evaluation commensurate with the average earning capacity impairment. 38 C.F.R. § 3.321(b)(1) (2011). The criterion for such an award is a finding that the case presents an exceptional or unusual disability picture with related factors as marked interference with employment or frequent periods of hospitalization as to render impractical application of regular schedular standards. 38 C.F.R. § 3.321(b). The Board is precluded by regulation from assigning an extraschedular rating under 38 C.F.R. § 3.321(b)(1) in the first instance; however, the Board is not precluded from raising this question, and in fact is obligated to liberally read all documents and oral testimony of record and identify all potential theories of entitlement to a benefit under the law and regulations. Floyd v. Brown, 9 Vet. App. 88 (1996). Extraschedular consideration involves a three step analysis. Thun v. Peake, 22 Vet. App. 111 (2008). First, the Board or the RO must determine whether the schedular rating criteria reasonably describe the Veteran's disability level and symptomatology. Id. at 115. If the schedular rating criteria do reasonably describe the Veteran's disability level and symptomatology, the assigned schedular evaluation is adequate, referral for extraschedular consideration is not required, and the analysis stops. Id. If the RO or the Board finds that the schedular evaluation does not contemplate the Veteran's level of disability and symptomatology, then either the RO or the Board must determine whether the Veteran's exceptional disability picture includes other related factors such as marked interference with employment and frequent periods of hospitalization. Id. at 116. If this is the case, then the RO or the Board must refer the matter to the Under Secretary for Benefits or the Director of the Compensation and Pension Service for the third step of the analysis, determining whether justice requires the assignment of an extraschedular rating. The schedular criteria found at Diagnostic Code 7346 lists the Veteran's symptoms of regurgitation (and therefore arguably reflux), dysphagia, and pain. It also contemplates disability greater than that present in this case from those symptoms because it lists considerable impairment of health due to those symptoms and the Veteran does not have considerable impairment of health due to those symptoms. Finally, the criterion of "other symptom combinations productive of severe impairment of health" arguably takes into consideration all symptoms resulting from GERD. It is noted that there is no listing of hoarseness or temporary loss of voice or awakening from sleep due to the symptoms. There is no listing of heartburn, or dyspepsia, essentially indigestion, in the criteria. As it could be argued that not all of the Veteran's symptoms from GERD are actually listed in the schedule, the Board has considered the second step of Thun. The second step of Thun is not resolved favorable to the Veteran. There is no indication that she has ever been hospitalized for symptoms of GERD. In addressing not only the effects of her GERD, but also the effects of her wrist, spine, and gynecological conditions, the April 2009 examination report includes findings that the effect of her conditions on her usual occupation was moderate, due to fatigue from decreased sleep, chronic GI upset, and loss of work time. Given this description and even taking her GERD symptoms as the sole cause of her decreased sleep and loss of work time, the description is still that of moderate impairment of her occupation. This is evidence that her GERD does not caused marked impairment in employment. The descriptions in the examination reports, the Veteran's testimony, and the reports in treatment records do not provide evidence of that her GERD results in marked impairment in employment. Frequent hospitalization and marked impairment in employment are listed in 38 C.F.R. § 3.321 along with the language indicating that these are examples of other related factors. Evidence of records does not show any related factors similar in degree or kind to frequent hospitalization and marked impairment in employment. The Board therefore finds that the preponderance of evidence is against resolving the second step of the Thun analysis favorable to the Veteran. For these reasons, the Board declines to remand this issue for referral for extraschedular consideration. In summary, disability resulting from the Veteran's GERD approximates the criteria for a 10 percent schedular evaluation but the preponderance of evidence shows that such disability does not approximate the criteria for a schedular evaluation higher than 10 percent and the preponderance of the evidence is against referral for extraschedular consideration. To the extent of assignment of a 10 percent evaluation, only, the appeal is granted. There is no reasonable doubt to be resolved as to a higher rating or referral for extraschedular consideration. See 38 U.S.C.A. § 5107(b) (West 2002); 38 C.F.R. § 3.102 (2011); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). ORDER Service connection for a lumbar spine disorder is granted. Service connection for uterine fibroids and ovarian cysts is granted. Service connection for Meniere's disease is granted. Entitlement to a 10 percent rating, but no higher, for GERD is granted for the entire period on appeal, subject to the law and regulations governing the payment of monetary benefits. REMAND The issue of entitlement to an initial compensable evaluation for bilateral carpal tunnel syndrome must be remanded so that VA can afford the Veteran an additional medical examination and obtain an expert opinion. During the October 2011 hearing, the Veteran's representative stated that a physician had informed her that a cervical spine condition was causing some of her wrist symptoms. October 2011 hearing transcript at 13. This statement is supported by January and February 2008 treatment records signed by "M.A.K.," M.D., a neurologist in private practice. January 2008 notes document an evaluation of the Veteran's disability of the wrists. The notes include the Veteran's report that she has numbness of both hands when she wakes in the morning and multiple times during the day. There are reports of functional impairment similar to what she reported in an April 2009 examination, explained more fully below. The only objective findings on examination were reproducible tenderness in the wrist and extensor tendon. Assessment was paraesthesias involving both hands, rule out carpal tunnel syndrome versus radiculopathy. The treatment plan was to obtain an electromyography and nerve conduction study to assess for radiculopathy versus carpal tunnel syndrome. Of record are the results of a February 2008 electromyography and nerve conduction study. The conclusion was that the Veteran had mild to moderate chronic C5-T1 cervical radiculopathy on both sides and median neuropathy on both sides consistent with carpal tunnel syndrome, worse on the right. Based on that study, Dr. M.A.K. stated that there was electrophysiologic evidence showing the following: (1) Mild to moderate, chronic C5-T1 cervical radiculopathy on both sides. (2) Median neuropathy on both sides consistent with carpal tunnel syndrome, worse on the right side." It is not possible to discern from these findings or from any other evidence of record what percentage of the Veteran's symptoms of the wrists and hands is due to the C5-T1 pathology and what percentage is due to the carpal tunnel syndrome. Of note also is that service connection is in place for residuals, a scar, from the removal of a ganglion cyst from the Veteran's left wrist during service. The relative percentages of her hands and wrists symptoms is important as to what evaluation or evaluations are warranted for those symptoms because although she is entitled to compensation for disability resulting from her service-connected wrist pathology, she is not entitled to compensation for disability due to the C5-T1 pathology because it has not been established that the C5-T1 pathology is due to an injury or disease incurred or aggravated in service. See Mittleider v. West, 11 Vet. App. 181, 182 (1998) (holding that, when claimant has both service-connected and non-service-connected disabilities, the Board must attempt to discern the effects of each disability and, where such distinction is not possible, attribute such effects to the service-connected disability). How, or even if, the symptoms can be apportioned between her C5-T1 pathology and the pathology of her wrists is a medical matter and the Board is not permitted to substitute its own opinion for competent medical evidence. See Colvin v. Derwinski, 1 Vet. App. 171 (1991). VA provided the Veteran with a medical examination in April 2009. Although the examiner listed the Veteran's reports of symptoms, provided relevant findings, and addressed disability of her wrists and hands, there is no statement regarding any possible contribution of her cervical spine pathology and the diagnostic test results discussed above were not of record at that time. Those results are part of the relevant history of the Veteran's disability of the wrists and must be taken into account by an examination. A remand is therefore necessary so that VA can provide her with another examination that takes into account the diagnostic test results and to obtain an expert opinion as to what symptoms of her wrists and hands are due to her service-connected wrist disabilities as opposed to a nonservice-connected disability of the cervical spine. Accordingly, the case is REMANDED for the following action: 1. Schedule the Veteran for a VA examination to determine the extent of and etiology of symptoms of the Veteran's wrists and hands. The claims file must be provided to the examiner, the examiner must review the claims file in conjunction with the examination, and the examiner must annotate the examination report as to whether the claims file was reviewed. All necessary tests must be performed. The examiner must address the following: (a) Identify any and all symptoms involving the Veteran's wrists and hands. (b) Provide an opinion as to what percentage of symptoms of the Veteran's wrists and hands are the result of disease or injury at C1-T5, or any other identified pathology of the cervical or thoracic spine and what percentage of symptoms of the Veteran's wrists and hands are the result of the carpal tunnel syndrome and/or residual of the left wrist ganglion cyst removal during service. The examiner must explain how he or she arrived at the relative percentages. The examiner must specifically address the findings from the electromyography and nerve conduction study performed in February 2008 under the direction of Dr. M.A.K, and, if additional testing is performed, must address results of that testing. If the relative percentages cannot be determined without resorting to mere speculation the examiner must so state and must explain why this is so. 2. Then, readjudicate the issue of entitlement to an initial compensable evaluation for bipolar carpal tunnel syndrome. If the benefit sought is not granted in full, provide the Veteran and her representative with a supplemental statement of the case and allow an appropriate opportunity to respond thereto. The Veteran has the right to submit additional evidence and argument on the matter or matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate (CONTINUED ON NEXT PAGE) action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2011). ______________________________________________ ROBERT E. SULLIVAN Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs