Citation Nr: 1312282 Decision Date: 04/15/13 Archive Date: 05/02/13 DOCKET NO. 08-23 169A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Montgomery, Alabama THE ISSUES 1. Entitlement to an initial rating in excess of 40 percent for osteoarthritis and degenerative disc disease of the lumbar spine. 2. Entitlement to an initial rating in excess of 30 percent for status post cervical fusion residuals. 3. Entitlement to an initial rating in excess of 10 percent for carpal tunnel syndrome of the left wrist, status post ganglion cyst excision. 4. Entitlement to an initial rating in excess of 10 percent for carpal tunnel syndrome of the right wrist, status post carpal tunnel release. 5. Entitlement to an initial rating in excess of 10 percent for bilateral plantar fasciitis with pes planus. 6. Entitlement to an initial compensable rating for status post left distal first metatarsal bunionectomy residuals. 7. Entitlement to an initial compensable rating for status post right distal first metatarsal bunionectomy residuals. 8. Entitlement to an initial rating in excess of 50 percent for posttraumatic stress disorder (PTSD) and major depressive disorder. 9. Entitlement to a compensable rating prior to April 10, 2012, and in excess of 10 percent thereafter for gastroesophageal reflux disease (GERD). REPRESENTATION Veteran represented by: The American Legion ATTORNEY FOR THE BOARD J. Andrew Ahlberg, Counsel INTRODUCTION The Veteran served on active duty from February 1987 to February 2007. This case comes before the Board of Veterans' Appeals (Board) on appeal from May 2007 and April 2010 rating decisions by Department of Veterans Affairs (VA) Regional Offices (ROs). The Board notes that, in addition to the paper claims file, there is a paperless, electronic (Virtual VA) claims file associated with the Veteran's claim. The Veteran's Virtual VA electronic claims folder was reviewed in connection with this claim and does not contain any relevant documents that have not already been considered by the agency of original jurisdiction (AOJ). The Board further observes that an August 2008 rating decision granted service connection for bronchitis and assigned an initial noncompensable rating, effective March 1, 2007. Thereafter, also in August 2008, the Veteran entered a notice of disagreement with the propriety of the initially assigned rating. In a July 2010 rating decision, the AOJ increased the initial rating to 30 percent, effective March 1, 2007. A statement of the case was also issued in July 2010; however, the Veteran did not perfect her appeal as to such issue by filing a timely substantive appeal. Therefore, this issue is not properly before the Board. FINDINGS OF FACT 1. At no time during the appeal period has osteoarthritis and degenerative disc disease of the lumbar spine been manifested by unfavorable ankylosis of the entire thoracolumbar spine, incapacitating episodes of intervertebral disc disease (IDS), or neurologic impairment. 2. At no time during the appeal period has status post cervical fusion residuals been manifested by unfavorable ankylosis of the entire cervical spine or incapacitating episodes of IDS having a total duration of at least four weeks during a twelve month period, or neurologic impairment other than moderate right upper extremity radiculopathy as of April 10, 2012. 3. As of April 10, 2012, status post cervical fusion residuals resulted in right upper extremity radiculopathy manifested by no more than a moderate sensory and functional impairment, which more nearly approximates moderate incomplete paralysis of the upper radicular group (fifth and sixth cervicals). 4. At no time during the appeal period has carpal tunnel syndrome of the left wrist resulted in more than mild incomplete paralysis of the median nerve. 5. At no time during the appeal period has carpal tunnel syndrome of the right wrist resulted in more than mild incomplete paralysis of the median nerve. 6. At no time during the appeal period has bilateral plantar fasciitis with pes planus resulted in objective evidence of marked deformity, pain on manipulation and use accentuated, swelling on use, or characteristic callosities. 7. The left first metatarsal head has not been surgically resected and at no time during the appeal period have status post left distal first metatarsal bunionectomy residuals resulted in severe disability as would equate with an amputation of the great toe. 8. The right first metatarsal head has not been surgically resected and at no time during the appeal period have status post right distal first metatarsal bunionectomy residuals resulted in severe disability as would equate with an amputation of the great toe. 9. At no time during the appeal period have PTSD and major depressive disorder resulted in manifestations that more nearly approximate occupational and social impairment with deficiencies in most areas, or total occupational and social impairment. 10. For the period prior to April 10, 2012, GERD did not result in persistently recurrent epigastric distress with at least two of the following manifestations: dysphagia, pyrosis, or regurgitation accompanied by substernal or arm or shoulder pain productive of considerable impairment of health. 11. For the period from April 10, 2012, GERD has not resulted in substernal or arm or shoulder pain or symptoms productive of considerable impairment of health. CONCLUSIONS OF LAW 1. The criteria for an initial rating in excess of 40 percent for osteoarthritis and degenerative disc disease of the lumbar spine are not met at any time during the appeal period. 38 U.S.C.A. §§ 1155, 5103(a), 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.159, 4.1, 4.2, 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code (DC) 5242 (2012). 2. The criteria for an initial rating in excess of 30 percent for status post cervical fusion residuals are not met at any time during the appeal period. 38 U.S.C.A. §§ 1155, 5103(a), 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.159, 4.1, 4.2, 4.7, 4.40, 4.45, 4.59, 4.71a, DC 5241 (2012). 3. As of April 10, 2012, the criteria for a separate 40 percent rating, but no higher, for moderate right upper extremity radiculopathy have been met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 4.25, 4.26, 4.124a, DC 8510 (2012). 4. The criteria for an initial rating in excess of 10 percent for carpal tunnel syndrome of the left wrist, status post ganglion cyst excision, are not met at any time during the appeal period. 38 U.S.C.A. §§ 1155, 5103(a), 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.159, 4.1, 4.2, 4.7, 4.40, 4.45, 4.59, 4.124a, DC 8515 (2012). 5. The criteria for an initial rating in excess of 10 percent for carpal tunnel syndrome of the right wrist, status post status post carpal tunnel release, are not met at any time during the appeal period. 38 U.S.C.A. §§ 1155, 5103(a), 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.159, 4.1, 4.2, 4.7, 4.40, 4.45, 4.59, 4.124a, DC 8515 (2012). 6. The criteria for an initial rating in excess of 10 percent or bilateral plantar fasciitis with pes planus are not met at any time during the appeal period. 38 U.S.C.A. §§ 1155, 5103(a), 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.159, 4.1, 4.2, 4.7, 4.40, 4.45, 4.59, 4.71a, DC 5276 (2012). 7. The criteria for an initial compensable rating for status post left distal first metatarsal bunionectomy residuals are not met at any time during the appeal period. 38 U.S.C.A. §§ 1155, 5103(a), 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.159, 4.1, 4.2, 4.7, 4.40, 4.45, 4.59, 4.71a, DC 5280 (2012). 8. The criteria for an initial compensable rating for status post right distal first metatarsal bunionectomy residuals are not met at any time during the appeal period. 38 U.S.C.A. §§ 1155, 5103(a), 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.159, 4.1, 4.2, 4.7, 4.40, 4.45, 4.59, 4.71a, DC 5280 (2012). 9. The criteria for an initial rating in excess of 50 percent PTSD and major depressive disorder are not met at any time during the appeal period. 38 U.S.C.A. §§ 1155, 5103(a), 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.159, 4.1, 4.2, 4.7, 4.40, 4.45, 4.59, 4.130, DC 9411 (2012). 10. The criteria for a compensable rating prior to April 10, 2012, and in excess of 10 percent thereafter for GERD are not met. 38 U.S.C.A. §§ 1155, 5103(a), 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.159, 4.1, 4.2, 4.7, 4.40, 4.45, 4.59, 4.114, DC 7346 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. VA's Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA) and implementing regulations impose obligations on VA to provide claimants with notice and assistance. 38 U.S.C.A. §§ 5102, 5103, 5103A, 5107; 38 C.F.R §§ 3.102, 3.156(a), 3.159, 3.326(a). Proper VCAA notice 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 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b)(1). In Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006), the United States Court of Appeals for Veterans Claims (Court) held that the VCAA notice requirements of 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) apply to all five elements of a service connection claim. Those five elements include: 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. In Pelegrini v. Principi, 18 Vet. App. 112 (2004), the Court held that VCAA notice, as required by 38 U.S.C.A. § 5103(a), must be provided to a claimant before the initial unfavorable AOJ decision on the claim for VA benefits. With the exception of her claim for an increased rating for GERD, the Board observes that the Veteran has appealed with respect to the propriety of the initially assigned ratings for her service-connected disabilities from the original grants of service connection. VA's General Counsel has held that no VCAA notice is required for such downstream issues. VAOPGCPREC 8-2003, 69 Fed. Reg. 25180 (May 5, 2004). In addition, the Board notes that the Court held that "the statutory scheme contemplates that once a decision awarding service connection, a disability rating, and an effective date has been made, § 5103(a) notice has served its purpose, and its application is no longer required because the claim has already been substantiated." Dingess v. Nicholson, 19 Vet. App. 473, 490 (2006). In this case, the Veteran's claims for service connection for her disabilities on appeal was granted and initial ratings were assigned in the May 2007 and April 2010 rating decisions on appeal. Therefore, as the Veteran has appealed with respect to the initially assigned rating, no additional 38 U.S.C.A. § 5103(a) notice is required because the purpose that the notice is intended to serve has been fulfilled. Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007); Dunlap v. Nicholson, 21 Vet. App. 112 (2007). Regarding the Veteran's claim for an increased rating for GERD, the Board finds that VA has satisfied its duty to notify under the VCAA. Specifically, May 2009 and July 2009 letters, sent prior to the initial unfavorable decision issued in April 2010, advised the Veteran of the evidence and information necessary to substantiate her increased rating claim as well as her and VA's respective responsibilities in obtaining such evidence and information. Additionally, such letter advised him of the information and evidence necessary to establish an effective date in accordance with Dingess/Hartman, supra. Next, VA has a duty to assist the Veteran in the development of the claims. This duty includes assisting her in the procurement of service treatment records and pertinent treatment records and providing an examination 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 claims file contains the Veteran's service treatment records, post-service private and VA treatment records, and records from the Social Security Administration (SSA). Moreover, the Veteran's statements in support of the claims are of record. The Board has carefully reviewed such statements and concludes no available outstanding evidence has been identified. The Board has also perused the medical records for references to additional treatment reports not of record, but has found nothing to suggest that there is any outstanding evidence with respect to the Veteran's claims. Additionally, the Veteran was afforded VA examinations in December 2006, July 2008, October 2009, March 2012, and April 2012 to evaluate the severity of the service-connected disabilities on appeal. The Board finds that the VA examinations are adequate because, as discussed below, they were based upon consideration of the Veteran's pertinent medical history and her lay assertions and current complaints, and because they provide sufficient detail to allow the Board to make fully informed determinations. Barr v. Nicholson, 21 Vet. App. 303 (2007) (citing Ardison v. Brown, 6 Vet. App. 405, 407 (1994)). The Board accordingly finds no reason to remand for further examination. For the above reasons, no further notice or assistance to the Veteran is required to fulfill VA's duty to assist in the development of the claims. 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). II. Legal Criteria/Analysis Although the Board has an obligation to provide reasons and bases supporting its decision, there is no need to discuss, in detail, every piece of evidence of record. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (VA must review the entire record, but does not have to discuss each piece of evidence). Hence, the Board will summarize the relevant evidence as appropriate and the Board's analysis will focus specifically on what the evidence shows, or fails to show, as to the claims. In this regard, the Board notes that it has reviewed all of the evidence of record, to include in the Veteran's claims file and the Virtual VA file (VA's electronic data storage system), with an emphasis on the evidence relevant to this appeal. The Virtual VA file reveals VA outpatient treatment reports dated through September 26, 2012, and the September 2012 supplemental statement of the case (SSOC) documents review of such reports. As such, a remand for consideration of any documents contained in the Virtual File that are not physically of record in another SSOC pursuant to 38 C.F.R. § 20.1304(c) is not necessary. When describing a document contained in the Virtual VA file and not physically of record in the claims file, this fact will be so noted herein. Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities, found in 38 C.F.R., Part 4. The rating schedule is primarily a guide in the evaluation of disability resulting from all types of diseases and injuries encountered as a result of or incident to military service. The ratings are intended to compensate, as far as can practicably be determined, the average impairment of earning capacity resulting from such diseases and injuries and their residual conditions in civilian occupations. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. 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. All benefit of the doubt will be resolved in the appellant's favor. 38 C.F.R. § 4.3. In general, all disabilities, including those arising from a single disease entity, are rated separately, and all disability ratings are then combined in accordance with 38 C.F.R. § 4.25. Pyramiding, the evaluation of the same disability, or the same manifestation of a disability, under different diagnostic codes, is to be avoided when rating an appellant's service-connected disabilities. 38 C.F.R. § 4.14. In order to evaluate the level of disability and any changes in condition, it is necessary to consider the complete medical history of the Veteran's condition. Schafrath v. Derwinski, 1 Vet. App. 589, 594 (1991). Staged ratings are appropriate for an increased rating claim whenever the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. See Hart v. Mansfield, 21 Vet. App. 505 (2007); Fenderson v. West, 12 Vet. App. 119, 126 (1999). A. Lumbar Spine and Cervical Spine Disabilities Disability of the musculoskeletal system is primarily the inability, due to damage or infection in the parts of the system, to perform the normal working movements of the body with normal excursion, strength, speed, coordination, and endurance. It is essential that the examination on which ratings are based adequately portray the anatomical damage and the functional loss with respect to all of these elements. In evaluating disabilities of the musculoskeletal system, it is necessary to consider, along with the schedular criteria, functional loss due to flare-ups of pain, fatigability, incoordination, pain on movement, and weakness. DeLuca v. Brown, 8 Vet. App. 202 (1995). Functional loss may be due to absence of part, or all, of the necessary bones, joints and muscles, or associated structures, or to deformity, adhesions, defective enervation, or other pathology, or it may be due to pain, supported by adequate pathology and evidenced by visible behavior of the claimant undertaking the motion. Weakness is as important as limitation of motion, and a part that becomes painful on use must be regarded as seriously disabled. 38 C.F.R. §§ 4.10, 4.40, 4.45. The Court has held that VA must analyze the evidence of pain, weakened movement, excess fatigability, or incoordination and determine the level of associated functional loss under 38 C.F.R. § 4.40, which requires VA to regard as "seriously disabled" any part of the musculoskeletal system that becomes painful on use. See DeLuca v. Brown, 8 Vet. App. 202 (1995). In Mitchell v. Shinseki, 25 Vet. App. 32 (2011), the Court held that, although pain may cause a functional loss, "pain itself does not rise to the level of functional loss as contemplated by VA regulations applicable to the musculoskeletal system." Rather, pain may result in functional loss, but only if it limits the ability "to perform the normal working movements of the body with normal excursion, strength, speed, coordination, or endurance." Id., quoting 38 C.F.R. § 4.40. Furthermore, the intent of the rating schedule is to recognize painful motion with joint or periarticular pathology as productive of disability. Thus, actually painful, unstable, or malaligned joints, due to healed injury, are entitled to at least the minimum compensable rating for the joint. The joints should be tested for pain on both active and passive motion, in weight-bearing and nonweight-bearing and, if possible, with the range of the opposite undamaged joint. 38 C.F.R. § 4.59. In Burton v. Shinseki, 25 Vet. App. 1, 5 (2011), the Court found that, when 38 C.F.R. § 4.59 is raised by the claimant or reasonably raised by the record, even in non-arthritis context, the Board should address its applicability. As relevant, the General Rating Formula for Diseases and Injuries of the Spine holds that for DCs 5235 to 5243, a rating of 100 percent is warranted when there is unfavorable ankylosis of the entire spine. A 50 percent rating is warranted when there is unfavorable ankylosis of the entire thoracolumbar spine. A 40 percent rating is warranted when there is unfavorable ankylosis of the entire cervical spine; or, forward flexion of the thoracolumbar spine 30 degrees or less; or, favorable ankylosis of the entire thoracolumbar spine. A 30 percent rating is warranted when there is forward flexion of the cervical spine 15 degrees or less; or, favorable ankylosis of the entire cervical spine. The criteria also include the following provisions: Note (1): Evaluate any associated objective neurologic abnormalities, including, but not limited to, bowel or bladder impairment, separately, under an appropriate diagnostic code. Note (2): For VA compensation purposes, normal forward flexion of the cervical spine is zero to 45 degrees, extension is zero to 45 degrees, left and right lateral flexion are zero to 45 degrees, and left and right lateral rotation are zero to 80 degrees. Normal forward flexion of the thoracolumbar spine is zero to 90 degrees, extension is zero to 30 degrees, left and right lateral flexion are zero to 30 degrees, and left and right lateral rotation are zero to 30 degrees. The combined range of motion refers to the sum of the range of forward flexion, extension, left and right lateral flexion, and left and right rotation. The normal combined range of motion of the cervical spine is 340 degrees and of the thoracolumbar spine is 240 degrees. The normal ranges of motion for each component of spinal motion provided in this note are the maximum that can be used for calculation of the combined range of motion. Note (3): In exceptional cases, an examiner may state that because of age, body habitus, neurologic disease, or other factors not the result of disease or injury of the spine, the range of motion of the spine in a particular individual should be considered normal for that individual, even though it does not conform to the normal range of motion stated in Note (2). Provided that the examiner supplies an explanation, the examiner's assessment that the range of motion is normal for that individual will be accepted. Note (4): Round each range of motion measurement to the nearest five degrees. Note (5): For VA compensation purposes, unfavorable ankylosis is a condition in which the entire cervical spine, the entire thoracolumbar spine, or the entire spine is fixed in flexion or extension, and the ankylosis results in one or more of the following: difficulty walking because of a limited line of vision; restricted opening of the mouth and chewing; breathing limited to diaphragmatic respiration; gastrointestinal symptoms due to pressure of the costal margin on the abdomen; dyspnea or dysphagia; atlantoaxial or cervical subluxation or dislocation; or neurologic symptoms due to nerve root stretching. Fixation of a spinal segment in neutral position (zero degrees) always represents favorable ankylosis. Note (6): Separately evaluate disability of the thoracolumbar and cervical spine segments, except when there is unfavorable ankylosis of both segments, which will be rated as a single disability. The Diagnostic Codes for the spine are as follows: 5235 Vertebral fracture or dislocation; 5236 Sacroiliac injury and weakness; 5237 Lumbosacral or cervical strain; 5238 Spinal stenosis; 5239 Spondylolisthesis or segmental instability; 5240 Ankylosing spondylitis; 5241 Spinal fusion; 5242 Degenerative arthritis of the spine (see also diagnostic code 5003); 5243 Intervertebral disc syndrome. In the instant case, the Veteran's lumbar spine condition has been evaluated under DC 5242 pertinent to degenerative arthritis of the spine and her cervical spine condition has been evaluated under DC 5241 pertinent to spinal fusion. IDS (preoperatively or postoperatively) may be evaluated either under the General Rating Formula for Diseases and Injuries of the Spine or under the Formula for Rating Intervertebral Disc Syndrome (IDS) Based on Incapacitating Episodes, whichever method results in the higher evaluation when all disabilities are combined. See 38 C.F.R. § 4.25 (combined ratings table). As relevant, the Formula for Rating IDS Based on Incapacitating Episodes provides for a 60 percent rating when there are incapacitating episodes of IDS having a total duration of at least six weeks during the past 12 months. A 40 percent rating is warranted when there are incapacitating episodes of IDS having a total duration of at least four weeks, but less than six weeks during the past 12 months. An incapacitating episode is defined as a period of acute signs and symptoms due to IDS that required bed rest prescribed by a physician and treatment by a physician. An evaluation can be had either on the total duration of incapacitating episodes over the past 12 months or by combining separate evaluations of the chronic orthopedic and neurologic manifestations along with evaluations for all other disabilities under 38 C.F.R. § 4.25, whichever method resulted in the higher evaluation. The Veteran was treated for back and cervical spine problems during service, and the May 2007 rating decision granted service connection for osteoarthritis and degenerative disc disease of the lumbar spine and status post cervical fusion residuals at disability ratings, effective from March 1, 2007 (the first day of the month following service separation), of 10 and 20 percent respectively. These ratings were increased, effective from the date of the grants of service connection of March 1, 2007, to 40 and 30 percent, respectively, by a July 2008 rating decision. As set forth in the criteria listed above, a rating in excess of 40 percent for the service-connected lumbar spine disability would require unfavorable ankylosis of the entire thoracolumbar spine, or incapacitating episodes of IDS having a total duration of at least six weeks during a 12 month period, and a rating in excess of 30 percent for the service-connected cervical spine disability would require unfavorable ankylosis of the entire cervical spine or incapacitating episodes of IDS having a total duration of at least four weeks during a 12 month period. Turning first to whether the criteria for a rating in excess of 40 percent for the service-connected lumbar spine disability are met, the reports from the December 2006, July 2008, and April 2012 VA examinations, while documenting severe limitation of lumbar motion, do not reveal complaints or findings relating to the existence of any ankylosis of the lumbar spine, much less unfavorable ankylosis of the entire thoracolumbar spine. In this regard, the reports from the musculoskeletal examination conducted in conjunction with the July 2008 VA examination specifically document that no ankylosis was present. These examinations reports also do not reflect any complaints or findings as to the existence of IDS in the lumbar spine, and the reports from the April 2012 VA examination specifically document that the Veteran does not have IDS in the lumbar spine. Review of the VA outpatient treatment reports contain no contradictory findings in this regard. Pertinent to any associated neurologic impairment, the Board observes that, at the December 2006 VA examination, it was noted that MRI studies had revealed no nerve root compression. Upon neurological evaluation, deep tendon reflexes were symmetrical in the lower extremities. Vibratory, light touch, and pinprick sensation were well preserved to both lower extremities. Circumferential measurement of both calves were equal. Straight leg raising was negative bilaterally in the seated position. A September 2007 VA treatment record reflects complaints of numbness in the bottom of her feet. Thereafter, nerve conduction studies were obtained in November 2007 and such were without evidence of neuropathy. A February 2008 VA treatment record reflects that the Veteran's protective sensation was intact using monofilament. At the July 2008 VA examination, she complained of radiating pain, leg paresthesias, and leg numbness in the right lower extremity. However, upon physical examination, there was no evidence of motor loss or sensory loss, and Babinski sign was negative (normal) on bilaterally. Deep tendon reflexes were 2+ bilaterally. In February 2011, the Veteran complained of intermittent numbness/tingling in her right leg. At the April 2012 VA examination, the examiner noted that the Veteran had radiculopathy that resulted in severe intermittent pain in her bilateral lower extremities, and moderate paresthesias and/or dysesthesias and numbness in the right lower extremity. The examiner indicated that there were no other neurologic abnormalities, to include bowel or bladder problems, related to her lumbar spine disability. However, a review of the Virtual File reflects an August 2012 addendum that indicates that EMG (electromyography) and NCS (nerve conduction studies) testing of the lower limbs was normal. Therefore, while the Veteran has complained of radiating pain, leg paresthesias, and leg numbness, the objective evidence fails to demonstrate neurologic impairment associated with her lumbar spine disability. As such, the Board finds that a separate rating for neurologic impairment resulting from such disability is not warranted. As for a rating in excess of 30 percent for the service-connected cervical spine disability, although the Veteran has undergone a surgical fusion of C4-C5 and C5-C6, it is not shown by the December 2006, July 2008, or April 2012 VA examinations, or any other clinical evidence of record, that there is unfavorable ankylosis of the entire cervical spine. In this regard, while the cervical spine motion was shown to be severely limited at these examinations, active motion in the cervical spine was shown at each of these examinations and, as noted above, ankylosis was specifically said to not be present on the reports from the July 2008 VA examination. With respect to IDS, while the reports from the April 2012 VA examination indicated that the Veteran had IDS of the cervical spine, it was noted that the Veteran had not had any incapacitating episodes [as defined by the regulations set forth above as documented by the examination reports] of IDS in the past 12 months. No other clinical reports, to include the VA outpatient reports, indicate that the service-connected cervical spine disability has resulted in incapacitating episodes of IDS having a total duration of at least four weeks during a 12 month period. Pertinent to any associated neurologic impairment, the Board observes that, at the December 2006 VA examination, it was noted that the Veteran had cervical pain with distribution of such to the right upper extremity to the elbow and shoulder. It was noted that the radicular pain was largely relieved by the Veteran's in-service surgery. Upon neurological evaluation, the Veteran had bilaterally positive Tinel's signs at the wrists (which, as will be discussed herein, is related to her bilateral carpal tunnel syndrome). Her deep tendon reflexes in the upper extremities were symmetrical. At the July 2008 VA examination, she complained of radiating pain to the right arm. However, upon physical examination, there was no evidence of motor loss or sensory loss, and Babinski sign was negative (normal) on bilaterally. Deep tendon reflexes were 2+ bilaterally. At the April 2012 VA examination, the examiner noted that the Veteran had radiculopathy that resulted in moderate intermittent pain and numbness in the right upper extremity. No findings referable to the left upper extremity were noted. Likewise, the examiner indicated that there were no other neurologic abnormalities, to include bowel or bladder problems, related to her cervical spine disability. Review of the Virtual File reflects an August 2012 addendum that indicated that the EMG of the upper limbs revealed right C5 radiculopathy and the NCS was normal. Such addendum further reflects that the Veteran has involvement of the upper radicular group C5, resulting in incomplete paralysis, of the right side. There was no other nerve involvement. While the Veteran has complained of pain radiating to the right upper extremity during the course of appeal, the Board finds that a separate rating for neurologic impairment as a result of her cervical spine disability is not warranted until April 10, 2012, the date of the VA examination that confirmed findings of radiculopathy, which were later supported by the EMG findings showing right C5 radiculopathy. Moreover, there is no evidence of neurologic impairment resulting from such service-connected disability other than mild right upper extremity radiculopathy as of April 10, 2012. Diagnostic Code 8510 pertains to the upper radicular group (fifth and sixth cervicals). The Board notes that the April 2012 VA examination reveals that the Veteran is right hand dominant and, therefore, the ratings pertaining to the major (dominant) side. Such provides a 70 percent rating for complete paralysis (all shoulder and elbow movements are lost or severely affected, hand and wrist movements not affected), and 20, 40, and 50 percent ratings for mild, moderate, and severe incomplete paralysis, respectively. Under 38 C.F.R. § 4.124a, the term "incomplete paralysis" indicates a degree of lost or impaired function substantially less than the type picture for complete paralysis given with each nerve, whether due to varied level of the nerve lesion or to partial regeneration. When the involvement is wholly sensory, the rating should be for the mild, at most, the moderate degree. As the evidence shows that the Veteran's cervical spine disability results in incomplete paralysis of the right side affecting upper radicular group C5, the Board finds that a rating for complete paralysis is not warranted. Moreover, as the Veteran's impairment from such disorder results in no more than moderate intermittent pain and numbness in the right upper extremity, 3/5 strength resulting in active movement against gravity, 1+ (hypoactive) deep tendon reflexes in the biceps, triceps, and brachioradialis, and decreased sensation to light touch, the Board finds that such disability more nearly approximates moderate incomplete paralysis of the upper radicular group (fifth and sixth cervicals). Therefore, a separate 40 percent rating, but no higher, for moderate radiculopathy of the right upper extremity is warranted as of April 10, 2012. There is otherwise no clinical evidence demonstrating that the criteria for a rating in excess of 40 percent for the service-connected lumbar spine disability or 30 percent for the service-connected cervical spine disability are met. With regard to giving proper consideration to the effects of pain in assigning a disability rating, as well as the provisions of 38 C.F.R. § 4.45 and the holdings in DeLuca and Mitchell, supra, the reports from the VA examinations conducted above document consideration of these principles, and there is no indication that increased compensation would be warranted under these principles. In this regard, to the extent that pain due to the service-connected cervical or lumbar spine disabilities results in additional loss of motion, the ratings that have been assigned for these disabilities reflect the maximum amount of compensation which may be granted under the applicable rating criteria on the basis of limitation of motion in the thoracolumbar or cervical spine. As such, the criteria for a rating in excess of 40 percent for the service-connected lumbar spine disability and 30 percent for the service-connected cervical spine disability simply are not met. 38 C.F.R. § 4.71a, DCs 5242, 5241. B. Bilateral Carpal Tunnel Syndrome In rating a disability that is not listed in the Ratings Schedule, it is permissible to rate that disability under a closely related disease or injury in which not only the functions affected, but the anatomical location and symptomatology are closely analogous. 38 C.F.R. § 4.20. When choosing which diagnostic code to apply to an unlisted condition, codes for similar disorders or that provide general descriptions that encompass many ailments should be considered. Pernorio v. Derwinski, 2 Vet. App. 625, 629 (1992). In deciding which diagnostic code is "closely related" to the unlisted condition, the following three factors may be taken into consideration: (1) whether the functions affected by the condition are analogous; (2) whether the anatomical location of the condition is analogous; and (3) whether the symptomatology of the condition is analogous. Lendenmann v. Principi, 3 Vet. App. 345, 350-51 (1992). Mild impairment due to incomplete paralysis of the median nerve (major and minor) warrants a 10 percent disability rating. A rating in excess of 10 percent for incomplete paralysis of the major or minor median nerve requires a moderate level of impairment. 38 C.F.R. § 4.124a, DC 8515. During service, the Veteran was treated for a ganglion cyst and carpal tunnel syndrome in the left wrist and carpal tunnel syndrome in the right wrist. Service connection was granted for such disabilities as reflected in the May 2007 rating decision that granted service connection for carpal tunnel syndrome of the left wrist, status post ganglion cyst excision, and carpal tunnel syndrome of the right wrist, status post carpal tunnel release. A noncompensable rating was assigned for each disability, by analogy to DC 8515, effective from March 1, 2007. These ratings were increased to 10 percent, also effective from March 1, 2007, by a July 2008 rating decision. Findings pertinent to the Veteran's service-connected bilateral carpal tunnel syndrome include reports from the December 2006 VA examination demonstrating that the wrists moved freely and completely bilaterally. There was some minimal loss of sensation at the area of the incision from the ganglion cyst excision of the left wrist. The Veteran could make a full fist bilaterally and grip strength was 4/5 bilaterally. There was no intrinsic muscle atrophy in either hand. There was a mildly positive Tinel's sign bilaterally. In describing the nature of her carpal tunnel residuals at the July 2008 VA examination, the Veteran noted daily severe bilateral arm and wrist pain and indicated that her condition had become progressively worse. She reported no loss of strength or dexterity in the hands but did describe pain and numbness therein. The physical examination resulted in a diagnosis of left carpal syndrome that was resolved surgically but with remaining pain. This condition was said to mildly affect the Veteran's ability to complete chores. Referencing normal nerve conduction studies of the right median nerve conducted in October 2007, the examiner noted that there was insufficient evidence to warrant a diagnosis of right carpal tunnel syndrome. Based on the findings from this examination, the July 2008 rating decision explained that the increased ratings to 10 percent for the Veteran's carpal tunnel syndrome were assigned with consideration of functional loss due to pain pursuant to DeLuca, supra. A May 2009 VA examination report by an examiner who noted that the claims file had been reviewed indicated that the Veteran reported "no change" in the condition associated with her carpal tunnel syndrome since the July 2008 VA examination and that she agreed with the findings with respect to her carpal tunnel syndrome from this examination. At the most recent VA examination in April 2012, strength testing on flexion and extension of each wrist was to 3/5; grip strength was to 3/5 bilaterally; and strength with pinching of the thumb to the index finger was to 3/5 bilaterally. The sensory examination was normal in the left forearm, hand, and fingers, and decreased in the right forearm, hand, and fingers. The examiner noted that, while the Veteran demonstrated almost no muscle movement when testing, she was able to carry a heavy purse and dress/undress with no difficulty, thus suggesting symptom exaggeration. The Veteran said there were no flareups that impacted functioning of the wrists. Motion was as follows in the right wrist: Palmar flexion to 40 degrees with painful motion at 30 degrees and dorsiflexion to 45 degrees with pain at 40 degrees. Motion in the left wrist was as follows: Palmar flexion to 30 degrees with pain at 20 degrees and dorsiflexion to 40 degrees with pain at 20 degrees. Repetitive motion revealed no additional limitation of motion. The examiner stated that the Veteran did not have any functional loss or impairment of the wrists and that her wrist condition did not impact her ability to work. Localized tenderness in the wrist was described and strength on bilateral wrist flexion and extension was to 3/5. The examiner stated that carpal tunnel surgery had not resulted in residual signs or symptoms. Review of the Virtual File reflects an August 2012 addendum that indicated that the EMG of the upper limbs revealed right C5 radiculopathy, that the NCS was normal, and that the there was no other evidence of nerve involvement. As stated above, the rating criteria require a finding of moderate disability due to incomplete paralysis of the median nerve in order for increased compensation to be assigned for the major or minor wrist under DC 8515. Given the addendum to the April 2012 VA examination reporting the results of the EMG and NCS demonstrating no nerve involvement with the exception of those supplying C5, which pertains to the Veteran's service-connected cervical spine disability and was addressed in the previous section, it does not appear that incomplete paralysis, or carpal tunnel syndrome, is currently active in either wrist. Moreover, as indicated, the examiner who conducted the April 2012 VA examination concluded that the Veteran did not have any functional loss or impairment of the wrists and that her wrist conditions did not impact her ability to work. This examiner also found no residual signs or symptoms from her carpal tunnel syndrome surgeries. While residual pain from this surgery was noted at the July 2008 examination, the 10 percent rating assigned, as indicated above, contemplate the effects of pain and resulting functional loss pursuant to Deluca and Mitchell, supra. In addition, there has some exaggeration of wrist symptoms, as observed by the examiner at the April 2012 VA examination, and the clinical findings contained in the VA outpatient treatment reports do not otherwise describe any more than mild, if that, loss of functioning associated with the Veteran's bilateral carpal tunnel syndrome. As such, the Board finds that moderate disability due to incomplete paralysis of either median nerve is not demonstrated so as to warrant an increased rating for the service-connected carpal tunnel syndrome of either wrist under DC 8515. C. Bilateral Plantar Fasciitis with Pes Planus The Veteran's bilateral plantar fasciitis with pes planus is evaluated under DC 5276. Under DC 5276 (acquired flatfoot), moderate flatfoot with weight-bearing line over or medial to the great toe, inward bowing of the tendo achillis, pain on manipulation and use of the feet, bilateral or unilateral, is rated 10 percent disabling. Severe flatfoot, with objective evidence of marked deformity (pronation, abduction, etc.), pain on manipulation and use accentuated, indication of swelling on use, characteristic callosities, is rated 30 percent disabling for bilateral disability. Id. The Veteran was treated during service for pes planus and fasciitis and the December 2006 VA examination diagnosed bilateral pes planus. Thereafter, the May 2007 rating decision granted service connection for bilateral plantar fasciitis with pes planus. A noncompensable rating was assigned by analogy to DC 5276 effective from March 1, 2007. Thereafter, a January 2008 VA outpatient treatment report reflects a referral to the podiatry clinic to treat complaints of foot pain associated with pes planus. The July 2008 VA examination report, in pertinent part, showed the Veteran describing daily burning pain in the bottom of her feet and indicating that special shoe inserts only provided fair relief. She reported no flareups involving the feet. The physical examination showed the Veteran to walk with a slow antalgic gait and the examiner stated that the Veteran's pes planus resulted in mild effects on her ability to travel. Following this examination, the rating was increased to 10 percent, also effective from March 1, 2007, by a July 2008 rating decision. The basis for this increase as stated therein was functional loss due to pain. A May 2009 VA examination report by an examiner who noted that the claims file had been reviewed indicated that the Veteran reported "no change" in the condition of her pes planus since the July 2008 VA examination and that she agreed with the findings with respect to pes planus from this examination. At the most recent VA examination in April 2012, the Veteran described pain in the left foot on use that was not accentuated on use. The Veteran was said to have pain on manipulation of both feet but that the pain was not accentuated on manipulation. She was also said to have no swelling in the feet on use and no calluses characteristic of those caused by flatfeet. Symptoms were said to not be relieved by arch supports or orthotics. The Veteran was said to not have extreme tenderness of the plantar surface of either foot; decreased longitudinal arch height on weight-bearing; objective evidence of marked deformity of a foot (defined on the examination reports as "pronation, abduction etc." per the applicable rating criteria); or marked pronation. Weight-bearing was said to not fall over or medial to the great toe and the Veteran was said to not have inward bowing of the Achilles' tendon or marked inward displacement and severe spasm of the Achilles' tendon. X-rays were said to have demonstrated traumatic arthritis of each foot. The examiner stated that the Veteran's pes planus did not impact her ability to work. A rating in excess of 10 percent for the Veteran's bilateral flatfoot requires severe disability, with objective evidence of marked deformity (pronation, abduction, etc.), pain on manipulation and use accentuated, indication of swelling on use, or characteristic callosities. The most recent VA examination specifically found that a marked deformity such as pronation or abduction was not demonstrated, that pain was not accentuated on manipulation and use, and that there was no swelling on use. The reports from this examination also indicated that there were no calluses characteristic of those caused by flatfeet. Review of the other VA examination reports conducted prior to April 2012, and VA outpatient treatment reports, also does not reveal the findings required for an increased rating under DC 5276. D. Status Post Left and Right Distal First Metatarsal Bunionectomy Residuals The Veteran's status post left and right distal first metatarsal bunionectomy residuals are evaluated under DC 5280. Under DC 5280 (hallux valgus, unilateral), a maximum 10 percent rating is assigned if there has been an operation and resection of the metatarsal head, or if hallux valgus is severe so as to equate with disability that would result from amputation of the great toe. Private treatment records reflect that, during service, the Veteran underwent a left Austin bunionectomy in October 1999 and a right bunionectomy in December 1999. The May 2007 rating decision granted service connection for status post left and right distal first metatarsal bunionectomy residuals and assigned separate noncompensable ratings for such disability under DC 5280 effective from March 1, 2007. Pertinent findings to these residuals include a December 2006 VA examination report reflecting a reduction of passive and active motion of the right great toe by 50 percent in each plane. There was a slight degree of valgus deformity in the right first metatarsal phalangeal joint. No other cock-up deformities were shown in the remaining toes, and there were no dystrophic or fungal nail changes. X-rays of each foot showed no fractures or dislocations and post bunionectomy changes in each distal first metatarsal. At the July 2008 VA examination, no foot or toe deformities were reported. The examiner noted that left hallux valgus had been resolved by bunionectomy but that there was residual pain with resultant mild effects on the ability to travel. A May 2009 VA examination report by an examiner who indicated that the claims file had been reviewed indicated that the Veteran reported "no change" in the condition of her bunionectomy residuals since the July 2008 VA examination and that she agreed with the findings with respect to these residuals from this examination. At the April 2012 VA examination, the examiner noted that the Veteran did not have a Morton's neuroma, metatarsalgia, hallux valgus, hallux rigidus, claw foot, malunion or nonunion of tarsal or metatarsal bones, or any other foot injuries. The examiner stated that the bunionectomy residuals did not result in the same level of disability as would result from an amputation and that these residuals did not impact the Veteran's ability to work. A compensable rating for the bunionectomy residuals would be warranted if there has been an operation and resection of the metatarsal head, or if hallux valgus is severe so as to equate with disability that would result from amputation of the great toe. No treatment report of record, to include those from the surgery conducted in 1999, indicate that the metatarsal head of either first digit was resected, and the examiner who conducted the most recent VA examination specifically found that the bunionectomy residuals did not result in a level of disability as would equate with an amputation. No other findings from the other VA examinations conducted, or the VA outpatient treatment reports, reflects such severe disability due to bunionectomy residuals as would result from an amputation of either great toe. As such, a compensable rating for the service-connected bunionectomy residuals cannot be assigned under DC 5280. E. PTSD and Major Depressive Disorder The Veteran's duties during service included providing urgent medical care for victims of a terrorist attack in Dhahran, Saudi Arabia, and she has described such intrusive memories of this incident as to result in PTSD. An April 2010 rating decision granted service connection for PTSD with major depressive disorder at a rating of 50 percent effective from June 24, 2009. Such disability is rated under DC 9411, pertinent to PTSD. Pursuant to the General Rating Formula for evaluating psychiatric disabilities other than eating disorders, a 50 percent rating is warranted where the disorder is manifested by 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 for example, retention of only highly learned material, forgetting to complete tasks; impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships. See 38 C.F.R. § 4.130. A 70 percent rating is assigned when psychiatric disability results in occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a worklike setting); inability to establish and maintain effective relationships. Id. Use of the phrase "such symptoms as," followed by a list of examples, provides guidance as to the severity of symptoms contemplated for each rating, in addition to permitting consideration of other symptoms, particular to each Veteran and disorder, and the effect of those symptoms on a Veteran's social and work situation. Mauerhan v. Principi, 16 Vet. App. 436, 442 (2002). Psychiatric examinations frequently include assignment of a Global Assessment of Functioning (GAF) score. According to the Fourth Edition of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM-IV), GAF is a scale reflecting the "psychological, social, and occupational functioning on a hypothetical continuum of mental health-illness." There is no question that the GAF score and interpretations of the score are important considerations in rating a psychiatric disability. See e.g., Richard v. Brown, 9 Vet. App. 266, 267 (1996); Carpenter v. Brown, 8 Vet. App. 240 (1995). However, the GAF score assigned in a case, like an examiner's assessment of the severity of a condition, is not dispositive of the evaluation issue; rather, the GAF score must be considered in light of the actual symptoms of the Veteran's disorder, which provide the primary basis for the rating assigned. See 38 C.F.R. § 4.126(a). Pertinent evidence to the evaluation for the service-connected psychiatric disability includes the reports from an October 2009 VA psychiatric examination that resulted in a diagnosis of PTSD and major depressive disorder. The GAF score was 51 and the examiner found that the Veteran's prognosis was guarded given significant medical problems and poor social support. The Veteran reported significant impairment in family relationships and social and recreational functioning. The examiner found that such impairment was attributable to a combination of physical medical problems and psychological problems, and that the severity of the Veteran's PTSD and major depressive disorder was most likely exacerbated by physical problems and an inability to work. The examiner found that psychiatric disability did not, by itself, render the Veteran unemployable, and that her psychiatric disability did not result in total occupational and social impairment or decencies in judgment, thinking, family relations, or mood. The examiner did find that the Veteran's PTSD resulted in reduced reliability and productivity in social and recreational functioning and would likely significantly reduce functioning in an occupational setting if she were physically able to work. Findings from the mental status examination conducted in October 2009 included a clean appearance; avoidance of eye contact with the examiner; lethargic and fatigued psychomotor activity; impoverished, slow, and mumbled speech; a hostile, suspicious, irritable and apathetic attitude; flat affect; a hopeless, depressed and dysphoric mood; orientation to three spheres; thought process characterized by a paucity of ideas; unremarkable thought content; insight as to her psychiatric problems; sleep impairment; auditory hallucinations that were not persistent; no inappropriate behavior; non appropriate interpretation of proverbs; obsessive/ritualistic behavior; panic attacks; no homicidal or suicidal ideation; fair impulse control; an ability to maintain personal hygiene; no problems with the activities of daily living; and mildly impaired remote and immediate memory and moderately impaired recent memory. The reports from a March 2012 VA psychiatric examination showed the examiner noting that the Veteran was evasive and uncooperative during the interview and exaggerated symptoms such that the nature and extent of PTSD symptoms could not be ascertained from the interview. After referencing VA mental health clinic notes since June 2011, the examiner found it likely that current symptoms of PTSD were at least mild in nature and resulted in at least mild impairment in psychosocial functioning. The examiner also noted that symptoms of major depressive disorder were at least mild to moderate in nature and resulted in mild to moderate impairment in psychosocial functioning. The GAF score was estimated to be 55-65, and the examiner stated that a GAF score could not be definitively assigned due to the Veteran's lack of cooperation and exaggeration of symptoms. She noted that the last GAF score assigned by a treating mental health provider was 58 in January 2011. In reporting what best summarized the level of occupational and social impairment resulting solely from psychiatric disability as set forth in the rating criteria, the examiner selected the statement "occupational and social impairment with reduced reliability and productivity." As such, the examiner specifically selected the level of disability characterized by a 50 percent rating, and not a 70 percent rating or higher, as codified under 38 C.F.R. § 4.130. Psychiatric symptoms were said to include depressed mood; anxiety; suspiciousness; pain attacks occurring more than once a week; chronic sleep impairment; flattened affect; disturbances of motivation and mood; and difficulty of establishing and maintaining effective work and social relationships. The examiner noted that since her last VA psychiatric examination of October 2009, the Veteran continued to live alone; that she had never married; and that her living relatives consisted of two sisters who she has no contact with. She also reported that she had no friends currently and that she was not involved in social activities. Review of VA outpatient treatment reports does not reflect a level of psychiatric impairment that is significantly at odds with that described above, and considering the pertinent evidence of record set forth above, the Board finds that the criteria for a rating in excess of 50 percent for PTSD with major depressive disorder are not met. In making this determination, the Board notes that while some of the suggested symptomatology codified at 38 C.F.R. § 4.130 for a 70 percent rating was noted on examination reports, to include obsessional rituals at the May 2009 VA and panic attacks at the May 2009 and March 2012 VA examination, the exaggeration of psychiatric symptoms has been clinically noted and the far majority of the examples of symptoms listed for a 70 percent rating are still simply not demonstrated. In addition, the GAF scores, taking as a whole, show essentially moderate difficulty in functioning (even with an exaggeration of symptoms) and are consistent with the examiner's conclusion after the March 2012 VA examination that there is, at worst, mild to moderate impairment of psychosocial functioning. See Carpenter, supra. Moreover, the Board finds that the criteria for a 100 percent rating under the General Rating Formula are not met. In this regard, the evidence does not show that the Veteran has total occupational and social impairment due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. In determining that the criteria for a rating in excess of 50 percent for the Veteran's service-connected PTSD and major depressive disorder are not met, the Board has considered the applicable rating criteria not as an exhaustive list of symptoms, but rather, as examples of the type and degree of the symptoms or effects that would justify a particular rating. The Board has not required the presence of a specified quantity of symptoms in the rating schedule to warrant the assigned rating for the psychiatric disability in question. See supra, Mauerhan. F. GERD The Veteran's service-connected GERD is evaluated under DC 7346. See 38 C.F.R. § 4.114. DC 7346 (hiatal hernia) provides for a 30 percent rating if there is persistently recurrent epigastric distress with dysphagia, pyrosis, and regurgitation, accompanied by substernal or arm or shoulder pain, productive of considerable impairment of health. With two or more of the symptoms for the 30 percent evaluation of less severity, a 10 percent rating in warranted. The Veteran was diagnosed with GERD during service, and the May 2007 VA rating decision granted service connection for GERD. A noncompensable rating was assigned by analogy to DC 7346, effective from March 1, 2007. The Veteran did not enter a notice of disagreement as to the propriety of the initially assigned rating and, while treatment records were associated with the claims file within the one year following the issuance of the May 2007 rating decision, such did not demonstrate a factually ascertainable increase in severity and thus are not considered new and material. 38 C.F.R. § 3.156(b). Thereafter, VA received the Veteran's claim for an increased rating for such disability in August 2008. In the April 2010 rating decision on appeal, an initial rating was denied and the Veteran subsequently appealed such decision. Thereafter, the Veteran's rating for GERD was increased to 10 percent, effective from April 10, 2012 (the date of the April 2012 VA examination showing increased symptoms), by a September 2012 rating decision. As such, there are two periods of time for consideration; namely, whether a compensable rating may be assigned prior to April 10, 2012, and whether a rating in excess of 10 percent may be assigned for the period thereafter. See Hart, supra; AB v. Brown, 6 Vet. App. 35(1993)(a claim for an increased rating remains in controversy when less than the maximum available benefit is awarded, unless the claimant expressly limits the appeal). Addressing first whether a compensable rating may be assigned for GERD for the period prior to April 10, 2012, at the July 2008 VA examination, the Veteran reported severe gastric emptying. It was again reported that there had been a good response to medication. The Veteran denied a history of nausea, vomiting, diarrhea, indigestion, regurgitation, hematemesis, melena, and abdominal pain but did describe a history of heartburn. The gastrointestinal examination was normal. A May 2009 VA examination report by an examiner who indicated that the claims file had been reviewed indicated that the Veteran reported "no change" in the condition of her GERD since the July 2008 VA examination and that she agreed with the findings with respect to this disability form this examination. As the findings above (or any other clinical report during the pertinent period) do not show at least two of the following manifestations: dysphagia, pyrosis, and regurgitation, accompanied by substernal or arm or shoulder pain for the period from March 1, 2007, to April 9, 2012, a compensable rating for GERD for this period cannot be assigned under DC 7346. As for whether a rating in excess of 10 percent may be assigned for the period from April 10, 2012, the discussion of disability due to GERD at the VA examination of April 2012 indicated that the Veteran was on continuous medication for her GERD and that signs and symptoms of the condition included dysphagia, pyrosis, and regurgitation but no other symptoms, to include episodes of epigastric distress, reflux, or substernal arm pain and no anemia, nausea, vomiting, hematemesis, or melena. The examiner indicated that GERD did no interfere with the Veteran's ability to work. The criteria for a rating in excess of 10 percent under 7336 require persistently recurrent epigastric distress with dysphagia, pyrosis, and regurgitation, accompanied by substernal or arm or shoulder pain, productive of considerable impairment of health (emphasis added). As such, while the April 2012 examination reports noted that the Veteran had dysphagia, pyrosis, and regurgitation, it was specifically found at this examination that she did not have substernal or arm or shoulder pain. Moreover, the Board finds that the findings from this examination do not reflect that there is considerable impairment of health due given that the Veteran's GERD was not said at this examination to result in any symptoms other than dysphagia, pyrosis, and regurgitation, to include epigastric distress, reflux, anemia, nausea, vomiting, hematemesis, or melena. As such, and as the VA outpatient treatment records otherwise do not reflect the findings required for a rating in excess of 10 percent, Board finds that the criteria for a rating in excess of 10 percent for GERD under DC 7346 for the period from April 10, 2012, are not met. G. Other Considerations The Board notes that in finding that the rating criteria were not met for increased compensation for any of the disabilities discussed above, entitlement to increased compensation for any of these disabilities on the basis of a staged rating has been considered but has not been demonstrated. See Fenderson, supra; Hart, supra. In making its determinations in this case, the Board has also carefully considered the Veteran's contentions with respect to the nature of her service-connected disabilities at issue and notes that her lay testimony is competent to describe certain symptoms associated with these disabilities. The Veteran's history and symptom reports have been considered, including as presented in the medical evidence discussed above, and has been contemplated by the disability ratings that have been assigned. Moreover, the competent medical evidence offering detailed specific findings pertinent to the rating criteria is the most probative evidence with regard to evaluating the pertinent symptoms of the service-connected disabilities at issue. As such, while the Board accepts the Veteran's testimony with regard to the matters she is competent to address, the Board relies upon the competent medical evidence with regard to the specialized evaluation of functional impairment, symptom severity, and details of clinical features of the service-connected conditions at issue. Additionally, the Board has contemplated whether the case should be referred for extra-schedular consideration for any of the disabilities at issue. An extra-schedular disability rating is warranted if the case presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization that application of the regular schedular standards would be impracticable. 38 C.F.R. § 3.321(b)(1). In Thun v. Peake, 22 Vet. App. 111, 115-16 (2008), the Court explained how the provisions of 38 C.F.R. § 3.321 are applied. Specifically, the Court stated that the determination of whether a claimant is entitled to an extra-schedular rating under 3.321 is a three-step inquiry. First, it must be determined whether the evidence presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. In this regard, the Court indicated that there must be a comparison between the level of severity and symptomatology of the claimant's service-connected disability with the established criteria found in the rating schedule for that disability. Under the approach prescribed by VA, if the criteria reasonably describe the claimant's disability level and symptomatology, then the claimant's disability picture is contemplated by the rating schedule, the assigned schedular evaluation is, therefore, adequate, and no referral is required. Second, if the schedular evaluation does not contemplate the claimant's level of disability and symptomatology and is found inadequate, the RO or Board must determine whether the claimant's exceptional disability picture exhibits other related factors such as "marked interference with employment" and "frequent periods of hospitalization." Third, when an analysis of the first two steps reveals that the rating schedule is inadequate to evaluate a claimant's disability picture and that picture has attendant thereto related factors such as marked interference with employment or frequent periods of hospitalization, then the case must be referred to the Under Secretary for Benefits or the Director of the Compensation and Pension Service to determine whether, to accord justice, the claimant's disability picture requires the assignment of an extra-schedular rating. Id. The Board has carefully compared the level of severity and symptomatology of the Veteran's service-connected disabilities at issue with the established criteria found in the rating schedule. The Board finds that the disabilities at issue are fully addressed by the rating criteria under which each such disability is rated. In this regard, the specific diagnostic criteria adequately addresses the whole of the Veteran's symptoms referable to each of her service-connected disabilities. There are no additional symptoms of the service-connected disabilities at issue. Therefore, the Board finds that the rating criteria reasonably describe the Veteran's disability level and symptomatology associated with the service-connected disabilities addressed above. As such, the Board need not proceed to consider the second factor, viz., whether there are attendant thereto related factors such as marked interference with employment or frequent periods of hospitalization. Consequently, the Board concludes that referral of this case for consideration of an extra-schedular rating for any of the service-connected disabilities addressed above is not warranted. Id.; Bagwell v. Brown, 9 Vet. App. 337, 338-39 (1996); Floyd v. Brown, 9 Vet. App. 88, 96 (1996). In Rice v. Shinseki, 22 Vet. App. 447 (2009), the Court held that a claim for total disability rating for compensation based on individual unemployability (TDIU) is part of an increased rating claim when such claim is expressly raised by the Veteran or reasonably raised by the record. The Court further held that when evidence of unemployability is submitted at the same time that the Veteran is appealing the initial rating assigned for a disability, the claim for TDIU will be considered part and parcel of the claim for benefits for the underlying disability. Id. During the course of the Veteran's claims, a claim for TDIU was considered and denied by the RO in August 2008 and April 2010 rating decisions. The Veteran has not appealed such decisions. Such adjudications reflects the permissive bifurcation of the increased rating claims from the TDIU claim. See Roebuck v. Nicholson, 20 Vet. App. 307, 315 (2006) (acknowledging that the Board can bifurcate a claim and address different theories or arguments in separate decisions); Holland v. Brown, 6 Vet. App. 443, 447 (1994) (holding that "it was not inappropriate" for the Board to refer a TDIU claim to the RO for further adjudication and still decide an increased-ratings claim). Moreover, while acknowledging the Rice decision, in Locklear v. Shinseki, 24 Vet. App. 311 (2011), the Court held that it is permissive for VA to address a claim for TDIU independently of other claims, including increased rating and service connection claims. Id. at 315. Given the foregoing, the Board concludes that the TDIU claim was separately adjudicated and not perfected for appellate review. Accordingly, the Board does not have jurisdiction over the claim and need not refer or remand the matter. In sum, Board finds that the preponderance of the evidence is against each increased rating claim on appeal; as such, the benefit of the doubt doctrine is not applicable and the claims must be denied. 38 U.S.C.A. § 5107; 38 C.F.R. §§ 4.3, 4.7. ORDER An initial rating in excess of 40 percent for osteoarthritis and degenerative disc disease of the lumbar spine is denied. An initial rating in excess of 30 percent for status post cervical fusion residuals is denied. As of April 10, 2012, a separate 40 percent rating for moderate radiculopathy of the right upper extremity is granted, subject to applicable law and regulations governing the award of monetary benefits. An initial rating in excess of 10 percent for carpal tunnel syndrome of the left wrist, status post ganglion cyst excision is denied. An initial rating in excess of 10 percent for carpal tunnel syndrome of the right wrist, status post carpal tunnel release is denied. An initial rating in excess of 10 percent for bilateral plantar fasciitis with pes planus is denied. An initial compensable rating for status post left distal first metatarsal bunionectomy residuals is denied. An initial compensable rating for status post right distal first metatarsal bunionectomy residuals is denied. An initial rating in excess of 50 percent for PTSD and major depressive disorder is denied. A compensable rating prior to April 10, 2012, and in excess of 10 percent thereafter for GERD is denied. ______________________________________________ A. JAEGER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs