Citation Nr: 1320237 Decision Date: 06/24/13 Archive Date: 07/02/13 DOCKET NO. 09-06 595 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Montgomery, Alabama THE ISSUES 1. Entitlement to an initial compensable evaluation for a headache syndrome with vertigo and migraine headaches prior to March 28, 2012. 2. Entitlement to an evaluation in excess of 30 percent for a headache syndrome with vertigo and migraine headaches beginning on March 28, 2012. 3. Entitlement to an initial compensable evaluation for a cervical laceration and hemorrhage, status-post cervical dysplasia. 4. Entitlement to a total evaluation based upon individual unemployability due to service-connected disabilities (TDIU). REPRESENTATION Appellant represented by: Virginia A. Girard-Brady, Attorney ATTORNEY FOR THE BOARD K. Osegueda, Associate Counsel INTRODUCTION The Veteran had active service from October 1999 to March 2007. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a December 2007 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Montgomery, Alabama. In that rating decision, the RO granted service connection for a headache syndrome with vertigo and for a cervical laceration with hemorrhage (to include a claim for anemia), status-post cervical dysplasia, and assigned separate noncompensable evaluations for each disability effective from March 22, 2007. She appealed the initial evaluations for both disorders. During the pendency of the appeal, in a November 2012 rating decision, the RO increased the evaluation for the Veteran's service-connected headache syndrome with vertigo and migraine headaches to 30 percent effective from March 28, 2012. Applicable law mandates that when a veteran seeks an increased evaluation, it will generally be presumed that the maximum benefit allowed by law and regulation is sought, and it follows that such a claim remains in controversy where less than the maximum benefit available is awarded. See AB v. Brown, 6 Vet. App. 35 (1993). Therefore, the issue remains on appeal. In May 2013, Disabled American Veterans (DAV) submitted a statement requesting that the Board determine whether DAV was the Veteran's accredited representative in this case. DAV noted that, in April 2013, the RO received a VA Form 21-22a (Appointment of Attorney or Agent as Claimant's Representative), appointing Ms. Girard-Brady as the Veteran's accredited attorney. The Board notes that the Veteran is entitled to representation at all stages of an appeal. 38 C.F.R. § 20.600 (2012). However, only one organization, representative, agent, or attorney may be recognized at a time in the prosecution of a VA claim. 38 C.F.R. § 14.631(e)(1) (2012). A power of attorney may be revoked at any time. 38 C.F.R. § 14.631(f)(1) (2012). Unless a claimant specifically indicates otherwise, the receipt of a new power of attorney executed by both the claimant and the individual providing representation will constitute a revocation of an existing power of attorney. Id. Therefore, DAV is no longer the Veteran's representative, and Ms. Girard-Brady is now the accredited attorney representing the Veteran. The Board notes that, pursuant to her request, the Veteran was scheduled for a May 2013 hearing before the Board at the RO in Montgomery, Alabama. However, prior to the proceeding, her attorney cancelled that hearing. The Veteran and her attorney have not requested that the hearing be rescheduled, nor have they provided good cause. Therefore, the Veteran's hearing request is deemed withdrawn, and the Board will proceed with its review on the present record. See 38 C.F.R. § 20.704(d), (e). In addition to the paper claims file, there is a Virtual VA paperless file associated with the Veteran's claims. A review of the documents in the paperless claims file reveals documents that are either duplicative of the evidence in the paper claims file or irrelevant to the issues on appeal. The issues of entitlement to an initial compensable evaluation for a cervical laceration and hemorrhage, status-post cervical dysplasia, and entitlement to TDIU are addressed in the REMAND portion of the decision below and are REMANDED to the RO. FINDING OF FACT Throughout the entire appeal period, the Veteran's service-connected headaches have been productive of characteristic prostrating attacks occurring at least once a month that require medication. She has not had very frequent completely prostrating and prolonged productive of severe economic inadaptability. CONCLUSIONS OF LAW 2. The criteria for an initial 30 percent rating, but not higher, for headache syndrome with vertigo and migraine headaches has been approximated for the period prior to March 28, 2012. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107(b) (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1-4.14, 4.124a, Diagnostic Code 8100 (2012). 3. The criteria for an initial rating in excess of 30 percent for headache syndrome with vertigo and migraine headaches have not been met or approximated at any time during the appeal period. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107(b) (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1-4.14, 4.124a, Diagnostic Code 8100 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veterans Claims Assistance Act of 2000 (VCAA) describes VA's duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2012). Upon receipt of a substantially complete application for benefits, VA must notify the claimant of what information or evidence is needed in order to substantiate the claim and it must assist the claimant by making reasonable efforts to get the evidence needed. 38 U.S.C.A. §§ 5103(a), 5103A; 38 C.F.R. § 3.159(b); see Quartuccio v. Principi, 16 Vet. App. 183, 187 (2002). The notice required must be provided to the claimant before the initial unfavorable decision on a claim for VA benefits, and it must (1) inform the claimant about the information and evidence not of record that is necessary to substantiate the claim; (2) inform the claimant about the information and evidence that VA will seek to provide; and, (3) inform the claimant about the information and evidence the claimant is expected to provide. 38 U.S.C.A. §§ 5103(a); 38 C.F.R. § 3.159(b)(1); Pelegrini v. Principi, 18 Vet. App. 112, 120 (2004). In Dingess v. Nicholson, 19 Vet. App. 473 (2006), the United States Court of Appeals for Veterans Claims (Court) held that, upon receipt of an application for a service connection claim, 38 U.S.C. § 5103(a) and 38 C.F.R. § 3.159(b) require VA to review the information and the evidence presented with the claim and to provide the claimant with notice of what information and evidence not previously provided, if any, will assist in substantiating, or is necessary to substantiate, each of the five elements of the claim, including notice of what is required to establish service connection and that a disability rating and an effective date for the award of benefits will be assigned if service connection is awarded. In this case, the Veteran is challenging the initial evaluation assigned following the grant of service connection for a headache syndrome with vertigo and migraine headaches. In Dingess, the Court held that in cases where service connection has been granted and an initial disability rating and effective date have been assigned, the typical service connection claim has been more than substantiated, it has been proven, thereby rendering section 5103(a) notice no longer required because the purpose that the notice is intended to serve has been fulfilled. Id. at 490-91. See also VAOPGCPREC 8- 2003 (December 22, 2003). Thus, because the notice that was provided before service connection was granted was legally sufficient, VA's duty to notify has been satisfied with respect to the issue of entitlement to a higher initial rating for the Veteran's service-connected headache disability. In addition, the duty to assist the Veteran has also been satisfied in this case. The Veteran's service treatment records and all identified and available post-service medical records are in the claims file and were reviewed by both the RO and the Board in connection with the claim. The Veteran has not identified any other outstanding records that are pertinent to the issue currently on appeal. The duty to assist also includes providing a medical examination or obtaining a medical opinion when such is necessary to make a decision on the claim, as defined by law. McLendon v. Nicholson, 20 Vet. App. 79 (2006). In this case, the Veteran was afforded a VA headaches examination in March 2012 and a VA examination addendum opinion was provided in June 2012. The Board finds that the VA examination and opinion obtained in this case are adequate, as they are predicated on a review of the claims file and all pertinent evidence of record, as well as on an examination, and fully address the rating criteria that are relevant to rating the headache disability in this case. Moreover, there is no objective evidence indicating that there has been a material change in the severity of the Veteran's service-connected headache disability since she was last examined. 38 C.F.R. § 3.327(a). The duty to assist does not require that a claim be remanded solely because of the passage of time since an otherwise adequate VA examination was conducted. VAOPGCPREC 11- 95. Thus, there is adequate medical evidence of record to make a determination in this case. Accordingly, the Board finds that VA's duty to assist with respect to obtaining a VA examination or opinion regarding the issues on appeal has been met. 38 C.F.R. § 3.159(c)(4). VA has further assisted the Veteran and her representative throughout the course of this appeal by providing them with an SOC and an SSOC, which informed them of the laws and regulations relevant to the Veteran's claim. The Board concludes that the Veteran was provided the opportunity to meaningfully participate in the adjudication of her claim, and she did, in fact, participate. Washington v. Nicolson, 21 Vet. App. 191 (2007). For these reasons, the Board concludes that VA has fulfilled the duty to assist the Veteran in this case. Hence, there is no error or issue that precludes the Board from addressing the merits of this appeal. The Veteran and her representative have not made the RO or the Board aware of any additional evidence that needs to be obtained in order to fairly decide the particular claim on appeal. She has been given ample opportunity to present evidence and argument in support of her claim. All relevant evidence necessary for an equitable disposition of the Veteran's appeal of this issue has been obtained, and the case is ready for appellate review. General due process considerations have been complied with by VA. See 38 C.F.R. § 3.103 (2012). Laws and Regulations Disability evaluations are determined by evaluating the extent to which a veteran's service-connected disability adversely affects his ability to function under the ordinary conditions of daily life, including employment, by comparing his symptomatology with the criteria set forth in the Schedule for Rating Disabilities (Rating Schedule). 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 4.1, 4.2, 4.10 (2012). If two evaluations are potentially applicable, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that evaluation; otherwise, the lower evaluation will be assigned. 38 C.F.R. § 4.7. Where a veteran appeals the initial rating assigned for a disability when a claim for service connection for that disability has been granted, evidence contemporaneous with the claim for service connection and with the rating decision granting service connection would be most probative of the degree of disability existing at the time that the initial rating was assigned and should be the evidence "used to decide whether an [initial] rating on appeal was erroneous..." Fenderson v. West, 12 Vet. App. 119, 126 (1999). If later evidence obtained during the appeal period indicates that the degree of disability increased or decreased following the assignment of the initial rating, "staged" ratings may be assigned for separate periods of time based on facts found. Id.; see also Hart v. Mansfield, 21 Vet. App. 505 (2007) (VA's determination of the "present level" of a disability may result in a conclusion that the disability has undergone varying and distinct levels of severity throughout the entire time period the increased rating claim has been pending). The assignment of a particular diagnostic code is "completely dependent on the facts of a particular case." See Butts v. Brown, 5 Vet. App. 532, 538 (1993). One diagnostic code may be more appropriate than another based on such factors as an individual's relevant medical history, the current diagnosis, and demonstrated symptomatology. Any change in a diagnostic code by VA must be specifically explained. Pernorio v. Derwinski, 2 Vet. App. 625 (1992). It is possible for a veteran to have separate and distinct manifestations from the same injury that would permit rating under several Diagnostic Codes; however, the critical element in permitting the assignment of several ratings under various Diagnostic Codes is that none of the symptomatology for any one of the conditions is duplicative or overlapping with the symptomatology of the other condition. See Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994); 38 C.F.R. § 4.14 (2012) (precluding the assignment of separate ratings for the same manifestations of a disability under different diagnoses). In this case, the Veteran's headache syndrome with vertigo and migraine headaches, has been evaluated pursuant to 38 C.F.R. § 4.124a, Diagnostic Code 8100. Migraine headaches are assigned disability ratings based on the frequency of prostrating attacks. 38 C.F.R. § 4.124a, Diagnostic Code 8100. A noncompensable evaluation is assigned for migraine headaches with less frequent attacks. A 10 percent rating is warranted for migraine headaches with characteristic prostrating attacks averaging one in 2 months over the last several months. A 30 percent rating is provided for migraine headaches with characteristic prostrating attacks occurring on an average once per month over the last several months. A maximum 50 percent rating is assigned for migraine headaches with very frequent completely prostrating and prolonged attacks productive of severe economic inadaptability. Id. The Rating Schedule does not define "prostrating." However, "prostration" has been defined as "complete physical or mental exhaustion." Merrian-Webster's new Collegiate Dictionary 999 (11th ed. 2007). "Prostration" has also been defined as "extreme exhaustion or powerlessness." Dorland's Illustrated Medical Dictionary 1554 (31st ed. 2007). According to Stedman's Medical Dictionary, 27th Edition (2000), p. 1461, "prostration" is defined as "a marked loss of strength, as in exhaustion." See Eady v. Shinseki, No. 11-3223, 2013 WL 500460 (Vet. App. Feb. 12, 2013). Additionally, the terms "productive of severe economic adaptability" have not been clearly defined by regulations or by case law. The United States Court of Appeals for Veteran's Claims (Court) has noted that "productive of" can either have the meaning of "producing" or "capable of producing." Pierce v. Principi, 18 Vet. App. 440, 445 (2004). Thus, migraines need not actually "produce" severe economic inadaptability to warrant the 50 percent rating. Id. at 445-46. Further, "economic inadaptability" does not mean unemployability, as such would undermine the purpose of regulations pertaining to TDIU. Id. at 446; see also 38 C.F.R. § 4.16 (2012). The Board notes, however, that the migraines must be, at a minimum, capable of producing "severe" economic inadaptability. Factual Background and Analysis As previously noted, the RO granted service connection in a December 2007 rating decision and assigned an initial noncompensable evaluation effective from March 22, 2007. During the pendency of the appeal, the Veteran was assigned a 30 percent evaluation effective from March 28, 2012. A review of the Veteran's service treatment records show that she was treated for chronic, unremitting headaches with dizziness during service. In a statement received in May 2008, the Veteran reported that she took four different medications for her headache disability and that she continued to have severe migraines five days per week. She noted that the only way she could control her migraines was to take her prescribed medications, but she indicated that the medications caused extreme drowsiness and an inability to work. She also stated that she had dizziness and passed out during migraine episodes. In a February 2009 statement, the Veteran reported that she had migraines four to five times per week. She also stated that the medications she took to treat her headaches made her drowsy. During a March 2012 VA examination, the Veteran reported that she had migraines and sensitivity to light during service. She indicated that her migraines were accompanied by dizziness and lightheadedness, which caused her to pass out on a couple of occasions. She also reported that she experienced headaches at least five times per week, and she stated that she currently had a headache lasting for eight days. The Veteran related that she did not have current health insurance so she took an over-the-counter pain medication to control her headache symptoms up to six times per day with "little to no relief." She indicated that she had the following symptoms with her headaches: constant head pain, pulsating or throbbing head pain, pain on both sides of the head, worsening pain with physical activity, nausea, sensitivity to light and sound, changes in vision, dizziness, and passing out. She reported that her typical head pain lasted for less than one day. The Veteran also indicated that she had characteristic prostrating attacks of migraine headache pain once every month. The examiner noted that the Veteran's headache disability impacted her ability to work. In this regard, the Veteran reported that she was unable to drive with headaches and that she was unable to look at a computer screen because it caused headaches and blurred vision. The examiner noted that the Veteran's subjective history was consistent with migraine headaches; however, she was unable to determine whether the migraines were symptoms of the Veteran's service-connected headache disability. During a June 2012 VA migraine examination, the examiner noted that the Veteran had a history of migraine-type headaches with aura and sensitivity to light and sound. The examiner noted that the Veteran's in-service headache syndrome had some features of migraine headaches and she currently had migraine headaches with some atypical features. The examiner also opined that it was more likely than not that the current migraine headaches were a continuation of the headache syndrome that was diagnosed during active duty. First, with respect to the time period prior to March 28, 2012, the evidence of record demonstrates that the Veteran's headaches more nearly approximate the criteria for a 30 percent rating. Throughout the period prior to March 28, 2012, the Veteran reported that she had severe migraines four to five times per week that were accompanied by dizziness and episodes in which she passed out. See May 2008 and February 2009 statements. There is no dispute that the Veteran is competent to report symptoms of headaches that require medication, including pain, vertigo, and loss of consciousness, because these are symptoms that may be actually observed and are within the realm of her personal knowledge. Layno v. Brown, 6 Vet. App. 465, 469-70 (1994). There is also no reason to doubt the credibility of these statements. Resolving the benefit of the doubt in favor of the Veteran, the Board finds that the Veteran has sufficiently described characteristic and prostrating migraines occurring at least once a month for the period prior to March 28, 2012. Therefore, the Board concludes that her symptoms more nearly approximate the next higher 30 percent rating for that period. The next pertinent inquiry is whether, throughout the entire appellate period (both prior to and after March 28, 2012), the Veteran's symptoms have more nearly approximated the criteria for the next higher, and maximum, 50 percent rating. After carefully reviewing the evidence of record, the Board finds that they do not. The 50 percent rating contemplates very frequent completely prostrating and prolonged attacks productive of severe economic inadaptability. As indicated above, the Veteran has consistently described persistent headaches occurring an average of four to five times per week. However, she told the March 2012 VA examiner that she only had characteristic prostrating attacks of migraine headache pain once per month, which corresponds to a 30 percent rating. Even if the Board were to consider the headaches to be very frequent, the evidence does not establish that these headaches are completely prostrating, prolonged attacks productive of "severe economic inadaptability." It is acknowledged that the Veteran describes persistent, severe headaches manifested by pain, nausea, visual disturbance, vertigo, and loss of consciousness. Additionally, her headache symptoms occasionally affected her work because she was unable to drive with headaches and she was unable to look at a computer screen because it caused headaches and blurred vision. See March 2012 VA examination report. However, in a statement received in May 2008, the Veteran reported that she was able to control her migraine symptoms by taking medication. Additionally, during the March 2012 VA examination, the Veteran reported that although over-the-counter pain medication was no longer effective in treating her symptoms, her headaches typically lasted for less than one day. This evidence shows that for a majority of the time, the Veteran was able to work, which is highly probative evidence that he does not experience the type of very frequent completely prostrating and prolonged attacks productive of severe economic inadaptability that are contemplated by a 50 percent rating. Therefore, throughout the entire appeal period, the Veteran's symptoms have not more nearly approximated the criteria for a 50 percent rating. 38 C.F.R. § 4.124a, Diagnostic Code 8100 (2012). The Board has also considered whether staged ratings are appropriate in this case. See Hart v. Mansfield, 21 Vet. App. 505 (2007). However, at no time during the relevant appeal period has the service-connected migraine headache disability more nearly met or nearly approximated the criteria for greater than a 30 percent rating under Diagnostic Code 8100. In addition, there is no evidence of distinct periods of time where the disability was of less severity than that contemplated by a 30 percent rating, and therefore, staged ratings are not for application in the instant case. In reaching this decision, the potential application of various provisions of Title 38 Code of Federal Regulations have been considered, whether or not they were raised by the Veteran. Schafrath v. Derwinski, 1 Vet. App. 589 (1991). In particular, the Board has considered the provisions of 38 C.F.R. § 3.321(b)(1). However, in this case, the Board finds that the record does not show that the Veteran's headache disability is so exceptional or unusual as to warrant the assignment of a higher rating on an extra-schedular basis. See 38 C.F.R. § 3.321(b)(1). The threshold factor for extraschedular consideration is a finding that the evidence before VA presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. See Thun v. Peake, 22 Vet. App. 111 (2008). In this regard, 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. If the criteria reasonably describe the claimant's disability level and symptomatology, then the claimant's disability picture is contemplated by the rating schedule and the assigned schedular evaluation is therefore adequate, and no extraschedular referral is required. Id., see also VAOGCPREC 6-96 (Aug. 16, 1996). Otherwise, if the schedular evaluation does not contemplate the claimant's level of disability and symptomatology and is found inadequate, VA must determine whether the claimant's exceptional disability picture exhibits other related factors, such as those provided by the extraschedular regulation (38 C.F.R. § 3.321(b)(1) ) as "governing norms" (which include marked interference with employment and frequent periods of hospitalization). The evidence in this case does not show such an exceptional disability picture that the available schedular evaluations for the service-connected disability are inadequate. A comparison between the level of severity and symptomatology of the Veteran's assigned rating with the established criteria found in the rating schedule show that the rating criteria reasonably describe the Veteran's disability level and symptomatology. The Veteran's chief complaints of pain, nausea, vertigo, visual disturbance, and occasional loss of consciousness are fully considered in the assignment of the 30 percent disability rating. Moreover, there is a higher rating available under Diagnostic Code 8100 for migraine headaches, but the Veteran's disability is not productive of such manifestations. Based on the foregoing, the Board finds that the requirements for an extraschedular evaluation for the Veteran's service-connected headache disability under the provisions of 38 C.F.R. § 3.321(b)(1) have not been met. Bagwell v. Brown, 9 Vet. App. 337 (1996); Shipwash v. Brown, 8 Vet. App. 218 (1995); Thun v. Peake, 22 Vet. App. 111 (2008). ORDER Prior to March 28, 2012, entitlement to an increased evaluation of 30 percent for the service-connected headache syndrome with vertigo and migraine headaches is granted, subject to the provision governing the payment of monetary benefits. Both prior to and after March 28, 2012, entitlement to an evaluation in excess of 30 percent for the service-connected headache syndrome with vertigo and migraine headaches is denied. REMAND The law provides that VA shall make reasonable efforts to notify a claimant of the evidence necessary to substantiate a claim and requires VA to assist a claimant in obtaining that evidence. 38 U.S.C.A. §§ 5103, 5103A (West 2002); 38 C.F.R. § 3.159. Such assistance includes providing the claimant a medical examination or obtaining a medical opinion when such an examination or opinion is necessary to make a decision on a claim. 38 U.S.C.A. §§ 5103, 5103A (West 2002); 38 C.F.R. § 3.159; see also Green v. Derwinski, 1 Vet. App. 121, 124 (1991) (VA has a duty to provide a veteran with a thorough and contemporaneous medical examination). A review of the Veteran's service treatment records shows that the Veteran underwent a Loop Electrosurgical Excision Procedure (LEEP) for cervical cell abnormalities in June 2006. Following the LEEP procedure, in July 2006, the Veteran was treated for vaginal bleeding from a laceration to the cervix requiring ligation of an arterial hemorrhage with sutures and vaginal packing. In a statement received in May 2008, the Veteran reported that, during her LEEP procedure, the physician performing the task of numbing her cervix to apply sutures poked one of her arteries causing an arterial bleed. During the March 2012 VA examination, the Veteran indicated that she currently experienced pain in her lower abdomen and that her menstrual cycle lasted three weeks with spotting throughout the remainder of the month. She also related that her cycle came every other month, and in 2011, her cycle did not come for six months. She stated that she changed sanitary napkins at least six times per day during her menstrual cycle. The Veteran noted that she was diagnosed with anemia in the past. The examiner observed that the Veteran had uterine fibroids, irregular menstruation with heavy menses that lasted 21 days from the LEEP procedure in service, and anemia. In a June 2012 VA addendum opinion, the VA examiner noted that the Veteran's previous examination did not show any abnormal gynecological findings. The examiner reported that the Veteran had a history of irregular menstruation that was unlikely from cervical dysplasia, its treatment, or the cervical laceration. The examiner also noted that the Veteran could develop menorrhagia from uterine fibroids, but she would need to be evaluated by her gynecologist for its etiology. On remand, a medical opinion should be obtained to determine whether the Veteran's irregular menstruation cycle is related to the service-connected cervical laceration and hemorrhage, status-post cervical dysplasia. Additionally, the examiner should provide an opinion as to whether the Veteran's service-connected gynecological condition is productive of symptoms that do not require continuous treatment; symptoms that require continuous treatment; or, symptoms that are uncontrolled by continuous treatment, in accordance with the rating criteria. See 38 C.F.R. § 4.116, Schedule of Ratings for Gynecological Conditions. It also appears that there may be additional medical records that are pertinent to the claim for an initial compensable evaluation for a cervical laceration and hemorrhage, status-post cervical dysplasia. In this regard, during the March 2012 VA examination, the Veteran denied having current treatment for her irregular menstrual cycles, and she stated that she was not currently under the care of a gynecologist or a physician. However, she also reported that she had a pap smear in September 2010. She noted that the Pap smear was normal, but that she was informed that she had fibroid tumors. Records from this treatment provider have not been obtained and associated with the claims file. Therefore, on remand, an attempt should be made to obtain any outstanding, relevant medical records. In addition, the Court has held that, if the claimant or the record reasonably raises the question of whether the Veteran is unemployable due to the disability for which an increased rating is sought, then part and parcel to that claim for an increased rating is whether a total rating based on individual unemployability (TDIU) as a result of that disability is warranted. Rice v. Shinseki, 22 Vet. App. 447 (2009). In this case, in a statement received in May 2008, the Veteran reported that she could not work a steady job due to her service-connected migraines. Therefore, the RO should develop a claim for TDIU in accordance with Rice v. Shinseki, 22 Vet. App. 447 (2009). Accordingly, the case is REMANDED for the following action: 1. The RO should request that the Veteran provide the names and addresses of any and all health care providers who have provided treatment for her service-connected cervical laceration and hemorrhage disability. After acquiring this information and obtaining any necessary authorization, the RO should obtain and associate these records with the claims file. The RO should specifically request that the Veteran provide a signed authorization to enable it to obtain all outstanding pertinent medical treatment records from the physician who performed a September 2010 pap smear identified during the March 2012 VA gynecological conditions examination. A specific request should also be made for any outstanding VA medical records. 2. After completing the preceding development, the Veteran should be afforded a VA examination to ascertain the current severity and manifestations of her service-connected cervical laceration and hemorrhage disability. Any and all studies, tests, and evaluations deemed necessary by the examiner should be performed. The examiner is requested to review all pertinent records associated with the claims file and to comment on the severity of the Veteran's service-connected disability. The examiner should report all signs and symptoms necessary for rating the Veteran's cervical laceration and hemorrhage disability under the rating criteria. In particular, the examiner should provide an opinion as to whether the Veteran's irregular menstrual cycle is a symptom related to the service-connected cervical laceration and hemorrhage, status-post cervical dysplasia. The examiner should also discuss whether the Veteran's service-connected gynecological condition is productive of symptoms that do not require continuous treatment; symptoms that require continuous treatment; or, symptoms that are uncontrolled by continuous treatment. This VA examination should also include a statement as the effect of the Veteran's cervical laceration and hemorrhage disability on her occupational functioning and daily activities. A clear rationale for all opinions would be helpful and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. Because it is important "that each disability be viewed in relation to its history [,]" 38 C.F.R. § 4.1, copies of all pertinent records in the appellant's claims file, or in the alternative, the claims file, must be made available to the examiner for review. 3. The RO should consider whether the Veteran is entitled to TDIU under the provisions of 38 C.F.R. § 4.16, based on impairment attributable to her service-connected disabilities, in accordance with Rice v. Shinseki, 22 Vet. App. 447 (2009). In so doing, the RO may decide to pursue further development of the Veteran's employment history or to obtain additional medical evidence or medical opinion, as is deemed necessary. 4. After completing the above actions, the RO should conduct any other development as may be indicated as a consequence of the actions taken in the preceding paragraphs. 5. When the development requested has been completed, the case should be reviewed by the RO on the basis of all additional evidence. If the benefits sought are not granted, the Veteran and her attorney should be furnished a Supplemental Statement of the Case and be afforded a reasonable opportunity to respond before the record is returned to the Board for further review. The Veteran has the right to submit additional evidence and argument on the matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2012). ______________________________________________ JESSICA J. WILLS Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs