Citation Nr: 1320509 Decision Date: 06/26/13 Archive Date: 07/05/13 DOCKET NO. 09-37 813 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Atlanta, Georgia THE ISSUES 1. Entitlement to an effective date earlier than August 28, 2007, for the award of a 30 percent disability rating for service-connected migraine headaches. 2. Entitlement to an effective date earlier than August 28, 2007, for the award of a 30 percent disability rating for service-connected gastroesophageal reflux disease (GERD) and pelvic adhesion status post appendectomy. 3. Entitlement to a disability rating in excess of 10 percent for service-connected ganglion cyst, left wrist. REPRESENTATION Appellant represented by: The American Legion ATTORNEY FOR THE BOARD S. M. Kreitlow INTRODUCTION The Veteran had active military service from January 1996 to February 2000 and June 2003 to June 2004. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a December 2008 rating decision prepared by the Department of Veterans Affairs (VA) Regional Office (RO) in Huntington, West Virginia. A few days later, the RO in Atlanta, Georgia, notified the Veteran of that determination. Due to the location of the Veteran's residence, the jurisdiction of her appeal remains with the RO in Atlanta, Georgia. In an April 2013 statement, the issues of increased disability ratings for service-connected GERD, migraine headaches and scar, left wrist, were raised by the Veteran, but have not been adjudicated by the Agency of Original Jurisdiction (AOJ). Therefore, the Board does not have jurisdiction over them, and they are referred to the AOJ for appropriate action. The issue of entitlement to an increased disability rating for ganglion cyst, left wrist, is addressed in the REMAND portion of the decision below and is REMANDED to the RO via the Appeals Management Center (AMC) in Washington, DC. FINDINGS OF FACT 1. Prior to August 28, 2007, the Veteran's service-connected migraine headaches were not productive of characteristic prostrating attacks or an exceptional disability picture. 2. Prior to August 28, 2007, the Veteran's GERD was not manifested by persistently recurrent epigastric distress with dysphagia, pyrosis, and regurgitation, accompanied by substernal or arm or shoulder pain, productive of considerable impairment of health, nor was her pelvic adhesion status post appendectomy productive of moderately severe peritoneal adhesions with partial obstruction manifested by delayed motility of barium meal and less frequent and less prolonged episodes of pain. In addition, neither disability represents an exceptional disability picture. CONCLUSIONS OF LAW 1. The criteria for an effective date prior to August 28, 2007 for the award of a 30 percent disability rating for service-connected migraine headaches are not met. 38 U.S.C.A. §§ 5103, 5103A, 5107, 5108, and 5110 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.156, 3.158, 3.160, 3.400, 4.124a, Diagnostic Code 8100 (2012). 2. The criteria for an effective date prior to August 28, 2007 for the award of a 30 percent disability rating for service-connected GERD and pelvic adhesion status post appendectomy are not met. 38 U.S.C.A. §§ 5103, 5103A, 5107, 5108, and 5110 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.156, 3.158, 3.160, 3.400, 4.114, Diagnostic Codes 7301, 7346 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Notice and Assistance Requirements VA's duties to notify and assist claimants in substantiating a claim for VA benefits are described in 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107 and 5126 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a) (2012) . Upon receipt of a complete or substantially complete 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 notify the claimant and his or her representative, if any, of what information and evidence not already provided, if any, is necessary to substantiate, or will assist in substantiating, each of the five elements of the claim including notice that a disability rating and an effective date for the award of benefits will be assigned if service connection is awarded. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b); Quartuccio v. Principi, 16 Vet. App. 183 (2002); Dingess v. Nicholson, 19 Vet. App. 473 (2006). The Board notes that the issues on appeal arise from the Veteran's disagreement with the effective dates assigned for the increased evaluations of her service-connected migraine headaches and GERD/pelvic adhesion status post appendectomy. The RO provided the Veteran with specific notice as to establishing entitlement to higher disability ratings in July 2006. In that notice, she was also advised of how VA determines effective dates. The Board finds that VA's obligation to notify the Veteran was met as the notice proceed clearly advised the Veteran on how effective dates are established. Consequently, no further notice is necessary and there is no prejudice to the Veteran. With respect to VA's duty to assist, all relevant, identified and available evidence has been obtained, and VA has notified the Veteran of any evidence that could not be obtained. The Veteran has not referred to any additional, unobtained evidence relevant to her claims. 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. The Veteran was afforded VA examinations on her claims for increased disability ratings in December 2007. In addition, the Board notes that the Veteran was previously examined in July 2006 for these disabilities. The Board finds that the examination reports are complete and adequate for rating purposes as they provide all relevant information needed to evaluate the Veteran's service-connected disabilities. The Board further finds that, since the Veteran's claims at this point are for earlier effective dates of the award of increased disability ratings, there is no duty to provide her with a contemporaneous examination as such would not address the relevant issue before the Board, to wit, whether the evidence of record prior to the established effective date demonstrates that a higher evaluation is warranted. Thus, there is no insufficiency in the duty to assist in not providing the Veteran with an examination in relation to her claims for earlier effective dates. Thus, the Board finds that VA has satisfied its duties to inform and assist the Veteran at every stage of this case. Additional efforts to assist or notify her would serve no useful purpose. Therefore, she will not be prejudiced as a result of the Board proceeding to the merits of her claims. II. Analysis The assignment of effective dates of awards is generally governed by 38 U.S.C.A. § 5110 and 38 C.F.R. § 3.400. The effective date of an award of increased compensation can be the earliest date as of which it was ascertainable that an increase in disability has occurred, if the application is received within one year from such date. 38 U.S.C.A. § 5110(b)(2); 38 C.F.R. § 3.400(o)(2). See Hazan v. Gober, 10 Vet. App. 511 (1997). The award of an increased rating should normally be effective either on the date of receipt of the claim or on some date in the preceding year if it was ascertainable that the disorder had increased in severity during that time. See also VAOGCPREC 12-98. Disability ratings are intended to compensate impairment in earning capacity due to a service-connected disorder. 38 U.S.C.A. § 1155. Separate diagnostic codes identify the various disabilities. Id. Evaluation of a service-connected disorder requires a review of the veteran's entire medical history regarding that disorder. 38 C.F.R. §§ 4.1 and 4.2. It is also necessary to evaluate the disability from the point of view of the veteran working or seeking work, 38 C.F.R. § 4.2, and to resolve any reasonable doubt regarding the extent of the disability in the veteran's favor, 38 C.F.R. § 4.3. If there is a question as to which evaluation to apply to the veteran's disability, 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. The Veteran argues that she filed her claims for increased disability ratings in June 2006, which were denied in a December 2006 rating decision, and that her August 2007 statement requesting reconsideration of her service-connected percentages was within the one year she was told she had to request reconsideration. Consequently, she argues that the effective date of the awards of increased disability ratings for her service-connected GERD and migraine headaches should be in June 2006 when she filed her claim. The Board finds that the Veteran is essentially claiming that the August 2007 statement requesting reconsideration should constitute a Notice of Disagreement with the December 2006 rating decision, which denied her June 2006 claim for increased disability ratings. The Board notes that a claimant has one year from notification of a RO decision to initiate an appeal by filing a Notice of Disagreement with the decision. 38 U.S.C.A. § 7105(b)(1); 38 C.F.R. § 20.302. A Notice of Disagreement is a written communication from a claimant or his representative expressing dissatisfaction or disagreement with an adjudicative determination by the AOJ and a desire to contest the result. 38 C.F.R. § 20.201; see also Gallegos v. Gober, 283 F.3d 1309, 1313 (Fed. Cir. 2002) (An NOD must (1) express disagreement with a specific determination of the agency of original jurisdiction (AOJ), i.e. the RO; (2) be filed in writing; (3) be filed with the AOJ; (4) be filed within one year after the date of mailing of notice of the AOJ decision; and (5) be filed by the claimant or the claimant's authorized representative. While special wording is not required, an NOD must be in terms that can be reasonably construed as disagreement with that determination and a desire for appellate review.). The Board finds that, even if it were to consider the August 2007 a Notice of Disagreement rather than a new claim for increased disability ratings for service-connected GERD/pelvic adhesion status post appendectomy and migraine headaches, an earlier effective date is not warranted for the increases awarded effective August 28, 2007, because the evidence prior thereto fails to demonstrate that the criteria for higher evaluations were met. Migraine Headaches The Veteran's service-connected migraine headaches are evaluated under Diagnostic Code 8100. Prior to August 28, 2007, a 10 percent disability rating was assigned. An increased disability rating of 30 percent was awarded effective August 28, 2007. Under Diagnostic Code 8100, a 10 percent evaluation for migraine headaches requires characteristic prostrating attacks averaging one in two months over the last several months. A 30 percent evaluation is warranted for migraine headaches where there is characteristic prostrating attacks occurring on an average of once a month over the last several months. A 50 percent evaluation is warranted if there are very frequent, completely prostrating and prolonged attacks productive of severe economic inadaptability. 38 C.F.R. § 4.124a, Diagnostic Code 8100. In determining whether the Veteran experiences the type and frequency of prostrating attacks of migraine headaches necessary for a higher rating under Diagnostic Code 8100, the Board observes that the rating criteria do not define "prostrating," nor has the Court. Cf. Fenderson v. West, 12 Vet. App. 119 (1999) (in which the Court quotes Diagnostic Code 8100 verbatim but does not specifically address the matter of what is a prostrating attack). By way of reference, the Board notes that according to WEBSTER'S NEW WORLD DICTIONARY OF AMERICAN ENGLISH, THIRD COLLEGE EDITION (1986), p. 1080, "prostration" is defined as "utter physical exhaustion or helplessness." A very similar definition is found in DORLAND'S ILLUSTRATED MEDICAL DICTIONARY 1367 (28th Ed. 1994), in which "prostration" is defined as "extreme exhaustion or powerlessness." VA treatment records from December 2005 to June 2006 do not show any treatment for migraine headaches although they do note a past medical history of migraine headaches, two per week. Although this evidence lists a history of the frequency of the Veteran's migraine headaches, it does not give any indication as to their severity, i.e., whether they are prostrating or not. Consequently, this evidence is not sufficient to establish the criteria for a 30 percent disability rating under Diagnostic Code 8100. Furthermore, the VA examination conducted in June 2006 fails to demonstrate that a 30 percent evaluation under Diagnostic Code 8100 is warranted in that it fails to demonstrate that the Veteran has characteristically prostrating attacks. At this examination, the Veteran reported that she has recurring headaches, which she described as migraines. They are productive of severe temple pain, seeing spots, and feeling the room is spinning around. When the attacks occur, she reported being able to go to work but having to take medication (which is over the counter pain medication). As to frequency, she reported that the attacks are intermittent occurring as often as three times a week with each occurrence lasting up to five hours. Although she reported that sometimes the attacks are so severe she has to stay home from work, it is not noted how often these attacks occur or whether they are prostrating (i.e., causing extreme exhaustion or helplessness). In contrast, the Veteran reported at the December 2007 VA examination (upon which the grant to a 30 percent disability rating was based) that her migraine headaches are extremely painful and caused vomiting and sensitivity to light. She reported that, when the headaches occur, she has to stay in bed and is unable to do anything. She stated that she experiences these types of headaches on average of once a week lasting for two hours. Current treatment was over the counter medications such as Tylenol, Excedrin and Motrin with good relief. Consequently, the earliest evidence demonstrating that the Veteran's migraine headaches are productive of the criteria for a 30 percent disability rating (i.e., characteristic prostrating attacks of at least once a month) is the December 2007 VA examination. The Board finds, therefore, that an effective date prior to August 28, 2007, for the award of a 30 percent disability rating for the Veteran's service-connected migraine headaches is not warranted based upon the schedular criteria. Finally, the Board finds that referral for extraschedular consideration under 38 C.F.R. § 3.321(b) is not warranted in the present case as the evidence fails to show that the Veteran's migraine headaches presents such an exceptional disability picture that the available schedular evaluations for that disability are inadequate. 38 C.F.R. § 3.321(b)(1); see also, Thun v. Peake, 22 Vet. App. 111, 115 (2008); Shipwash v. Brown, 8 Vet. App. 218, 227 (1995). The evidence does not show that the Veteran's headaches caused marked interference with her employment as she stated at the July 2006 VA examination that she was able to work with the use of medications whenever she had a headache. Moreover, the evidence shows that the Veteran has not had frequent periods of hospitalization due to her migraine headaches that has interfered with her employment or daily life. In fact, she denied having any medical treatment for this condition and reported using only over-the-counter medications to treat it. Finally, her symptoms reported are consistent with those related to migraine headaches. She has not reported any symptoms that are not contemplated by the rating schedule. Thus the Board finds that the preponderance of the evidence is against referral of the Veteran's claim for extraschedular consideration. The Board has considered the doctrine of reasonable doubt, but finds that the record does not provide an approximate balance of negative and positive evidence on the merits. The claim is, therefore, denied. Gilbert v. Derwinski, 1 Vet. App. 49, 57-58 (1990); 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102. GERD/Pelvic Adhesion Status Post Appendectomy Prior to August 28, 2007, the Veteran's GERD and pelvic adhesion status post appendectomy were both assigned a 10 percent disability rating. In February 2008, an increased disability rating of 30 percent was awarded for both disability (as explained in more detail below) effective August 28, 2007. The Board notes that, in the February 2008 rating decision that granted the 30 percent disability rating, the RO combined the Veteran's service-connected GERD and pelvic adhesion status post appendectomy. The reasoning for this was that separate evaluations of these two disabilities was prohibited by law because they are both evaluated under gastrointestinal system Diagnostic Codes. This arose because, in a December 2006 rating decision denying an increased disability rating in excess of 10 percent for both the Veteran's service-connected GERD and right pelvic adhesion status post appendectomy, the RO changed the Diagnostic Code under which it evaluated the service-connected pelvic adhesion status post appendectomy. Initially, when service connection for this disability was granted, the RO evaluated it as analogous to adhesions of the uterus under Diagnostic Code 7613 and evaluated it as 10 percent disabling. In the December 2006 rating decision, however, the RO changed the Diagnostic Code used to evaluate this disability to 7329-7301. Thus, it rated it as analogous peritoneum adhesions due to resection of the large intestine; however, it continued the 10 percent disability rating previously assigned. In this same rating decision, service connection for GERD was established and a separate 10 percent disability rating was assigned for this disability. However, pursuant to 38 C.F.R. § 4.114, ratings under Diagnostic Codes 7301 to 7329, inclusive, 7331, 7342, and 7345 to 7348 inclusive will not be combined with each other. Rather a single evaluation will be assigned under the Diagnostic Code which reflects the predominant disability picture, with elevation to the next higher evaluation where the severity of the overall disability warrants such elevation. Hence, the RO's finding in the February 2008 rating decision that it could not provide separate ratings for these two disabilities was correct as both are now evaluated using the Diagnostic Codes for gastrointestinal disabilities. The Board notes that there is not a specific Diagnostic Code for GERD. Thus, the Veteran's GERD has been evaluated as analogous to the diagnostic criteria set forth in Diagnostic Code 7346 for hiatal hernia. Under Diagnostic Code 7346, a 10 percent evaluation is warranted where the evidence shows two or more of the symptoms for the 30 percent evaluation of less severity. A 30 percent evaluation is warranted where 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. A 60 percent evaluation contemplates a level of impairment which includes symptoms of pain, vomiting, material weight loss and hematemesis or melena with moderate anemia; or other symptom combinations productive of severe impairment of health. 38 C.F.R. § 4.114, Diagnostic Code 7346. Words such as "moderate" and "severe" are not defined in the VA Schedule for rating disabilities. Rather than applying a mechanical formula, the Board must evaluate all of the evidence to the end that its decisions are "equitable and just." 38 C.F.R. § 4.6. As for the Veteran's pelvic adhesion status post appendectomy, that has essentially been evaluated under Diagnostic Code 7301 for adhesions of the peritoneum. Under that Diagnostic Code, adhesions of the peritoneum are assigned a 10 percent rating for moderate adhesions of the peritoneum with pulling pain on attempting work or aggravated by movements of the body, or occasional episodes of colic pain, nausea, constipation (perhaps alternating with diarrhea) or abdominal distension. A 30 percent rating is assigned for moderately severe adhesions of the peritoneum with partial obstruction manifested by delayed motility of barium meal and less frequent and less prolonged episodes of pain. A 50 percent disability rating is assigned for severe adhesions of the peritoneum with definite partial obstruction shown by X-ray, with frequent and prolonged episodes of severe colic distension, nausea or vomiting, following severe peritonitis, ruptured appendix, perforated ulcer, or operation with drainage. 38 C.F.R. § 4.114. VA treatment records from December 2005 to June 2006 do not show any treatment for GERD or pelvic adhesions although they do note a past medical history of GERD and status post appendectomy. Consequently, as this evidence does not demonstrate what symptoms the Veteran has relating to these two disabilities, it is not sufficient to establish the criteria for a 30 percent disability rating under either Diagnostic Code 7301 or 7346. The Veteran underwent VA examination initially relating to her claims for increased disability ratings for her service-connected disabilities in July 2006. At that time, with regard to her pelvic adhesion status post appendectomy, she reported having irregular menstruation (20 day cycle) and intermittent pelvic pain on the right side especially when standing for long periods. She denied a history of urinary tract infections or urinary incontinence. She refused having a pelvic examination done stating it had been done previously. The examiner noted that this condition caused subjective pain in the abdomen. At the December 2007 VA examination, the Veteran reported having abdominal pain located at the lower right side occurring frequently. She described it as colic pain; however, there was no association with abdominal distension, constipation or diarrhea. There was nausea and vomiting as often as three times per week usually brought on by eating. She treated the pain with Motrin. Physical examination revealed a scar at the right lower abdomen. The scar had tenderness, keloid formation of less than six square inches and hyperpigmentation. There was tenderness to palpation of the abdomen with thickening of subcutaneous tissue underneath the scar. The assessment was right pelvic adhesion status post appendectomy with subjective pain in the lower right abdominal region and objective tenderness in lower abdominal region. As for her GERD, she reported having heart burn/reflux, chest and scapular pain, and regurgitation after meals. She denied that this condition has affected her body weight. She reported her symptoms occur frequently and without notice. She treated her symptoms with Aciphex. Physical examination of the abdomen was within normal limits. The examiner noted that the condition caused subjective gastrointestinal upset but did not cause significant anemia or malnutrition. In contrast, at the December 2007 VA examination, the Veteran reported that this condition affects her general body health and that her body weight went from 145 pounds to 128 pounds within the prior 12 months. She reported undergoing treatment to correct her weight change, to include taking Aciphex. The treatment helped by stabilizing her weight. She reported symptoms of dysphagia, heartburn, epigastric pain, scapular pain, reflux, regurgitation of stomach contents, and nausea and vomiting. She denied arm pain, hematemesis and passing black tarry stools. The symptoms described occur intermittently, as often as 3 times a week, with each occurrence lasting 30 minutes. The number of attacks reported within the prior year were 150. The current treatment consisted of Aciphex and avoiding spicy and fried foods. Physical examination of the abdomen revealed tenderness to palpation. The assessment was GERD because of subjective heartburn, abdominal pain and intolerance to certain food items and objective tenderness in the epigastric region. There was no anemia or malnutrition noted. The Board finds that the medical evidence prior to August 28, 2007 does not demonstrate that the criteria for a 30 percent disability rating for GERD under Diagnostic Code 7346 were met as the evidence fails to show that her GERD was productive of considerable impairment of health. On examination in July 2006, she denied that her GERD had any effect on her weight. Furthermore the examiner noted there was no objective evidence of anemia or malnutrition. Nor are the requirements met for a 30 percent evaluation under Diagnostic Code 7301 as the evidence fails to demonstrate that she had moderately severe adhesions with partial obstruction manifested by delayed motility of barium meal and less frequent and less prolonged episodes of pain. Moreover, based upon the evidence prior to August 28, 2007, the Board finds that the predominant gastrointestinal disability is the Veteran's GERD as this disability causes the most symptoms. Her service-connected pelvic adhesion status post appendectomy merely resulted in some right lower abdominal pain with tenderness to palpation in that area compared to the significant symptoms of heartburn/reflux, epigastric and scapular pain, and regurgitation caused by her service-connected GERD. The Board finds that the severity of the service-connected pelvic adhesions status post appendectomy was not such that would make her overall disability picture of such severity that the rating should be elevated to the next higher rating (i.e., her overall disability picture was not consistent with a 30 percent disability rating under either Diagnostic Code 7301 or 7346) because her symptoms from this disability were merely intermittent right lower abdominal pain for which she received no treatment and it caused no functional impairment. Consequently, the earliest evidence demonstrating that the Veteran's GERD and pelvic adhesion status post appendectomy are productive of the criteria for a 30 percent disability rating is the December 2007 VA examination. The Board finds, therefore, that an effective date prior to August 28, 2007, for the award of a 30 percent disability rating for the Veteran's service-connected GERD and pelvic adhesion status post appendectomy is not warranted under the schedular criteria. Finally, the Board finds that referral for extraschedular consideration under 38 C.F.R. § 3.321(b) is not warranted in the present case as the evidence fails to show that the Veteran's GERD and/or pelvic adhesion status post appendectomy presents such an exceptional disability picture that the available schedular evaluations for that disability are inadequate. 38 C.F.R. § 3.321(b)(1); see also, Thun v. Peake, 22 Vet. App. 111, 115 (2008); Shipwash v. Brown, 8 Vet. App. 218, 227 (1995). The evidence does not show that these disabilities caused marked interference with the Veteran's employment. The July 2006 VA examination report notes that there was no functional impairment resulting from the pelvic adhesion and GERD. Moreover, the evidence shows that the Veteran has not had frequent periods of hospitalization due to her GERD and pelvic adhesion that has interfered with her employment or daily life. In fact, she denied having any medical treatment for these conditions and reported using only over-the-counter medications to treat them. Finally, her symptoms reported are consistent with the criteria set forth under the applicable Diagnostic Codes used to evaluate her disabilities. She has not reported any symptoms that are not contemplated by the rating schedule. Thus the Board finds that the preponderance of the evidence is against referral of the Veteran's claim for extraschedular consideration. The Board has considered the doctrine of reasonable doubt, but finds that the record does not provide an approximate balance of negative and positive evidence on the merits. The claim is, therefore, denied. Gilbert v. Derwinski, 1 Vet. App. 49, 57-58 (1990); 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102. ORDER Entitlement to an effective date earlier than August 28, 2007, for the award of a 30 percent disability rating for service-connected migraine headaches is denied. Entitlement to an effective date earlier than August 28, 2007, for the award of a 30 percent disability rating for service-connected gastroesophageal reflux disease (GERD) and pelvic adhesion status post appendectomy is denied. REMAND The Board finds remand of the Veteran's claim for an increased disability rating for her service-connected ganglion cyst of the left wrist is warranted. In an April 2013 statement, the Veteran indicated that her condition has worsened since her appeal has been in progress and she is constantly going to the doctor. She requested that her appeal be withdrawn so that she could file a re-open claim for an increase. The Board finds this statement to be contradictory. It appears she mistakenly believed that this would somehow quicken her getting an increased disability rating. However, in May 2013, the Veteran filed another statement asking that her withdrawal be cancelled and that she desired to continue her appeal. Given that the Veteran's April 2013 was unclear, the Board finds that the issue remains on appeal. At this time, since the Veteran has indicated that her condition has worsened, the Board cannot proceed to adjudicate her claim but must remand for a VA examination to assess the current nature, extent and severity of her service-connected ganglion cyst of the left wrist. See Palczewski v. Nicholson, 21 Vet. App. 174, 181 (2007); Snuffer v. Gober, 10 Vet. App. 400, 403 (1997); see also VAOPGCPREC 11-95 (1995), 60 Fed. Reg. 43186 (1995). Thus, the Board has no discretion and must remand this claim. Moreover, as the Veteran has indicated she has had to see the doctor for these conditions, treatment records should be sought. The Board notes that the Veteran has not indicated whether such treatment was with VA or a private physician such that, on remand, she should first be asked to identify where she received such treatment before those treatment records are obtained. Accordingly, the case is REMANDED for the following action: 1. Contact the Veteran and ask her to identify all medical care providers, whether VA or non-VA, which have treated her for her service-connected left wrist ganglion cyst. For all non-VA providers, she should be asked to complete a release form authorizing VA to obtain these private treatment records. The Veteran should be advised that, in lieu of submitting a completed release form, she can submit these private medical treatment records to VA herself. If the Veteran provides completed release forms, then the medical records identified should be requested. All efforts to obtain these records, including follow-up requests, if appropriate, should be fully documented. The Veteran and her representative should be notified of unsuccessful efforts in this regard and afforded an opportunity to submit the identified records. 2. When the above development has been accomplished and any available evidence has been obtained, the Veteran should be scheduled for a VA joints examination. The claims file must be provided to the examiner for review in conjunction with the examination. The examiner should indicate in the report that the claims file was reviewed. All necessary tests and studies should be conducted in order to ascertain the severity of the Veteran's service-connected left wrist ganglion cyst. The examiner should elicit information as to the frequency, duration, and severity of any associated symptomatology, and loss of function in daily activities, including work and physical activity. The examiner should determine the limitation of motion, if any, of the Veteran's left wrist caused by recurrent ganglion cysts and residuals related to excisions thereof and discuss whether there is pain on movement, swelling, tenderness, deformity or atrophy of disuse. The examiner should also determine whether there is any evidence of ankylosis, ligamentous laxity or other impairment of the left wrist. Repetitive motion testing should be conducted, and the examiner should comment on whether there is additional functional loss due to weakness, fatigability, incoordination, or pain on movement. Functional loss contemplates the inability of the body to perform the normal working movements of the body with normal excursion, strength, speed, coordination and endurance, and must be manifested by adequate evidence of disabling pathology, especially when it is due to pain. 3. Thereafter, the Veteran's claim for an increased disability rating for service-connected ganglion cyst, left wrist, should be readjudicated. If such action does not resolve the claim, a Supplemental Statement of the Case should be issued to the Veteran and her representative. An appropriate period of time should be allowed for response. Thereafter, this claim should be returned to this Board for further appellate review, if in order. The Veteran has the right to submit additional evidence and argument on the matter the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2012). ______________________________________________ MICHAEL MARTIN Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs