Citation Nr: 1323004 Decision Date: 07/18/13 Archive Date: 07/24/13 DOCKET NO. 05-32 986 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Cleveland, Ohio THE ISSUE 1. Entitlement to a compensable evaluation for pelvic abscesses and adhesions. 2. Entitlement to a total disability rating based upon individual unemployability due to service connected disabilities (TDIU). REPRESENTATION Appellant represented by: Disabled American Veterans WITNESSES AT HEARING ON APPEAL The Veteran and her son ATTORNEY FOR THE BOARD Russell P. Veldenz, Counsel INTRODUCTION The Veteran served on active duty from January 1967 to January 1970. These matters are before the Board of Veterans' Appeals (Board) on appeal of a rating decision in November 2004 of a Department of Veterans Affairs (VA) Regional Office (RO) in Philadelphia, Pennsylvania. During the pendency of this appeal, the Veteran's claims files were transferred to the jurisdiction of the Cleveland, Ohio RO, which has certified the case for appellate review. In January 2008, the Veteran appeared at a hearing before a Decision Review Officer. A transcript of the hearing is in the record. The Veteran had requested a hearing before the Board, but the Veteran withdrew that request in writing in December 2005. In January 2010 and May 2012, the Board remanded the case to the RO for additional development. As the requested development has been completed, no further action is necessary to comply with the Board's remand directives. Stegall v. West, 11 Vet. App. 268, 271 (1998). The Board has reviewed both the Veteran's physical claims files and her Virtual VA file so as to insure a total review of the evidence. The issue of TDIU 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. FINDING OF FACT Pelvic abscesses and adhesions are manifested by symptoms that cannot be controlled by continuous treatment. CONCLUSION OF LAW Affording the Veteran the benefit of the doubt, the schedular criteria for a 30 percent rating for the service-connected pelvic abscesses and adhesions have been met. 38 U.S.C.A. §§ 1155, 5103, 5107 (West 2002); 38 C.F.R. §§ 3.159, 4.3, 4.7, 4.116, Diagnostic Code 7613 (2012). REASONS AND BASES FOR FINDING AND CONCLUSION The Veterans Claims Assistance Act of 2000 (VCAA) The VCAA, codified in part at 38 U.S.C.A. §§ 5103, 5103A, and implemented in part at 38 C.F.R § 3.159, amended VA's duties to notify and to assist a claimant in developing information and evidence necessary to substantiate the claims. Duty to Notify Under 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b), when VA receives a complete or substantially complete application for benefits, it will notify the claimant of the following: (1) any information and medical or lay evidence that is necessary to substantiate the claim, (2) what portion of the information and evidence VA will obtain, and (3) what portion of the information and evidence the claimant is to provide. Also, the VCAA notice requirements apply to all five elements of a service connection claim. The five elements are: 1) veteran status; 2) existence of a disability; 3) a connection between the Veteran's service and the disability; 4) degree of disability; and 5) effective date of the disability. Dingess v. Nicholson, 19 Vet. App. 473, 484-86 (2006). In a claim for increase, the VCAA notice requirements are the type of evidence needed to substantiate the claim, namely, evidence demonstrating a worsening or increase in severity of the disability and the effect that worsening has on employment. Vazquez-Flores v. Shinseki, 580 F.3d 1270 (Fed. Cir. 2009) (interpreting 38 U.S.C.A. § 5103(a) as requiring generic claim-specific notice and rejecting Veteran-specific notice as to effect on daily life and as to the assigned or a cross-referenced Diagnostic Code under which the disability is rated). The VCAA notice, as required by 38 U.S.C.A. § 5103(a), must be provided to a claimant before the initial unfavorable adjudication by the RO. Pelegrini v. Principi, 18 Vet. App. 112, 119 (2004). The RO provided pre- and post- adjudication VCAA notice by letters, dated in November 2004, March 2006, and August 2008. The notice included the type of evidence needed to substantiate the claims for increase, namely, evidence that the symptoms had increased. The Veteran was notified that VA would obtain service treatment records, VA records, and records from other Federal agencies, and that she could submit other records not in the custody of a Federal agency, such as private medical records or with her authorization VA would obtain any non-Federal records on her behalf. The notice included the provisions for the effective date of a claim and for the degree of disability assignable. As for content of the VCAA notice, the documents complied with the specificity requirements of Quartuccio v. Principi, 16 Vet. App. 183, 186-87 (2002) (identifying evidence to substantiate a claim and the relative duties of VA and the claimant to obtain evidence); of Charles v. Principi, 16 Vet. App. 370, 374 (2002) (identifying the document that satisfies VCAA notice); of Pelegrini v. Principi, 18 Vet. App. 112, 119-120 (2004) (38 C.F.R. § 3.159 notice); of Dingess v. Nicholson, 19 Vet. App. 473, 484-86 (2006) (notice of the elements of the claim); and of Vazquez-Flores v. Peake, 580 F.3d 1270 (Fed. Cir. 2009) (evidence demonstrating a worsening or increase in severity of a disability and the effect that worsening has on employment). Further VCAA notice is not required. To the extent that the VCAA notice came after the initial adjudication, the timing of the notice did not comply with the requirement that the notice must precede the adjudication. The timing error was cured by content-complying VCAA notice after which the claims were readjudicated as evidenced by the supplemental statements of the case, dated in October 2008, April 2009, October 2011, and April 2013. Mayfield v. Nicholson, 499 F.3d 1317, 1323 (Fed. Cir. 2007) (Timing error cured by adequate VCAA notice and subsequent readjudication without resorting to prejudicial error analysis.) Duty to Assist Under 38 U.S.C.A. § 5103A, VA must make reasonable efforts to assist the claimant in obtaining evidence necessary to substantiate the claim. The RO has obtained service treatment records, VA records, records from private medical caregivers, and afforded the Veteran a VA examination in October 2004 and January 2006. The reports of the VA examinations included a review of the Veteran's medical history, including her service treatment records, an interview and an examination of the Veteran, as well as sufficient findings to rate disability. Therefore, the Board concludes that the VA examinations are adequate. 38 C.F.R. § 4.2; see Barr v. Nicholson, 21 Vet. App. 303, 312 (2007) (holding that when VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate). The October 2004 VA examination referred to a gynecological examination occurring in May 2004. As it was not clear to the Board whether the examiner was referring only to a private examination discussed below, or a separate VA gynecological examination also occurring in May 2004, the Board remanded with directions to the RO to obtain the records of any VA gynecological examination occurring in May 2004. The Board also directed that a complete copy of a VAMC triage note and addendum, both dated in May 2004, be associated with the file. The VAMC triage note and addendum are now part of the file through Virtual VA. In March 2013, the RO learned that no such records for a May 2004 VA gynecological examination exist and the RO found further efforts would be futile. The Veteran was notified in March 2013 that the RO had not located records of a May 2004 VA gynecological examination. The Board therefore finds that VA has complied with the duty to assist with respect to any potential additional records from May 2004. In Bryant v. Shinseki, 23 Vet. App. 488 (2010), the United States Court of Appeals for Veterans Claims held that 38 C.F.R. § 3.103(c)(2) (2012) requires that the Decision Review Officer (DRO) who conducts a hearing fulfill two duties to comply with the above the regulation. These duties consist of (1) the duty to fully explain the issues and (2) the duty to suggest the submission of evidence that may have been overlooked. Here, during a January 2008 hearing, the DRO explained the issues on appeal, and asked questions pertinent to the elements of the claims that were lacking. The DRO also solicited information as to any potentially outstanding pertinent available evidenc. The Veteran was assisted at the hearing by a representative. No pertinent evidence that might have been overlooked and that might substantiate the claim decided herein was identified by the Veteran. The Veteran, through his testimony, demonstrated that he had actual knowledge of the elements necessary to substantiate his claim for an increased rating. The Veteran did not suggest any deficiency in the conduct of the hearing. Therefore, the Board finds that, consistent with Bryant, the DRO complied with the duties set forth in 38 C.F.R. § 3.103(c)(2). As the Veteran has not identified any additional evidence pertinent to the claim and as there are no additional records to obtain, the Board concludes that no further assistance to the Veteran in developing the facts pertinent to the claims is required to comply with the duty to assist. Rating Principles A disability rating is determined by the application of VA's Schedule for Rating Disabilities (Rating Schedule). 38 C.F.R. Part 4. The percentage ratings contained in the Rating Schedule represent, as far as can be practicably determined, the average impairment in earning capacity resulting from diseases and injuries incurred or aggravated during military service and their residual conditions in civil occupations. 38 U.S.C.A. § 1155. 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. The Board will consider whether separate ratings may be assigned for separate periods of time based on facts found, a practice known as "staged ratings," whether it is an initial rating case or not. Fenderson v. West, 12 Vet. App. 119, 126-27 (1999); Hart v. Mansfield, 21 Vet. App. 505, 510 (2007). The Veteran asserts that a compensable evaluation is warranted for her service-connected pelvic abscess and adhesions. Her service-connected disability is rated under Diagnostic Codes 7699-7613, which means the condition is rated by analogy. When an unlisted condition is encountered it is permissible to rate under a closely related disease or injury in which not only the functions affected, but also the anatomical localization and symptomatology are closely analogous. Conjectural analogies will be avoided, as will the use of analogous ratings for conditions of doubtful diagnosis, or for those not fully supported by clinical and laboratory findings, nor will ratings assigned to organic disease and injuries be assigned by analogy to conditions of functional origin. See 38 C.F.R. § 4.20. The "7699" indicates that the Veteran's service-connected pelvic abscesses and adhesions is an unlisted condition rated by analogy to Diagnostic Code 7613 pertaining to a disease, injury, or adhesion of the uterus. As will be discussed more thoroughly below, the Board finds that Diagnostic Code 7613 is most closely analagous to the Veteran's disability in functions affected, anatomical localization, and symptomatology. Diagnostic Code 7613 is designated for disease, injury, or adhesions of the uterus that are rated under the General Rating Formula for Disease, Injury, or Adhesions of the Female Reproductive Organs. Under the formula, symptoms that do not require continuous treatment warrant a noncompensable rating, and a 10 percent rating is assigned for disease, injury, or adhesions of the uterus where symptoms require continuous treatment. Id. A 30 percent rating is warranted where symptoms cannot be controlled by continuous treatment. Id. Initially, the Board notes it has reviewed all of the evidence in the Veteran's claims file, with an emphasis on the evidence relevant to this appeal. Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, the extensive evidence of record. Indeed, the Federal Circuit has held that the Board must review the entire record, but does not have to discuss each piece of evidence. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000). Therefore, the Board will summarize the relevant evidence where appropriate, and the Board's analysis below will focus specifically on what the evidence shows, or fails to show, as to each claim. In September 2002, the Veteran was seen for urinary incontinence, uterine bleeding, and uterus collapse. At that time, it was noted she was being followed for the urinary incontinence. In January 2003, she had a Pap smear which it was noted the Veteran was very tense. The examination revealed a cystocele, but the gynecological examination was otherwise normal. A May 2003 note indicates the Pap smear was negative for intraepithelial lesion or malignancy. It was noted the Veteran had a history of cervical cancer. Also in January 2003, the Veteran underwent a private CT scan of her abdomen and pelvis. The images were severely degraded by body habitus and the uterus was hard to define. There was an oval density to the right between the bladder and rectum which may represent the cervix, right ovary, or a right ovarian cyst. No free fluid was noted. Mildly prominent inguinal lymph nodes were noted bilaterally. She also underwent at a private pelvic examination in January 2003 where she was crying and distressed. She gave a history of pelvic pain and pressure. Past surgical history included pelvic adhesions. A pelvic ultrasound demonstrated several small uterine fibroids. Examination of the abdomen was soft, tender, and no masses were felt. The vagina showed bulging underneath the urethra, which was suspicious for a urethral diverticulum. The cervix was not examined due to tenderness and obesity. In a letter dated in February 2003, her private physician appears to refer to the January 2003 pelvic examination. The vulva and vagina were atrophic. The perineal body was in a normal position. She had a first to second degree rugated cystocele. There were no perineal bodies, retroceles, or uterine prolapse. The uterus was anteverted, mobile, nontender, and not enlarged. The diagnosis included pelvic pain as well as rule out stress urinary incontinence, and rule out urethral diverticulum. The Veteran would not allow use of a speculum. No adenexal masses were felt but the examination was severely limited by obesity. A separate treatment noted the diagnoses as stress urinary incontinence, a mild cystocele, and pelvic muscle atrophy. In April 2003, the Veteran was privately evaluated for urinary incontinence. She reported being told she has a possible urethral diverticulum. She was noted to have multiple medical problems and was morbidly obsess. On physical examination, she had a first to second degree rugated cystocele and no other prolapse. The examiner did not find an obvious urethral diverticulum. Her levators were extremely weak and she had moderate hypermobility of the urethra. The Veteran had a normosensitive bladder of decreased capacity and normal compliance. Genuine stress incontinence was not demonstrated with cough or valsalva. It was noted that the Veteran did not tolerate a pelvic exam well. The physician stated that careful inspection and palpation of the anterior vaginal wall and suburethral area did not reveal an obvious diverticulum. She was tender just below the urethral meatus without a mass observed or felt. In November 2003, it was noted the Veteran had urinary incontinence since the early 90's. She described total incontinence not necessarily associated with stress or urgency. She had been evaluated by 3 urologists in the past and no physiologic dysfunction was discovered. The cystocele, described as Grade 1-2 was recently discovered and after the start of her urinary incontinence. In December 2003, the Veteran underwent a gynecological examination which revealed a yeast infection but the cervix was within normal limits and the adnexa was nontender. In April 2004, it was noted the Veteran had difficulty tolerating a gynecological examination secondary to rape and she had PTSD. She complained of vaginal bleeding for the past four days. The external genitalia were normal and the cystocele was noted. The cervix could not be visualized secondary to the Veteran's intolerance for the examination and the "BME" could not be assessed due to the body habitus. Scant red blood was noted on the gloved finger of the physician and a hysteroscopy was planned. In May 2004, a private physician office note indicated the Veteran complained of pelvic pressure and urinary pressure. That same month, the Veteran underwent a private pelvic examination under general anesthesia as she could not otherwise tolerate a pelvic examination secondary to a history of sexual abuse. She had a history of postmenopausal bleeding and cervical dysplasia with a cone biopsy in the early 1990s. The procedure included a hysteroscopy, dilatation and curettage, Pap test, and examination. The doctor was unable to palpate the uterus secondary to body habitus but no adenexal masses were palpitated. The rectovaginal examination revealed no pelvic masses. The uterus was sounded to 6.5 cm. Hysteroscopic findings included an atrophic-appearing endometrium. The cervix was somewhat stenotic but eventually, was dilated for the examination and then the D & C was performed. The pathology report noted no significant cytologic atypia was identified. The Pap smear was negative for intraepithelial lesion or malignancy. In July 2004, the Veteran sought treatment at VA for urinary incontinence. She stated when she tries to void, she felt a pressure. Past treatment for the urinary incontinence had been unsuccessful. The Veteran was diagnosed with a possible overactive bladder. In October 2004, the Veteran was provided a VA gynecological examination. The examiner noted the Veteran had two problems: urinary incontinence and chronic pelvic pain. In service, she developed a serious pelvic inflammatory disease with vaginal abscess drainage. She was told that she also had adhesions. Subsequently, she had a cone biopsy in 1991. In May 2004, she had a D & C at a private hospital for vaginal bleeding pathology. The urinary incontinence started in 1994 and the Veteran was diagnosed with a grade II cystocele with a normal post void residual. Various methods of treatment have not been successful in treating the incontinence problem. As to the pelvic abscesses and adhesions, she has a long standing, chronic ache. She cannot stand for long periods of time without a pulling sensation going down into the groin. The Veteran also has low back pain. A pelvic examination was not performed because she could not tolerate it. It was noted a pelvic examination had been performed in May 2004. The examiner diagnosed urinary incontinence most likely due to an overactive bladder as opposed to true stress incontinence although he could not rule out a relatively weak sphincter. As to her chronic pain, the examiner concluded that it is most likely due to the long standing adhesions given the Veteran's habitus and relatively minimal symptomatology and possible relation to the back pain. The examiner did not believe she was a good candidate for surgical exploration. In January 2005, as part of her notice of disagreement, the Veteran stated that due to extreme pain, the only way she can tolerate a pelvic examination is if it occurs under general anesthesia. In September 2005, as part of her substantive appeal, the Veteran reported that physicians have told her it would be too dangerous to operate on her to remove the adhesions and she would not make it off the operating table. In September 2005, VAMC treatment notes indicated the Veteran was diagnosed with a prolapsed bladder with urinary incontinence and has been at baseline for years. She also reported chronic pain at baseline for years for which she takes Tylenol. She was not interested in additional medications because other medications in the past caused gastrointestinal bleeding. In January 2006, during a VA examination to evaluate the pelvic abscess and adhesion disability, it was noted the Veteran used a walker. She stated she believed she could not stand independently due to a combination of the pain from varicose veins and the pain from pelvic adhesions. The Veteran stated the pelvic adhesion pain are worsening and are 6/10 when sitting still and 8/9 when either standing or walking because of the downward pull of her weight on the adhesions. It was noted that the Veteran could not undergo a pelvic examination because of pain and PTSD. The examiner stated that in the absence of a gynecological examination, whether the pain resulted from the adhesions of previous gynecological surgery would be speculative. Given the Veteran's physical and psychic trauma, such an examination for the sole purpose of rating would be medically contraindicated. A previous examination or if one occurred in the future would be helpful. In February 2006, it was noted the Veteran's urinary urgency incontinence was more likely than not related to morbid obesity. Surgery was not indicated for the stage II cystocele due to the morbid obesity. It was also concluded that there was no relationship between her gynecologic condition and current bladder problems. In August 2006, the Veteran was evaluated for her cystocele. She complained of pelvic pain and wanted to make sure the cystocele had not worsened. She still had urinary incontinence and because she was trying to lose weight through Weight Watchers, she had urinary frequency due to increased water consumption. She also had some occasional rectal incontinence. The vulva was within normal limits. The vagina had ruggated pink redundant tissue. The cystocele was visualized and was described as small. An approximately 1-2 inch tender suburethral diverticulum was palpated. The cervix was not visualized secondary to redundant tissue and patient discomfort. The assessment was a suburethral diverticulum In June 2009, a private physician, Dr. M. Reigle noted that in 2003, the Veteran felt a pop or low sensation and felt a vaginal bulge. After several evaluations, it was believed she had a urethral diverticulum but a follow-up MRI revealed periurethral cysts. On examination, she had a suburethral soft, tender mass. She had active leakage on valsalva but did not have an active cystocele. The physician recommended a vaginal obturator sling and also an excision of the periurethral cyst. In August 2009, the Veteran underwent surgery for incision of a suburethral cyst and drainage of an abscess. Dr. Reigle had intended to insert the vaginal obturator sling, but did not do so after the incision and drainage of the cyst. After a careful review of the available evidence, the Board has determined that the Veteran is entitled to a rating of 30 percent for the entire rating period on appeal. Initially, the Board notes that the October 2004 VA examination referred to a gynecological examination occurring in May 2004. As it was not clear to the Board whether the examiner was referring only to the private examination noted above, or a separate VA gynecological examination also occurring in May 2004, the Board remanded with directions to the RO to obtain the records of any VA gynecological examination occurring in May 2004. In March 2013, the RO learned that no such records for a May 2004 VA examination exist and the RO found further efforts would be futile. The Board therefore finds that the VA examiner in October 2004 was referring to the private May 2004 gynecological examination referred to above. The Board also notes that the VA examiners in October 2004 and January 2006 could not perform a physical, pelvic examination of the Veteran because the Veteran could not tolerate a pelvic examination. A full VA examination could have provided information and evidence needed to assist the Board in analyzing the Veteran's entitlement to a compensable rating for the pelvic abscesses and adhesions disability. The Board, however, must sympathetically review the records and the Veteran's contentions and assertions. See also 38 C.F.R. §§ 4.6, 4.23. In this instance, as noted above, the Veteran was very tender in this area and in addition, has been the victim of multiple sexual traumas. In the VA examination of January 2006, the examiner noted that, given her physical and psychic trauma, an examination for the sole purposes of rating is medically contraindicated. Therefore, instead of denying the claim for increase, see 38 C.F.R. § 3.655, or remanding the Veteran's claim for another VA examination, the Board will determine the Veteran's claim based on the evidence of record. Further, there are examinations of record where the Veteran has been able to tolerate a pelvic examination, including the private May 2004 examination under general anesthesia, as well as the January 2003, February 2003, April 2003, and August 2006. Based upon the evidence of record, and resolving all doubt in favor of the Veteran, the Board finds that the Veteran's pelvic abscesses and adhesions have resulted in "symptoms not controlled by continuous treatment." The Veteran has testified there is always continuous pain, which affects her ability to stand. She cannot stand for long periods of time without a pulling sensation going down into the groin. Although the only medication she has used to control the pain has been Tylenol, the record also indicates she has allergies to other medication such as aspirin. Other methods of treatment such as surgery have been contraindicated because of other medical conditions such as her weight. It appears that given the Veteran's overall disability picture, the Veteran has required treatment, albeit limited in what can be offered to her, but still experiences pain. The Veteran is competent to describe symptoms of the pelvic adhesions. Layno v. Brown, 6 Vet. App. 465, 469-71 (1994) (lay testimony is competent as to symptoms of an injury or illness, which are within the realm of personal knowledge). Further, the record indicates the Veteran is a nurse and therefore has medical knowledge. 38 C.F.R. § 3.159. The Board finds the Veteran's testimony to be credible in identifying and describing her symptoms of her pelvic abscesses and adhesions. Thus, with consideration of the Veteran's complaints, symptoms, and unsuccessful attempts at treatment, and after resolving all reasonable doubt in her favor, the Board concludes that the Veteran's pelvic abscesses and adhesions disability picture more nearly approximates or resembles the criteria for a schedular rating of 30 percent. See 38 C.F.R. §§ 4.7, 4.116, DC 7613. The 30 percent rating is the highest available under DC 7613 as well as the General Rating Formula for Disease, Injury, or Adhesions of Female Reproductive Organs. A rating in excess of 30 percent would require rating under another diagnostic code, for which symptoms must include one of the following: the removal or prolapse of the uterus or ovary(ies) (DCs 7617, 7618, 7619, 7621), surgical complications of pregnancy (DC 7623), or fistula (see DC 7624 for rectovaginal or DC 7625 for urethrovaginal). However, in this case, the Veteran has not asserted or been diagnosed with any of above-cited symptoms or diagnoses as related to her service-connected pelvic abscesses or adhesions. As the Veteran has not been shown to have any of those diagnoses, a rating in excess of 30 percent for pelvic abscesses and adhesions is not warranted. The Board notes the Veteran claimed her urinary incontinence disorder was due to the pelvic abscesses and adhesions but in January 2010, the Board denied her claim for service connection for urinary incontinence including as secondary to the pelvic disability. Extraschedular Consideration Although the Board is precluded by regulation from assigning an extraschedular rating under 38 C.F.R. § 3.321(b)(1) in the first instance, the Board is not precluded from considering whether the case should be referred to the Director of VA's Compensation and Pension Service for a rating. The threshold factor for extraschedular consideration is a finding that the evidence presents such an exceptional disability picture that the available schedular ratings for that service-connected disability are inadequate. This is accomplished by comparing the level of severity and symptomatology of the service-connected disability with the established criteria. If the criteria reasonably describe the disability level and symptomatology, then the disability picture is contemplated by the Rating Schedule, and the assigned schedular rating is, therefore, adequate and referral for an extraschedular rating is not required. Thun v. Peake, 22 Vet. App. 111, 115 (2008), aff'd sub nom. Thun v. Shinseki, 572 F.3d 1366 (Fed. Cir. 2009). In this instance, as noted the Veteran's disability is already rated under the General Formula for Disease, Injury, or Adhesions of Female Reproductive Organs. The disability has primarily resulted in pain. That formula already recognizes that a condition such as pelvic abscesses and adhesions result in residuals such as pain. Further, the Formula recognizes that the residuals may not be alleviated or controlled by treatment. There also has not been any evidence the pelvic abscesses and adhesions markedly interfered with employment or resulted in frequent hospitalizations. There is no unusual clinical picture presented, nor is there any other factor which takes the disability outside the usual rating criteria. Comparing the Veteran's current disability level and symptomatology to the Rating Schedule, the degree of disability is contemplated by the Rating Schedule and the assigned schedule ratings are, therefore, adequate and no referral for an extraschedular rating is required under 38 C.F.R. § 3.321(b)(1). TDIU Finally, the Board is cognizant of the ruling of the Court in Rice v. Shinseki, 22 Vet. App. 447 (2009). In Rice, the Court held that a claim for a total rating based on unemployability due to service-connected disability, either expressly raised by the Veteran or reasonably raised by the record, involves an attempt to obtain an appropriate rating for a disability and is part of the claim for an increased rating. As noted above, this issue is addressed below in the REMAND portion of this decision. ORDER A rating of 30 percent for pelvic abscesses and adhesions is granted, subject to the law and regulations, governing the payment of monetary benefits. REMAND The Board notes that a claim for total disability based upon individual unemployability (TDIU) is already part of her claim for a higher rating for pelvic abcesses and adhesions if raised by the Veteran or reasonably raised by the record. See Rice v. Shinseki, 22 Vet. App. 447, 453 (2009) (a request for a total disability rating for compensation based on individual unemployability raised by the Veteran is not a separate claim for benefits, but part of the claim for increase). Entitlement to a TDIU was denied in the November 2004 rating decision on appeal. Although the Veteran did not specifically reference that decision in his substantive appeal, under Rice, the matter of entitlement to a TDIU is nevertheless before the Board as part of the appeal for a higher rating for the service-connected pelvic abscesses and adhesions. As such, the Board will consider entitlement to a TDIU for the rating period from February 2003, one year prior to the date of receipt of the February 2004 increased rating claim. The Board is aware that the Veteran was granted a 100 percent combined schedular rating for her service-connected disabilities, effective April 14, 2010, in a rating decision dated in October 2011. In a rating decision dated in May 2012, the RO granted an earlier effective date for a pes planus disability, and as a result, the 100 percent combined schedular rating became effective February 29, 2008. It does not appear, however, that the Veteran was awarded special monthly compensation based on being housebound. See 38 U.S.C.A. § 1114 (s). The TDIU claim is not moot as no single disability has been rated total (at 100 percent) and there has not been an award for special monthly compensation. See Bradley v. Peake, 22 Vet. App. 280, 292 (2008) (Congress intended a single disability be rated as total for § 1114 (s), but TDIU may be used as a basis for establishing second requirement under § 1114 (s)); Buie v. Shinseki, 24 Vet. App. 242, 249-250 (2010) (TDIU rating based upon multiple disabilities does not meet the requirement of a single disability requirement of § 1114 (s).) VA also has a "well-established" duty to maximize a claimant's benefits. See Buie, 24 Vet. App. at 250. For this reason, a TDIU may become relevant if the Veteran becomes eligible for special monthly compensation benefits. While it appears that the Veteran is currently retired, the Board does not find that such fact alone is dispositive of the issue. TDIU is to be determined without consideration of nonservice-connected disabilities or age. Accordingly, the case is REMANDED for the following action: 1. Issue a VCAA notice letter to the Veteran's current address of record for the issue of entitlement to a total disability rating due to service-connected disabilities based on individual unemployability (TDIU). Provide the Veteran a VA Form 21-8940, VETERAN'S APPLICATION FOR INCREASED COMPENSATION BASED ON UNEMPLOYABILITY, for completion. Request that the Veteran provide information on her employment status since February 2003, to include the average weekly hours worked, and annual wages. If she is currently employed, she should be asked to state why such employment should not be considered substantially gainful employment. If she is currently not employed, the Veteran should be asked to provide an authorization from her prior employer concerning the reasons the employment relationship ended. All efforts to obtain records must be documented. If the records do not exist or further attempts to obtain the records would be futile, notify the Veteran in accordance with 38 C.F.R. § 3.159(e). Any additional development, including a VA examination, deemed necessary to adjudicate the issue of entitlement to a total rating based on individual unemployability due to service-connected disabilities should be accomplished. 2. Thereafter, readjudicate the issue of entitlement to a TDIU. In this regard, it should be noted that, pursuant to Rice, the VA may consider entitlement to a TDIU for the rating period from February 2003, one year prior to receipt of the increased rating claim. Notice of the determination should be issued to the Veteran and her representative. If the benefit sought is not granted, issue a statement of the case and afford the appropriate period to respond. Thereafter, the matter should be returned to the Board for appellate consideration. The appellant 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 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). ______________________________________________ U. R. POWELL Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs