Citation Nr: 1327604 Decision Date: 08/28/13 Archive Date: 09/05/13 DOCKET NO. 10-01 937 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Waco, Texas THE ISSUES 1. Entitlement to a disability rating in excess of 10 percent for neurosarcoidosis; mood disorder not otherwise specified with depressive features prior to July 1, 2009, in excess of 50 percent from July 1, 2009, to April 27, 2012, and in excess of 70 percent thereafter. 2. Entitlement to a disability rating in excess of 30 percent for pulmonary sarcoidosis with asthma. 3. Entitlement to a disability rating in excess of 20 percent for fibromyalgia prior to May 3, 2012, and in excess of 40 percent thereafter. 4. Entitlement to a disability rating in excess of 10 percent for tendonitis of the left ankle. 5. Entitlement to a disability rating in excess of 10 percent for retropatellar pain syndrome, myxoid degeneration of the medial meniscus of the right knee. 6. Entitlement to a disability rating in excess of 10 percent for retropatellar pain syndrome, myxoid degeneration of the medial meniscus of the left knee. 7. Entitlement to a disability rating in excess of 10 percent for human papilloma virus, squamous metaplasia and dysplasia. 8. Entitlement to a disability rating in excess of 10 percent for carpal tunnel syndrome (dominant) of the right wrist. 9. Entitlement to a disability rating in excess of 10 percent for carpal tunnel syndrome (non-dominant) of the left wrist. 10. Entitlement to an initial compensable disability rating for residuals of fracture, tendonitis, of the left little finger (non-dominant). 11. Entitlement to a compensable disability rating for costochondritis. 12. Entitlement to a compensable disability rating for uveitis. 13. Entitlement to a compensable disability rating for vertigo prior to December 6, 2012, and a disability rating in excess of 30 percent thereafter. 14. Entitlement to a compensable disability rating for allergic rhinitis with sinusitis. 15. Entitlement to a compensable disability rating for Gilbert's syndrome. 16. Entitlement to a compensable disability rating for gastroesophageal reflux disease (GERD). 17. Entitlement to an initial compensable disability rating for bilateral ovarian cysts. REPRESENTATION Appellant represented by: Texas Veterans Commission WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD Anthony M. Flamini, Counsel INTRODUCTION The Veteran served on active duty from January 1988 to August 2000. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a February 2009 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Waco, Texas. The Veteran testified before the undersigned Veterans Law Judge in January 2012. A copy of the transcript of this hearing has been associated with the claims file. The Court of Appeals for Veterans Claims (Court) held that once a Veteran submits evidence of a medical disability, makes a claim for the highest rating possible, and submits evidence of unemployability, the requirement in 38 C.F.R. § 3.155(a) (2012) that an informal claim identify the benefit sought has been satisfied, and VA must consider whether the claimant is entitled to a total disability rating for compensation on the basis of individual unemployability (TDIU) rating. See Rice v. Shinseki, 22 Vet. App. 447, 451 (2009). However, the record reflects that the Veteran has already been awarded entitlement to a TDIU rating. Accordingly, additional consideration of the issue of TDIU is not required. The Veteran's appeal was last remanded by the Board in April 2012 in order to obtain additional treatment records and afford the Veteran additional examinations. These additional treatment records have been obtain and associated with the record, and additional examination were provided in April 2012, May 2012, June 2012, and December 2012. Accordingly, the Board finds that there has been substantial compliance with the directives of the April 2012 Remand, such that an additional remand to comply with such directives is not required. See Stegall v. West, 11 Vet. App. 268 (1998); D'Aries v. Peake, 22 Vet. App. 97 (2008) (holding that only substantial, and not strict compliance with the terms of a remand request, is required); Dyment v. West, 13 Vet. App. 141, 146-47 (holding that there was no Stegall violation when the examiner made the ultimate determination required by the Board's remand, because such determination more than substantially complied with the Board's remand order). The issues of entitlement to service connection for sensorineural hearing loss and tinnitus have been raised by the record, 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 a compensable disability rating for vertigo prior to December 6, 2012, and a disability rating in excess of 30 percent thereafter 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 July 1, 2009, the Veteran's PTSD was manifested by occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks. 2. From July 1, 2009, to April 27, 2012, the Veteran's PTSD was manifested by occupational and social impairment with reduced reliability and productivity. 3. Since April 27, 2012, the Veteran's PTSD was manifested by occupational and social impairment, with deficiencies in most areas, such as work, school, family relationships, judgment, thinking, or mood. 4. The Veteran's service-connected pulmonary sarcoidosis with asthma was treated with intermittent inhalational bronchodilator therapy and resulted in a Forced Expiratory Volume at one second (FEV-1) of no worse than 59 percent of predicted value, a ratio of FEV-1 to Forced Vital Capacity (FEV-1/FEC) of no worse than 73 percent, and Diffusion Capacity of the Lung for Carbon Monoxide by the Single Breath Method (DLCO (SB)) of 65-percent predicted. 5. For the entire rating period under appeal, the Veteran's fibromyalgia has been manifested by symptomatology that is continuous or nearly-continuous. 6. The Veteran's left ankle tendinitis is manifested by moderate limitation of motion even taking into account her complaints of pain. 7. The Veteran's retropatellar pain syndrome of the left knee is manifested by a full range of motion, but with subjective complaints of pain upon motion. 8. The Veteran's retropatellar pain syndrome of the right knee is manifested by a full range of motion, but with subjective complaints of pain upon motion. 9. The Veteran's human papilloma virus, squamous metaplasia and dysplasia have been productive of symptoms that can be controlled by continuous treatment. 10. The Veteran's carpal tunnel syndrome of the left wrist is manifested by no more than mild symptoms, to include subjective complaints of pain, weakness, tingling, and numbness; the evidence does not indicate that this disorder is manifested by moderate symptomatology. 11. The Veteran's carpal tunnel syndrome of the right wrist is manifested by no more than mild symptoms, to include subjective complaints of pain, weakness, tingling, and numbness; the evidence does not indicate that this disorder is manifested by moderate symptomatology. 12. Residuals of the injury to the left little finger are manifested by complaints of pain, ankylosis, and the functional loss of the Veteran's left fifth finger as a result of the flexion deformity of the proximal interphalangeal joint 13. While the Veteran has reported subjective chest pain, she has not been subject to rib removal or resection. 14. The Veteran's service-connected uveitis has shown no manifestations of pain, swelling, redness, corrected visual acuity impairment, visual field loss, rest-requirements, or episodic incapacity; his bilateral eyesight is 20/40 or better, corrected. 15. The Veteran's service-connected allergic rhinitis with sinusitis does not manifest in greater than 50 percent obstruction of both nasal passages, complete obstruction of one nasal passage and without polyps, headaches, pain, or purulent discharge or crusting due to maxillary sinusitis. 16. The Veteran's service-connected Gilbert's syndrome is manifested by severe, intermittent fatigue, with no evidence of Cirrhosis with portal hypertension and splenomegaly or of daily fatigue, malaise, and anorexia requiring dietary restriction or continuous medication. 17. The Veteran's service-connected GERD is manifested by vomiting and reflux, with no evidence of substernal or arm or shoulder pain productive of considerable impairment of health. 18. The Veteran's service-connected ovarian cysts are manifested by symptoms that do not require continuous treatment. CONCLUSIONS OF LAW 1. The criteria for a rating of 30 percent, but no more, for PTSD prior to July 1, 2009, have been met. 38 U.S.C.A. §§ 1155, 5103A, 5107 (West 2002); 38 C.F.R. § 4.130, Diagnostic Code 9411 (2012). 2. The criteria for a rating in excess of 50 percent for PTSD prior from July 1, 2009, to April 27, 2012, have not been met. 38 U.S.C.A. §§ 1155, 5103A, 5107 (West 2002); 38 C.F.R. § 4.130, Diagnostic Code 9411 (2012). 3. The criteria for a rating in excess of 70 percent for PTSD prior since April 27, 2012, have not been met. 38 U.S.C.A. §§ 1155, 5103A, 5107 (West 2002); 38 C.F.R. § 4.130, Diagnostic Code 9411 (2012). 4. The criteria for a disability rating in excess of 30 percent for pulmonary sarcoidosis are not met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. § 4.79, Diagnostic Codes 6600, 6602, 6846 (2012). 5. For the entire rating period under appeal, the criteria for a rating of 40 percent, but no more, for fibromyalgia have been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107(b) (West 2002); 38 C.F.R. §§ 3.102, 3.159, 3.321(b)(1), 4.1, 4.3, 4.7, 4.10, 4.14, 4.7, 4.71a, Diagnostic Code 5025 (2012). 6. The criteria for a rating in excess of 10 percent for left ankle tendinitis have not been met. 38 U.S.C.A. §§ 1155, 5100, 5102, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 3.326, 4.1, 4.2, 4.3, 4.7, 4.10, 4.20, 4.27, 4.40, 4.45, 4.71a, Diagnostic Codes 5024, 5271 (2012). 7. The criteria for a rating higher than 10 percent for retropatellar pain syndrome of the left knee have not been met. 38 U.S.C.A. §§ 1155, 5107(b) (West 2002); 38 C.F.R. §§ 4.7, 4.71a, Diagnostic Codes 5257, 5260, 5261 (2012). 8. The criteria for a rating higher than 10 percent for retropatellar pain syndrome of the right knee have not been met. 38 U.S.C.A. §§ 1155, 5107(b) (West 2002); 38 C.F.R. §§ 4.7, 4.71a, Diagnostic Codes 5257, 5260, 5261 (2012). 9. The criteria for a disability rating in excess of 10 percent for human papilloma virus have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. § 4.71a, Diagnostic Code 7612 (2012). 10. The criteria for a rating in excess of 10 percent for the Veteran's service-connected carpal tunnel syndrome of the right wrist have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.159, 4.1-4.14, 4.124a, Diagnostic Code 8515 (2012). 11. The criteria for a rating in excess of 10 percent for the Veteran's service-connected carpal tunnel syndrome of the left wrist have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.159, 4.1-4.14, 4.124a, Diagnostic Code 8515 (2012). 12. The criteria for a non-schedular rating of 10 percent for residuals of a left little finger injury have been met, based functional loss of the Veteran's left fifth finger as a result of the flexion deformity of the proximal interphalangeal joint. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 3.321, (b), 4.40, 4.45, 4.59, 4.68, 4.71a, Diagnostic Codes 5003, 5156, 5227, 5230, 5307, 8512 (2012); see DeLuca v. Brown, 8 Vet. App. 202 (1995). 13. The criteria for a compensable evaluation for costochondritis have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.159, 4.1, 4.7, 4.20, 4.27, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5297 (2012). 14. The criteria for a compensable rating for uveitis have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 3.321, 3.383, 4.3, 4.7, 4.75, 4.84a, Diagnostic Code 6000 (2012). 15. The criteria for a compensable rating for service-connected chronic rhinitis have not been met. 38 U.S.C.A. § 1155 (West 2002); 38 U.S.C.A. § 4.97, Diagnostic Code 6522 (2012). 16. The criteria for a 10 percent rating, but no more, for service-connected Gilbert's syndrome have been met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 4.7, 4.114, Diagnostic Codes 7301, 7311, 7312, 7345 (20012). 17. The criteria for a 10 percent rating, but no more, for service-connected GERD have been met. 38 U.S.C.A. §§ 1155, 5103A, 5107 (West 2002); 38 C.F.R. § 4.114, Diagnostic Code 7346 (2012). 18. The criteria for an initial compensable rating for service-connected ovarian cysts have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 4.1, 4.2, 4.7, 4.116, DC 7699-7615 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. The Duty to Notify and the Duty to Assist The Board has considered the Veterans Claims Assistance Act of 2000 (VCAA). See 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126 (West 2002 and Supp. 2012). The regulations implementing VCAA have been enacted. See 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2012). VA has a duty to notify the claimant of any information and evidence needed to substantiate and complete a claim. 38 U.S.C.A. §§ 5102, 5103; see also Quartuccio v. Principi, 16 Vet. App. 183 (2002). After having carefully reviewed the record on appeal, the Board has concluded that the notice requirements of VCAA have been satisfied. The notice and assistance provisions of VCAA should be provided to a claimant prior to any adjudication of the claim. Pelegrini v. Principi, 18 Vet. App. 112 (2004). In this case, the RO sent the Veteran correspondences in October 2007 and September 2008, prior to adjudication, which informed her of the requirements needed to establish entitlement to service connection and increased ratings. In compliance with the duty to notify, the Veteran was informed in these correspondences about disability ratings and effective dates. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). In accordance with the requirements of VCAA, the October 2007 and September 2008 correspondences informed the Veteran what evidence and information she was responsible for and the evidence that was considered VA's responsibility. Additional private evidence was subsequently added to the claims files after the letters. VA has a duty to assist the claimant in obtaining evidence necessary to substantiate a claim. VCAA also requires VA to provide a medical examination when such an examination is necessary to make a decision on the claim. 38 U.S.C.A. § 5103A(d); 38 C.F.R. § 3.159. Relevant medical examinations were provided to the Veteran in September 2007, April 2009, May 2010, April 2012, May 2012, June 2012, and December 2012. When VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). The Board finds that the VA evaluations obtained in this case are adequate, as they include a discussion of the Veteran's relevant symptomatology. There is adequate medical evidence of record, which include VA treatment records, to make a determination on the increased rating issue in this case. Accordingly, the Board finds that VA's duty to assist with respect to obtaining VA examinations relevant to the increased rating issues on appeal has been met. 38 C.F.R. § 3.159(c)(4). The Board concludes that all available evidence has been obtained and that there is sufficient medical evidence on file on which to make a decision on the issue decided herein. The Veteran has been given ample opportunity to present evidence and argument in support of her claim, including at her January 2012 Board videoconference hearing. The Board additionally finds that general due process considerations have been complied with by VA, and the Veteran has had a meaningful opportunity to participate in the development of the claims. Mayfield v. Nicholson, 19 Vet. App. 103 (2005), rev'd on other grounds, 444 F.3d 1328 (Fed. Cir. 2006); 38 C.F.R. § 3.103 (2007). In Bryant v. Shinseki, 23 Vet. App. 488 (2010), the Court recently held that 38 C.F.R. § 3.103(c)(2) (2012) requires that the VLJ 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 the Board hearing, the elements of the claims that were lacking to warrant a higher rating were noted and discussed. The VLJ asked questions to ascertain the level of symptomatology. Following the hearing, the claims were remanded in an attempt to obtain additional pertinent evidence that might substantiate the claims. The hearing focused on the elements necessary to substantiate the claims, and the Veteran, through her testimony, demonstrated that she had actual knowledge of the elements necessary to substantiate the claims. Therefore, the Board finds that, consistent with Bryant, the VLJ complied with the duties set forth in 38 C.F.R. § 3.103(c)(2). II. Increased Rating Claims Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (Rating Schedule). 38 C.F.R. Part 4. The Rating Schedule is primarily a guide in the evaluation of disability resulting from all types of diseases and injuries encountered as a result of or incident to military service. The ratings are intended to compensate, as far as can practicably be determined, the average impairment of earning capacity resulting from such diseases and injuries and their residual conditions in civilian occupations. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. In resolving this factual issue, the Board may only consider the specific factors as are enumerated in the applicable rating criteria. See Massey v. Brown, 7 Vet. App. 204, 208 (1994); Pernorio v. Derwinski, 2 Vet. App. 625, 628 (1992). The Board notes that the symptoms listed in the rating criteria are only examples of the type of symptoms reflective of each rating level. See Sellers v. Principi, 372 F.3d 1318, 1326-27 (Fed. Cir. 2004); Mauerhan v. Principi, 16 Vet. App. 436, 442-44 (2002). In considering the severity of a disability, it is essential to trace the medical history of the Veteran. 38 C.F.R. §§ 4.1, 4.2, 4.41. Consideration of the whole recorded history is necessary so that a rating may accurately reflect the elements of disability present. 38 C.F.R. § 4.2; see Peyton v. Derwinski, 1 Vet. App. 282 (1991). Although the regulations do not give past medical reports precedence over current findings, the Board is to consider the Veteran's medical history in determining the applicability of a higher rating for the entire period in which the appeal has been pending. See Powell v. West, 13 Vet. App. 31, 34 (1999). The primary concern in a claim for an increased evaluation for service-connected disability is the present level of disability. Although the overall history of the disability is to be considered, the regulations do not give past medical reports precedence over current findings. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). However, when an appeal is based on the assignment of an initial rating for a disability, following an initial award of service connection for this disability, the rule articulated in Francisco does not apply. Fenderson v. West, 12 Vet. App. 119 (1999). Instead, the evaluation must be based on the overall recorded history of a disability, giving equal weight to past and present medical reports. Id. In all claims for increase, VA has a duty to consider the possibility of assigning staged ratings. See Hart v. Mansfield, 21 Vet. App. 505 (2007). In determining the applicable disability rating, pertinent regulations do not require that all cases show all findings specified by the Rating Schedule; rather, it is expected in all cases that the findings be sufficiently characteristic as to identify the disease and the resulting disability, and above all, to coordinate the impairment of function with the rating. 38 C.F.R. § 4.21. Therefore, the Board will consider the potential application of various other provisions of the regulations governing VA benefits, whether or not they were raised by the Veteran. See Schafrath v. Derwinski, 1 Vet. App. 589, 594 (1991). In general, all disabilities, including those arising from a single disease entity, are rated separately, and all disability ratings are then combined in accordance with 38 C.F.R. § 4.25 (2012). Pyramiding, the evaluation of the same disability, or the same manifestation of a disability, under different diagnostic codes, is to be avoided when rating a veteran's service-connected disabilities. 38 C.F.R. § 4.14 (2012). It is possible for a veteran to have separate and distinct manifestations from the same injury which 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). Neurosarcoidosis; Mood Disorder Not Otherwise Specified with Depressive Features The Veteran seeks higher ratings for her service connected neurosarcoidosis, which has been evaluated under Diagnostic Codes 9499-9435. Regulations provide that, when the disability being rated is not specifically provided for in the rating schedule, it will be rated under a closely related disease or injury in which not only the functions affected, but the anatomical localization and symptomatology are closely analogous. 38 C.F.R. § 4.20. Further, the provisions of 38 C.F.R. § 4.27 provide that unlisted disabilities requiring rating by analogy will be coded with the first two numbers of the schedule provisions for the most closely related body part and "99." Hyphenated diagnostic codes are used when a rating under one diagnostic code requires use of an additional diagnostic code to identify the basis for the evaluation assigned. The additional code is shown after a hyphen. At the time the Veteran filed her August 2007 increased rating claim, she was receiving a 10 percent evaluation. In a August 2010 rating decision, the RO increased her rating to 50 percent effective July 1, 2009. Subsequently, in an April 2013 rating decision, the RO increased her rating to 70 percent effective April 27, 2012. As such, the Board will evaluate the propriety of the 10 percent rating assigned prior to July 1, 2009, the 50 percent rating assigned from July 1, 2009, to April 27, 2012, and the 70 percent rating assigned since April 27, 2012. Under Diagnostic Code 9435, a 30 percent rating is assigned for occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment; mild memory loss (such as forgetting names, directions, recent events). A 50 percent rating is assigned when there is occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships. A 70 percent evaluation is warranted for occupational and social impairment, with deficiencies in most areas, such as work, school, family relationships, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work like setting); inability to establish and maintain effective relationships. Lastly, a 100 percent evaluation is warranted for total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent ability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. 38 C.F.R. § 4.130, Diagnostic Code 9411 (2012). According to the Diagnostic and Statistical Manual of Mental Disorders, Fourth edition (DSM IV), a Global Assessment of Function (GAF) score reflects the "psychological, social, and occupational functioning in a hypothetical continuum of mental health-illness." DSM IV, American Psychiatric Association (1994), pp.46-47; 38 C.F.R. §§ 4.125(a), 4.130. A GAF score of 31-40 indicates some impairment in reality testing or communication (e.g., speech is at times illogical, obscure, or irrelevant) or major impairment in several areas, such as work or school, family relations, judgment, thinking or mood (e.g., depressed man avoids friends, neglects family, and is unable to work; child frequently beats up younger children, is defiant at home, and is failing at school. A GAF score of 41-50 indicates serious symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent shoplifting) or any serious impairment in social, occupational or school functioning (e.g., no friends, unable to keep a job). A GAF score of 51-60 represents moderate symptoms (e.g., flat affect and circumstantial speech, occasional panic attacks) or moderate difficulty in social, occupational, or school functioning (e.g., few friends, conflicts with peers or co-workers). A GAF score of 61-70 indicates some mild symptoms (e.g., depressed mood and mild insomnia) or some difficulty in social, occupational, or school functioning (e.g., occasional truancy, or theft within the household), but generally functioning pretty well, has some meaningful interpersonal relationships. The Veteran was provided with a VA mental disorders examination in May 2006, at which time she was diagnosed as having adjustment disorder with depressed mood, with sarcoidosis and fibromyalgia considered as chronic stressors, and assigned a GAF score of 64. The Veteran indicated that she was divorced and maintained positive relations with her two sons, although she felt that her extended family was not supportive of her and no longer made attempts to contact them. She further described having several friends with whom she made efforts to remain in contact. She denied any history of assaultive or violent behavior towards others, as well as homicidal or suicidal ideation. Upon objective examination, the Veteran was alert and oriented as to person, time, and place. Her mood was mildly irritable with restricted affect. Her speech was normal with respect to volume, content, and clarity. Her thought content was logical while her thought processes were clear and coherent. Although she endorsed short-term memory difficulties, she denied any significant long-term memory problems. The Veteran also reported mild concentration difficulties, although these were not evident during the evaluation. There was no evidence of delusions, hallucinations, suicidal ideations, or homicidal ideations. The Veteran's insight and judgment appeared relatively intact. The Veteran reported feelings of sadness and depression related to a variety of matters, to include her health conditions and limited finances, as well as sleep disruptions. Although she also endorsed occasional episodes of increased anxiety, she did not endorse symptoms of manic episodes or panic attacks. There was also no evidence of auditory hallucinations, visual hallucinations, or delusions. The examiner indicated that results from the Beck Depression Inventory were indicative of mild-to-moderate depression, which was consistent with the Veteran's self report. The examiner concluded that the Veteran's functional impairments, namely insufficient mood management skills (irritability and depression) have compromised her relationships in both domestic and business settings. The examiner opined that the Veteran's occupational and interpersonal functioning had been mildly impaired by her adjustment order with depressed mood, as reflected in the GAF score of 64. At a September 2007 examination, the Veteran denied any current depression. A VA primary care initial evaluation note dated in February 2009 indicated that the Veteran denied any suicidal or homicidal thoughts. The Veteran was provided with a VA mental disorders examination in April 2009, at which time she was diagnosed as having adjustment disorder with mixed anxiety and chronic depressed mood, and assigned a GAF score of 67. She subjectively reported feelings of sadness, stress, and sleep difficulties, which worsened due to other medical problems and major life stressors. Upon physical examination, she was clean and appropriately dressed. Her speech and psychomotor activity were unremarkable. He affect was appropriate, while her mood was anxious and depressed. The Veteran reported mild-to-moderate attention and concentration difficulties, as well as mild-to-moderate short-term memory problems. Her orientation was intact as to person, time, and place. Her thought process was unremarkable, although her thought content contained mild paranoid ideations. There was no evidence of delusions, hallucinations, panic attacks, homicidal thoughts, suicidal thoughts, episodes of violence, inappropriate behavior, or obsessive/ritualistic behavior. The Veteran understood the outcome of her behavior as well as that she had a problem. Her impulse control was good. She indicated having difficulty staying asleep and reported sleeping approximately 6 hours per night. The examiner opined that there was not total occupational and social impairment due to psychiatric symptomatology. Rather, the examiner concluded that there was an occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks due to sadness, stress, and sleep difficulties. The Veteran was provided with a VA mental disorders examination in May 2010, at which time she was diagnosed as having mood disorder due to neurosarcoidosis, with depressive features, and assigned a GAF score of 58. Upon examination, she was cooperative and neatly groomed, and her speech and psychomotor activity were unremarkable. Her affect was normal while her mood was depressed. Her attention was intact, and she was oriented as to person, time, and place. Her though process and thought content were unremarkable. She was of average intelligence and understood the outcome of her behavior and that she had a problem. There was no evidence of delusions, hallucinations, inappropriate behavior, obsessive/ritualistic behavior, panic attacks, episodes of violence, or homicidal thoughts. However, she did report episodic passive suicidal ideation with some onset of passive ideation related to higher levels of pain, although she denied any current suicidal ideation. The Veteran further reported experiencing 3 to 4 hours of restless sleep due to increased pain levels, which had a moderate impact on occupational and/or social functioning. The Veteran's impulse control was fair, while her memory was normal. The examiner explained that the Veteran experienced irritability, poor concentration, low frustration tolerance, and some self-isolative preferences which rendered her unable to perform at a satisfactory level within her primary occupational environment in the education field. It was further noted that the Veteran was unable to pursue an additional college degree due, in part, to her mood disorder, as of July 2009. The Veteran was provided with a VA examination in May 2010, at which time the examiner found that she exhibited normal affect, mood, and judgment, as well as appropriate behavior. There was no evidence of obsessive behavior, delusions, or hallucinations. The Veteran's comprehension of commands was normal. An August 2011 private treatment note indicated that the Veteran was being followed for depression. It noted that her depression was severe, although she had no suicidal or homicidal thoughts. The Veteran was provided with a VA mental disorders examination in April 2012, at which time she was diagnosed as having mood disorder, not otherwise specified, as well as paranoid personality disorder and assigned a GAF score of 50. The examiner indicated that it was not possible to differentiate which of the Veteran's psychiatric symptoms were attributable to each disorder. The Veteran's psychiatric symptoms included depressed mood, anxiety, suspiciousness, chronic sleep impairment, mild memory loss, disturbances of motivation and mood, difficulty in establishing and maintaining effective work and social relationships, an inability to establish and maintain effective relationships, and suicidal ideation. Upon objective examination, the Veteran had a somewhat disheveled appearance, but remained alert and oriented as to person, time, and place. Her affect was appropriate, although her mood was depressed and anxious. She reported problems with sleeping too little, crying spells, feelings of hopelessness, and transitory suicidal thoughts with no plans. She further reported problems with short-term memory and concentration. However, she denied traumatic memories, nightmares, homicidal thoughts, hallucinations, and delusions. She denied having any friends or close family members other than her son. She further denied any hobbies and did not engage in any meaningful activities other than taking care of her son. The examiner opined that the Veteran's psychiatric symptoms resulted in occupational and social impairment with reduced reliability and productivity. The Board reiterates that the symptoms listed in the rating criteria are only examples of the type of symptoms reflective of each rating level. See Sellers v. Principi, 372 F.3d 1318, 1326-27 (Fed. Cir. 2004); Mauerhan v. Principi, 16 Vet. App. 436, 442-44 (2002). Prior to July 1, 2009, in consideration of this evidence, the Board finds that the Veteran's service-connected acquired psychiatric disorder was adequately severe so as to result in occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks. The May 2006 VA examiner specifically opined that the Veteran's occupational and interpersonal functioning had only been mildly impaired by her adjustment order with depressed mood. Similarly, the April 2009 examiner opined that there was an occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks due to sadness, stress, and sleep difficulties. These opinions were reflected in the assignment of the GAF scores of 64 and 67, indicative of merely some mild symptomatology. Significantly, although the Veteran denied any panic attacks, she explicitly reported depression, anxiety, impaired sleep, and short-term memory difficulty. Additionally, the Veteran reported having good relationships with her two children as well as a handful of friends. As such, the Board finds that an evaluation of 30 percent is warranted prior to July 1, 2009. However, the Board does not find that an evaluation in excess of 30 percent is warranted prior to July 1, 2009. Specifically, there is no evidence of flattened affect, abnormal speech, panic attacks, difficulty in understanding commands, judgment impairment, or abstract thinking impairment, as contemplated by the criteria for a 50 percent evaluation. See 38 C.F.R. § 4.130. From July 1, 2009, to April 27, 2012, the Board finds that an evaluation in excess of 50 is not warranted. The May 2010 VA examiner explained that the Veteran experienced irritability, poor concentration, low frustration tolerance, and some self-isolative preferences which rendered her unable to perform at a satisfactory level within her primary occupational environment in the education field. It was further noted that the Veteran was unable to pursue an additional college degree due, in part, to her mood disorder, as of July 2009. This is reflected in the GAF score of 58, indicative of moderate symptoms. Although the Veteran reported passive suicidal ideation (with no active plan or intent of suicide), the Board emphasizes there was no evidence of obsessional rituals, abnormal speech, near-continuous panic or depression, impaired impulse control, spatial disorientation, or neglect of personal appearance and hygiene. To the contrary, the Veteran was neatly groomed and her speech was unremarkable. Has such, her symptomatology during this period did not more closely approximate the symptomatology of the next-higher 70-percent rating. See 38 C.F.R. § 4.130. Since April 27, 2012, the Board finds that an evaluation in excess of 70 percent is not warranted. The April 2012 VA examiner opined that the Veteran's psychiatric symptoms resulted in occupational and social impairment with reduced reliability and productivity. She was assigned a GAF score of 50, indicative of serious symptoms. The Board emphasizes that there is nothing in the record to suggest that the Veteran's psychiatric symptomatology resulted in total occupational and social impairment. Additionally, there is no evidence of gross impairment in thought processes or communication, persistent delusions or hallucinations, grossly inappropriate behavior, danger of hurting herself or others, inability to perform activities of daily living, disorientation as to time or place, or severe memory loss, as contemplated by the criteria for the maximum schedular 100-percent rating. See 38 C.F.R. § 4.130. Pulmonary Sarcoidosis with Asthma The Veteran also seeks entitlement to an increased rating for her service-connected pulmonary sarcoidosis with asthma, which has been rated as 30 percent disabling under Diagnostic Code 6846. Under Diagnostic Code 6846, a 30 percent rating is assigned where there is pulmonary involvement with persistent symptoms requiring chronic low dose (maintenance) or intermittent corticosteroids. A 60 percent rating is assigned where there is pulmonary involvement requiring systemic high dose (therapeutic) corticosteroids for control, and a 100 percent rating where there is cor pulmonale or there cardiac involvement with congestive heart failure or there is progressive pulmonary disease with fever, night sweats and weight loss despite treatment. 38 C.F.R. § 4.97, Diagnostic Code 6846 (2012). In addition, Diagnostic Code 6846 provides that either the active disease or residuals may be rated as chronic bronchitis (Diagnostic Code 6600) and extra-pulmonary involvement under the specific body system involved. Since sarcoidosis may be rated as chronic bronchitis, Diagnostic Code 6600 is also relevant to the rating of the Veteran's disability. Under Diagnostic Code 6600, a minimum 10 percent evaluation is warranted in cases of Forced Expiratory Volume at one second (FEV-1) of 71- to 80-percent of predicted value; the ratio of Forced Expiratory Volume at one second to Forced Vital Capacity (FEV-1/FVC) of 71 to 80 percent; or Diffusion Capacity of the Lung for Carbon Monoxide by the Single Breath Method (DLCO (SB)) of 66- to 80-percent of predicted value. A 30 percent evaluation is assigned in cases of FEV-1 of 56- to 70-percent of predicted value; FEV-1/FVC of 56 to 70 percent; or DLCO (SB) of 56- to 65- percent of predicted value. A 60 percent evaluation is in order in cases of FEV-1 of 40-to 55-percent of predicted value; FEV- 1/FVC of 40 to 55 percent; DLCO (SB) of 40-to 55-percent of predicted value; or maximum oxygen consumption of 15 to 20 ml/kg/min (with cardiorespiratory limit). A 100 percent evaluation is warranted in cases of FEV-1 less than 40 percent of predicted value; FEV-1/FVC of less than 40 percent; DLCO (SB) of less than 40-percent predicted value; maximum exercise capacity less than 15 ml/kg/min oxygen consumption (with cardiac or respiratory limitation); cor pulmonale (right heart failure); right ventricular hypertrophy; pulmonary hypertension (shown by Echo or cardiac catheterization); episode(s) of acute respiratory failure; or the requirement of outpatient oxygen therapy. See 38 C.F.R. § 4.97 (2012). Under Diagnostic Code 6602, a 30 percent evaluation is warranted for bronchial asthma when there is evidence of an Forced Expiratory Volume at one second (FEV-1) of 56 to 70 percent of predicated value; FEV-1/Forced Vital Capacity (FVC) of 56 to 70 percent of predicated value; or a Diffusion Capacity of the Lung for Carbon Monoxide by the Single Breath Method (DLCO (SB)) of 56 to 70 percent of predicated value. A higher 60 percent evaluation is warranted with an FEV-1 of 40 to 55 percent of predicated value; FEV-1/FVC of 40 to 55 percent of predicated value; at least monthly visits to a physician for required care of exacerbations; or intermittent (at least three per year) courses of systemic (oral or parenteral) corticosteroids. See 38 C.F.R. § 4.97 (2012). At an annual VA gynecological examination in September 2005, the Veteran denied any shortness of breath and/or chest pain. The Veteran was provided with a VA respiratory examination in May 2006, at which time she was diagnosed as having pulmonary sarcoidosis. At that time, the Veteran denied any cough, sputum production, hemoptysis, or anorexia. She indicated that she became short of breath after walking half a block. Although she denied asthmatic attacks, she kept an albuterol inhaler for treatment of wheezing once or twice per week. She denied any periods of incapacitation. She was prescribed methotrexate 2.5 mg, hydroxychloroquine sulfate 200 mg, and a fluticasone 250/salmeterol 50 inhaler. Upon objective examination, jugular venous pressure was not increased and no chest deformity was noted. Percussion note was resonant bilaterally. There were no rales or rhonchi audible bilaterally upon auscultation. There was no evidence of pulmonary hypertension, right ventricular hypertrophy, or cor pulmonale. Chest X-rays revealed stable fibrosis and hilar adenopathy. On a VA pulmonary consultation note dated one day later, the Veteran indicated that she experienced shortness of breath with less than one flight of stairs and reported using her albuterol inhaler approximately 2 times per day. The physician indicated there was no change from pulmonary function tests dated in June 2005, which showed FEV-1/FVC of 86 percent, and 91 percent after bronchodilators. The physician diagnosed the Veteran as having sarcoidosis with stable fibrosis by chest X-ray. At a September 2007 VA examination, the Veteran denied any shortness of breath, wheezing, or dyspnea. She indicated that she did not take any medications for her sarcoidosis or asthma. Objectively, her chest was clear without crackles, wheezes, rhonchi, or rales. The examiner diagnosed her as having pulmonary sarcoidosis with asthma. A VA primary care initial evaluation note dated in February 2009 indicated that the Veteran reported getting exhausted easily and becoming short of breath even while at rest. She also reported chest pain unrelated to activity. Upon objective examination, she exhibited slightly diminished breath sounds, bilaterally, although there was no evidence of rales or wheezing. She was diagnosed as having a history of sarcoidosis. The Veteran was afforded a VA examination in April 2009, at which time she was diagnosed as having pulmonary sarcoidosis and asthma. There was no evidence of wheezing, shortness of breath, cough, sputum, or hemoptysis. X-rays showed interstitial infiltrate superimposed upon chronic, diffuse, upper lobe greater than the lower lobe, as well as interstitial pulmonary fibrotic changes with question of left perihilar adenopathy. Pulmonary function testing performed at the VA Health Care Center in April 2009 revealed FEV-1 of 64 percent predicated, and 68 percent predicated after bronchodilators; FEV-1//FVC of 73 percent, and 77 percent after bronchodilators; and DLCO of 65 percent predicated. The physician noted that the FVC, FEV-1, FEV-1/FVC ratio, and FEF 25-75 percent were reduced, indicating airway obstruction. The airway resistance was increased and the lung volumes were reduced. The reduced diffusing capacity indicated a mild loss of functional alveolar capillary surface. The physician concluded that moderate airway obstruction was present and diagnosed the Veteran as having moderate obstructive airway disease. A May 2009 VA primary care note indicated that the Veteran was treated for sarcoidosis with steroids in 2002 and 2003, although she did not have any steroid treatments since then. The Veteran reported occasional shortness of breath, and there was no evidence of jaundice. Her lungs were clear. The Veteran was provided with a VA examination in May 2010, at which time she reported a history of wheezing and shortness of breath. There was no history cough, dyspnea, non-anginal chest pain, hemoptysis, fever, anorexia, respiratory failure, cor pulmonale, right ventricular hypertrophy, or pulmonary hypertension. Upon objective examination, there was no evidence of abnormal breath sounds. X-rays revealed that her lungs were hyperinflated with minimal bilateral fibrotic changes and hilar retraction superiorly associated with hilar calcifications; however, the examiner noted that these findings were in keeping with pulmonary sarcoidosis and that there was significant improvement since November 2000. The examiner diagnosed the Veteran as having pulmonary sarcoidosis, but opined that this disability alone did not have any effect on the Veteran's usual occupation or daily activities. An August 2011 private treatment note indicated that the Veteran was being followed for sarcoidosis with lung involvement as well as mild, persistent asthma. The Veteran was provided with a VA respiratory examination in May 2012, at which time he was diagnosed as having asthma, sarcoidosis, and neurosarcoidosis. However, these conditions did not require the use of oral or parenteral corticosteroid medications, nor did it require oral bronchodilators or oxygen therapy; rather, the Veteran intermittently used inhalational bronchodilator therapy. The Veteran denied any asthma attacks with episodes of respiratory failure in the previous year as well as any physician visits for required care of exacerbations. She exhibited persistent symptoms of sarcoidosis, including cough, shortness of breath, chest tightness, anorexia, and nightly sweats and fever. There was also evidence of chronic hilar adenopathy, stable bilateral lung infiltrates, and pulmonary involvement. Chest X-rays revealed infiltrative changes to both lungs due to sarcoidosis. The examiner noted that the Veteran's asthma was predominantly responsible for her limitation in pulmonary function. The examiner concluded that the Veteran's shortness of breath, wheezing, and chest tightness impacted her ability to work. Pulmonary function testing conducted in March 2013 revealed FEV-1 of 59 percent predicated, and 61 percent predicated after bronchodilators; FEV-1//FVC of 82 percent, and 76 percent after bronchodilators; and DLCO of 68 percent predicated. The physician noted that the FVC, FEV-1, FEV-1/FVC ratio, and FEF 25-75 percent were reduced, indicating airway obstruction. The airway resistance was normal and the lung volumes were reduced. There was no significant response following administration of bronchodilators. The physician concluded that moderately-severe airway obstruction was present. There was severe restriction and increased diffusion. The Veteran's sarcoidosis with asthma is rated as 30 percent disabling during the entire period on appeal. To obtain a higher disability rating of 60 percent under Diagnostic Code 6864, pulmonary involvement requiring systemic high dose (therapeutic) corticosteroids for control must be demonstrated. In the instant case, pulmonary involvement requiring systemic high dose corticosteroids has not been demonstrated. The evidence suggests that the Veteran did not undergo steroid treatment since 2003, and during the period of appeal she was treated with, at most, intermittent inhalational bronchodilator therapy. Accordingly, based on the evidence indicating that systemic high dose corticosteroid were not required, a disability rating in excess of 30 percent is not warranted under Diagnostic Code 6846. As noted above, Diagnostic Code 6846 provides that sarcoidosis may alternatively be rated as chronic bronchitis under Diagnostic Code 6600. Review of the record, however, reveals that this diagnostic code also does not avail the Veteran. To obtain the next highest disability rating of 60 percent under Diagnostic Code 6600, the Veteran would have to exhibit a FEV-1 of 40- to 55-percent predicted, or; FEV-1/FVC of 40 to 55 percent, or; DLCO (SB) of 40- to 55-percent predicted, or; maximum oxygen consumption of 15 to 20 ml/kg/min. Alternatively, to obtain a higher disability rating under Diagnostic Code 6602, the evidence must show FEV-1 of 40 to 55 percent of predicated value; FEV-1/FVC of 40 to 55 percent; at least monthly visits to a physician for required care of exacerbations; or intermittent (at least three per year) courses of systemic (oral or parenteral) corticosteroids. These requirements have not been met. At worst, the Veteran's FEV-1 was demonstrated to be 59-percent predicated and his FEV-1/FVC was demonstrated to be 73 percent, both prior to administration of bronchodilators. At worst, her DLCO (SB) was recorded as 65-percent predicated. Clearly, the Veteran's PFT results do not indicate that the next higher disability schedular rating of 60 percent is warranted under Diagnostic Codes 6600 or 6602 for any portion of the appeal period. Accordingly, this portion of the Veteran's appeal must be denied. Fibromyalgia The Veteran seeks higher ratings for her service-connected fibromyalgia, which has been evaluated under 38 C.F.R. § 4.71a, Diagnostic Code 5025. At the time the Veteran filed her August 2007 increased rating claim, she was receiving a 20 percent evaluation for fibromyalgia. Subsequently, in an April 2013 rating decision, the RO increased her rating to the maximum schedular 40 percent effective May 3, 2012. As such, the Board will evaluate the propriety of the 20 percent rating assigned prior to May 3, 2012, as well as the 40 percent rating assigned since May 3, 2012. Diagnostic Code 5025 defines fibromyalgia as widespread musculoskeletal pain and tender points, with or without associated fatigue, sleep disturbance stiffness, paresthesias, headache, irritable bowel symptoms, depression, anxiety, or Raynaud's-like symptoms. A Note to Diagnostic Code 5025 provides that widespread pain means pain in both the left and right sides of the body, that is both above and below the waist, and that affects both the axial skeleton (i.e., cervical spine, anterior chest, thoracic spine, or low back) and the extremities. Under Diagnostic Code 5025, a 20 percent rating is appropriate for symptoms that are episodic, with exacerbations often precipitated by environmental or emotional stress or by overexertion, but that are present more than one-third of the time. The highest rating of 40 percent is warranted for symptoms that are constant, or nearly so, and refractory to therapy. See 38 C.F.R. § 4.71a, Diagnostic Code 5025. The Veteran was afforded a VA examination in September 2007, at which time the Veteran was diagnosed as having fibromyalgia. Subjectively, she reported that her entire body, from head to toe, including all of her muscles and joints, was in constant pain. However, she reported that she no longer took any medicine to treat her fibromyalgia. Upon examination, the examiner noted that the Veteran indicated pain whenever any part of her body was touched. A VA primary care initial evaluation note dated in February 2009 indicated that the Veteran reported generalized aches and pains. She was diagnosed as having fibromyalgia. In an April 2009 VA mental disorders examination, the Veteran reported that she was in "constant pain" due to fibromyalgia. The Veteran was also afforded a VA general examination in April 2009, at which time she was diagnosed as having fibromyalgia. She described the pain as constant and not aggravated by anything. The Veteran was provided with a VA fibromyalgia examination in May 2010, at which time she was diagnosed as having active fibromyalgia. The Veteran described her current symptoms associated with fibromyalgia as trigger points, unexplained fatigue, sleep disturbance, headaches, diarrhea, abdominal cramps, depression, and difficulty concentrating. She reported that these symptoms were episodic and present more than one-third of the time rather than constant or near constant in nature. The examiner noted a number of tender points on each side of her body, and indicated that the fibromyalgia had significant effects on the Veteran's occupation. Specifically, decreased concentration, decreased mobility, difficulty lifting and carrying, and weakness or fatigue associated with the fibromyalgia impacted her occupational activities. The examiner noted that the Veteran suffered from generalized body aches which had been treated with Nortryptiline and other medications without lasting relief, and that the Veteran's fibromyalgia may cause her to be unemployable in a normal occupational environment. An August 2011 private treatment note indicated that the Veteran was being followed for myalgia and myotosis. The Veteran was provided with a VA fibromyalgia examination in May 2012, at which time the Veteran was diagnosed as having fibromyalgia which required continuous medication (Tylenol with codeine tablet 2 times per day) for control of symptoms. Despite this medication, she continued to have widespread chronic muscle and joint pain, stiffness, muscle weakness, fatigue, sleep disturbances, paresthesias, headaches, depression, and anxiety. These symptoms were constant or nearly constant. The examiner concluded that the Veteran's persistent, widespread muscle and joint pain impacted her ability to work. After a review of all the evidence, lay and medical, the Board finds that, for the entire rating period under appeal, the Veteran's fibromyalgia disability was manifested by symptomatology more nearly approximating that required for the maximum schedular 40 percent rating under Diagnostic Code 5025. Specifically, for the entire rating period under appeal, the Board finds that the Veteran's fibromyalgia has been manifested by symptoms (solely related to fibromyalgia as opposed to another service-connected disability) constant or near-constant in nature. The Board acknowledges that the May 2010 VA examination report indicated that the Veteran's active fibromyalgia symptoms were merely episodic in nature and present more than one-third of the time. However, the examiner also indicated that there were no precipitating or alleviating factors with respect to the fibromyalgia. Moreover, the Veteran's symptoms were described as either constant or nearly constant in nature both before and after the May 2010 VA examination; specifically, the VA examiners in September 2007, April 2009, and May 2012 described the fibromyalgia symptoms as constant or nearly constant. The Board notes that 40 percent is the maximum schedular rating for fibromyalgia, and finds that the criteria for the 40 percent rating under Diagnostic Code 5025 adequate describe the level of the Veteran's symptomatology throughout the period on appeal. Because the preponderance of the evidence is against a rating in excess of 40 percent for the service-connected fibromyalgia, the benefit of the doubt doctrine is not for application. See 38 U.S.C.A. § 5107; 38 C.F.R. §§ 4.3, 4.7. Tendonitis of the Left Ankle The September 2007 rating decision granted service connection for a left ankle disability and assigned it a 10 percent rating under 38 C.F.R. § 4.71a, Diagnostic Code 5271-5024, effective from August 1, 2007. Under 38 C.F.R. § 4.71a, Diagnostic Code 5024, tenosynovitis is rated as limitation of motion of the affected part like arthritis. Under 38 C.F.R. § 4.71a, Diagnostic Code 5271, limitation of motion of the ankle is rated as 10 percent disabling if moderate and 20 percent disabling if marked. In this regard, normal range of motion of the ankle is zero to 20 degrees of dorsiflexion and zero to 45 degrees of plantar flexion. See 38 C.F.R. § 4.71a, Plate II (2012). The Veteran was provided with a VA joints examination in September 2007, at which time she was diagnosed as having left ankle tendinitis. Subjectively, she complained of intermittent, intense pain in the left ankle after walking for more than five minutes. Upon objective examination, range of motion testing revealed dorsiflexion to 20 degrees and plantar flexion to 45 degrees. These ranges of motion did not change after three repetitions. There were no additional limitations in the range of motion or joint function following repetition due to pain, fatigue, weakness, lack of endurance, or incoordination. There was no varus or valgus angulation and the Achilles was midline. The Veteran's gait was normal. The Veteran was afforded a VA general examination in April 2009, at which time she was diagnosed as having tendinitis of the left ankle without evidence of arthritis. Subjectively, she reported pain in the posterior part of the ankle joint which was aggravated by walking. She additionally reported swelling and giving way of the left ankle, but denied any incidents of locking or dislocation. Upon objective examination, there was no swelling of the left ankle, although there was some tenderness and pain upon range of motion. Range of motion testing revealed left dorsiflexion to 20 degrees and left plantar flexion to 45 degrees, with no limitation of motion during repetitive use. The examiner estimated that the functional range of motion of her left ankle remained at 20 degrees dorsiflexion and 45 degrees plantar flexion, even during flare-ups and repetitive use. X-rays of the left ankle were normal. The Veteran was afforded a VA joints examination in May 2010, at which time she was diagnosed as having a resolved left ankle injury. There were no subjective complaints of deformity, giving way, instability, pain, stiffness, weakness, incoordination, inflammation, or other symptoms. Upon objective examination, the Veteran exhibited an antalgic gait. Range of motion testing revealed left dorsiflexion to 20 degrees and left plantar flexion to 45 degrees, with no objective evidence of pain upon active range of motion. Moreover, there was no objective evidence of pain following repetitive motion, and no additional limitations following three repetitions of range of motion. X-rays were normal, with no evidence of fracture, dislocation, or other specific bone abnormalities. The Veteran was provided with a VA ankle conditions examination in May 2012, at which time she was diagnosed as having tendonitis of the left ankle which was resolving. The Veteran denied that flare-ups impacted ankle function. Left ankle plantar flexion was to 45 degrees or greater and left ankle dorsiflexion was to 20 degrees or greater, with no objective evidence of painful motion. The Veteran was able to perform repetitive-use testing with three repetitions. There was no additional limitation in range of motion following repetitive-use testing, and no functional loss or functional impairment of the left ankle. The Veteran described localized tenderness or pain upon palpation of the joint/soft tissue of the left ankle. However, plantar flexion and dorsiflexion movements demonstrated normal strength. There was no evidence of ankylosis, laxity, or arthritis, although the Veteran regularly wore an ankle brace to help minimize ankle pain. As to an increased rating under 38 C.F.R. § 4.71a, Diagnostic Code 5271, the Board notes that the range of motion of the left ankle has 20 degrees of dorsiflexion and 45 degrees of plantar flexion thorough the period on appeal. There was no ankylosis. There were no additional limitations in the range of motion or joint function following repetition due to pain, fatigue, weakness, lack of endurance, or incoordination. Given the above, the Board finds that even when considering the Veteran's complaints of pain in light of 38 C.F.R. §§ 4.40, 4.45, and the Court's holding in DeLuca, supra, that the clinical evidence of record, which shows normal range of motion of the left ankle even after taking into account the Veteran's complaints of pain, does not demonstrate that her adverse symptomatology equates to marked limitation of motion of the left ankle. Accordingly, a higher evaluation is not warranted under Diagnostic Code 5271. See 38 C.F.R. § 4.71a. This is true throughout the appeals period, and therefore the Board need not consider further staged ratings. As to rating the Veteran's left ankle disability under Diagnostic Codes 5270 and 5272, the Board notes that the record is negative for a diagnosis of ankylosis. In the absence of ankylosis, the Board may not rate his service-connected left ankle disability as ankylosis. Consequently, a higher evaluation is not warranted for the Veteran's service-connected left ankle disability under 38 C.F.R. § 4.71a, Diagnostic Codes 5270 and 5272 (2012). As to rating the Veteran's left ankle disability under one of the other Diagnostic Codes for the ankle, the Board notes that the record is negative for problems similar to malunion of the os calcis or astragalus or astragalectomy. See 38 C.F.R. § 4.71a, Diagnostic Codes 5273 and 5274 (2012). In the absence of such adverse symptomatology, the Board will not rate the Veteran's service connected left ankle disability as one of these other disabilities. See 38 C.F.R. § 4.20; Butts v. Brown, 5 Vet. App. 532, 539 (1993) (holding that the Board's choice of diagnostic code should be upheld so long as it is supported by explanation and evidence). Therefore, the Board finds that Diagnostic Codes 5273 and 5274 are not applicable to the current appeal. Retropatellar Pain Syndrome, Myxoid Degeneration of the Medial Meniscus of the Right and Left Knees The Veteran asserts that higher ratings are warranted for right and left knee disabilities. Each of the Veteran's knees is separately evaluated as 10 percent disabling under 38 C.F.R. § 4.71a, Diagnostic Codes 5299-5260, for retropatellar pain syndrome with myxoid degeneration of the medial meniscus. Under 38 C.F.R. § 4.71a , Diagnostic Code 5003, degenerative arthritis established by X-ray findings is rated on the basis of limitation of motion under the appropriate Diagnostic Code for the specific joint or joints involved. Normal or full range of motion of the knee is from zero degrees of extension to 140 degrees of flexion. 38 C.F.R. § 4.71 , Plate II. Limitation of flexion of the leg to 60 degrees is rated as noncompensable; flexion limited to 45 degrees is rated as 10 percent disabling; flexion limited to 30 degrees is rated as 20 percent disabling; and flexion limited to 15 degrees is rated as 30 percent disabling. 38 C.F.R. § 4.71a, Diagnostic Code 5260. Limitation of extension of the leg to 5 degrees is rated as noncompensable; extension limited to 10 degrees is rated as 10 percent disabling; extension limited to 15 degrees is rated as 20 percent disabling; extension limited to 20 degrees is rated as 30 percent disabling; extension limited to 30 degrees is rated as 40 percent disabling; and extension limited to 45 degrees is rated as 50 percent disabling. 38 C.F.R. § 4.71a, Diagnostic Code 5261. Separate ratings may be assigned for arthritis with limitation of motion of a knee under Diagnostic Codes 5003-5010 and for instability of the knee under Diagnostic Code 5257. VAOPGCPREC 23-97 (July 1, 1997). Separate ratings for each knee joint may also be assigned for both limitation of flexion and limitation of extension. VAOPGCPREC 9-04 (September 17, 2004). Under 38 C.F.R. § 4.71a, Diagnostic Code 5257, the criterion for a 10 percent rating is slight recurrent subluxation or lateral instability of the knee. A rating of 20 percent rating requires moderate recurrent subluxation or lateral instability, and a rating of 30 percent requires severe recurrent subluxation or lateral instability. The Veteran was provided with a VA joints examination in September 2007, at which time she was diagnosed as having retropatellar pain syndrome and myxoid degeneration of the medial meniscus and bilateral knees. Subjectively, the Veteran described intense knee pain if she walked for more than two minutes. She indicated that the pain never went away, even upon sitting. Upon objective range of motion her flexion was to 140 degrees and her extension was to zero degrees, bilaterally, with subjective complaints of pain. There were no additional limitations in range of motion or joint function following repetition due to pain, fatigue, weakness, lack of endurance, or incoordination. The Veteran was able to squat and her gait was normal. Lachman, drawer, and McMurray testing was normal. X-rays of the bilateral knees revealed no significant joint or bony abnormality. The joint spaces were well maintained with no arthritic changes. The Veteran was provided with a VA general examination in April 2009, at which time she was diagnosed as having retropatellar pain syndrome of the bilateral knees with myxoid degeneration of the medial meniscus. Subjectively, she described constant pain in the center of her bilateral kneecaps which was aggravated upon walking. She also reported a history of swelling and giving way, but denied any locking or dislocation. Upon objective examination, her right and left knees were symmetrical. There was no genu varum or genu valgum. Anterior drawer sign, Lachman, and McMurray testing were negative. Range of motion testing revealed flexion to 140 degrees and extension to -10 to zero degrees, bilaterally, with no additional limitation of motion during repetitive use. Although the Veteran subjectively reported pain during the range of motion, the examiner opined that the Veteran would experience no additional functional limitation of motion during flare-ups or repetitive use. The Veteran was provided with a VA joints examination in May 2010, at which time she was diagnosed as having myxoid degeneration of the knees. Subjectively, the Veteran described pain and giving way of the bilateral knees, as well as locking episodes several times per year in the left knee. However, she denied deformity, instability, stiffness, weakness, incoordination, effusions, inflammation, or other symptoms. There were no constitutional symptoms or incapacitating episodes of arthritis. Upon objective examination, the Veteran exhibited bilateral crepitus and an antalgic gait, although there was no inflammatory arthritis. Bilaterally, there was no evidence of clicks, snaps, grinding, instability, patellar abnormality, meniscal abnormality, or other knee abnormalities. Range of motion testing revealed flexion to 130 degrees and extension to zero degrees, bilaterally, with no objective evidence of pain upon active motion. Moreover, there was no objective evidence of pain upon active motion and no additional limitations after three repetitions of range of motion, bilaterally. X-rays were normal, with well-maintained joint spaces and no specific bone or joint abnormalities. A VA general examination report dated in May 2010 indicated that the Veteran experienced pain in both knees. Subjectively, the Veteran described joint pain in her lower extremities. Knee jerk and ankle jerk reflex testing were normal. The Veteran was provided with a VA knee examination in May 2012, at which time she was diagnosed as having bilateral retropatellar pain syndrome. The Veteran denied flare-ups impacting function of the knee and lower leg. Range of motion testing revealed flexion to 140 degrees or greater and extension to zero degrees, with no objective evidence of painful motion. The Veteran was able to perform repetitive-use testing with three repetitions. There was no additional limitation of range of motion of the bilateral knees following repetitive-use testing, nor was there any functional loss and/or functional impairment of the knee or lower leg. The Veteran exhibited normal strength in both flexion and extension. Lachman testing, posterior drawer testing, and medial-lateral stability testing were within normal limits. There was no evidence of a prior meniscectomy or total knee joint replacement. However, the Veteran used knee braces constantly to minimize bilateral knee pain. There was no evidence of ankylosis, degenerative arthritis, traumatic arthritis, or patellar subluxation. The examiner concluded that the Veteran's bilateral knee pain impacted her ability to walk long distances and climb stairs. Although the principal symptom of the Veteran's bilateral retropatellar pain syndrome is pain, the objective findings do not show that pain limits either of her knees to such an extent as to satisfy the criteria provided for higher ratings for either limitation of flexion or limitation of extension under Diagnostic Codes 5260 or 5261. Further, there was no additional limitation of motion after repetitive use from fatigue, weakness, lack of endurance, and incoordination, even considering functional loss due to pain and painful movement, which was considered by the VA examiners. 38 C.F.R. §§ 4.40, 4.45; DeLuca v. Brown, 8 Vet. App. 202 (1995). For example, VA examiners consistently indicated that there were no additional limitations in range of motion or joint function following repetition due to pain, fatigue, weakness, lack of endurance, or incoordination. Moreover, in May 2012, the Veteran denied flare-ups impacting function. Although the Veteran subjectively reported giving way and locking of the knee, McMurray testing was normal and there was no evidence of ankylosis, arthritis, or subluxation. In the absence of objective medical evidence of other separate and distinct manifestations of the service-connected right and left knee disabilities not contemplated in the current rating assignment, the Board finds no basis upon which to assign higher or separate disability ratings. No other Diagnostic Codes are shown to be applicable based on the nature of the symptoms complained of by the Veteran and documented in the medical evidence of record. For example, there is no evidence of knee ankylosis, so evaluating the Veteran under 38 C.F.R. § 4.71a, Diagnostic Code 5256, is not appropriate. Also, her service-connected disabilities are not shown to be manifested by cartilage impairment (i.e., experiencing frequent episodes of locking, pain, and effusion into the joint) or that she has undergone surgery to remove knee cartilage, so application of 38 C.F.R. § 4.71a, Diagnostic Codes 5258 and 5259, are not warranted. For the reasons articulated, the preponderance of the evidence is against the claims for initial ratings higher than 10 percent each for the right and left knee retropatellar pain syndrome. 38 U.S.C.A. § 5107(b). In arriving at this conclusion, the Board has considered whether assignment of "staged" ratings under Fenderson v. West, 12 Vet. App. 119, 126-27 (1999) was appropriate. Human Papilloma Virus, Squamous Metaplasia and Dysplasia The Veteran seeks a higher rating for her service-connected human papilloma virus, squamous metaplasia and dysplasia, which is evaluated as 10 percent disabling under Diagnostic Code 7612, which provides ratings for disease or injury of the cervix. Under Diagnostic Code 7612, a noncompensable rating is assigned where symptoms do not require continuous treatment. Where continuous treatment is required, a 10 percent rating is assigned. Where continuous treatment does not control the symptoms, a maximum schedular 30 percent rating is warranted. 38 C.F.R. § 4.116, Code 7612 (2012). The Veteran underwent Papanicolaou (Pap) testing in September 2005 which revealed a low grade squamous intraepithelial lesion (LSIL) encompassing human papillomavirus (HPV), mild dysplasia, and cervical intraepithelial neoplasia. A VA primary care initial evaluation note dated in February 2009 indicated that the Veteran had a history of abnormal Papanicolaou testing. The Veteran was afforded a VA gynecological conditions examination in April 2009, at which time she was diagnosed as having abnormal Papanicolaou testing and dysplasia as well as dysmenorrhea. The examiner indicated that the Veteran had an abnormal Papanicolaou test in October 1999 showing parakeratosis squamous metaplasia, and that she had been having abnormal Papanicolaou tests since then. After undergoing loop electrosurgical excision procedure (LEEP) in response to her abnormal Papanicolaou testing, the Veteran's tests showed atypical squamous dysplasia with human papilloma virus changes. The examiner indicated that the Veteran complained of abdominal cramps before and during periods every month which she treated with Motrin. The Veteran was provided a VA gynecological conditions examination in May 2012, at which time the examiner acknowledged past diagnoses of mennorhagia as well as positive Papanicolaou testing for human papilloma virus. Her symptoms included moderate pain and irregular menstruation. The examiner further acknowledged that the Veteran underwent a LEEP in response to her abnormal Papanicolaou testing, and noted that the Veteran was on estrogen replacement therapy for total abdominal hysterectomy. However, the examiner explicitly indicated that the Veteran did not require treatment or medications for symptoms related to her service-connected reproductive tract disabilities. As there is no evidence that continuous treatment does not control the Veteran's symptoms, the Board finds that a rating in excess of 10 percent is not warranted. Carpal Tunnel Syndrome (Dominant) of the Right Wrist and (Non-Dominant) of the Left Wrist The Veteran asserts that higher ratings are warranted for right and left wrist carpal tunnel syndrome. Each of the Veteran's wrists is separately evaluated as 10 percent disabling under 38 C.F.R. § 4.124a, Diagnostic Code 8515, which pertains to paralysis of the median nerve. Pursuant to diagnostic Code 8515, a 10 percent evaluation is warranted when there is mild incomplete paralysis of the nerves of either hand. A 30 percent evaluation is warranted for the major extremity, and a 20 percent evaluation is warranted for the minor extremity when there is moderate incomplete paralysis of the nerves of the hand. A 50 percent evaluation is warranted for the major extremity, and a 40 percent evaluation is warranted for the minor extremity when there is severe incomplete paralysis of the nerves of the hand. A maximum 70 percent evaluation is warranted for the major hand, and 60 percent evaluation is warranted for the minor extremity when there is complete paralysis of the nerves of the hand. 38 C.F.R. § 4.124a, Diagnostic Code 8515. The term "incomplete paralysis" indicates impairment of function of a degree substantially less than the type of picture for complete paralysis given for each nerve, whether due to varied level of the nerve lesion or to partial regeneration. When the involvement is wholly sensory, the rating should be for the mild, or, at most, the moderate degree. 38 C.F.R. § 4.124a, Note. The Veteran is right-hand dominant. The Veteran was provided with a VA general examination in April 2009, at which time the examiner did not find carpal tunnel syndrome of the wrists. Subjectively, the Veteran described pain on the volar aspects and palmar aspects of the wrists aggravated with repetitive movement. She also reported swelling, although she denied any locking, giving way, or dislocation. The examiner indicated that electromyography (EMG) and nerve conduction velocity (NCV) of the bilateral wrists did not produce electrodiagnostic evidence of carpal tunnel syndrome. Upon objective examination, her wrists were symmetrical with no swelling, although the Veteran reported tenderness upon palpation. Phalen maneuver and compression tests as well as Tinel's sign were negative. Range of motion testing revealed dorsiflexion to 70 degrees, palmar flexion to 80 degrees, radial deviation to 20 degrees, and ulnar deviation to 45 degrees, bilaterally, with no additional limitation of motion during repetitive use. The examiner further opined that there would be no functional limitation of the bilateral wrists during flare-ups or repetitive use. X-rays of the bilateral wrists were normal. The Veteran was provided with a VA joints examination in May 2010, at which time carpal tunnel syndrome of the bilateral wrists was again not found. Subjectively, the Veteran described weakness, pain, and swelling of the bilateral wrists; however, she denied deformity, giving way, instability, stiffness, incoordination, locking, inflammation, or effusions. There were no constitutional symptoms or incapacitating episodes of arthritis. Upon objective examination, Tinel's sign, compression testing, and Phalen maneuver were negative. Range of motion testing revealed dorsiflexion to 70 degrees, palmar flexion to 80 degrees, radial deviation to 20 degrees, and ulnar deviation to 45 degrees, bilaterally. There was no objective evidence of pain upon active motion, no objective evidence of pain following repetitive motion, and no additional functional limitations after three repetitions of range of motion. X-rays were normal, with no evidence of fracture, dislocation, or specific bony abnormalities. An August 2011 private treatment note indicated that the Veteran was being followed for carpal tunnel syndrome. The Veteran was provided with a VA wrist conditions examination in May 2012, at which time she was diagnosed as having bilateral carpal tunnel syndrome which was improving and resolving. The Veteran denied flare-ups that impacted wrist function. Palmar flexion was to 80 degrees or greater, bilaterally, with no objective evidence of painful motion. Dorsiflexion was to 70 degrees or greater, bilaterally, with no objective evidence of painful motion. The Veteran was able to perform repetitive-use testing with three repetitions, and there was no additional limitation in range of motion following repetitive-use testing. Moreover, there was no functional loss and/or functional impairment of the wrist. However, the Veteran reported localized tenderness or pain, bilaterally, upon palpation of the joint/soft tissue of the wrists. He exhibited normal strength upon flexion and dorsiflexion. There was no evidence of ankylosis, degenerative arthritis, or traumatic arthritis. The examiner concluded that the Veteran's bilateral wrist pain, numbness, and tingling impacted daily activities such as washing dishes, writing, and hold objects. The Veteran was also provided with a VA peripheral nerves examination in May 2012, at which time she was diagnosed as having bilateral carpal tunnel syndrome with median nerve neuropathy (entrapment). Subjectively, the Veteran described constant mild pain, mild paresthesias and/or dysesthesias, and mild numbness in her bilateral upper extremities. Muscle strength testing was normal, with no evidence of muscle atrophy. Reflexes of the biceps, triceps, and brachioradialis were also normal, bilaterally. Sensory examination in the shoulder, forearm, and hands/fingers were normal. Her upper extremity nerves were all found to be within normal limits, with no evidence of paralysis. However, the Veteran occasionally wore bilateral wrist braces to help minimize pain. The Board finds that the evidence of record does not support separate evaluations greater than 10 percent for the Veteran's carpal tunnel syndrome of the bilateral wrists. The objective medical evidence containing the aforementioned VA examination reports do not indicate that the veteran exhibited more than mild symptoms of carpal tunnel syndrome at any time during the rating period. Although she subjectively complained of bilateral weakness and pain, the Veteran exhibited a full range of wrist motion. Moreover, although the Veteran complained of numbness and tingling, sensory examination was normal. On these bases, the Board finds that separate schedular ratings in excess of 10 percent are not warranted for the Veteran's carpal tunnel syndrome of the left wrist and right wrist during the rating period as there was no objective evidence of greater than mild incomplete paralysis of the upper extremities during this period. Residuals of Fracture, Tendonitis, of the Left Little Finger (Non-Dominant) The Veteran seeks a compensable rating for her service-connected residuals of fracture and tendonitis of the left little finger, which is evaluated as noncompensable by analogy to Diagnostic Codes 5299-5227. A maximum zero percent rating also is assigned under DC 5227 for favorable or unfavorable ankylosis of the ring or little finger (whether on the major (dominant) or minor (non-dominant) hand). See 38 C.F.R. § 4.71a, Diagnostic Code 5227 (2012). A Note to Diagnostic Code 5227 provides that evaluation as amputation should be considered and whether an additional evaluation is warranted for any resulting limitation of motion of other digits or interference with the overall function of the hand. Id. The Board also will consider other potentially applicable Diagnostic Codes in the Rating Schedule. A maximum zero percent rating is assigned under Diagnostic Code 5230 for any limitation of motion of the ring or little finger (whether on the major (dominant) or minor (non-dominant) hand). See 38 C.F.R. § 4.71a, Diagnostic Code 5230 (2012). A compensable rating for a fifth finger disability requires amputation. See 38 C.F.R. § 4.71a, Diagnostic Code 5156. Under Diagnostic Code 5156, amputation of the little finger, a 10 percent evaluation is warranted for amputation of the little finger on the major or minor hand, without metacarpal resection, at the proximal interphalangeal joint or proximal thereto. 38 C.F.R. § 4.71a, Diagnostic Code 5156. It is noted that single finger amputation ratings are the only applicable ratings for amputations of whole or part of single fingers. 38 C.F.R. § 4.71a, Diagnostic Code 5156, at Note. In order for ankylosis to be rated as amputation, the condition must manifest with extremely unfavorable ankylosis. See Note (3)(i) preceding 38 C.F.R. § 4.71a, Diagnostic Code 5216, unfavorable ankylosis of five digits of one hand. In other words, in order to be evaluated as amputation, there must be ankylosis of both the metacarpophalangeal and proximal interphalangeal joints either in extension or full flexion or with rotation or angulation of a bone. Id. Note (3)(ii) explains that if both the metacarpophalangeal and proximal interphalangeal joints of a digit were ankylosed, it should be evaluated as unfavorable ankylosis even if each joint was individually fixed in a favorable position. Note (3)(iii) indicates that if only the metacarpophalangeal or proximal interphalangeal joints were ankylosed and there was a gap of more than 2 inches (5.1 cm.) between the fingertips and the proximal transverse crease of the palm, with the fingers flexed to the extent possible, the condition should be evaluated as unfavorable ankylosis. Consideration is to be given to whether there is less movement than normal, more movement than normal, weakened movement, excess fatigability, incoordination, pain on movement, swelling, deformity or atrophy of disuse, instability of station, or interference with standing, sitting, or weight bearing. For the purpose of rating disability from arthritis, multiple involvements of the metacarpal and carpal joints of the upper extremities are considered groups of minor joints ratable on a parity with major joints. 38 C.F.R. § 4.45 (2012). VA must consider "functional loss" of a musculoskeletal disability separately from consideration under the diagnostic codes; "functional loss" may occur as a result of weakness, fatigability, incoordination, or pain on motion. 38 C.F.R. §§ 4.40, 4.45, 4.59; DeLuca v. Brown, 8 Vet. App. 202 (1995). VA must consider any part of the musculoskeletal system that becomes painful on use to be "seriously disabled." The Veteran is right-hand dominant. The Veteran was afforded a VA general examination in April 2009, at which time she was diagnosed as having a fracture residual of the left little finger with ankylosis. Subjectively, the Veteran complained of pain and flexion deformity. However, she denied any history of swelling, giving way, or dislocation. Upon objective examination, the fifth finger of the left hand was ankylosed at the interphalangeal joint with an angulation of 15 to 20 degrees. The Veteran was able to reach the transverse palmar crease without any gap with the tip of her fifth finger. Range of motion of her fifth finger was limited on extension. It remained at flexion with a deformity at 20 to 30 degrees of flexion. X-rays were negative for fracture or dislocation. A September 2009 VA occupational therapy consultation note indicated that the Veteran complained of lack of movement in the proximal interphalangeal joint of the left little finger. Active range of motion in the proximal interphalangeal joint was 65 to 85 degrees, while passive range of motion was 55 to 100 degrees. Active range of motion in the distal interphalangeal joint was zero to 35 degrees, while passive range of motion was zero to 50 degrees. The Veteran reported increased pain upon stretching. The physician opined that the Veteran demonstrated limited range of motion in both passive and active motions. The Veteran was provided with a VA hand and finger examination in May 2012, at which time she was diagnosed with an old fracture of the left fifth finger. The Veteran denied that flare-ups impacted left hand function. However, left fifth finger extension was limited by more than 30 degrees (unable to extend finger fully, with extension limited to 31 degrees or more of flexion), although there was no objective evidence of painful motion. The Veteran was able to perform repetitive-use testing upon three repetitions, and there was no additional limitation of motion following repetitive-use testing. There was no gap between the fifth fingertip and the proximal transverse crease of the palm in attempting to touch the palm with the fingertip. Moreover, there was no functional loss or functional impairment of any of the fingers. The Veteran exhibited flexion deformity on the proximal interphalangeal joint of the left fifth finger. The Veteran reported tenderness or pain to palpation for the joints or soft tissue of the left fifth finger. Muscle strength testing was normal, and there was no evidence of ankylosis. The examiner concluded that the Veteran was unable to use her left fifth finger as a result of the flexion deformity of the proximal interphalangeal joint. As discussed above, a noncompensable rating is the maximum rating under Diagnostic Code 5230. A noncompensable rating is also the maximum rating under Diagnostic Code 5227 for ankylosis of the little finger. Thus, no increased schedular evaluation is warranted under these diagnostic codes. Despite the lack of evidence of extreme unfavorable ankylosis or amputation of the left fifth finger, the Board finds that a non-schedular rating of 10 percent is warranted pursuant to the DeLuca criteria, based upon the functional loss of the Veteran's left fifth finger as a result of the flexion deformity of the proximal interphalangeal joint. See also DeLuca v. Brown, 8 Vet. App. 202, 206 (1995). The Board is cognizant of the amputation rule, which states that "the combined rating for disabilities of an extremity shall not exceed the rating for the amputation at the elective level, were amputation to be performed." 38 C.F.R. § 4.68 (2012). As stated above, amputation of the little finger at the proximal interphalangeal joint warrants a 10 percent rating pursuant to Diagnostic Code 5156. The record shows no evidence of amputation or symptoms that would warrant assigning a rating based on amputation. Therefore, a rating in excess of 10 percent is not warranted. Costochondritis The Veteran seeks a compensable rating for her service-connected costochondritis. The Veteran has been assigned a noncompensable rating for this disability by analogy under 38 C.F.R. § 4.71a, Diagnostic Codes 5299-5297, concerning the removal of ribs. Ratings are assigned for the removal of one, or resection of two or more, ribs, without regeneration (10 percent); two ribs (20 percent); three or four ribs (30 percent); five or six ribs (40 percent); and more than six ribs (50 percent). The Veteran was provided with a VA general examination in April 2009, at which time she was diagnosed as having costochondritis. Subjectively, she complained of mild right anterior chest pain on the right upper quadrant of her chest, which is relieved when she sat down to rest. The examiner indicated that the costochondritis would not have an impact on her normal occupational environment. The Veteran was provided with a VA general examination in May 2010, at which time she was again diagnosed as having costochondritis. The Veteran reported suffering from recurrent upper anterior chest pain relieved with rest which she attributed to anxiety and mental stress. However, the examiner opined that this disability did not have any effect on her usual occupation or usual daily activities. Overall, the Veteran's complaints of costochondritis pain are not accompanied by objective medical findings suggesting such pain or tenderness, or any functional impairment. There is no evidence in the record suggesting that the Veteran underwent a removal or resection or one or more ribs. The Board is therefore unable to conclude that this disability picture warrants a compensable evaluation under either Diagnostic Code 5297 or 38 C.F.R. §§ 4.40, 4.45, or 4.59. As such, the claim for a compensable evaluation must be denied. 38 C.F.R. § 4.31. Uveitis The Veteran seeks a compensable rating for her service-connected uveitis, which has been rated as noncompensable under 38 C.F.R. § 4.84a, Diagnostic Code 6000. Under Diagnostic Code 6000, uveitis, in chronic form, is to be rated from 10 percent to 100 percent for impairment of visual acuity or field loss, pain, rest-requirements, or episodic incapacity, combining an additional rating of 10 percent during continuance of active pathology, with a minimum rating of 10 percent during active pathology. 38 C.F.R. § 4.84a. On a VA pulmonary consultation note dated in May 2006, the Veteran denied any problems except for photophobia. A VA ophthalmology consultation note dated later in May 2006 indicated that the Veteran complained of light sensitivity but denied other symptomatology at that time. However, the ophthalmologist indicated that there was no evidence of uveitis or vasculitis at that point. A VA primary care initial evaluation note dated in February 2009 indicated that the Veteran reported having pain in both eyes for 2 years, becoming worse in the sun, and wearing contact lenses to correct the problem. The physician diagnosed the Veteran with probable dry eye syndrome. The Veteran was provided with a VA eye examination in April 2009, at which time the examiner acknowledged that there was a history of uveitis when the Veteran was diagnosed as having sarcoidosis in 1999; however, there had been no further episodes of uveitis on any eye examination, and no ocular manifestations of sarcoidosis. The examiner indicated that the Veteran may have dry eyes. The Veteran was provided with a VA eye examination in May 2010, at which time the examiner found no evidence of chronic anterior uveitis in either eye secondary to sarcoidosis, no residuals from past episodes of anterior uveitis in either eye, no disabling eye conditions nor visual limitations evidence secondary to sarcoidosis, and benign trace bilateral pinguecula which was not deemed visually significant. Specifically, fundoscopic examination findings were normal, bilaterally, although there were physical findings of presbyopia. The Veteran was provided with a VA eye examination in May 2012, at which time the examiner opined that there was no evidence of past or present uveitis. Visual acuity testing revealed distance vision of 20/70 (20/40 or better corrected) in the right eye and 20/200 (20/40 or better corrected) in the left eye, and near vision of 20/70 (20/40 or better corrected), bilaterally. The Veteran's pupils were round and reactive to light, with no evidence of afferent pupillary defect, corneal irregularity that resulted in severe astigmatism, diplopia, or visual field defect. Examination revealed normal eyelids, eyelashes, conjunctiva, sclera, cornea, anterior chamber, iris, and lens. Her fundus as also normal, bilaterally. The examiner diagnosed the Veteran as having conjunctivitis manifested by bilateral dry eye syndrome. However, this did not result in a decrease in visual acuity or other visual impairment. The Veteran did not have scarring or other disfigurement due to an eye condition. Given the evidence of record, the Board finds that the Veteran is not entitled to a compensable rating for her service-connected uveitis. Throughout the period on appeal, the Veteran has not had visual acuity or field loss, pain, rest-requirement or episodic incapacity due to uveitis. The preponderance of the evidence is therefore against the claim. There is no doubt to be resolved, and an initial compensable rating for the Veteran's uveitis is not warranted. See 38 C.F.R. § 5107(b); Gilbert, 1 Vet. App. at 54-56. Allergic Rhinitis with Sinusitis The Veteran seeks a compensable rating for her service-connected allergic rhinitis with sinusitis, which has been rated as noncompensable pursuant to 38 C.F.R. § 4.97, Diagnostic Code 6522 (2012). Diagnostic Code 6522, allergic or vasomotor rhinitis, allows for 10 percent rating for greater than 50 percent obstruction of both nasal passages or complete obstruction of one nasal passage and without polyps. A 30 percent rating is assigned for when polyps are present. Diagnostic Code 6513, chronic maxillary sinusitis, is rated under the General Rating Formula for Sinusitis. Under that regulation, sinusitis following radical surgery with chronic osteomyelitis, or near constant sinusitis characterized by headaches, pain, and tenderness of the affected sinus, and purulent discharge or crusting after repeated surgeries warrants a 50 percent disability rating. Sinusitis with three or more incapacitating episodes per year requiring prolonged (lasting four to six weeks) antibiotic treatment, or more than six non-incapacitating episodes per year of sinusitis characterized by headaches, pain, and purulent discharge or crusting warrants a 30 percent disability rating. Sinusitis with one or two incapacitating episodes per year requiring prolonged (lasting four to six weeks) antibiotic treatment, or three to six non-incapacitating episodes per year of sinusitis characterized by headaches, pain, and purulent discharge or crusting warrants a 10 percent disability rating. Sinusitis detected by X-ray only warrants a zero percent disability rating. 38 C.F.R. § 4.97. At an annual VA gynecological examination in September 2005, the Veteran denied any sinus drainage. The Veteran was provided with a VA general examination in April 2009, at which time she was diagnosed with rhinitis, although sinusitis was not found. Subjectively, the Veteran reported nasal congestion most of the time which was aggravated by cold weather. Upon examination, her nasal mucosa was pink with no sign of inflammation while her inferior turbinates were enlarged at 30 percent obstruction, bilaterally. Her sinuses were nontender. X-rays of the sinuses were negative. The Veteran was provided with a VA general examination in May 2010, at which time she was diagnosed as having allergic rhinitis. Subjectively, the Veteran described a history of frequent nasal congestion aggravated by cold weather changes. However, there had been no episodes of sinusitis in the past year. Objective examination of the nose revealed that her nasal vestibule, turbinates, and septum were normal, without evidence of obstruction or polyps. Examination of the sinuses was also normal. X-rays revealed that the right frontal sinus was underdeveloped, although the paranasal sinuses appeared essentially clear. There was no evidence of fluid levels, polyps, or retention cysts. The examiner opined that the Veteran's rhinitis had no effect on her usual occupation or usual daily activities. The Veteran was provided with a VA sinusitis and rhinitis examination in December 2012, at which time she was diagnosed as having chronic maxillary sinusitis and allergic rhinitis. The examiner specified that continuous medication was not required to control these disabilities. The sinusitis was episodic in nature rather than constant, and the Veteran denied any episodes of sinusitis characterized by headaches, pain, and purulent discharge or crusting during the previous year. The Veteran's allergic rhinitis was not manifested by greater than 50 percent obstruction of the nasal passage on both sides, nor complete obstruction of the nasal passage on one side. Although there was no evidence of nasal polyps or granulomatous conditions, there was permanent hypertrophy of the nasal turbinates. There was no deviation of the nasal septum. Based on the above subjective complaints and objective findings, the Board determines that a compensable rating for service-connected allergic rhinitis with sinusitis is not warranted. The competent medical evidence does not establish that the Veteran has nasal polyps or that her nasal obstruction exceeds 50 percent. Moreover, the report of the December 2012 examination explicitly found that there was no evidence of headaches, pain, or purulent discharge or crusting due to maxillary sinusitis. The Board notes that the degree of nasal obstruction and the presence of polyps can only be determined by someone with knowledge of the structure of the nose, and the equipment and ability to adequately examine and assess the inside of the nasal passages. Despite the Veteran's assertions, the clinical findings as to her nasal passages do not support the claim of increased disability. A compensable rating for service-connected chronic rhinitis with sinusitis is denied. Gilbert's Syndrome The Veteran seeks a compensable rating for her service-connected Gilbert's syndrome, which has been evaluated as noncompensable by analogy to 38 C.F.R. § 4.114, Diagnostic Codes 7399-7311. Residuals of a liver injury are rated on the basis of the specific residuals present under Diagnostic Code 7311; more specifically to be rated utilizing Diagnostic Codes 7301, 7312, and 7345. 38 C.F.R. § 4.114, Diagnostic Code 7311 (2012). Diagnostic Code 7301 indicates that moderate peritoneal adhesions manifested by 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 distention warrant a 10 percent evaluation. A noncompensable rating is to be assigned for mild manifestations. Note: Ratings for adhesions will be considered when there is history of operative or other traumatic or infectious (intraabdominal) process, and at least two of the following: disturbance of motility, actual partial obstruction, reflex disturbances, presence of pain. 38 C.F.R. § 4.114, Diagnostic Code 7301 (2012). Under Code 7312, with cirrhosis of the liver, primary biliary cirrhosis, or cirrhotic phase of sclerosing cholangitis, for symptoms such as weakness, anorexia, abdominal pain, and malaise, a 10 percent rating is assigned. Cirrhosis with portal hypertension and splenomegaly, with weakness, anorexia, abdominal pain, malaise, and at least minor weight loss, is rated 30 percent disabling. Id. Cirrhosis with history of one episode of ascites, hepatic encephalopathy, or hemorrhage from varices or portal gastropathy (erosive gastritis), is rated 50 percent disabling. Id. 38 C.F.R. § 4.114, Diagnostic Code 7312 (2012). Under Diagnostic Code 7345, a noncompensable evaluation is provided for nonsymptomatic liver disease. A 10 percent evaluation is prescribed where liver disease is productive of intermittent fatigue, malaise, and anorexia, or where there are incapacitating episodes (with symptoms such as fatigue, malaise, nausea, vomiting, anorexia, arthralgia, and right upper quadrant pain) having a total duration of at least one week, but less than two weeks during the previous 12 month period. A 20 percent rating is assigned for symptoms of daily fatigue, malaise, and anorexia (without weight loss or hepatomegaly), requiring dietary restriction or continuous medication; or incapacitating episodes (with symptoms such as fatigue, malaise, nausea, vomiting, anorexia, arthralgia, and right upper quadrant pain) having a total duration of at least two weeks, but less than four weeks, during the past 12-month period. A 40 percent rating is assigned for symptoms of daily fatigue, malaise, and anorexia, with minor weight loss and hepatomegaly, or; incapacitating episodes (with symptoms such as fatigue, malaise, nausea, vomiting, anorexia, arthralgia, and right upper quadrant pain) having a total duration of at least four weeks, but less than six weeks, during the past 12-month period. 38 C.F.R. § 4.114, Diagnostic Code 7345 (2012). The Veteran was provided a VA general examination in April 2009, at which time she was diagnosed as having asymptomatic Gilbert's syndrome. Subjectively, the Veteran admitted that she had not been treated for this condition for many years, and denied any right upper quadrant pain, hematemesis, or melena. She exhibited no yellowish discoloration of the skin, nausea, vomiting, diarrhea, constipation, or abdominal pain. There was also no evidence of anorexia, although the Veteran weighed only 100 pounds. There was no evidence of jaundice or pallor. The Veteran was provided with a VA general examination in May 2010, at which time she was diagnosed as having asymptomatic Gilbert's disease, without jaundice. The examiner indicated that the Veteran had been diagnosed in the military with Gilbert's disease due to yellowish discoloration of her skin and generalized body malaise, although there had been no other episodes since then. Upon objective examination, although the Veteran weighed only 80 pounds due to poor nourishment, there was no evidence of anorexia, jaundice, or incapacitating episodes. The liver and spleen were indicated to be normal. The examiner opined that the Veteran's Gilbert's disease alone did not have any effect on her usual occupation or her usual daily activities. An August 2011 private treatment note indicated that the Veteran was being followed for macrocytic anemia with vitamin B12 deficiency. The Veteran was provided with a VA liver examination in December 2012, at which time he was diagnosed as having Gilbert's syndrome. The examiner specified that continuous medication was not required for control of the disability. However, Gilbert's syndrome was manifested by intermittent fatigue. There were no other pertinent physical findings, complications, conditions, or symptoms related to the Veteran's Gilbert's syndrome. The examiner concluded that the Veteran may be unable to perform strenuous physical activities due to the severe fatigue caused by Gilbert's syndrome. The evidence of record supports a 10 percent rating for Gilbert's syndrome. Although the May 2010 examination report indicated that the Gilbert's syndrome was asymptomatic, the December 2012 examination report indicated that it was productive of severe, intermittent fatigue, as contemplated by the criteria for a 10 percent evaluation under Diagnostic Code 7345. However, an evaluation in excess of 10 percent for Gilbert's syndrome is not warranted for any period during the appeal, as there is no evidence of Cirrhosis with portal hypertension and splenomegaly or of daily fatigue, malaise, and anorexia requiring dietary restriction or continuous medication. As such, a 10 percent evaluation, but no higher, for the Veteran's service-connected Gilbert's syndrome is warranted. GERD The Veteran seeks a compensable rating for her service-connected GERD, which has been evaluated as noncompensable by analogy to 38 C.F.R. § 4.114, Diagnostic Codes 7399-7346. While diseases of the digestive system, particularly within the abdomen, differ in the site of pathology, they produce a common disability picture characterized in the main by varying degrees of abdominal distress or pain, anemia and disturbances in nutrition. Consequently, certain coexisting diseases in this area, as indicated in the instruction under the title Diseases of the Digestive System, do not lend themselves to distinct and separate disability evaluations without violating the fundamental principle relating to pyramiding as outlined in 38 C.F.R. § 4.14. See also 38 C.F.R. § 4.113 (2012). Disabilities of the digestive system are rated in accordance with 38 C.F.R. § 4.114, Diagnostic Codes 7200-7348. Section 4.114 provides that ratings under Diagnostic Codes 7301 to 7329, inclusive, 7331, 7342, and 7345 to 7348, inclusive, will not be combined with each other. A single rating 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. 38 C.F.R. § 4.114. Based on the Veteran's predominant symptoms and disability, GERD, Diagnostic Code 7346, is the most appropriate code, as well as the code most beneficial to the Veteran. Diagnostic Code 7346 rates on the basis of symptoms, such as recurrent epigastric distress with dysphagia, pyrosis, and regurgitation or, in more severe situations, vomiting, hematemesis, melena, or material weight loss. 38 C.F.R. § 4.114, Diagnostic Code 7346. A 10 percent rating is warranted when there are two or more symptoms for the 30 percent evaluation of less severity. Id. A 30 percent rating is warranted for persistently recurrent epigastric distress with dysphagia, pyrosis, and regurgitation, accompanied by substernal or arm or shoulder pain, productive of considerable impairment of health. Id. The maximum 60 percent rating is warranted when there are for symptoms of pain, vomiting, material weight loss, and hematemesis or melena with moderate anemia; or other symptom combinations productive of severe impairment of health. Id. As noted above, a noncompensable evaluation shall be assigned when the requirements for a compensable evaluation are not met. 38 C.F.R. § 4.31. A VA primary care initial evaluation note dated in February 2009 indicated that the Veteran reported an upset stomach. The Veteran was provided with a VA general examination in April 2009, at which time the examiner concluded that GERD was not found. Subjectively, the Veteran conceded that her heartburn subsided many years ago, and that she had no symptoms of heartburn at the time of the examination. The Veteran was provided with a VA general examination in May 2010, at which time the examiner again concluded that GERD was not found. Subjectively, the Veteran described vague, generalized abdominal pains at least daily as well as intermittent diarrhea, nausea, and vomiting. The Veteran denied any heartburn for many years. The Veteran reported a history of nausea, vomiting, diarrhea, and regurgitation, but denied any indigestion, heartburn, hernia, or abdominal masses. Inspection of the abdomen was normal, with no evidence of palpable masses or hernias. An August 2011 private treatment note indicated that the Veteran was being followed for atypical chest pain. However, it was specifically noted that she did not suffer from dysphagia. The Veteran was provided with a VA esophageal conditions examination in December 2012, at which time he was diagnosed as having GERD. Symptoms included reflux as well as episodes mild nausea less than one day in duration. The evidence of record supports a 10 percent rating for GERD. Although there is no evidence of dysphagia or pyrosis, there is evidence of reflux and vomiting. As such, the Veteran exhibits two or more symptoms contemplated by the higher disability ratings under Diagnostic Code 7346, only of less severity. However, an evaluation in excess of 10 percent for GERD is not warranted for any period during the appeal, as there is no evidence of substernal or arm or shoulder pain productive of considerable impairment of health. As such, a 10 percent evaluation, but no higher, for the Veteran's service-connected GERD is warranted. Bilateral Ovarian Cysts The Veteran seeks a compensable rating for her service-connected bilateral ovarian cysts, which have been evaluated as noncompensable by analogy to 38 C.F.R. § 4.116, DC 7699-7615. Disabilities rated under DC 7615 are evaluated under a General Rating Formula for Disease, Injury, or Adhesions of Female Reproductive Organs (diagnostic codes 7610 through 7615) ("General Rating Formula"). Under the General Rating Formula, a zero percent rating is assigned for gynecological disability with symptoms that do not require continuous treatment. A minimum 10 percent rating is assigned for gynecological disability with symptoms that require continuous treatment. A maximum 30 percent rating is assigned for gynecological disability with symptoms not controlled by continuous treatment. See 38 C.F.R. § 4.116, DC 7610-7615 (2012). The Veteran underwent Papanicolaou (Pap) testing in September 2005 which revealed a low grade squamous intraepithelial lesion (LSIL) encompassing human papillomavirus (HPV), mild dysplasia, and cervical intraepithelial neoplasia. A February 2009 routine gynecological examination indicated that the Veteran's ovaries were within normal limits, with no masses present. An ultrasound of the pelvis conducted in March 2009 revealed that the Veteran's uterus was within normal limits. Her ovaries appeared normal in size, bilaterally, with no significant fluid seen on either side. Although there were follicular cysts, no dominant cysts were seen. The physician's impression was a retroverted uterus with no fibroids identified. The Veteran was provided with a VA gynecological conditions examination in April 2009, at which time the examiner noted that her uterus was inverted, but there was no dominant cyst present in the ovaries. An August 2011 private treatment note indicated that examination revealed no enlargement of the uterus, no ovarian masses, and no lesions. The Veteran was provided a VA gynecological conditions examination in May 2012, at which time the examiner noted that the Veteran did not exhibit uterine fibroids, enlargement of the uterus, or displacement of the uterus. The examiner indicated that the Veteran did not exhibit atrophy or other diseases of/injuries to the ovaries. The examiner indicated that the Veteran did not have any benign or malignant neoplasm or metastases. However, the examiner noted that the Veteran experienced pelvic pain as well as heavy or irregular bleeding as a result of endometriosis. Pelvic ultrasound revealed a simple right ovarian cyst 2.9 centimeters in size as well as a complex left ovarian mass 2.2 centimeters in size and consistent with hemorrhagic corpus lutem. Polyps, hyperplasia, and malignancy were not identified. Significantly, however, the examiner opined that the Veteran did not require any treatment or medications for symptoms related to her reproductive tract disabilities. As such, the evidence explicitly shows that the Veteran does not require any treatment or medications, let alone continuous treatment, for symptoms related to her reproductive tract disabilities. The preponderance of the evidence is therefore against the claim. There is no doubt to be resolved, and an initial compensable rating for the Veteran's bilateral ovarian cysts is not warranted. See 38 C.F.R. § 5107(b); Gilbert, 1 Vet. App. at 54-56. III. Extraschedular Consideration To accord justice in an exceptional case where the schedular standards are found to be inadequate, the field station is authorized to refer the case to the Chief Benefits Director or the Director, Compensation and Pension Service, for assignment of an extraschedular evaluation commensurate with the average earning capacity impairment. 38 C.F.R. § 3.321(b)(1). The criterion for such an award is a finding that the case presents an exceptional or unusual disability picture with related factors as marked interference with employment or frequent periods of hospitalization as to render impractical application of regular schedular standards. The United States Court of Appeals for Veterans Claims has held that the Board is precluded by regulation from assigning an extraschedular rating under 38 C.F.R. § 3.321(b)(1) in the first instance; however, the Board is not precluded from raising this question, and in fact is obligated to liberally read all documents and oral testimony of record and identify all potential theories of entitlement to a benefit under the law and regulations. Floyd v. Brown, 9 Vet. App. 88 (1996). The Court further held that the Board must address referral under 38 C.F.R. §3.321(b)(1) only where circumstances are presented which the Director of VA's Compensation and Pension Service might consider exceptional or unusual. Shipwash v. Brown, 8 Vet. App. 218, 227 (1995). The Court has clarified the analytical steps necessary to determine whether referral for extraschedular consideration is warranted. See Thun v. Peake, 22 Vet. App. 111 (2008). The Court stated that the RO or the Board must first determine whether the schedular rating criteria reasonably describe the Veteran's disability level and symptomatology. Id. at 115. If the schedular rating criteria do reasonably describe the Veteran's disability level and symptomatology, the assigned schedular evaluation is adequate, referral for extraschedular consideration is not required, and the analysis stops. Id. If the RO or the Board finds that the schedular evaluation does not contemplate the Veteran's level of disability and symptomatology, then either the RO or the Board must determine whether the Veteran's exceptional disability picture includes other related factors such as marked interference with employment and frequent periods of hospitalization. Id. at 116. If this is the case, then the RO or the Board must refer the matter to the Under Secretary for Benefits or the Director of the Compensation and Pension Service for the third step of the analysis, determining whether justice requires assignment of an extraschedular rating. Id. In this case, the Veteran reported pain associated with her fibromyalgia and service-connected orthopedic disabilities. As seen in the analysis above, the Board has considered these aspects of the Veteran's disabilities, and finds that the rating schedule adequately provides for ratings based on these symptoms or impairments. Specifically, the Board has considered any additional functional limitation of motion due to pain, fatigue, or lack of endurance upon repetitive use as a result of the Veteran's disabilities. Under 38 C.F.R. §§ 4.40, 4.45, 4.59, and DeLuca, pain, weakened movement, excess fatigability and incoordination, which may cause additional limitation of motion or joint function, are made a part of the schedular rating criteria. The Board notes that the VA examiners addressed the effect of pain and repetition in determining the Veteran's range of motion measurements for all affected joints, and the Board has also considered the Veteran's lay statements addressing her pain and limitation of motion. As the Board has considered all facets of the Veteran's disabilities in its schedular analysis, the Board finds that the Rating Schedule adequately measures and contemplates these aspects of her service-connected disabilities. As the rating schedule is adequate to rate these service-connected disabilities, referral for extraschedular consideration for these disabilities is not warranted. ORDER Entitlement to a disability rating of 30 percent, but no more, for neurosarcoidosis; mood disorder not otherwise specified with depressive features prior to July 1, 2009, is granted. Entitlement to a disability rating in excess of 50 percent from July 1, 2009, to April 27, 2012, and in excess of 70 percent thereafter is denied Entitlement to a disability rating in excess of 70 percent since April 27, 2012, is denied. Entitlement to a disability rating in excess of 30 percent for pulmonary sarcoidosis with asthma is denied. Entitlement to a disability rating of 20 percent, but no more, for fibromyalgia prior to May 3, 2012, is granted. Entitlement to a disability rating in excess of 40 percent for fibromyalgia since May 3, 2012, is denied. Entitlement to a disability rating in excess of 10 percent for tendonitis of the left ankle is denied. Entitlement to a disability rating in excess of 10 percent for retropatellar pain syndrome, myxoid degeneration of the medial meniscus of the right knee is denied. Entitlement to a disability rating in excess of 10 percent for retropatellar pain syndrome, myxoid degeneration of the medial meniscus of the left knee is denied. Entitlement to a disability rating in excess of 10 percent for human papilloma virus, squamous metaplasia and dysplasia, is denied. Entitlement to a disability rating in excess of 10 percent for carpal tunnel syndrome (dominant) of the right wrist is denied. Entitlement to a disability rating in excess of 10 percent for carpal tunnel syndrome (non-dominant) of the left wrist is denied. Entitlement to an initial disability rating of 10 percent, but no more, for residuals of fracture, tendonitis, of the left little finger (non-dominant) is granted. Entitlement to a compensable disability rating for costochondritis is denied. Entitlement to a compensable disability rating for uveitis is denied. Entitlement to a compensable disability rating for allergic rhinitis with sinusitis is denied. Entitlement to a disability rating of 10 percent, but no more, for Gilbert's syndrome is granted. Entitlement to a disability rating of 10 percent, but no more, for GERD is granted. Entitlement to an initial compensable disability rating for bilateral ovarian cysts is denied. REMAND The Veteran also seeks higher ratings for her service-connected vertigo, which has been evaluated by analogy to 38 C.F.R. § 4.87, Diagnostic Code 6205. At the time the Veteran filed her August 2007 increased rating claim, she was receiving a noncompensable evaluation for vertigo. Subsequently, in an April 2013 rating decision, the RO increased her rating to 30 percent effective December 6, 2012. As such, the Board must evaluate the propriety of the noncompensable rating assigned prior to December 6, 2012, as well as the 30 percent rating assigned since December 6, 2012. Diagnostic Code 6205 provides ratings for Meniere's syndrome (endolymphatic hydrops). Meniere's syndrome manifesting hearing impairment with vertigo less than once a month, with or without tinnitus, is rated 30 percent disabling. Meniere's syndrome manifesting hearing impairment with attacks of vertigo and cerebellar gait occurring from one to four times a month, with or without tinnitus is rated 60 percent disabling. Meniere's syndrome manifesting hearing impairment with attacks of vertigo and cerebellar gait occurring more than once weekly, with or without tinnitus, is rated 100 percent disabling. A Note to Diagnostic Code 6205 provides that Meniere's syndrome is to be rated either under these criteria or by separately rating vertigo (as a peripheral vestibular disorder), hearing impairment, and tinnitus, whichever method results in a higher overall rating. The Note also provides that a rating for hearing impairment, tinnitus, or vertigo is not to be combined with a rating under Diagnostic Code 6205. 38 C.F.R. § 4.87. Diagnostic Code 6204, peripheral vestibular disorders, provides a 10 percent rating is assigned under Diagnostic Code 6204 for occasional dizziness. A 30 percent rating is warranted for dizziness and occasional staggering. 38 C.F.R. § 4.87, Diagnostic Code 6204 (2012). The Veteran was provided with a VA general medical examination in May 2010, at which time she was diagnosed as having postural dizziness. Subjectively, the Veteran reported experiencing dizziness with sudden upright positioning, and described accompanying nausea, vomiting, and headache at least once or twice per day. The dizziness was not constant, but rather intermittent with remissions. The Veteran's ears were normal, while her bilateral hearing acuity was grossly normal. She exhibited normal coordination, orientation, and memory. However, the examiner opined that decreased concentration associated with her dizziness effected her occupational activities, and that postural dizziness stopped her from doing her usual daily activities whenever a bout of dizziness occurred. The Veteran was provided with a VA audiological examination in December 2012, at which time she was diagnosed as having right ear sensorineural hearing loss and tinnitus. However, the examiner opined that these disabilities were at least as likely as not directly caused by in-service acoustic trauma rather than secondary to service-connected vertigo. Nonetheless, in the April 2013 rating decision, the RO treated the diagnosed hearing loss and tinnitus as if they were merely symptoms of the vertigo, rather than free-standing disabilities caused by acoustic trauma in their own right, and relied on the diagnoses rendered in the December 2012 VA audiological examination to increase the Veteran's disability evaluation for vertigo from noncompensable to 30 percent effective December 6, 2012, the date of the examination. However, the Board determines that the findings of the December 2012 VA audiological examination, specifically the finding that sensorineural hearing loss and tinnitus were at least as likely as not directly caused by in-service acoustic trauma, reasonably raise the issues of entitlement to service connection for sensorineural hearing loss and tinnitus. As indicated in the Introduction above, since these claims have not been adjudicated by the Agency of Original Jurisdiction (AOJ), the Board finds that it does not have jurisdiction to adjudicate the merits thereof. As such, the Board has referred these claims to the AOJ for the appropriate action. As the Diagnostic Code under which the Veteran's service-connected vertigo is rated lists hearing loss and tinnitus among the criteria required to warrant higher ratings, and mindful of the fundamental principle relating to pyramiding as outlined in 38 C.F.R. § 4.14, the Board finds that it cannot adjudicate the claim for a higher rating for vertigo until the reasonably-raised claims of entitlement to service connection for sensorineural hearing loss and tinnitus are granted or the time to appeal the denial of those claims had expired. See Harris v. Derwinski, 1 Vet. App. 180, 183 (1991) (issues are "inextricably intertwined" when they are so closely tied together that a final Board decision cannot be rendered unless all issues have been considered). Consequently, a remand of the Veteran's claim of entitlement to higher rating for her service-connected vertigo is required. Accordingly, the case is REMANDED for the following action: 1. Adjudicate the claims for service connection for hearing loss and tinnitus. 2. Do not continue with development of the increased rating for vertigo claim until the claims of entitlement to service connection for hearing loss and tinnitus have been granted, or the appellate period following the denial of the claims of entitlement to service connection for sensorineural hearing loss and tinnitus have expired, or until an appeal is filed that can be merged with the current appeal 3. Schedule the Veteran for an examination to determine the current extent of her vertigo. All necessary tests should be conducted and the examination should be conducted in accordance with VA rating criteria. The examiner is specifically asked to address the relationship between the Veteran's bilateral hearing loss and tinnitus and her vertigo. A complete rationale must be provided for any opinion offered. 4. Readjudicate the claim (or claims if an appeal has been perfected with respect to bilateral hearing loss and tinnitus). If any benefit sought is denied, issue an SSOC to the Veteran and her representative, and an opportunity to respond, and then return the case to the Board. The appellant has the right to submit additional evidence and argument on the matter or matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2012). ______________________________________________ ROBERT C. SCHARNBERGER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs