Citation Nr: 1329654 Decision Date: 09/16/13 Archive Date: 09/20/13 DOCKET NO. 05-28 439 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Chicago, Illinois THE ISSUES 1. Entitlement to service connection for a gastrointestinal disorder, claimed as colitis and irritable bowel syndrome (IBS). 2. Entitlement to service connection for a cardiovascular disorder, claimed as a heart murmur. 3. Entitlement to an increased rating for service-connected migraines, currently evaluated as 30 percent disabling. REPRESENTATION Appellant represented by: Veterans of Foreign Wars of the United States WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD T. Stephen Eckerman, Counsel INTRODUCTION The Veteran served on active duty from June 1990 to October 1997. This matter is on appeal from a December 2004 rating decision by the Chicago, Illinois, Department of Veterans Affairs (VA) Regional Office (RO), which denied claims for service connection for colitis, and a heart murmur, and which granted service connection for migraines, evaluated as 10 percent disabling. In July 2010, the Board remanded the service connection claims, and granted the increased initial evaluation claim, to the extent that it assigned a 30 percent rating. The RO subsequently assigned an effective date of January 22, 2010 for the 30 percent rating. In December 2012, the Board remanded the service connection claims, assigned an effective date of May 15, 2003 for the 30 percent rating (date of claim), and remanded the issue of entitlement to a rating in excess of 30 percent for migraine headaches. Since these actions did not constitute a full grant of the benefit sought, the increased initial evaluation issue remains in appellate status. AB v. Brown, 6 Vet. App. 35, 39 (1993). The Veteran testified before the undersigned Veterans Law Judge in February 2010. A transcript of the hearing is of record. The issue of entitlement to service connection for a gastrointestinal disorder, claimed as colitis and irritable bowel syndrome (IBS), 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. The Veteran does not have a cardiovascular disorder other than hypertension. 2. The Veteran's service-connected migraines are not shown to have been productive of very frequent completely prostrating and prolonged attacks productive of severe economic inadaptability. CONCLUSIONS OF LAW 1. The criteria for service connection for a cardiovascular disorder have not been met. 38 U.S.C.A. §§ 1110, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.303 (2013). 2. The criteria for an initial evaluation in excess of 30 percent for migraines have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.7, 4.124a, Diagnostic Code 8100 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Service Connection The Veteran asserts that she has a cardiovascular disorder due to her service. Specifically, she argues that she was found to have a heart murmur during service. Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C.A. § 1110; 38 C.F.R. § 3.303. Regulations also provide that service connection may be granted for a disability diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disability is due to disease or injury which was incurred in or aggravated by service. 38 C.F.R. § 3.303(d). With chronic disease shown as such in service so as to permit a finding of service connection, subsequent manifestations of the same chronic disease at any later date are service connected, unless clearly attributable to intercurrent causes. 38 C.F.R. § 3.303(b). For the showing of chronic disease in service there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time. Id. When the disease identity is established (leprosy, tuberculosis, multiple sclerosis, etc.), there is no requirement of evidentiary showing of continuity. Id. For this purpose, a chronic disease is one listed at 38 C.F.R. § 3.309(a). See Walker v. Shinseki, 708 F.3d 1331, 1338-39 (Fed. Cir. Feb. 21, 2013) (holding that the term "chronic disease in 38 C.F.R. § 3.303(b) is limited to a chronic disease listed at 38 C.F.R. § 3.309(a)). A grant of service connection under 38 C.F.R. § 3.303(b) does not require proof of the nexus element; it is presumed. Id. As will be discussed below, the Veteran has not been diagnosed with any cardiovascular disorder other than hypertension. Application of 38 C.F.R. § 3.303(b) is not warranted. The Board initially notes that in May 2012, the Appeals Management Center (AMC) granted service connection for hypertension. Therefore, the term "cardiovascular disorder" is not intended to include hypertension. The Veteran's service treatment reports show that in August 1989 (pre-induction), her heart was noted to have a RRR (regular rate and rhythm). In September 1989, the Veteran reported that she had a history of a heart murmur. A January 1991 dental report notes a history of a heart murmur, and shows that SBE (subacute bacterial endocarditis) prophylaxis was recommended. A February 1991 report notes "click murmur syndrome." Reports, dated in July 1991, show that she gave birth, and that her diagnoses included cardiac murmur, with antibiotic prophylaxis for subacute bacterial endocarditis administered for mitral valve prolapsed (MVP). There were several notations of a history of asymptomatic murmur consistent with MVP. Reports, dated in December 1993, show that the Veteran received dental care. The reports show that her heart had a RRR, but that there was a murmur, Grade II/VII, and that she had been recommended for prophylactic coverage. The Veteran reported a history of a click heart murmur. The Veteran's separation examination report, dated in June 1997, shows that she was noted to have a Grade I/IV MVP (mitral valve prolapse). An associated chest X-ray was normal. As for the post-service medical evidence, it consists of VA and non-VA reports, dated between 2001 and 2013. This evidence includes a report from Holy Cross Hospital, dated in September 1991, which notes that the Veteran had a normal sinus rhythm with no murmur. A VA examination report, dated in March 2004, shows that on examination, S1 and S2 had a regular rate and rhythm. There is a notation that reads "question systolic murmur at mitral area." The report contains diagnoses that included "innocent heart murmur." VA progress notes, dated between 2004 and 2009, show that the Veteran was noted not to have a heart murmur on at least ten occasions. There are also at least five findings that her heart had a regular rate and rhythm during this time. A VA examination report, dated in October 2011, notes that the Veteran had a history of cardiac murmur in service and was told that it was consistent with mitral valve prolapse. However, after a review of all medical records dating back to 2004, the examiner indicated there was no documentation of a murmur. She added that her current examination also did not reveal a murmur. In an addendum, dated that same month, the examiner stated that she was unable to provide a nexus opinion, as the Veteran currently does not have a murmur that is consistent with mitral valve prolapse. In December 2012, the Board remanded the claim, and directed, in part, that the Veteran be afforded another examination, and that an etiological opinion be obtained, should a current cardiovascular disorder be found. A VA heart Disability Benefits Questionnaire (DBQ), dated in February 2013, shows that the Veteran reported that in 1991 she had been told that she had a heart murmur, but that she had never been told that she had a heart condition. She was noted not to have a condition within the definition of ischemic heart disease, not to require continuous medication for control of a heart condition, and not to have a history of myocardial infarction, congestive heart failure, or cardiac arrhythmia, a heart valve condition, an infectious cardiac condition, including active valvular infection, endocarditis, pericarditis, or syphilitic heart disease. The Veteran did not have a history of surgical or non- surgical procedures, or hospitalization, for a heart condition. On examination, the Veteran's heart had a regular rhythm, with normal heart sounds. There was no evidence of cardiac hypertrophy, or cardiac dilation. An echocardiogram was noted to show normal wall motion, and wall thickness. The examiner concluded that the Veteran had an asymptomatic heart murmur that was not heard at this time, and a normal echocardiogram. An associated echocardiogram report notes a grossly normal LV (left ventricular ejection fraction), and RV size and function, with an EF (ejection fraction) of between 55 and 60 percent, with no aortic stenosis or AI (aortic insufficiency), and trivial MR (mitral regurgitation). In an addendum, dated in April 2013, the examiner stated that the Veteran currently does not have a heart condition, and that she had a normal echocardiogram. In an opinion, dated in May 2013, a VA physician stated that the Veteran's medical files and CAPRI (Compensation and Pension Records Interchange) files had been reviewed. The physician concluded that it was less likely as not that the Veteran's claimed cardiovascular condition was caused by or had a nexus to her military service. She explained the following: in July 1991, the Veteran had been given prophylaxis antibiotics for her cardiac murmur (mitral valve prolapse), and that this treatment was consistent with the best practice of medicine and in no way indicated a complication or residual of childbirth. There is no medical base, or scientific evidence in the current literature, to support a nexus between childbirth and the acute development of a cardiac murmur. In December 1993, the Veteran was given prophylaxis antibiotics for her cardiac murmur (mitral valve prolapse). This treatment was consistent with the best practice of medicine and in no way indicated a complication or residual of tooth extractions. The examiner also summarized the findings in the Veteran's February 2013 VA heart DBQ. The Board finds that the claim must be denied, as the preponderance of the evidence fails to establish the presence of a cardiovascular disorder (other than hypertension) at any time during the appeal period or proximate to her claim for benefits. See McLain v. Nicholson, 21 Vet. App. 319, 321 (2007) (holding that the requirement of the existence of a current disability is satisfied when a claimant has a disability at the time a claim for VA disability compensation is filed, or during the pendency of that claim, and that a claimant may be granted service connection even though the disability resolves prior to the Secretary's adjudication of the claim); Romanowsky v. Shinseki, No. 11-3272 (Vet. App. July 10, 2013) (considering the application of McClain on a recent diagnosis predating the filing of a claim). The Veteran was noted to have a heart murmur during service. However, the only post-service medical evidence to show the existence of a heart disorder is found in the March 2003 VA examination report. The finding was equivocal in its terms ("question systolic murmur at mitral area"), and the preponderance of the medical evidence dated during the appeal period (i.e., as of May 2003) shows that she does not have a heart disorder. For example, there is no post- service medical evidence of a heart murmur dated prior to, or after, the May 2003 report. See e.g., September 1991 report from Holy Cross Hospital; January 2004 VA progress note; see also VA progress notes, dated between September 2004 and April 2009 (showing that the Veteran was repeatedly noted not to have a heart murmur, and that there were at least five findings that her heart had a regular rate and rhythm). The VA examination reports, dated in October 2011, and February 2013, both show that the Veteran was found not to currently have a heart condition. The facts of the present case are clearly distinguished from those of McClain and Romanowsky. There is no evidence that the Veteran had a cardiovascular/ heart disability that resolved during the pendency of the appeal. Rather, as discussed above, the Board finds that the totality of the evidence fails to establish a current diagnosis of a cardiovascular/heart disability or at any time during the appeal period. The aforementioned examination reports and treatment records heavily outweigh the one speculative report from 2003. Consideration has been given to the Veteran's assertion that she presently suffers from a heart disorder that had its onset during her active service. However, whole lay persons are competent to provide opinions on some medical issues, see Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011), as to the specific issue in this case, a cardiovascular disorder, including a heart murmur or defect, falls outside the realm of common knowledge of a lay person. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007) (lay persons not competent to diagnose cancer). Cardiovascular disorders are not the type of conditions that are readily amenable to mere lay diagnosis or probative comment regarding their etiology, as the evidence shows that a echocardiograms and other specific findings is needed to properly assess and diagnose the disorder. See Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009); Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007); and Woehlaert v. Nicholson, 21 Vet. App. 456, 462 (2007). That is, although the Board readily acknowledges that Veteran is competent to report symptoms of an accelerated heartbeat and fatigue, there is no indication that the Veteran is competent to etiologically to render a diagnosis as to the cause of the symptoms. The Veteran has not been shown to possess the requisite medical training, expertise, or credentials needed to render a diagnosis or a competent opinion as to medical causation. Nothing in the record demonstrates that the Veteran received any special training or acquired any medical expertise in evaluating cardiovascular disorders. See King v. Shinseki, 700 F.3d 1339, 1345 (Fed.Cir.2012). Accordingly, this lay evidence does not constitute competent medical evidence and lacks probative value. The Board has considered the applicability of "benefit of the doubt" doctrine, however, the record does not demonstrate an approximate balance of positive and negative evidence as to warrant the resolution of this matter on that basis. 38 U.S.C.A. § 5107(b). II. Increased Initial Evaluation The Veteran asserts that she is entitled to an initial evaluation in excess of 30 percent for her service-connected migraines. She argues that she has experienced between two and three headaches per week. See e.g., Veteran's letter, received in August 2005, Veteran's appeal, received in November 2007. During her hearing, held in February 2010, she testified that she lost one to two days of work per week due to her headaches, or about 52 days a year. With regard to the history of the disability in issue, the Veteran's service treatment reports show that beginning in September 1989, she complained of headaches. The Veteran's separation examination report, dated in June 1997, includes a notation of migraines. See 38 C.F.R. § 4.1 (2012). In December 2004, the RO granted service connection for migraines, evaluated as 10 percent disabling, with an effective date for service connection for May 15, 2003. In March 2005, after additional evidence was received, the RO denied an initial evaluation in excess of 10 percent. In July 2010, the Board granted the increased initial evaluation claim, to the extent that it assigned a 30 percent rating. The RO subsequently assigned an effective date of January 22, 2010 for the 30 percent rating. In December 2012, the Board assigned an effective date of May 15, 2003 for the 30 percent rating, and remanded the issue of entitlement to an initial evaluation in excess of 30 percent for additional development. The Veteran is appealing the original assignment of a disability evaluation following an award of service connection. In such a case it is not the present level of disability which is of primary importance, but rather the entire period is to be considered to ensure that consideration is given to the possibility of staged ratings; that is, separate ratings for separate periods of time based on the facts found. See Fenderson v. West, 12 Vet. App. 119, 126 (1999). Disability evaluations are determined by comparing the veteran's present symptomatology with the criteria set forth in the VA's Schedule for Ratings Disabilities. 38 U.S.C.A. § 1155; 38 C.F.R. § Part 4. Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. The Veteran's migraines have been evaluated under 38 C.F.R. § 4.124a, Diagnostic Code (DC) 8100. Under DC 8100, a 30 percent evaluation is warranted for migraines manifested by characteristic prostrating attacks occurring on an average of once a month over several months. A 50 percent evaluation is warranted for migraines with very frequent completely prostrating and prolonged attacks productive of severe economic inadaptability. A February 2004 VA progress note indicates that the Veteran complained of one or two migraine headaches per month, previously relieved by Vioxx (a request for which had not been approved). The Veteran reported that her father died in September 2002, and that she quit her job four months later. The Veteran also reported that she had had a job in customer service, but that she had difficulty with tasks due to depression, and that she had changed jobs a lot. A September 2004 report notes a complaint of worsening headaches, lasting three hours to two days, relieved by taking three or four Tylenols. An October 2004 report shows that the Veteran reported lessening headaches. A VA examination report, dated in March 2004, shows that the Veteran reported a history of migraines beginning in about 1992, with aura and nausea, that were often preceded by a non-migraine headache. She complained that her headaches had stayed the same since her service. The relevant diagnosis was mild headache, migraine, non-prostrating. A VA examination report, dated in January 2005, shows that the Veteran complained of headaches that were often accompanied by nausea and photophobia, occurring every other day, with two headaches per week requiring her to lay down in a dark room to try to sleep them off. She reported taking butalbital, and Elavil for control of her symptoms, with occasional use of an anti-nausea pill. The diagnosis was mixed headache disorder with both tension type and migraine components, currently under poor control, with a normal neurological examination. A report from a private physician, dated in August 2005, states that the Veteran has chronic migraines with use of medication which interfere with her ability to drive. An August 2005 VA progress note shows a complaint of two to three headaches per week, lasting two to three hours, with nausea and vomiting, relieved by medication. An addendum to the January 2005 VA examination report, dated in September 2005, shows that the physician who performed the January 2005 VA examination states that the Veteran's migraines are productive of frequent moderately severe headaches about twice per week that could potentially interfere with her performing activities related to her job. The degree of interference was moderate, given that she typically describes the need to be in a dark room in an attempt to sleep the headache off. Therefore, it was opined that positions where she would not be allowed to take off 20 to 30 minutes to lie down may be difficult for her. It was also noted that her current headache disorder does not appear to be adequately treated with preventative symptomatic medications and this also plays a role in her migraine frequency. The physician concluded that given that the Veteran stated that she had headaches that required her to lay down twice a week, "one would have to say that the current migraine disorder does prevent her from maintaining and holding gainful employment. The opinion is also modified by the fact that it does not appear that her headache disorder is currently being treated appropriately with the appropriate preventive and symptomatic medication this with the right combination headache frequency definitely improved." A December 2005 VA progress note shows that the Veteran complained of a headache every one to two days, and that she was in a motor vehicle accident in October 2005 during which she sustained a concussion. A statement from a former employer of the Veteran, received in December 2005, shows that the employer indicated that the reason for the Veteran's termination was unknown. A VA progress report, dated in March 2006, notes that the Veteran's migraines were stable. There is also a notation of complaints of two to three headaches per week, lasting two to three hours. She took butalbital and amitryptiline with relief, and had just been started on naproxen in replacement of amitryptiline. Imitrex nasal spray was noted to help her symptoms. She had tried a number of other medications in the past. A December 2004 MRI (magnetic resonance imaging) study of her brain was noted to have been normal. A June 2006 report notes that she had seven hours of credits to go until she obtained her bachelor's degree in business management. A statement from the VA hospital in Hines, Illinois ("Hines VAH"), dated in January 2007, shows that the Veteran had been hired in February 2006, subject to a one-year probationary period, and that it was determined that she was not to be retained because of excessive use of leave between February 2006 and January 2007. She was noted to have used 117 hours of annual leave, and 88.5 hours of sick leave, and 97 hours of leave without pay. In an e-mail response, dated in January 2007, the Veteran indicated that she had a Workmen's Compensation case in progress, that she was receiving physical therapy, and that she had taken a week off for her back. She also indicated that she had taken some time off due to her migraines, and that when she had one, her medications made it impossible for her to function. An April 2007 VA progress note shows that the Veteran reported that she had not been retained at her job at Hines "because she was taking too much time off in order to have physical therapy on her shoulder." A July 2007 report shows complaints of three to four episodes per month for the last five months. The symptoms had by nearly 80 percent with use of imitrex. A January 2008 report notes a complaint of about two headaches per week, that were less severe, but more frequent. Reports, dated in May and December of 2008, show that the Veteran reported that her migraines were decreasing in frequency. A July 2009 report notes moderate to severe headaches that were not helped by medication; the Veteran reported having three to four headaches per week with nausea, but no vomiting. She said she stayed in the dark because she was sensitive to light. There is a notation that the Veteran reported that she was taking too much time off from work due to her migraines. A September 2009 report notes complaints of two to three headaches per week, with symptom relief with depakote, which made her sleepy; there is a notation that, "She almost certainly has sleep apnea triggering her migraines." Reports, dated in February, August, and November of 2012, and February 2013, show that the Veteran complained of two headaches per week, and/or 8 headaches per month. A February 2012 report shows that the Veteran reported that her headaches were "substantially" reduced with topamax, and that when they did occur, they were usually relieved by use of naprosyn, comprazine, or imitrex. The report notes, "She is for the most part satisfied with her headache control," and notes that she was "doing well." A November 2012 report notes improvement with propranolol, and that the Veteran reported that overall she feels better, and was improving. The claims file includes print-outs from the Veteran's former employer, dated between January 2007 and July 2010. In a September 2010 cover letter, the Veteran stated that the code "SV" stood for "sick veteran," and that it had been replaced by the code "OA" which stood for "other away." She stated that she had run out of sick time and had been using vacation time, and had therefore been offered FMLA (Family and Medical Leave Act) on several occasions. Adding together "OA", "SV" and "SI" leave, this evidence indicates that the Veteran took a total of about 105 hours of sick leave. This evidence also indicates that she took a total of about 65 hours of vacation leave. A "request for a hardship transfer" to a state agency, dated in April 2012, shows that the Veteran reported having four to five migraines per month, with use of several medications, and "I do have some breakthroughs that render me incapacitated." She stated that her medications made her unable to drive, and that she had to drive 11/2 hours to and from work. An associated "certification of health care provider," signed by a VA neurologist (J.W.) in December 2011, notes the following: the Veteran has frequent headaches "but generally not continuous." Her headaches are frequent and incapacitating, and partially controlled by medication. Her treatment schedule was expected to be one to two times per month from December 2011 to December 2012. She is not medically restricted from working 40 hours per week. Her headaches caused episodic flare-ups periodically preventing her from performing her job. An associated "certification of health care provider," signed by M.M., M.D. in April 2012, notes the following: the Veteran has not been incapacitated more than three full, consecutive calendar days. She had no overnight hospital stays. She is not unable to perform any of her job functions due to her condition. She will not be incapacitated for a single continuous period of time due to her condition. The Veteran received follow-up treatment from neurology and primary care. She did not need to work part-time or a reduced schedule because of her medical condition. Her condition caused episodic flare-ups that periodically prevented her from performing her job functions, for which she would need to be absent from work during her flare-ups. She has chronic migraine headaches and is on medications with a frequency of three times per month. A FMLA decision, dated in April 2012, shows that the Veteran was approved, with an expected period of intermittent absences between March and September of 2012, and with flare-ups of up to three times per month, lasting up to one day per event. A VA psychiatric Disability Benefits Questionnaire (DBQ), dated in June 2012, shows that the Veteran reported that she had used up all of her sick time due to migraines, and that she was now taking FMLA leave. A VA headache DBQ, dated in April 2013, shows that the examiner indicated that the Veteran's claims file had been reviewed. The diagnosis was "migraine including migraine variants." The report notes the following: the Veteran was taking Topamax, propranolol, Imitrix subQ and nasal, and naproxen. Her headaches were accompanied by nausea, sensitivity to light, and sensory changes. She does not have characteristic prostrating attacks of migraine headache pain, or of non-migraine pain. She had two headaches per week, or eight per month. To the questions of whether or not the Veteran has characteristic prostrating and prolonged attacks of migraine headache pain, and whether she has any other pertinent physical findings, complications, conditions, signs and/or symptoms related to any conditions listed in the diagnosis section, the report notes, "No response provided." The Veteran's headache did not impact her ability to work. The Board finds that an initial evaluation in excess of 30 percent is not warranted for the Veteran's migraines. Under DC 8100, a 50 percent evaluation is warranted for migraines with very frequent completely prostrating and prolonged attacks productive of severe economic inadaptability. In this case, the evidence shows that the Veteran has been diagnosed with migraine headaches by physicians, and that she has been taking several medications for control of her symptoms. Although her reports have varied, the Veteran has generally complained of headaches from one to three times per week, and has stated on several occasions that she has to lie down in a dark room during her headaches. Her neurological examinations have been unremarkable and have not resulted in any relevant objective findings. The March 2004 VA examination report shows that the examiner characterized her headaches as "mild," and "non- prostrating." The January 2005 VA examination report shows contains a diagnosis of mixed headache disorder with both tension type and migraine components, currently under poor control, with a normal neurological examination. An addendum to the January 2005 VA examination report, dated in September 2005, shows that the Veteran's migraines were noted to be productive of frequent moderately severe headaches about twice per week that could potentially interfere with her performing activities related to her job. The degree of interference was characterized as "moderate." A March 2006 VA progress report notes that her migraines were stable. Thereafter, VA progress notes show that she received ongoing treatments for headaches. None of the reports characterize her headaches as "prostrating," nor do they otherwise provide a basis to find that her headaches were "very frequent completely prostrating and prolonged attacks." As previously discussed, Dr. M.M.'s report, dated in April 2012, notes that the Veteran will not be incapacitated for a single continuous period of time due to her condition. Dr. M.M. noted that the Veteran has chronic migraine headaches and is on medications with a frequency of three times per month. The April 2013 VA headache DBQ shows that the examiner states that the Veteran does not have characteristic prostrating attacks of migraine headache pain, or of non-migraine pain. She had two headaches per week, or eight per month. The examiner specifically noted that the Veteran's headaches did not impact her ability to work. In summary, there is evidence of frequent headaches, which, at times, require the Veteran to lay down and/or to be unable to drive, but overall, the evidence is insufficient to show that her headaches were productive of "very frequent completely prostrating and prolonged attacks." The evidence is also insufficient to show that the Veteran's headaches were productive of severe economic inadaptability. In this regard, the evidence indicates that Hines VAH put the Veteran on a one-year probationary period of employment, upon which it was determined that she was not to be retained because of excessive use of leave between February 2006 and January 2007. She was noted to have used 117 hours of annual leave, and 88.5 hours of sick leave, and 97 hours of leave without pay. However, the Veteran's own correspondence indicates that much of her leave was unrelated to her migraines. Specifically, she indicated that she had taken time off for physical therapy for her shoulder, that she had taken a week off for her back, and that she had a Workmen's Compensation case in progress (presumably for her shoulder or back, although this is not clear). Consideration has been to the print-outs from the Veteran's former employer, dated between January 2007 and July 2010. However, that evidence does not indicate the reason for the Veteran's taking of leave, nor, when it is considered together with the medical evidence, is it sufficient to show that the Veteran's migraines were productive of severe economic inadaptability. The amount of leave taken, whether considered for any one-month period, or when the total amount of leave is spread out over the duration of the time period involved (a period of over three years), does not warrant the conclusion that the Veteran's migraines were productive of severe economic inadaptability. Considerable weight has been given to the April 2012 report from Dr. M.M. and the April 2013 VA examination report. In this regard, Dr. M.M.'s April 2012 report notes that the Veteran has not been incapacitated more than three full, consecutive calendar days, that she is not unable to perform any of her job functions due to her condition, and that she will not be incapacitated for a single continuous period of time due to her condition. Dr. M.M. further stated that the Veteran did not need to work part-time or a reduced schedule because of her medical condition. The Board notes that Dr. M.M.'s conclusions are not inconsistent with the FMLA decision, dated in April 2012, which indicates that the Veteran was expected to have flare-ups of up to three times per month, lasting up to one day per event. Finally, the April 2013 VA headache DBQ shows that the examiner states that the Veteran's headache did not impact her ability to work. In summary, the evidence is insufficient to show that the Veteran has very frequent completely prostrating and prolonged attacks productive of severe economic inadaptability. See Melson v. Derwinski, 1 Vet. App. 334 (1991) (use of the conjunctive 'and' in a statutory provision meant that all of the conditions listed in the provision must be met). In reaching this decision, the Board has considered Dr. J.W.'s December 2011 report, which notes frequent and incapacitating headaches, and that the Veteran's headaches caused episodic flare-ups periodically preventing her from performing her job. However, when this report is considered together with the other medical evidence of record, it is insufficiently probative to warrant an increased initial evaluation. I is significantly at odds with Dr. M.M.'s report, as well as the findings in the April 2013 VA DBQ. Finally, the Board has considered that the Veteran's FMLA request was approved. However, their criteria are distinct from that applicable by VA. Furthermore, their conclusion was that the Veteran was expected to have flare-ups of up to three times per month, lasting up to one day per event, which in the Board's judgment, insufficient to show that the required criteria have been met. In summary, the objective medical evidence is insufficient to show that the Veteran's headaches are of such frequency and severity to meet the criteria for an initial evaluation in excess of 30 percent under DC 8100. Accordingly, the preponderance of the evidence is against an initial evaluation in excess of 30 percent. In deciding the Veteran's increased initial evaluation claim, the Board has considered the determinations in Fenderson v. West, 12 Vet. App. 119 (1999) and Hart v. Mansfield, 21 Vet. App. 505 (2007), and whether the Veteran is entitled to increased evaluations for separate periods based on the facts found during the appeal period. In Fenderson, the U.S. Court of Appeals for Veterans Claims (Court) held that evidence to be considered in the appeal of an initial assignment of a rating disability was not limited to that reflecting the then current severity of the disorder. In that decision, the Court also discussed the concept of the "staging" of ratings, finding that, in cases where an initially assigned disability evaluation has been disagreed with, it was possible for a veteran to be awarded separate percentage evaluations for separate periods based on the facts found during the appeal period (as in this case). Id. at 126. The Board does not find evidence that the Veteran's evaluation for her migraines should be increased for any other separate period based on the facts found during the whole appeal period. The evidence of record from the day the Veteran filed the claim to the present supports the conclusion that she is not entitled to additional increased compensation during any time within the appeal period. In reaching this decision, the Board considered the doctrine of reasonable doubt, however, as the preponderance of the evidence is against the appellant's claim, the doctrine is not for application. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). III. The Veterans Claims Assistance Act of 2000 The Board is required to ensure that the VA's "duty to notify" and "duty to assist" obligations have been satisfied. See 38 U.S.C.A. §§ 5103, 5103A (West 2002 & Supp. 2012); 38 C.F.R. § 3.159 (2013). The notification obligation in this case was accomplished by way of a letter from the RO to the Veteran, dated in August 2003, and May 2005. Quartuccio v. Principi, 16 Vet. App. 183 (2002); Pelegrini v. Principi, 18 Vet. App. 112 (2004); Mayfield v. Nicholson, 19 Vet. App. 103 (2005), rev'd on other grounds, 444 F. 3d 1328 (Fed. Cir. 2006). With regard to the claim for an increased initial evaluation, in August 2003, the Veteran was issued a VCAA notice in association with her claim for service connection for migraines. Where, as here, service connection has been granted and an initial disability rating and effective date have been assigned, the typical service connection claim has been more than substantiated, it has been proven, thereby rendering section 5103(a) notice no longer required because the purpose that the notice was intended to serve has been fulfilled. Dingess/Hartman v. Nicholson, 19 Vet. App. 473, 491 (2006). The RO has provided assistance to the Veteran as required under 38 U.S.C.A. § 5103A and 38 C.F.R. § 3.159(c), as indicated under the facts and circumstances in this case. It appears that all known and available service treatment reports, and post-service records relevant to the issues on appeal have been obtained and are associated with the Veteran's claims file. The RO has obtained the Veteran's service treatment reports, to include records from the Moncrief and Darnall Army Hospitals, and the 121st Evacuation Hospital in Seoul, Korea. The RO has also obtained the Veteran's VA and non-VA medical records. In this regard, in a memorandum, dated in March 2012, the AMC determined that no records were available from the Eisenhower Army Hospital, that all procedures to obtain such records had been correctly followed, and exhausted, and that any further attempts would be futile. See 38 C.F.R. § 3.159(d) (2013). The Veteran has been afforded VA examinations. In December 2012, the Board remanded these claims. The Board directed that an attempt be made to acquire all treatment records from the VA Medical Center in Hines, Illinois for the period since October 2011. This has been done. The Board further directed that the Veteran be afforded a VA examination with a cardiologist or other examiner with specific experience in cardiovascular disorders to determine the nature, extent, onset and etiology of any cardiovascular disorder that may be present, and specifically the presence of a mitral valve prolapse. In February 2013, the Veteran was afforded a heart examination, and although the examiner did not list her qualifications, she is presumed to be competent. Rizzo v. Shinseki, 580 F.3d 1288, 1292 (Fed. Cir. 2009) (applying the presumption of regularity to the competence of VA examiners). The examiner determined that the Veteran does not currently have a heart disorder. In addition, in May 2013, a supplemental opinion was obtained in which a VA physician concluded that it was less likely as not that the Veteran's claimed cardiovascular condition was caused by, or had a nexus to, her military service. Id. As discussed supra, the Veteran is not shown to have a heart disorder. Gilpin. Finally, the Board directed that the RO issue a supplemental statement of the case with regard to the claim for an increased initial evaluation for service-connected migraines. In June 2013, this was done. Under the circumstances, the Board finds that there has been substantial compliance with its remand. See Dyment v. West, 13 Vet. App. 141, 146-147 (1999) (remand not required under Stegall v. West, 11 Vet. App. 268 (1998) where Board's remand instructions were substantially complied with); Sabonis v. Brown, 6 Vet. App. 426, 430 (1994) (remands which would only result in unnecessarily imposing additional burdens on VA with no benefit flowing to the veteran are to be avoided). The Board concludes, therefore, that decisions on the merits at this time do not violate the VCAA, nor prejudice the Veteran under Bernard v. Brown, 4 Vet. App. 384 (1993). Based on the foregoing, the Board finds that the Veteran has not been prejudiced by a failure of VA in its duty to assist, and that any violation of the duty to assist could be no more than harmless error. See Conway v. Principi, 353 F.3d 1369 (Fed. Cir. 2004). ORDER Service connection for a heart disorder is denied. An initial evaluation in excess of 30 percent for service- connected migraines is denied. REMAND In December 2012, the Board remanded this claim. The Board noted the following: in an October 2011 VA examination report addressing the Veteran's gastrointestinal disorder, the examiner (a nurse practitioner) concluded that there was no formal diagnosis of a gastrointestinal disorder in the treatment records. Thus, she was unable to provide an opinion as to whether any current gastrointestinal disorder is related to active duty service. The Board stated that this conclusion was inconsistent with the evidence of record, as the Veteran was diagnosed with IBS at a prior VA examination in March 2004, and was routinely receiving VA care from 2007 to 2009 (although IBS was not noted during this time). See McLain v. Nicholson, 21 Vet. App. 319, 321 (2007) (holding that the requirement of the existence of a current disability is satisfied when a claimant has a disability at the time a claim for VA disability compensation is filed, or during the pendency of that claim, and that a claimant may be granted service connection even though the disability resolves prior to the Secretary's adjudication of the claim); Romanowsky v. Shinseki, No. 11- 3272 (Vet. App. July 10, 2013). The Board directed that the Veteran be afforded a VA examination to determine the nature, extent, onset and etiology of any gastrointestinal disorder found to be present. The Board stated that the examiner should identify any gastrointestinal disorder diagnosed during the appeal period (since 2003). Then, he or she should express an opinion as to whether it is at least as likely as not (i.e., a 50% possibility or greater) that any identified gastrointestinal disorder had its onset in, or is otherwise etiologically related to, her active service. If no gastrointestinal disorder is found to be present, the examiner is asked to discuss the post-service treatment records that have diagnosed her with both irritable bowel syndrome and colitis. In February 2013, the Veteran was afforded a VA examination. The report of that examination shows that the examiner concluded that although the Veteran had been treated for abdominal pain, and later for colitis, during service, she has been without gastrointestinal problems since 1998. See also addendum, dated in April 2013. In addition, in May 2013, a supplemental opinion was obtained, in which a VA physician concluded that it was less likely than not that a gastrointestinal condition was incurred, caused by, or had a nexus to military service. The physician further stated that it was less likely than not that the Veteran's treatment for a urinary tract infection during service was related to her claimed IBS, or colitis. The physician specifically concluded that it is less likely as not that the Veteran's colitis was related to her service. However, the physician (as is the case with the February 2013 VA examiner) did not specifically discuss whether it was at least as likely as not that the Veteran's IBS (shown in the May 2004 VA examination) was related to her service or reconcile the earlier diagnosis of IBS, as requested by the Board in its remand. The Board is obligated by law to ensure that the RO complies with its directives; where the remand orders of the Board are not complied with, the Board errs as a matter of law when it fails to ensure compliance. Stegall v. West, 11 Vet. App. 268 (1998). On remand, the RO/AMC should attempt to obtain a supplemental opinion from the examiner who performed the Veteran's February 2013 VA examination as to whether it is at least as likely as not that the Veteran's IBS is related to her service, or, if that examiner is unavailable or if otherwise appropriate, the Veteran should be scheduled for another examination, to include obtaining an etiological opinion. The Veteran is advised that it is her responsibility to report for any examination and to cooperate in the development of her claim. The consequences for failure to report for a VA examination without good cause may include denial of the claim. 38 C.F.R. § 3.655 (2013). Accordingly, the case is REMANDED for the following action: 1. Request a supplemental opinion from the examiner who performed the Veteran's February 2013 VA gastrointestinal examination. In the event that the examiner who performed the Veteran's February 2013 VA gastrointestinal examination is not available, afford the Veteran another gastrointestinal examination. The claims folder and a copy of this REMAND should be reviewed by the examiner, and she must annotate the supplemental opinion to show that the claims file was in fact made available for review in conjunction with the opinion. The examiner should state whether it is at least as likely as not (i.e., a likelihood of 50 percent or greater) that the Veteran's irritable bowel syndrome (as shown in her March 2004 VA examination) had its onset in service or is otherwise etiologically related thereto. If the examiner does not believe that the March 2004 diagnosis of IBS was accurate (as opposed to having existed but resolved), such should be stated and explained. Rationale for all requested opinions shall be provided. If the examiner cannot provide an opinion without resorting to mere speculation, he or she shall provide a complete explanation stating why this is so. In so doing, the examiner shall explain whether the inability to provide a more definitive opinion is the result of a need for additional information or that he or she has exhausted the limits of current medical knowledge in providing an answer to that particular question(s). 2. Readjudicate the issue on appeal. If the determination remains unfavorable to the appellant, she should be provided with a supplemental statement of the case (SSOC) that addresses all relevant actions taken on the claim for benefits, to include a summary of the evidence, and applicable law and regulations considered. The appellant and her representative should be given an opportunity to respond to the SSOC. 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 2002 & Supp. 2012). ____________________________________________ MICHAEL A. HERMAN Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs