Citation Nr: 1329931 Decision Date: 09/18/13 Archive Date: 09/25/13 DOCKET NO. 07-03 941 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUES 1. Entitlement to an initial increased rating for migraine headaches, currently evaluated as 30 percent disabling. 2. Entitlement to an initial increased rating for degenerative joint and disc disease of the thoracolumbar spine, currently evaluated as 20 percent disabling. 3. Entitlement to an initial increased rating for degenerative joint and disc disease of the cervical spine, currently evaluated as 20 percent disabling. 4. Entitlement to an initial increased rating for right carpal tunnel syndrome, currently evaluated as 10 percent disabling. 5. Entitlement to an initial increased rating for left carpal tunnel syndrome, currently evaluated as 10 percent disabling. 6. Entitlement to service connection for a disability manifested by numbness of the upper extremities, to include cervical radiculopathy. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD S. Keyvan, Counsel INTRODUCTION The Veteran had unverified periods of active duty and active duty for training in the United States Coast Guard from April 1998 through January 2005. These matters come before the Board of Veterans' Appeals (Board) on appeal from an October 2005 rating decision by the St. Petersburg, Florida Regional Office (RO) of the Department of Veterans Affairs (VA). In this decision, the RO denied entitlement to service connection for numbness of the extremities, but granted: entitlement to service connection for the thoracolumbar spine disability evaluating it as 20 percent disabling; degenerative disc disease of the cervical spine at 10 percent disabling; right and left carpal tunnel syndrome, at noncompensably disabling; and post-traumatic headaches, which was also found to be noncompensable (all of which were effective on February 15, 2005, the date of separation from service). In the December 2006 rating decision, the RO increased the disability rating for the service-connected post-traumatic headaches to 30 percent and further increased the disability ratings for the service-connected right and left carpal tunnel syndrome to 10 percent, effective February 15, 2005. In the June 2012 rating decision, the RO increased the disability evaluation for the service-connected cervical spine disability to 20 percent, effective from April 14, 2011. See Fenderson v. West, 12 Vet. App. 119, 126 (1999) (where evidence indicates that the degree of disability increased or decreased during appeal period following the assignment of the initial rating, "staged" ratings may be assigned for separate periods of time based on facts found). The Veteran has not expressed satisfaction with these ratings. Accordingly, all these issues remain in appellate status for the entire appeal period. AB v. Brown, 6 Vet. App. 35 (in which the United States Court of Appeals for Veterans Claims (Court) stipulated that, unless a veteran expresses a desire for a specific rating for a service-connected disability, he/she is presumed to be seeking the maximum benefit permitted under the regulations). Additionally, in the November 2010 remand, the Board asked that the Agency of Original Jurisdiction (AOJ) contact the Veteran and inquire as to whether she wished to be rated under the new criteria for a traumatic brain injury. The Veteran was thereafter scheduled for a VA brain and spinal chord examination in April 2011. Based on the examination results, and by way of the June 2012 rating action, the RO determined that the Veteran had a traumatic brain injury (TBI), and granted service connection for this disability, assigning it a separate evaluation. The Veteran has not expressed disagreement with this determination and the Board finds that this issue is not before it as this time. The applicable regulation, 38 C.F.R. § 4.123, Diagnostic Code 8045, notes that residuals such as migraine headaches may be separately evaluated under the appropriate diagnostic code, as is the case here. As such, the claim for an initial increased rating for migraine headaches remains on appeal. In the December 2012 remand, the Board instructed the AOJ to secure the Veteran's Social Security Administration (SSA) records and associate them with the claims file. The AOJ was also instructed to schedule the Veteran for a VA examination to determine the extent and severity of her migraine headaches. The issue of entitlement to an initial rating in excess of 30 percent for service-connected migraine headaches is addressed in the REMAND portion of the decision below and are REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. FINDINGS OF FACT 1. The Veteran does not have incapacitating episodes of thoracolumbar intervertebral disc syndrome having a total duration of at least four weeks; forward flexion of the thoracolumbar spine at 30 degrees or less; ankylosis of the thoracolumbar spine or any associated neurological pathology (except for the already service-connected radiculopathy of his right and left lower extremities). 2. For the period from February 15, 2005 to April 13, 2011, forward flexion of the cervical spine was no worse than 35 degrees, and the combined range of motion of the cervical spine has been no worse than 183 degrees; there has been no muscle spasm or guarding of the cervical spine severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis; nor has it been productive of incapacitating episodes having a total duration of at least two weeks during the past 12 months; and there have been no separately compensable associated neurological abnormalities. 3. Since April 14, 2011, the cervical spine disability has not been productive of forward flexion to 15 degrees or less or ankylosis; there have not been incapacitating episodes having a total duration of at least four weeks during the past 12 months; and no separately compensable neurological abnormalities. 4. The carpal tunnel syndrome has been manifested by no more than mild impairment in each upper extremity, to include intermittent symptoms of pain, numbness and a tingling sensation in the forearms, hands and wrist. 5. The Veteran does not have a disability manifested by numbness in the upper extremities other than the service-connected carpal tunnel syndrome. CONCLUSIONS OF LAW 1. The criteria for an evaluation greater than 20 percent for degenerative joint and disc disease of the thoracolumbar spine are not met. 38 U.S.C.A. §§ 1155, 5110 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1-4.14, 4.40-4.46, 4.71a, Diagnostic Codes 5235-5243 (2013). 2. The criteria for an initial evaluation greater than 10 percent for degenerative joint and disc disease of the cervical spine, for the period from February 15, 2005 to April 13, 2011, are not met. 38 U.S.C.A. §§ 1155, 5110 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1-4.14, 4.40-4.46, 4.71a, Diagnostic Codes 5235-5243 (2013). 3. The criteria for an initial evaluation greater than 20 percent for cervical spine degenerative joint and disc disease, since April 13, 2011, are not met. 38 U.S.C.A. §§ 1155, 5110 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1-4.14, 4.40-4.46, 4.71a, Diagnostic Codes 5235-5243 (2013). 4. The criteria for an initial disability rating in excess of 10 percent for carpal tunnel syndrome of the right upper extremity have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.159, 4.124(a), Diagnostic Code 8515 (2013). 5. The criteria for an initial disability rating in excess of 10 percent for carpal tunnel syndrome of the left upper extremity have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.159, 4.124(a), Diagnostic Code 8515 (2013). 6. The Veteran does not have a disability manifested by numbness in the upper extremities other than the service-connected carpal tunnel syndrome. 38 U.S.C.A. §§ 1110, 1131, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.303, 3.304 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSION Duties to Notify and Assist As a preliminary matter, the Board finds that no further notice or development action is necessary in order to satisfy VA's duties to the Veteran under the Veterans Claims Assistance Act of 2000 (VCAA). In an August 2004 letter, VA notified the Veteran of the information and evidence needed to substantiate and complete her claims, and of what part of that evidence she was to provide and what part VA would attempt to obtain for her. 38 U.S.C.A. § 5103(a) (West 2002); 38 C.F.R. § 3.159(b)(1) (2013). In addition, in the August 2006 letter, the RO provided the Veteran with a letter for the express purpose of advising her of the additional notification requirements imposed by the United States Court of Appeals for Veterans Claims (Court) in Dingess/Hartmen v. Nicholson, 19 Vet. App. 473 (2006). Since the issuance of these letters, the RO has reconsidered the Veteran's claims, most recently in the December 2006 Statement of the Case (SOC) and the June 2012 and April 2013 Supplemental Statements of the Case (SSOCs). See Prickett v. Nicholson, 20 Vet. App. 370, 376 (2006) (holding that the issuance of a fully compliant VCAA notification followed by readjudication of the claim, such as a Statement of the Case or Supplemental Statement of the Case, is sufficient to cure a timing defect). The Board also notes that a majority of the issues on appeal stem from the Veteran's appeal of the initial rating and effective date assigned by the RO following the award of service connection. In such cases, VCAA notice is generally not required. Dingess/Hartman, 19 Vet. App. at 490 (noting that "once a decision awarding service connection, a disability rating, and an effective date has been made, section 5103(a) notice has served its purpose, and its application is no longer required because the claim has already been substantiated"); see also Dunlap. Nicholson, 21 Vet. App. 112 (2007). Rather, under those circumstances, the provisions of 38 U.S.C.A. §§ 5104, 7105 and 38 C.F.R. § 3.103 are for application. Id. In that regard, the Board finds that the notification requirements of 38 U.S.C.A. §§ 5104 and 7105 have been met. A review of the record indicates that the Veteran was duly provided notice of the decisions on appeal, as well as an explanation of the procedure for obtaining appellate review of the decisions. Following receipt of her notices of disagreement, the Veteran was appropriately notified of the applicable legal criteria in the Statement of the Case and Supplemental Statements of the Case. The Board also notes that neither the Veteran nor her representative has raised any allegation of prejudice regarding any notification deficiencies. Goodwin v. Peake, 22 Vet. App. 128 (2008). With respect to VA's duty to assist, the record shows that VA has undertaken all necessary development action. 38 U.S.C.A. § 5103A (West 2002); 38 C.F.R. § 3.159 (2013). Her service treatment records as well as all identified and available private and VA treatment records pertinent to the years after service are in the claims file and were reviewed by both the RO and the Board in connection with the service connection claims adjudicated herein. Furthermore, in accordance with the December 2012 remand, the Veteran's SSA records have since been retrieved and associated with the claims file. Significantly, with the exception of the Veteran's claim for a higher rating for her service-connected migraine headaches (which the Board is remanding for further evidentiary development) neither the Veteran, nor her representative, has otherwise alleged that there are any outstanding medical records probative of her claims on appeal that need to be obtained. In addition, the Veteran was offered the opportunity to attend a hearing before a Veterans Law Judge (VLJ), which she declined. The Veteran has also been afforded VA medical examinations for her service-connected disorders in September 2005 and most recently in April 2011. The Board acknowledges that the SSA records were associated with the claims file subsequent to the April 2011 VA examinations. However, there is no objective evidence in these records, and in the more recent VA treatment records indicating that there has been a material change in the severity of her service-connected disorders since the Veteran was last examined. See 38 C.F.R. § 3.327(a) (2013). The duty to assist does not require that a claim be remanded solely because of the passage of time since otherwise adequate VA examinations were conducted. See VAOPGCPREC 11-95. Here, the Board finds that the VA examinations obtained in this case are adequate, as they were predicated on physical examinations of the Veteran, as well as consideration of the medical records in the Veteran's claims file and the Veteran's reported history and symptomatology. The opinions consider all of the pertinent evidence of record, to include statements given by the Veteran at the time of the VA examinations, and provide a complete rationale for the opinions stated. Accordingly, the Board finds that VA's duty to assist with respect to obtaining a VA examination or opinion with respect to the claims on appeal has been met. 38 C.F.R. § 3.159(c)(4). Finally, the Board notes that the Veteran is represented by a veterans' service organization (VSO) and that organization is presumed to have knowledge of what is necessary to substantiate a claim for VA benefits. Neither the Veteran, nor her representative, has pled prejudicial error with respect to the content or timing of VCAA notices. See Shinseki v. Sanders, 129 U.S. 1696 (2009). As there is no indication that any failure on the part of VA to provide additional notice or assistance reasonably affects the outcome here, the Board finds that any such failure is harmless. Mayfield v. Nicholson, 19 Vet. App. 103 (2005), rev'd on other grounds, Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). Increased Rating Claims Applicable Law Disability evaluations are determined by comparing a Veteran's symptoms with criteria set forth in VA's Schedule for Rating Disabilities, which are based on average impairment in earning capacity. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. Part 4 (2013). When a question arises as to which of two ratings applies under a particular diagnostic code, the higher of the two evaluations is assigned if the disability more closely approximates the criteria for the higher rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7 (2013). After consideration of the evidence, any reasonable doubt remaining is resolved in favor of the Veteran. 38 C.F.R. § 4.3 (2013). The veteran's entire history is reviewed when making disability evaluations. See generally Schafrath v. Derwinski, 1 Vet. App. 589 (1991); 38 C.F.R. § 4.1. Where, as in the case of the Veteran's claim, the question for consideration is the propriety of the initial evaluation assigned, consideration of the medical evidence since the effective date of the award of service connection and consideration of the appropriateness of a staged rating are required. See Fenderson v. West, 12 Vet. App. 119, 126 (1999). If evidence obtained during the appeal period indicates that the degree of disability increased or decreased following the assignment of the initial rating, "staged" ratings may be assigned for separate periods of time based on facts found. Id. Further, "[w]here 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 (2013). It should also be noted that when evaluating disabilities of the musculoskeletal system, 38 C.F.R. § 4.40 allows for consideration of functional loss due to pain and weakness causing additional disability beyond that reflected on range of motion measurements. DeLuca v. Brown, 8 Vet. App. 202 (1995). Further, 38 C.F.R. § 4.45 provides that consideration also be given to weakened movement, excess fatigability and incoordination. Under VA regulations, separate disabilities arising from a single disease entity are to be rated separately. See 38 C.F.R. § 4.25 (2013); see also Esteban v. Brown, 6 Vet. App. 259, 261 (1994). Entitlement to an initial increased rating degenerative disc disease of the thoracolumbar spine On September 26, 2003, revisions to the VA rating schedule established a General Rating Formula for Diseases and Injuries of the Spine and a Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes. See 68 Fed. Reg. 51454-51458 (August 27, 2003). Diagnostic Code 5243 indicates that degenerative disc disease of the spine should be evaluated under the General Rating Formula for Diseases and Injuries of the Spine or under the Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes, whichever method results in a higher evaluation when all disabilities are combined under § 4.25. Note 6 further provides that the thoracolumbar and cervical spine segments should be separately evaluated, except when there is unfavorable ankylosis of both segments, which will be rated as a single disability. The thoracolumbar segment of the spine includes the thoracic and lumbosacral spine. Under the General Rating Formula for Diseases and Injuries of the Spine, a 20 percent disability evaluation is contemplated when there is forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees; or, the combined range of motion of the thoracolumbar spine is not greater than 120 degrees; or, muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. A 40 percent disability evaluation is assigned for forward flexion of the thoracolumbar spine 30 degrees or less; or favorable ankylosis of the entire thoracolumbar spine. A 50 percent disability evaluation is warranted for unfavorable ankylosis of the entire thoracolumbar spine, and 100 percent disability evaluation is contemplated when there is unfavorable ankylosis of the entire spine. Note (1) to the rating formula specifies that any associated objective neurologic abnormalities, including, but not limited to, bowel or bladder impairment, should be separately evaluated under an appropriate diagnostic code. Note (2): (See also Plate V.) For VA compensation purposes, normal forward flexion of the cervical spine is zero to 45 degrees, extension is zero to 45 degrees, left and right lateral flexion are zero to 45 degrees, and left and right lateral rotation are zero to 80 degrees. Normal forward flexion of the thoracolumbar spine is zero to 90 degrees, extension is zero to 30 degrees, left and right lateral flexion are zero to 30 degrees, and left and right lateral rotation are zero to 30 degrees. The combined range of motion refers to the sum of the range of forward flexion, extension, left and right lateral flexion, and left and right rotation. The normal combined range of motion of the cervical spine is 340 degrees and of the thoracolumbar spine is 240 degrees. The normal ranges of motion for each component of spinal motion provided in this note are the maximum that can be used for calculation of the combined range of motion. Note (3): In exceptional cases, an examiner may state that because of age, body habitus, neurologic disease, or other factors not the result of disease or injury of the spine, the range of motion of the spine in a particular individual should be considered normal for that individual, even though it does not conform to the normal range of motion stated in Note (2). Provided that the examiner supplies an explanation, the examiner's assessment that the range of motion is normal for that individual will be accepted. Note (4): Round each range of motion measurement to the nearest five degrees. Note (5): For VA compensation purposes, unfavorable ankylosis is a condition in which the entire cervical spine, the entire thoracolumbar spine, or the entire spine is fixed in flexion or extension, and the ankylosis results in one or more of the following: difficulty walking because of a limited line of vision; restricted opening of the mouth and chewing; breathing limited to diaphragmatic respiration; gastrointestinal symptoms due to pressure of the costal margin on the abdomen; dyspnea or dysphagia; atlantoaxial or cervical subluxation or dislocation; or neurologic symptoms due to nerve root stretching. Fixation of a spinal segment in neutral position (zero degrees) always represents favorable ankylosis. The Diagnostic Codes for the spine are as follows: 5235 Vertebral fracture or dislocation; 5236 Sacroiliac injury and weakness; 5237 Lumbosacral or cervical strain; 5238 Spinal stenosis; 5239 Spondylolisthesis or segmental instability; 5240 Ankylosing spondylitis; 5241 Spinal fusion; 5242 Degenerative arthritis of the spine (see also diagnostic code 5003); 5243 Intervertebral disc syndrome. Intervertebral disc syndrome (preoperatively or postoperatively) may be evaluated either under the General Rating Formula for Diseases and Injuries of the Spine or under the Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes, whichever method results in the higher evaluation when all disabilities are combined. See 38 C.F.R. § 4.25 (combined ratings table). The Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes provides for a 10 percent disability rating for intervertebral disc syndrome with incapacitating episodes having a total duration of at least one week but less than 2 weeks during the past 12 months. A 20 percent disability rating is awarded for disability with incapacitating episodes having a total duration of at least 2 weeks but less than 4 weeks during the past 12 months. With incapacitating episodes having a total duration of at least 4 weeks but less than 6 weeks during the past 12 months, a 40 percent evaluation is in order. Finally, a maximum schedular rating of 60 percent is assigned for intervertebral disc syndrome with incapacitating episodes having a total duration of at least 6 weeks during the past 12 months. DC 5003, for degenerative arthritis provides that degenerative arthritis, established by X-ray findings will be rated on the basis of limitation of motion under the appropriate diagnostic codes for the specific joint or joints involved (DC 5200, etc.). When however, the limitation of motion of the specific joint or joints involved is noncompensable under the appropriate diagnostic codes, a rating of 10 percent is for application for each such major joint or group of minor joints affected by limitation of motion, to be combined, not added under DC 5003. 38 C.F.R. § 4.71a, DC 5003. Analysis Historically, the Veteran's service treatment records demonstrate that she was involved in two motor vehicle accidents in service. The records also reflect that subsequent to these accidents, the Veteran presented at the military clinic on numerous occasions with complaints of continuing back pain that radiated to her lower extremities. In August 2003, the Veteran presented at a private treatment facility where she underwent a comprehensive spine consultation and, on a scale of one to ten, (with one being the least level of pain and ten being the highest) she rated the pain in her neck and back at a five. The treatment physician, P.Z., M.D. noted that a magnetic resonance imaging (MRI) of the thoracic spine revealed a T8/9 left central disc protrusion, T3/4 small central disc protrusion and T6/7 slight disc bulge. The Veteran was diagnosed with having a thoracic sprain/strain, a lumbar sprain/strain, lumbar radiculopathy and lumbar herniated nucleus pulposus at L4/5. Results from the July 2004 Medical Board evaluation revealed diagnoses of lumbar myofascial pain, lumbar radiculitis, thoracic spine herniated nucleus pulposus at T3-T4, and lumbar disk bulge at L4-5 and L5-S1, all of which were determined to be secondary to her in-service motor vehicle accidents. The Veteran filed a claim for service connection for low back disability in August 2004. In the October 2005 rating decision, the RO granted service connection for thoracic and lumbar spine degenerative joint disease with disc disease at T8-9, T9-10, and L5-S1, effective February 15, 2004 pursuant to Diagnostic Code 5243. The Veteran contends that her service-connected back disability is more disabling than currently evaluated. In considering the evidence of record under the General Rating Formula for Diseases and Injuries of the Spine, the Board concludes that the Veteran is not entitled to an increased evaluation in excess of 20 percent for her service-connected degenerative disc disease of the thoracolumbar spine. The evidence of record does not indicate that the Veteran had forward flexion of the thoracolumbar spine at 30 degrees or less, and it also does not show that she had favorable ankylosis of the entire thoracolumbar spine. In this regard, the Veteran was afforded a VA examination in August 2004, prior to her discharge from service, at which time, she provided her medical history and reported to have been involved in two motor vehicle accidents in service; once in 2000 and another time in 2003. On physical examination, the Veteran was shown to have flexion to 70 degrees, extension to 15 degrees, right and left lateral flexion to 20 degrees and right and left rotation to 30 degrees. The examiner noted that the Veteran had pain with palpation to the lumbar and thoracic spine. The Board notes that prior to her August 2004 examination, the Veteran performed range of motion exercises during several in-service treatment visits, however the these recorded results did not demonstrate forward flexion to 30 degrees or favorable ankylosis of the thoracolumbar spine. Report of the September 2005 VA examination shows the Veteran was found to have forward flexion to 50 degrees, extension to 30 degrees, right and left lateral flexion to 30 degrees, and right and left rotation to 20 degrees during both active and passive range of motion. Although the Veteran exhibited pain upon repetitive motion, the examiner did not observe evidence of additional loss of motion due to pain, fatigue, weakness, lack of endurance or incoordination upon repetition. Reports of VA physical therapy treatment sessions dated in October 2006, March 2007, and October 2008 demonstrate that the Veteran continued to experience, and receive treatment, for chronic back pain. During these treatment visits, the Veteran described the pain as constant, throbbing, shooting and sharp in nature, and, on a scale of one to ten (with one being the least level of pain and ten being the highest), she rated her pain level at a 6 or 7. On physical examination, the physical therapist noted that the Veteran's range of motion during flexion was 100 percent. While the Board is unclear as to whether this assessment means that the Veteran's range of motion during flexion was 100 degrees, or at the level required for normal forward flexion of the thoracolumbar spine (90 degrees), either way, these records are absent for any indication that the Veteran had forward flexion of the lumbar spine to 30 degrees or less. VA treatment records dated from 2005 to 2011 reflect that the Veteran received ongoing treatment, to include physical therapy, for her low back pain throughout the years. During these visits, the Veteran described the pain as sharp and stabbing in nature, and noted that activities such as sitting, walking, driving and standing serve to worsen her pain. During one particular physical therapy session dated in July 2010, the treatment provider noted that the Veteran was 9 inches from the floor when performing forward flexion. While these treatment records focus on the Veteran's subjective complaints and the treatment provided to alleviate her symptoms, they do not address the objective criteria, to include numerical range of motion measurements, necessary in determining whether she was entitled to a higher disability rating. The Veteran underwent a subsequent VA examination of her thoralumbar spine in April 2011, the results of which found her to have flexion to 55 degrees, extension to 15 degrees, right and left lateral flexion to 25 degrees, and right and left rotation to 15 degrees. The examiner observed no additional limitation of motion in the Veteran's range of motion measurements due to pain, fatigue, weakness, lack of endurance or incoordination following repetitive use. Although the Veteran complained of pain in the lumbar spine region during range of motion exercises, the examiner noted no signs of lumbar weakness, thoracic muscle spasm or thoracic pain with range of motion. Even when taking into account the Veteran's complaints of pain on motion, such complaints do not approximate flexion limited to 30 degrees or less. In addition, both VA examination reports were clear for any evidence of ankylosis of the lumbar spine. The Board notes that ankylosis is defined as immobility and consolidation of a joint due to disease, injury, or surgical procedure. Lewis v. Derwinski, 3 Vet. App. 259 (1992) (citing Saunders Encyclopedia and Dictionary of Medicine, Nursing, and Allied Health at 68 (4th ed. 1987)); Dinsay v. Brown, 9 Vet. App. 79, 81 (1996) (Ankylosis is "stiffening or fixation of a joint as the result of a disease process, with fibrous or bony union across the joint," citing Stedman's Medical Dictionary 87 (25th ed. 1990)). The evidence of record reflects that the Veteran is able to perform the range of motion exercises, and while her movement may be somewhat limited during these exercises, there is no indication that her spine is fixated in the neutral position or fixed in flexion and extension. The Board does not doubt that the Veteran has pain; however, in light of the ranges of motion documented at the examinations, the Board cannot find that her service-connected low back disability equates to limitation of flexion of 30 degrees or less or favorable ankylosis of his entire thoracolumbar spine. As such, the Board finds that the Veteran has not met the criteria for an evaluation in excess of 20 percent under the revised rating criteria. The Board has also considered whether the Veteran would be entitled to a higher rating under the Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes. However, the medical evidence of record does not show that the Veteran has had incapacitating episodes with a total duration of at least four weeks during the past 12 months. There are no treatment records documenting the Veteran as having been prescribed bed rest by her physician due to her back disability. In fact, at both VA examinations, the VA examiner noted that the Veteran's thoracolumbar spine condition had not resulted in any incapacitating episodes during the past twelve months requiring bed rest or treatment by a physician. Thus, a higher rating is not warranted under the criteria for intervertebral disc syndrome. The Board has also considered the provisions of 38 C.F.R. §§ 4.40, 4.45, 4.59, and the holdings in DeLuca. However, an increased evaluation for the Veteran's service-connected thoracolumbar spine disability is not warranted on the basis of functional loss due to pain or weakness in this case, as the Veteran's symptoms are supported by pathology consistent with the assigned 20 percent rating, and no higher. In this regard, the Board observes that the Veteran has complained of pain on numerous occasions and further acknowledges objective evidence of pain following certain range of motion exercises. However, as previously noted, the VA examiner did not observe evidence of additional limitation of motion or functional loss due to pain, fatigue, weakness, lack of endurance, or incoordination following repetitive movement. Indeed, the Board finds that the effect of the pain in the Veteran's thoracolumbar spine is contemplated in the currently assigned 20 percent disability evaluation. The Veteran's complaints do not, when viewed in conjunction with the medical evidence, tend to establish weakened movement, excess fatigability, or incoordination to the degree that would warrant an increased evaluation. Therefore, the Board concludes that an evaluation in excess of 20 percent for the Veteran's low back disability is not warranted. The Board recognizes the Veteran's statements attesting to her constant pain and discomfort. Statements made by the Veteran at the April 2011 VA examination, reflect that she avoided walking, standing and sitting for long intervals at a time due to her back disability. A November 2011 decision of the Social Security Administration (SSA) shows that the Veteran was granted disability benefits based, in part, on her back problems. In the Disability Report, the Veteran described how her back disability affected her day to day activities. She noted that she is unable to sit, stand or walk for longer than fifteen minutes - limitations which makes it difficult to complete even the most regular of duties. Lay persons can attest to observable symptomatology. In addition, the Veteran's statements describing her symptoms are considered to be competent evidence. Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007); see also Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2007). These statements, however, must be viewed in conjunction with the objective medical evidence as required by the rating criteria. In this regard, the objective medical evidence, including the VA treatment records and the September 2005 and April 2011 VA examinations, include the information necessary to rate the Veteran's disability in accordance with the rating criteria. In addition, the VA examiner took into consideration the Veteran's reported symptomatology when conducting both examinations. Thus, when considering the overall evidence of record, including the Veteran's statements, the Veteran's disability does not warrant an initial disability rating in excess of 20 percent. Based on this evidentiary posture, the Board concludes that the totality of the evidence of record has not shown that the Veteran's service-connected thoracolumbar disability warrants a rating in excess of 20 percent at any time during the appeal period. Thus, this claim must be denied. With respect to any neurological complications, the Veteran has already been service-connected and separately rated for radiculopathy of the lower extremities. See June 2012 rating decision. Furthermore, the Veteran has denied experiencing any bowel or bladder symptomatology, and the medical evidence of record does not reflect any such pathology. Thus, a separate compensable rating for such symptoms is not warranted. See 38 C.F.R. § 4.71a, General Rating Formula for Diseases and Injuries of the Spine, Note (1) (2013) (which stipulates that associated objective neurologic abnormalities, including, but not limited to, bowel or bladder impairment, should be evaluated separately, under an appropriate diagnostic code). Entitlement to an initial increased rating for Cervical Spine Degenerative Arthritis In the October 2005 rating decision, the RO granted service connection for degenerative joint and disc disease of the cervical spine ("cervical spine disability") and evaluated it as 10 percent disabling, pursuant to 38 C.F.R. § 4.71a, Diagnostic Code 5243. The Veteran contends that her service-connected cervical spine disability is more disabling than currently evaluated. Under the General Rating Formula for Diseases and Injuries of the Spine, an evaluation of 20 percent is warranted for forward flexion of the cervical spine greater than 15 degrees but not greater than 30 degrees, or the combined range of motion of the cervical spine not greater than 170 degrees, or muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis; a 30 percent is warranted for forward flexion of the cervical spine 15 degrees or less; or, favorable ankylosis of the entire cervical spine. An evaluation of 40 percent is warranted for unfavorable ankylosis of the entire cervical spine. An evaluation of 50 percent is warranted for unfavorable ankylosis of the entire thoracolumbar spine. An evaluation of 100 percent requires unfavorable ankylosis of the entire spine. Analysis A. For the period prior to April 14, 2011 Review of the Veteran's service treatment records reflect that she was diagnosed with having a cervical sprain/strain and cervical radiculopathy at the August 2003 treatment visit with Dr. Z. Results from the cervical spine MRI specifically revealed a disc bulge at the C3/4 level that was asymmetric towards the right with moderate right foraminal narrowing, as well as another disc bulge at the C5/6 level with osteophyte complex present and spondylitic changes. Findings from the July 2004 Medical Board evaluation demonstrated diagnoses of cervicothoracic myofascial pain, cervical radiculitis, and cervical stenosis, all of which were determined to be secondary to her in-service motor vehicle accidents. The Veteran was afforded a VA examination in August 2004, prior to her separation from service, at which time she provided her medical history and reported to have injured her neck as a result of her in-service motor vehicle accidents. According to the Veteran, she experiences pain at the base of her neck everyday upon awakening, as well as symptoms of numbness which radiate throughout her arms. The Veteran was afforded another VA examination in connection to her cervical spine condition in September 2005, at which time, she provided her medical history and described her ongoing symptoms. According to the Veteran, she is unable to sit or talk on the phone longer than fifteen minutes at a time as a result of her cervical spine symptoms. The examiner reviewed an August 2005 MRI of the cervical spine, the findings of which were clear for any signs of adenopathy, mass or aneurysm, and further revealed a normal signal intensity in the osseous structures and spinal cord. The Veteran reported to experience constant pain in her neck - a sensation she described to be tight and achy in nature. She also reported to have flare-ups of pain once a week which can last four days in duration. According to the Veteran, she was currently experiencing a flare-up pain in the cervical spine at the September 2005 VA examination. In considering the evidence of record under the General Rating Formula for Diseases and Injuries of the Spine, the Board concludes that the Veteran is not entitled to an initial evaluation in excess of 10 percent for her service-connected cervical spine disability for the period prior to April 14, 2011. As noted above, in order for the Veteran to meet or approximate the criteria for a rating in excess of 10 percent under the current rating criteria for the cervical spine, there must be forward flexion greater than 15 degrees but not greater than 30 degrees; or combined range of motion of the cervical spine not greater than 170 degrees; or muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. Report of the August 2004 VA examination reflects that on physical examination of the neck, the Veteran was shown to have forward flexion to 45 degrees, extension to 20 degrees, right and left lateral flexion to 15 degrees, right lateral rotation to 50 degrees, and left lateral rotation to 60 degrees. Report of the September 2005 VA examination report reflects that the Veteran had forward flexion to 35 degrees during active and passive range of motion. She was also shown to have extension to 18 degrees, right and left lateral flexion to 20 degrees, and right and left lateral rotation to 45 degrees. The examiner observed no additional limitation of motion due to pain, fatigue, weakness, lack of endurance or incoordination following repetitive use. VA clinical records dated from 2005 to 2011 reflect that the Veteran received ongoing treatment for her neck pain throughout the years. However, these treatment records focus on the Veteran's subjective complaints and the various methods of treatment she underwent to alleviate her symptoms, and do not address the objective criteria, to include range of motion measurements, necessary in determining whether she was entitled to a higher disability rating. As such, based on the objective evidence of record, the Veteran's range of motion during flexion has always been shown to be greater than 30 degrees, and the combined range of motion of the cervical spine has always been greater than 170 degrees for the period prior to April 14, 2011. In addition, the objective evidence of record for the period prior to April 14, 2011 has been clear for any indications of muscle spasm or guarding severe enough to result in abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. Although she (the examiner) observed tenderness in the spine and lateral muscles as well as cervical pain during range of motion exercises, she did not detect any signs of weakness in the cervical muscles, nor did she perceive any cervical muscle spasms upon evaluation. The Board has also considered whether the Veteran is entitled to a higher rating under the Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes. However, the Veteran never reported to experience any incapacitating episodes during her examination or during her VA treatment visits. Moreover, the medical evidence of record prior to April 14, 2011 did not show that the Veteran had incapacitating episodes with a total duration of at least two weeks but less than four weeks during the prior 12 months. There are no treatment records documenting the Veteran as having been prescribed bed rest by her physician due to her spine disability. In fact, at the September 2005 VA examination, the Veteran denied experiencing any incapacitating episodes of spine disease during the past twelve months requiring bed rest or treatment by a physician. Indeed, the medical evidence of record is negative for any evidence or documentation indicating that the Veteran has been prescribed with bed rest by any of her physicians or treatment providers. Thus, a rating in excess of 10 percent is not warranted under the criteria for intervertebral disc syndrome for the period prior to April 14, 2011. The Board has also considered whether a higher evaluation is warranted under Diagnostic Code 5003. The Board acknowledges x-rays obtained in September 2003 which reflect "[m]ild changes of disk degeneration" at the C4-5 level, and "moderate changes of disk degeneration with osteophye formations" at the C5-6 level, as well as report of an MRI produced in August 2005 reflecting "minimal disk disease" at C4-5. However, for the period from February 15, 2005 to April 13, 2011, the Veteran has never been noted to display symptoms other than pain, stiffness and an aching sensation as a result of her disability, symptoms which are contemplated by the 10 percent evaluation already assigned. Therefore, the Board finds that a increased rating in excess of 10 percent is not warranted for the Veteran's service-connected cervical disability pursuant to 38 C.F.R. § 4.71a, Diagnostic Code 5003 for the period from February 15, 2005 to April 13, 2011. The Board has also considered the provisions of 38 C.F.R. §§ 4.40, 4.45, 4.59, and the holdings in DeLuca. However, an increased evaluation for the Veteran's cervical spine disability is not warranted on the basis of functional loss due to pain or weakness in this case, as the Veteran's symptoms are supported by pathology consistent with the assigned 10 percent rating, and no higher. In this regard, the Board observes that the Veteran has complained of pain on numerous occasions and acknowledges objective medical findings of pain in the cervical spine region during her range of motion exercises. However, as previously noted above, the September 2005 VA examiner commented that the Veteran's range of motion was not additionally limited due to pain, fatigue, weakness, lack of endurance or incoordination following repetitive use. It should also be noted that the September 2005 range of motion exercises were carried out at a time when the Veteran was experiencing a flare-up of pain in the cervical spine region. Indeed, the Board finds that the effect of the pain in the Veteran's cervical spine is contemplated in the currently assigned 10 percent disability evaluation. The Veteran's complaints do not, when viewed in conjunction with the medical evidence, tend to establish weakened movement, excess fatigability, or incoordination to the degree that would warrant an increased evaluation. Therefore, the Board concludes that an evaluation in excess of 10 percent for the Veteran's cervical spine disability, for the period prior to April 14, 2011 is not warranted. With respect to any neurological complications, the Board takes note of the August 2004 VA examination wherein the Veteran reported to experience pain in her wrists when using the computer, writing, driving or riding her bike. According to the Veteran, the pain had its onset in 2000 after her first motor vehicle accident. The Veteran also reported to have intermittent numbness in her arms and legs - a sensation that reportedly lasts for 20 to 30 minutes at a time. On neurological examination, the Veteran's reflexes were 2+ and her motor strength was 5/5 in the upper extremities. She was diagnosed with bilateral carpal tunnel syndrome with residuals and bilateral numbness to the arms and legs, secondary to the motor vehicle accident. The Board notes that the Veteran has already been service-connected and separately rated for carpal tunnel syndrome in the upper extremities. With respect to the Veteran's complaints of bilateral numbness to the arms, the Board has reviewed the evidence of record associated with the pertinent period on appeal to determine whether the Veteran has any neurological disorders in the upper extremities separate from the already service-connected carpal tunnel syndrome. Findings from the June 2005 neurological evaluation were clear for any neurological abnormalities although the Veteran did have decreased sensation to pinprick in the right palmar second and third digits. Review of the neurological portion of the September 2005 VA examination was absent any neurological abnormalities, and based on her evaluation of the Veteran, the examiner assessed her with intermittent numbness and tingling in the forearms bilaterally with no objective findings on examination. Results from a February 2006 electromyography (EMG) were also clear for any signs of polyneuropathy and it was noted that the physical examination results did not reveal sensory or motor findings suggestive of radiculopathy. VA treatment records dated from 2006 to 2011 reflect that the Veteran underwent periodic neurological consultations and evaluations throughout the years. However, these records are also negative for any neurological abnormalities or objective findings of a neurological disorder in either upper extremity as a result of the cervical spine disability. Therefore, the Board finds that a separate rating for a neurological disability in the right and left upper extremity, separate from her service-connected bilateral carpal tunnel syndrome, is not warranted for the period prior to April 14, 2011. Thus, a separate compensable rating for such symptoms is not warranted. See 38 C.F.R. § 4.71a, General Rating Formula for Diseases and Injuries of the Spine, Note (1) (2013). In conclusion, the Board finds that for the period to April 14, 2011, the Veteran's level of disability in the cervical spine more nearly approximates the criteria for a 10 percent disability rating and a higher disability rating is not warranted. As such, the Board finds that for the period prior to April 14, 2011, the preponderance of the evidence is against the Veteran's claim for an initial disability rating in excess of 10 percent, and therefore the claim must be denied. 38 U.S.C.A. § 5107; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). B. On and after April 14, 2011 The Veteran was afforded another VA examination in connection to her cervical spine disability in April 2011, at which time she reported to experience pain in the cervical spine region two to three times a week, the severity of which, on a scale of one to ten, reportedly ranges somewhere between a six to a ten. According to the Veteran, this pain radiates throughout her forearms bilaterally and certain methods of treatment, to include medication, undergoing massages, the application of heat and ice and swimming help alleviate the pain. The Veteran stated that she is able to move without the use of an orthotic brace, but avoids lifting items over ten pounds, and working on the computer and/or driving for long periods of time as a result of her cervical spine condition. She also stated that she avoids working in the yard, and activities such as golf or tennis as a result of her cervical spine disability. In the June 2012 rating action, the RO increased the disability rating for the cervical spine disability to 20 percent disabling, effective April 14, 2011. The Veteran contends that her cervical spine disability is more disabling than currently evaluated. VA treatment records dated from 2011 to December 2012 reflect the Veteran's ongoing complaints of pain in the cervical spine. In considering the evidence of record under the General Rating Formula for Diseases and Injuries of the Spine, the Board concludes that the Veteran is not entitled to an initial evaluation in excess of 20 percent for her service-connected cervical spine disability for the period on and after April 14, 2011. As noted above, in order for the Veteran to meet or approximate the criteria for a rating in excess of 20 percent for her service-connected neck disorder under the current rating criteria for the cervical spine, there must be forward flexion of the cervical spine 15 degrees or less, favorable ankylosis of the entire cervical spine, or unfavorable ankylosis of the entire cervical spine. First and foremost, a review of the medical evidence is absent any findings of favorable or unfavorable ankylosis. In this regard, the VA examiner did not observe any ankylosis in the cervical spine and the medical evidence of record is devoid of any findings, treatment or diagnosis of unfavorable ankylosis. Indeed, report of the April 2011 examination reflects that the Veteran had forward flexion to 30 degrees, extension to 45 degrees, right and left lateral extension to 30 degrees and right and left lateral rotation to 60 degrees. While she experienced pain with motion, the examiner did not observe any additional limitation of motion following repetitive use. She (the examiner) also noted that the cervical spine region was clear for any signs of tenderness, muscle spasms, or muscle weakness. Additionally, the more recent VA treatment records referenced above focus on the Veteran's subjective complaints and do not address the objective criteria necessary in determining whether she was entitled to a higher disability rating. As such, while the Veteran's treatment records reflect limited cervical range of motion, they are absent any findings suggesting that her cervical spine is fixed in the neutral position, or during flexion or extension. Additionally, the Veteran has not been shown to have any of the above-mentioned symptoms cited in 39 C.F.R. § 4.71a, Diagnostic Codes 5235-5243, Note (5) in conjunction with fixed flexion or extension in the cervical spine. Thus, a rating in excess of 20 percent for the service-connected cervical spine disability under the General Rating Formula for Diseases and Injuries of the Spine is not warranted for the period on and after April 14,2011. The Board has also considered whether the Veteran would be entitled to a higher rating under the Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes. However, the medical evidence of record does not show that the Veteran has had incapacitating episodes with a total duration of at least four weeks during the past 12 months. There are no treatment records documenting the Veteran as having been prescribed bed rest by her physician due to her spine disability. In fact, at the April 2011 VA examination, the VA examiner noted that the Veteran's cervical spine condition had not resulted in any incapacitating episodes requiring bed rest or treatment by a physician during the past twelve months. Thus, a higher rating is not warranted under the criteria for intervertebral disc syndrome. The Board has also considered the provisions of 38 C.F.R. §§ 4.40, 4.45, 4.59, and the holdings in DeLuca. However, an increased evaluation for the Veteran's service-connected cervical spine disability is not warranted on the basis of functional loss due to pain or weakness in this case, as the Veteran's symptoms are supported by pathology consistent with the assigned 20 percent rating, and no higher. In this regard, the Board observes that the Veteran has complained of pain on numerous occasions and acknowledges the objective evidence of record which reflects guarding of movement due to pain during range of motion exercises. However, as previously noted, the VA examiner did not observe evidence of additional limitation of motion due to pain, fatigue, weakness, lack of endurance, or incoordination following repetitive movement. Indeed, the Board finds that the effect of the pain in the Veteran's cervical spine is contemplated in the currently assigned 20 percent disability evaluation. The Veteran's complaints do not, when viewed in conjunction with the medical evidence, tend to establish weakened movement, excess fatigability, or incoordination to the degree that would warrant an increased evaluation. Therefore, the Board concludes that an evaluation in excess of 20 percent for the Veteran's cervical spine disability for the period on and after April 14, 2011 is not warranted. With respect to any neurological complications, the Veteran has complained of radiating pain and numbness in the upper extremities. However, at the April 2011 VA examination, the Veteran's sensory function was shown to be intact to monofilament and light touch on the hand and arms. In addition, the Veteran's grip strength, was 5/5 bilaterally, and her arm strength with shoulder flexion, elbow flexion and wrist flexion was normal and 5/5 bilaterally. Furthermore, the Veteran's reflexes in the upper extremities were 2+/2+ bilaterally. Based on these neurological findings, the VA examiner assessed the Veteran with subjective bilateral upper extremity forearm radiculopathy, with no objective evidence of this disease on examination. According to the examiner, the medical evidence was insufficient to support a diagnosis of upper extremity radiculopathy. The Veteran underwent another more exhaustive neurological evaluation during the April 2011 brain and spinal cord VA examination, and the findings derived from this examination were also negative for any neurological abnormalities. Thus, while the Veteran has reported pain and numbness in her upper extremities, the medical findings from both April 2011 examinations are clear for any evidence of radiculopathy or any other underlying neurological disability other than carpal tunnel syndrome. Thus, a separate compensable rating for such symptoms is not warranted. See 38 C.F.R. § 4.71a, General Rating Formula for Diseases and Injuries of the Spine, Note (1) (2013). The Board acknowledges that the Veteran is competent to testify as to symptoms associated with her disability which are non-medical in nature, however, she is not competent to testify as to the severity of her disability. See Barr v. Nicholson, 21 Vet. App. 303 (2007) (noting that lay testimony is competent to establish the presence of observable symptomatology that is not medical in nature). As such, entitlement to an initial disability rating greater than 20 percent for service-connected cervical spine degenerative joint disease with disc disease at C3-4, C4-5, and C5-6, for the period on and after April 14, 2011 must be denied. Entitlement to an initial increased rating for Right and Left Carpal Tunnel Syndrome The Veteran contends that she is entitled to initial evaluations in excess of 10 percent for her service-connected right and left carpal tunnel syndrome. Service connection for carpal tunnel syndrome of the right and left wrist was granted in an October 2005 rating action, and separate noncompensable disability ratings were assigned for both disorders effective February 15, 2005, under the provisions of 38 C.F.R. § 4.124a, Diagnostic Code 8599-8515. In the December 2006 rating action, the RO increased the disability rating for both service-connected disorders to 10 percent, effective February 15, 2005. When an unlisted disease, injury, or residual is encountered, requiring rating by analogy, the diagnostic code number will be 'built-up' as follows. The first two digits will be selected from that part of the schedule most closely identifying the part or system of the body involved. The last two digits will be '99' for all unlisted conditions. 38 C.F.R. §§ 4.20, 4.27 (2013). Here, the Veteran's disability is not specifically listed in the rating schedule and is therefore rated analogous to a disability in which not only the functions are affected, but the anatomical location and symptoms are closely related. Under Diagnostic Code 8515, which addresses the median nerve, a 10 percent rating is appropriate for both the major and minor hand when there is mild incomplete paralysis of the median nerve. For moderate incomplete paralysis, a 30 percent rating is assigned for the major hand and a 20 percent rating is assigned for the minor hand. For severe incomplete paralysis, a 50 percent rating is assigned for the major hand and a 40 percent rating is assigned for the minor hand. A 70 percent rating is assigned for complete paralysis of the median nerve on the major side with such manifestations such as the hand inclined to the ulnar side; the index and middle fingers more extended than normal; considerable atrophy of the muscles of the thenar eminence; the thumb in the plane of the hand (ape hand); pronation incomplete and defective; absence of flexion of index finger and feeble flexion of middle finger; an inability to make a fist; the index and middle fingers remain extended; an inability to flex the distal phalanx of thumb; defective opposition and abduction of the thumb, at right angles to the palm; weakened wrist flexion; and pain with trophic disturbances. Complete paralysis of the minor hand is rated as 60 percent disabling. 38 C.F.R. § 4.124a, Diagnostic Code 8515 (2013). The term 'incomplete paralysis' indicates a degree of lost or impaired function substantially less than the type pictured for complete paralysis given with each nerve, whether due to a varied level of the nerve lesion or to partial regeneration. When the involvement is wholly sensory, the rating should be for mild, or at most, the moderate degree. 38 C.F.R. § 4.124a. The words 'slight,' 'mild,' 'moderate' and 'severe' as used in the various diagnostic codes are not defined in the VA Schedule for Rating Disabilities. Rather than applying a mechanical formula, the Board must evaluate all of the evidence to the end that its decisions are 'equitable and just.' 38 C.F.R. § 4.6. It should also be noted that use of terminology such as 'severe' by VA examiners and others, although an element of evidence to be considered by the Board, is not dispositive of an issue. All evidence must be evaluated in arriving at a decision regarding an increased rating. 38 C.F.R. §§ 4.2, 4.6. Right- or left-handedness for the purpose of a dominant-side disability rating will be determined by the evidence of record, or by testing on VA examination. Only one hand shall be considered dominant. 38 C.F.R. § 4.69. The evidence reflects that the Veteran's right hand is dominant. For the reasons that follow, the Board concludes that the Veteran is not entitled to initial evaluations in excess of 10 percent for her carpal tunnel syndrome of the right and left upper extremities. A review of the service treatment records reflects the Veteran's complaints of intermittent pain and numbness in the forearms, wrist and hands. The Veteran underwent a VA examination in August 2004, at which time, her deep tendon reflexes were shown to be 2+ and her motor strength was 5/5 in the upper extremities. According to the examiner, results from the Tinel's test were positive in both wrists consistent with carpal tunnel syndrome. The diagnosis was bilateral carpal tunnel syndrome with residuals and bilateral numbness to the arms and legs secondary to her motor vehicle accident. After service, the Veteran presented at the Bay Pines VA Medical Center (VAMC) in June 2005 with complaints of intermittent numbness in her right hand - particularly at night. On neurological examination, the VA physician noted that the Veteran's motor strength, bulk and tone was normal in all four extremities, and that all individual groups tested in the upper extremities were clear for any indication of thenar atrophy or thumb adductor weakness. Results from the sensory examination were also shown to be normal in all four extremities. Although the Veteran exhibited decreased sensation to pinprick in the right palmar second and third digits, the VA physician commented that the Veteran's sensory reflexes to cold, touch, vibration and proprioception were normal. It was further noted that the Veteran's limb and gait modalities were normal and there was no evidence of clumsiness or tremor with alternating or fine repetitive hand movements. In addition, the Veteran's deep tendon reflexes were shown to be normal and equal throughout. The VA physician did detect a Tinel sign at the right wrist with tingling into the index finger, but did not observe similar findings at the elbows. Based on his evaluation of the Veteran, the VA physician determined that the Veteran had symptoms that were characteristic of carpal tunnel syndrome in the right wrist At the September 2005 VA examination, the Veteran reported to experience intermittent numbness and tingling in the arms, hands, and wrists bilaterally. She (the Veteran) also reported to experience weakness in the wrists and hands bilaterally. According to the Veteran, some of these symptoms can occur one to ten times a day. The Veteran denied using any medication to treat her symptoms, but did report to undergo warm soaks to help alleviate her symptoms. The Veteran also commented that she had used wrist splints in the past to help treat her symptoms, but had not used these splints since four months prior. When asked how these symptoms affected her activities of daily living, the Veteran responded that she is unable to type on the computer or hold the phone up to her ear for longer than fifteen minutes at a time. On physical examination, the examiner did not observe any tenderness in the shoulders, elbows, wrists, or hands. As previously discussed above, the Veteran's grip strength was 5/5 bilaterally, and her arm strength during flexion of the shoulders, elbows, and wrists was also 5/5 bilaterally. The examiner commented that the Veteran's arm muscles appeared symmetrical bilaterally and there were no visible anatomical defects of the hands and fingers. Upon further evaluation of the hands and the functional strength of the hands, the examiner noted that the tip of the Veteran's thumb can approximate the fingers, and the tips of the fingers can approximate the median transverse fold of the palm. The examiner noted that the Veteran is able to write, push, pull, twist, probe and touch with the hands. Further inspection of the neurological system showed that the Veteran's coordination was intact to rapid alternating hand movements, and her sensation was intact to light touch and monofilament on the face. The Veteran's sensory reflexes were also intact to light touch and pinprick on the hands and forearms. In addition, the Veteran's deep tendon reflexes were equal in the biceps bilaterally. The examiner did not observe any evidence of muscle wasting or atrophy of the hands or forearms, and noted that no joint was affected by a peripheral nerve condition. However, according to the examiner, while the Tinel's sign test was negative for any abnormalities in the left upper extremity, this same test did reveal abnormalities in the right upper extremity, and the Phalen's sign test revealed abnormalities in the right and left upper extremities. An X-ray of the bilateral wrists was shown to be normal and clear for any bone or joint injury or disease. The Veteran underwent an EMG in February 2006, that was reportedly clear for any evidence of polyneuropathy and physical examination findings did not reveal sensory and motor findings suggestive of radiculopathy. VA treatment records dated in February 2007 reflect that the Veteran presented at the Emergency room with shooting pain in her left hand. While the treatment provider observed mild tenderness in the extremities on flexion of the left fingers, she did not detect any findings of parasthesia in these extremities. The Veteran was assessed with carpal tunnel syndrome and provided a wrist splint for the left hand which she was instructed to wear at night. The Veteran's deep tendon reflexes were shown to be normal in the upper extremities during an August 2007 VA primary care visit. An October 2008 VA neurological consultation report recorded a finding of normal bulk and tone on motor examination. The Veteran exhibited 5/5 strength in the upper extremities, and her sensation was intact to light touch, pin prick, vibration and joint position. The Veteran did not display any dystaxia on finger-to-nose testing and she was able to walk with a normal stance and stride. VA medical records reflect that the Veteran began participating in an occupational therapy program to help alleviate and manage her left wrist pain in October 2008. During a March 2009 follow-up visit, the treatment provider noted that the Veteran had not attended the treatment sessions regularly, and she had functional use of both hands. At an October 2010 neurology consultation treatment visit, the treatment provider noted that the Veteran's muscle bulk was symmetric and her muscle tone was normal on motor examination. In addition, the Veteran's muscle strength was 5/5 in the upper extremities, her sensory function was intact to light touch and pinprick, and her muscle stretch reflexes were shown to be symmetric. The Veteran underwent a neuromusculoskeletal evaluation at the March 2011 consultation, at which time the treatment provider noted that the Tinel's sign "at CTs" was negative. It was further noted that the Veteran's muscle tone was normal bilaterally with no indications of atrophy and the Thenar strength was 4+/5 bilaterally. The Veteran's sensory function was normal to light touch perception in all nerve distributions and the motor planning was also shown to be normal. The treatment provider further noted that the Veteran's range of motion was within normal limits in the upper extremities. The Veteran denied any pain in her wrists and reported that her primary symptoms included tingling paresthesia two to three night a week and while driving. The Veteran was afforded another VA examination in April 2011, at which time she reported to experience numbness and a "pins and needles pressure" type sensation in both hands, middle ring and little fingers, and wrists on an intermittent basis every day. She also complained of weakness in the hands and wrists. According to the Veteran, she has wrist splints which she is supposed to use at night to help alleviate her symptoms. However, she reported that she only uses them when she remembers to despite the fact that they help her symptoms. When asked how this affects her activities of daily living, the Veteran stated that she has to take breaks when cooking, and she refrains from playing golf or tennis, and activities involving crocheting, sewing and woodwork. On physical examination, the Veteran was shown to have normal sensation to light touch and monofilament on both hands and arms bilaterally. The examiner noted no increased sensitivity to touch on the right hand, but did note evidence of tenderness in the right wrist. According to the examiner, the Phalen's sign test revealed abnormalities on the right and left side, and the Tinel's sign test while normal on the left side, did reveal abnormalities on the right side. Further evaluation of the neurological system showed that her grip strength was 5/5 bilaterally, and her arm strength during elbow, wrist and shoulder flexion was normal and 5/5 bilaterally. The examiner did not detect any evidence of muscle wasting or atrophy of the hands and arms. While the Veteran's range of motion in the wrist was slightly limited during certain exercises, the examiner did not observe additional limitation of motion due to pain, fatigue, weakness, lack of endurance, or incoordination following repetitive use. According to the examiner, while the Veteran experienced left and right wrist pain during the range of motion exercises, there was no evidence of tenderness in the left wrist, or any signs of weakness in either wrist. The Veteran was afforded a VA neurological examination that revealed peripheral nerve reflexes were 2+ in the biceps, triceps, brachioradialis, and finger jerk bilaterally. The sensory function was normal to vibration, pain/pinprick, position sense, and light touch in both extremities, and the Veteran did not indicate to have any dyesthesia in either extremity. On motor examination, the Veteran's motor strength was 5/5 during flexion and extension of the elbows bilaterally, flexion and extension of the wrists bilaterally, flexion and abduction of the fingers bilaterally, and thumb opposition bilaterally. The examiner described the Veteran's muscle tone as normal and noted no findings of muscle atrophy, or loss of muscle tone. Based on the Veteran's assertions during her VA examinations, treatment visits and occupational therapy sessions, she experiences pain, weakness and a tingling and numbing sensation in her upper extremities - symptoms which affect her ability to sleep, work on a computer for longer than 15 minute intervals, participate in certain extracurricular activities and lift objects heavier than ten pounds. However, while it is clear that there was pain and tenderness in the Veteran's upper extremities, the record was absent evidence of more significant symptoms. In this regard, the objective medical evidence of record is negative for any signs of muscle wasting or atrophy, and has consistently shown the Veteran's motor strength and reflexes in the upper extremities to be 5/5 and 2+, respectively. In addition, the Veteran's gait, stance and coordination have been described as normal, and her sensory function has consistently been intact to light touch, vibration, and position sense. Furthermore, at the September 2005 VA examination, the examiner conducted a detailed evaluation of the Veteran's hands and commented that the Veteran could move the tips of her thumbs and fingers, and that she could write, push, pull, twist, probe and touch with her hands. In this regard, the examiner did not detect any impairment when it came to the Veteran's functional strength in her hands. The March 2009 VA treatment provider further noted that the Veteran had functional use of both hands and the March 2011 VA treatment provider noted that the Veteran's range of motion in the upper extremities was within normal limits. In short, the aforementioned medical findings reveal little functional impairment of the right or left hand as a result of the service-connected carpal tunnel syndrome. Based on the evidence of record, the medical evidence suggests a disability that is no more than "mild," which is precisely the criterion for the assignment of a 10 percent rating under Diagnostic Code 8515. That is, the Veteran's current symptoms are more sensory and do no surpass the "average" or "medium" range and are best described as mild, thus warranting the 10 percent rating, but no more. The Board finds that the Veteran's symptoms, alone, do not constitute evidence which is sufficient to characterize the carpal tunnel syndrome of the right and left upper extremities as moderate. In this regard, the Board acknowledges the Veteran's complaints of ongoing pain and discomfort in her wrists, but notes that she herself has reported that the course of treatment she has pursued, namely wrist splints, do help alleviate these symptoms. However, it does not appear that the Veteran wears these wrist splints on a consistent basis, as she claimed that she only wore them when she remembers to. See April 2011 VA examination. In reaching this conclusion, the Board acknowledges the Veteran's belief that the symptoms in her upper extremities are more severe than that reflected by the current disability ratings. The Board finds that the Veteran is certainly competent to discuss the severity of her symptomatology. As a lay person, however, the Board gives more weight to the specific objective findings obtained through specialized testing and physical examinations. Such matters require medical expertise to determine. See Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). Therefore, the Board finds that the criteria for initial ratings in excess of 10 percent for carpal tunnel syndrome of the right and left upper extremities have not been met. Thus, the Veteran is not eligible for a higher rating under Diagnostic Code 8515, as there is no evidence of even moderate incomplete paralysis of either upper extremity. In reaching this decision, the potential application of various provisions of Title 38 Code of Federal Regulations have been considered, whether or not they were raised by the Veteran. Schafrath v. Derwinski, 1 Vet. App. 589 (1991). In particular, the Board has considered the provisions of 38 C.F.R. § 3.321(b)(1). As noted above, the very symptoms the Veteran has reported and have been found on examinations are those contemplated by the rating criteria. Therefore, referral for consideration of an extraschedular rating is not warranted. The Board also notes that by way of the June 2012 rating action, the RO granted the Veteran's claim for entitlement to a total rating based on individual unemployability (TDIU). Service Connection Applicable Law Service connection means that the facts establish that a particular injury or disease resulting in disability was incurred in the line of duty in the active military service or, if pre-existing such service, was aggravated during service. 38 U.S.C.A. § 1110, 1131; 38 C.F.R. § 3.303(a). Generally, establishment of direct service connection for a disorder requires evidence of (1) a current disability; (2) in-service incurrence of a disease or injury; and (3) a nexus between the claimed in-service disease or injury and the current disability. 38 C.F.R. § 3.303(a); Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Subsection (a) also refers to "each disabling condition...for which [a veteran] seeks a service connection" and states that "[d]eterminations as to service connection will be based on review of the entire evidence of record." Id. Also, the Court of Appeals for the Federal Circuit (Federal Circuit) held that, unlike §3.303(a) which is not limited to any specific condition, subsection (b) is restricted to chronic diseases. "If a veteran can prove a chronic disease 'shown in service,' and there are no intercurrent causes, the manifestations of the chronic disease present at the time the veteran seeks benefits establish service connection for the chronic disease. By treating all subsequent manifestations as service-connected, the veteran is relieved of the requirement to show a causal relationship between the condition in service and the condition for which disability compensation is sought. In short, there is no 'nexus' requirement for compensation for a chronic disease which was shown in service, so long as there is an absence of intercurrent causes to explain post-service manifestations of the chronic disease." Id. In addition, the Federal Circuit found that subsection (b) provides a second route by which service connection can be established for a chronic disease, which is if "evidence of a chronic condition is noted during service or during the presumptive period, but the chronic condition is not 'shown to be chronic, or where the diagnosis of chronicity may be legitimately questioned,' i.e., 'when the fact of chronicity in service is not adequately supported,' then a showing of continuity of symptomatology after discharge is required to support a claim for disability compensation for the chronic disease. Proven continuity of symptomatology establishes the link, or nexus, between the current disease and serves as the evidentiary tool to confirm the existence of the chronic disease while in service or a presumptive period during which existence in service is presumed." Id. Furthermore, the Federal Circuit held that that the term "chronic disease" as set forth in subsection (b) is properly interpreted as being constrained by § 3.309(a) in that the regulation is only available to establish service connection for the specific chronic diseases listed in § 3.309(a) regardless of the point in time when a veteran's chronic disease is either shown or noted. Id. The standard of proof to be applied in decisions on claims for VA benefits is set forth in 38 U.S.C.A. § 5107(b). Under that provision, VA shall consider all information and lay and medical evidence of record in a case before the Secretary with respect to benefits under laws administered by the Secretary. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C.A. § 5107(b) (West 2002); see also Gilbert v. Derwinski, 1 Vet. App. 49 (1990). In the present appeal, the Veteran contends that she suffers from a disability manifested by numbness in the upper extremities. According to the Veteran, this disability is separate and distinct from her already-service connected bilateral carpal tunnel syndrome. A review of the Veteran's service treatment records reflects that she served in the U.S. Coast Guard throughout her period of service. These records further demonstrate that the Veteran did not have any foreign service while serving in the military. As previously discussed above, the Veteran was involved in two motor vehicle accidents in service; once in March 2000 and once again in July 2003. According to the Veteran, she currently has a disability manifested by numbness and a tingling sensation in the upper extremities that is separate from her bilateral carpal tunnel syndrome, and these in-service incidents led to the development of this disability. Turning to the service treatment records, the Board notes the Veteran began experiencing and reporting symptoms of pain, numbness and a tingling sensation in her upper extremities after her in-service motor vehicle accidents. At a January 2002 treatment visit with her private physician, K.B., M.D., the Veteran described symptoms of neck and inner scapular pain, as well as symptoms of bilateral arm paresthesias and pain. On examination, the Veteran's motor strength was 5/5 and her reflexes were 2+ throughout the upper extremities. However, Dr. B. noted that the sensory examination was diminished subjectively in the right C6 distribution. Based on his evaluation of the Veteran, Dr. B. diagnosed the Veteran with having a cervical herniated nucleus pulposus with radiculopathy and cervical myofascial pain syndrome secondary to the March 2000 motor vehicle accidents. A February 2002 treatment report issued by Dr. B. reflects that the Veteran underwent electrodiagnostic studies of the upper extremities, and the results were consistent with left median mononeuropathy of the wrist, and clear for any evidence of acute cervical radiculopathy. The Veteran was afforded a neurological examination at the Florida Spine Institute in October 2002, the findings of which showed her sensory function to be normal to pain, temperature, vibration, light touch, stereognosis, and graphesthesia. In addition, the Veteran's motor strength was 5/5 during flexion and extension of the elbows and wrists, as well as abduction of the arms and fingers. Other than noting that the Veteran had an abnormal gait, the neurological findings were absent for any abnormalities. In July 2003, the Veteran presented at the Florida Spine Institute, at which time she described increasing pain in her neck. On examination, with the exception of the motor strength impairment in the arm abductors (5-/5) and arm flexors (5-/5), the Veteran's motor strength in the upper extremities was 5/5 and her reflexes were symmetric throughout the upper extremities. The examination findings were also negative for Spurling, Lhermitte, Tinel, Phalen, Offman and Adson signs. Based on his evaluation of the Veteran, Dr. B. diagnosed the Veteran with cervicothoracic myofascial pain and cervical radiculitis secondary to the July 2003 motor vehicle accident. Subsequent examination findings dated from August 2003 to October 2003, and issued by Dr. B., demonstrated that the Veteran's motor strength was 5/5, (with the exception of the arm abductors which were 5-/5), and his reflexes were 2+ throughout the upper extremities. These records as well as military clinical records dated from 2003 to August 2004 revealed ongoing diagnoses of cervicothoracic myofascial pain and cervical radiculitis secondary to the July 2003 motor vehicle accident. At a September 2003 treatment visit at the Florida Spine Institute, the Veteran reported increasing severity, frequency and duration of pain in her neck and arms. On examination, Dr. K.B. noted that the Veteran had an "essentially intact neurologic exam" in the upper extremities. During a July 2004 treatment visit, Dr. Z. attributed the Veteran's reported symptoms of intermittent numbness in both hands to her bilateral carpal tunnel syndrome. The Veteran was seen at a medical clinic in July 2004, at which time, the physician noted that her motor strength was 5/5 and her reflexes were 2+ throughout. She was diagnosed with cervicothoracic myofascial pain and cervical disk bulge with stenosis at C5-6. A July 2004 Initial Medical Board Narrative provided a chronological summary of the Veteran's medical records, which described the neurological symptoms she began experiencing in January 2002 and the treatment she underwent and received for these symptoms. Based on a review of these records, the Medical Board determined that the Veteran had multiple diagnoses pertaining to the cervical and lumbar spine, including but not limited to cervicothoracic myofascial pain, cervical stenosis and cervical radiculitis - all of which were determined to be secondary to her motor vehicle accidents. Based on these diagnoses, the Medical Board determined that the Veteran was unable to continue performing her military duties because of the undue risk of further harm to herself and to the mission. Upon consideration of the above evidence, the Board finds that the preponderance of the evidence is against the Veteran's claim of service connection for a disability manifested by numbness in the upper extremities, to include cervical radiculopathy. With regard to this claim, the Board notes that the existence of a current diagnosed disability is the cornerstone of a claim for VA disability compensation. 38 U.S.C.A. §§ 1110, 1131; see Degmetich v. Brown, 104 F.3d 1328, 1332 (1997) (holding that interpretation of sections 1110 and 1131 of the statute as requiring the existence of a present disability for VA compensation purposes cannot be considered arbitrary). Evidence must show that the Veteran currently has the disability for which benefits are being claimed. Here, the greater weight of the evidence points to the Veteran not having any diagnosed neurological pathology in the upper extremities beyond bilateral carpal tunnel syndrome, which has already been diagnosed and for which service connection has already been granted. A review of the post-service evidence of record does not reveal a diagnosis of any neurological disorder in the upper extremities that is separate and distinct from her bilateral carpal tunnel syndrome. At the August 2004 VA examination, the VA examiner assessed the Veteran with bilateral numbness to the arms and legs, but commented that the Veteran should follow up and undergo a neurological evaluation to be certain. While findings from the June 2005 neurological evaluation demonstrated decreased sensation to pinprick in the right palmar second and third digits, the treatment provider concluded that any abnormalities exhibited were characteristic for carpal tunnel syndrome in the right wrist. Results from the September 2005 VA examination were also clear for any neurological impairment in the upper extremities, and in the Diagnosis section, the examiner acknowledged the Veteran's symptoms of intermittent numbness and tingling in the forearms, but determined that the objective findings were clear for a neurological disorder manifested by these symptoms. As previously noted, findings from the February 2006 EMG were negative for evidence of polyneuropathy and the treatment provider noted that the sensory and motor findings were not indicative of radiculopathy. Neurological evaluations conducted throughout the years and at the April 2011 VA examination were also clear for any abnormalities suggestive of cervical radiculopathy. Indeed, based on the April 2011 neurological findings, the VA examiner diagnosed the Veteran with subjective bilateral upper extremity forearm radiculopathy, with no objective evidence of disease for the symptom on examination. According to this examiner, the medical evidence was insufficient to support a valid diagnosis of radiculopathy in the upper extremities. As previously noted above, the April 2011 VA examination in connection to another issue on appeal was also absent for any neurological abnormalities in the upper extremities. The service treatment records demonstrate ongoing diagnoses of cervicothoracic myofascial pain and cervical radiculitis secondary to her motor vehicle accidents. However, these diagnoses do not appear to be based on a the objective findings, as the Veteran's neurological findings, subject to a few isolated incidents, were consistently negative for any abnormalities in the upper extremities. While a few treatment records revealed some impairment in the Veteran's motor strength during abduction and flexion of the arms, these findings were recorded very soon after the July 2003 motor vehicle accident. Moreover, despite the fact that the Veteran's motor strength showed improvement at the July 2004 treatment visit, she was still diagnosed with having cervicothoracic myofascial pain and cervical radiculitis upon separation from service. As such, it does not appear that any impairment in the Veteran's motor strength was a clear manifestation of cervical radiculopathy. Indeed, even after an exhaustive review of the service treatment records, the Board is unclear as to the basis behind the physicians' diagnosis of cervical radiculitis and the objective medical findings relied upon in reaching this assessment. Regardless of this diagnosis, the more recent post-service treatment records dating from 2005 to the present time have consistently been clear for any signs or indications of a neurological disorder beyond that which has already been diagnosed and for which service connection has been granted. Moreover, the September 2005 and April 2011 VA examiner based her conclusions on thorough and comprehensive evaluations of the Veteran's neurological system and stated with certainty that the objective medical findings were insufficient to support a diagnosis of radiculopathy in the upper extremities. As such, the Board is more persuaded by the evaluations which concluded there to be no neurological abnormalities because of the more thorough approach taken during these evaluations and because these assessments were clearly supported by the objective medical evidence. The Board has also considered the Veteran's assertions that these symptoms are associated with neurological pathology that is related to her time in service. However, as a layperson, the Veteran is not competent to give a medical opinion on the diagnosis of a claimed disorder. She is competent to report on symptoms she experienced either during or following service, but not to say what any diagnosis is. Thus, while the Veteran is competent to report symptoms observable to a layperson, such as numbness and tingling in the upper extremities, a diagnosis that is later confirmed by clinical findings, or a contemporary diagnosis, she is not competent to independently provide a medical diagnosis or opine as to the specific etiology of a condition. See Davidson v. Shinseki, 581 F.3d 1313 (2009). Further, the September 2005 and April 2011 VA examiner considered the Veteran's report of in-service and post-service symptoms in reaching their medical conclusions. Consequently, in this case, lay assertions of medical diagnosis or etiology cannot constitute evidence upon which to grant a claim for service connection. Lathan v. Brown, 7 Vet. App. 359, 365 (1995). Because the medical evidence in the current appeal does not establish that the Veteran has any current pathology associated with the claimed symptoms on appeal, the Board concludes that the preponderance of the evidence is against the Veteran's claim for service connection for a disability manifested by tingling/numbness in the upper extremities, to include cervical radiculopathy. The benefit-of-the-doubt provisions do not apply. Service connection for a disability manifested by numbness in the upper extremities, to include cervical radiculopathy, is not warranted. ORDER Entitlement to an initial disability rating in excess of 20 percent for degenerative joint and disc disease of the thoracolumbar spine is denied. Entitlement to an initial disability rating in excess of 10 percent for degenerative joint and disc disease of the cervical spine, for the period from February 15, 2005 to April 13, 2011, is denied. Entitlement to an initial disability rating in excess of 20 percent for degenerative joint and disc disease of the cervical spine since April 14, 2011, is denied. Entitlement to an initial disability rating in excess of 10 percent left wrist carpal tunnel syndrome is denied. Entitlement to an initial disability rating in excess of 10 percent for right wrist carpal tunnel syndrome is denied. Entitlement to service connection for a disability manifested by numbness in the upper extremities, other than the service-connected carpal tunnel syndrome, is denied. REMAND A review of the Veteran's claims file reflects she underwent a VA examination pertaining to her claim for a higher rating for migraine headaches at the Bay Pines VA Medical Center in March 2013. In particular, the April 2013 Supplemental Statement of the Case issued by the Appeals Management Center (AMC) references this VA examination, which the AMC documented as having reviewed in connection with its adjudication of the Veteran's claim. Although the AMC/RO reviewed this examination report in connection with its adjudication of the Veteran's claim for a rating in excess of 30 percent for migraine headaches, the examination report has not been associated with the claims file. A review of the Veteran's claims file is absent for documentation of the March 2013 VA examination. Indeed, in the July 2013 Informal Hearing Presentation, the Veteran's representative asserted that they had been unable to locate these records when reviewing the Veteran's claims file. The AOJ should obtain the above-identified March 2013 VA examination report, and any other relevant records reviewed by the RO and discussed in the April 2013 SSOC pertinent to the Veteran's claim. Otherwise, another examination should be scheduled. Any records obtained must be associated with the Veteran's claims file. If any records sought are determined to be unavailable, the Veteran must be notified of that fact pursuant to 38 C.F.R. § 3.159(e) (2013). Accordingly, the case is REMANDED for the following action: 1. The AOJ must obtain from the Bay Pines VA Medical Center, or any other VA treatment facility, the March 2013 VA examination pertaining to the Veteran's claim for a higher rating for migraine headaches and all available medical records pertaining to the March 2013 VA examination. If the examination report is not located, another VA examination should be scheduled to assess the severity of the migraines. All records and/or responses received must be associated with the claims file. 2. After completing the requested actions and any additional notification and/or development deemed warranted, the claim remaining on appeal must be adjudicated in light of all pertinent evidence and legal authority. If the benefit sought on appeal is not granted, the Veteran and her representative must be furnished a supplemental statement of the case (SSOC) and afforded the appropriate time period for response before the claims file is returned to the Board for further appellate consideration. The Veteran 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 or by the Court 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). ______________________________________________ THOMAS J. DANNAHER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs