Citation Nr: 1334993 Decision Date: 11/01/13 Archive Date: 11/13/13 DOCKET NO. 08-26 512 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Atlanta, Georgia THE ISSUES 1. Entitlement to an initial compensable disability rating for service-connected seborrheic dermatitis of the scalp from February 1, 2005 to January 31, 2008. 2. Entitlement to an initial disability rating in excess of 10 percent for service-connected seborrheic dermatitis of the scalp for the period from February 1, 2008. 3. Entitlement to an initial disability rating for service-connected mitrovalve (MVP) prolapse for the period from February 1, 2005 to January 31, 2008. 4. Entitlement to an initial disability rating in excess of 10 percent for service-connected MVP for the period from February 1, 2008. 5. Entitlement to an initial disability rating in excess of 30 percent for service-connected post traumatic stress disorder (PTSD). 6. Entitlement to an initial disability rating in excess of 10 percent for service-connected low back disability. 7. Entitlement to an initial compensable disability rating for a right (major) shoulder disability. 8. Entitlement to an initial compensable disability rating for service-connected gastroesophageal reflux disease (GERD). 9. Entitlement to an initial compensable disability rating for service-connected fibroids, ovarian cysts, polyps. 10. Entitlement to service connection for a bilateral hip disorder. 11. Entitlement to service connection for sleep apnea. 12. Entitlement to service connection for metabolic syndrome. 13. Entitlement to service connection for deep vein thrombosis (DVT). 14. Entitlement to a compensable disability rating for service-connected hallux valgus of the right foot. 15. Entitlement to a compensable disability rating for service-connected hallux valgus of the left foot. 16. Entitlement to osteomyleitis, to include as secondary to service-connected hallux valgus of the feet. 17. Entitlement to service connection for Achilles tendonitis, to include as secondary to service-connected hallux valgus of the feet. 18. Entitlement to plantar aponeurosis enthesopathy, to include as secondary to service-connected hallux valgus of the feet. 19. Entitlement to a disability rating in excess of 10 percent for service-connected carpal tunnel syndrome (CTS) of the right hand. 20. Entitlement to a disability rating in excess of 10 percent for service-connected CTS of the left hand. REPRESENTATION Appellant represented by: Georgia Department of Veterans Affairs WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD Carole Kammel, Counsel INTRODUCTION The served on active duty from September 1981 to January 2005. These matters come before the Board of Veterans' Appeals (Board) on appeal from an April 2005 rating decision of the Winston-Salem, North Carolina, Regional Office (RO) of the Department of Veterans Affairs (VA). By that rating action, the RO, in part, granted service connection for service-connection for seborrheic dermatitis; MVP; right shoulder disability; GERD; low back disability; and, fibroids, ovarian cysts/polyps; initial noncompensable disability ratings were assigned; effective February 1, 2005--the date the RO received the Veteran's original claim for compensation for these disabilities. The RO also granted service connection for PTSD and low back disability; initial 30 and 10 percent disability ratings were assigned, effective February 1, 2005. The RO also denied service connection for a bilateral hip disorder. The Veteran appealed this rating action to the Board. Jurisdiction of the claims files currently resides with the Atlanta, Georgia RO. By a February 2008 rating action, the RO assigned initial 10 percent disability ratings to the service-connected seborrheic dermatitis; MVP and low back disability, effective February 1, 2008 (seborrheic dermatitis and MVP), the date of a VA examination report, and February 1, 2005 (low back disability). The Veteran is presumed to be seeking the maximum possible evaluation. See AB v. Brown, 6 Vet. App. 35 (1993) (while a claimant is presumed to be seeking the maximum benefit available under law, the claimant can choose to limit the claim to a lesser benefit). Thus, the initial rating claims with respect to these disabilities remain on appeal. The Board has framed the issues with respect to these service-connected disabilities as that noted on the title page In July 2012, the Veteran testified before the undersigned at the Atlanta, Georgia RO. A copy of the hearing transcript has been uploaded to the Veterans Appeals Contact and Locator System (VACOLS). Regarding issues numbered 11-19 on the title page, by a July 2011 rating action, the RO denied service connection for sleep apnea; metabolic syndrome; DVT and hallux valugs of the feet (also claimed as "mtp" joint degeneration and intermetatarsal bursitis). The RO also denied claims for service connection for osteomyleitis, Achilles tendonitis, and plantar aponeurosis enthesopathy, each to include as secondary to hallux valugs of the feet. Finally, the RO granted service connection for CTS of the right and left hands; each hand was assigned an initial 10 percent disability rating; effective June 28, 2010. In September 2011, the RO received the Veteran's Notice of Disagreement with its denial of service connection for the above-cited disabilities and assignment of 10 percent disability ratings to the CTS of the right and left hands. Under these circumstances, and as will be discussed in the remand below, the RO is required to issue a Statement of the Case that addresses the above-cited service connection and initial rating claims. See Manlicon v. West, 12 Vet. App. 238 (1999). The Board is required to remand, rather than refer, these issues. Id. The issues of entitlement to initial disability ratings in excess of 10 percent for service-connected seborrheic dermatitis and MVP for the period from February 1, 2008; entitlement to an initial disability rating in excess of 30 percent for service-connected PTSD; entitlement to an initial disability rating in excess of 10 percent for service-connected low back disability; entitlement to initial compensable disability ratings for service-connected right shoulder disability; GERD and fibroids, ovarian cysts, polyps; and, entitlement to a bilateral hip disorder are 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. For the period from February 1, 2005 to January 31, 2008, the service-connected seborrheic dermatitis of the scalp was not clinically identifiable; thus, there was no evidence of any disfiguring and tender scars that resulted in any limitation of function of the scalp. 2. For the period from February 1, 2005 to January 31, 2008, the service-connected MVP has exhibited a workload of 10.2 METs (metabolic equivalents) and without evidence of dyspnea, fatigue, angina, dizziness or syncope, or continuous medication. CONCLUSIONS OF LAW 1. For the period from February 1, 2005 to January 31, 2008, the criteria for an initial compensable disability rating for the Veteran's service-connected seborrheic dermatitis of the scalp were not met. 38 U.S.C.A. § 1155, 5103, 513A, 5107 (West 2002); 38 C.F.R. §§ 4.3, 4.118, Diagnostic Code 7806 (2008). 2. For the period from February 1, 2005 to January 31, 2008, the criteria for an initial compensable disability rating for the Veteran's service-connected MPV were not met. 38 U.S.C.A. § 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2011); 38 C.F.R. §§ 4.31, 4.104, Diagnostic Code 7000 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Duty to Notify and Assist VA has a duty to notify and a duty to assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5103, 5103A; 38 C.F.R. §§ 3.159, 3.326(a). Proper notice from VA must inform the claimant and his representative, if any, prior to the initial unfavorable decision on a claim by the agency of original jurisdiction (AOJ) of any information and any medical or lay evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b); Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). These notice requirements apply to all five elements of a service-connection claim (Veteran status, existence of a disability, a connection between the Veteran's service and the disability, degree of disability, and effective date of the disability). Dingess v. Nicholson, 19 Vet. App. 473 (2006). Information that a disability rating and an effective date for the award of benefits will be assigned if service connection is awarded must be included. Id. This appeal also arises, in part, from disagreement with initial noncompensable disability ratings following the grants of service connection for seborrhea dermatitis of the scalp and MVP in the appealed April 2005 rating action. The United States Court of Appeals for Veterans Claims (Court) has held that once service connection is granted the claim is substantiated, any deficiency in the VCAA notice is not prejudicial and further VCAA notice is generally not required. Dunlap v. Nicholson, 21 Vet App 112 (2007); Dingess v. Nicholson, 19 Vet. App. 473, 490-91 (2006). The United States Court of Appeals for the Federal Circuit has also held that additional VCAA notice is not required when there is an appeal from an initial grant of service connection. Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007). Thus, in view of the foregoing case precedent, the Board finds that no further VCAA notice was required once VA awarded service connection for seborrheic dermatitis of the scalp and MVP. VA has a duty to assist the Veteran in the development of the claims of entitlement to initial compensable disability ratings for service-connected seborrheic dermatitis of the scalp and MVP from February 1, 2005 to January 31, 2008. This duty includes assisting the Veteran in the procurement of service treatment records and pertinent private and VA treatment records and examination reports for the prescribed time period. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. After a careful review of the file, the Board finds that all necessary development has been accomplished, and therefore appellate review may proceed without prejudice to the Veteran. See Bernard v. Brown, 4 Vet. App. 384 (1993). The Board notes that adjudication of the above-cited initial evaluation claims is limited to the evidence physically or constructively to the time period from February 1, 2005 to January 31, 2008. Thus, the available records and medical evidence have been obtained in order to make adequate determinations as to these claims for the prescribed time period. The Board notes that the record does not otherwise indicate any additional existing evidence that is necessary for a fair adjudication of the initial evaluation claims that has not been obtained. Hence, no further notice or assistance is required to fulfill VA's duty to assist in the development of the claims of entitlement to initial compensable disability ratings for the service-connected seborrheic dermatitis of the scalp and MVP from February 1, 2005 to January 31, 2008. Smith v. Gober, 14 Vet. App. 227 (2000), aff'd, 281 F.3d 1384 (Fed. Cir. 2002); Dela Cruz v. Principi, 15 Vet. App. 143 (2001); see also Quartuccio v. Principi, 16 Vet. App. 183 (2002). Some discussion of the Veteran's July 2012 hearing before the undersigned is necessary. The individual presiding over a hearing must comply with the duties set forth in 38 C.F.R. § 3.103(c)(2). Bryant v. Shinseki, 23 Vet. App. 488 (2010). These duties consist of (1) fully explaining the issues and (2) suggesting the submission of evidence that may have been overlooked. They were met here. The issues on appeal were identified. Information was elicited from the Veteran concerning the severity of her service-connected seborrheic dermatitis of the scalp and MVP. Relevant evidence, in particular treatment records, was identified. As noted above, private and VA treatment records referable to the service-connected seborrheic dermatitis of the scalp and MVP for the period from February 1, 2005 to January 31, 2008 have been submitted and are associated with the record. The Board finds that no further assistance is warranted. VA may proceed with the consideration of the initial claims decided in the analysis below. II. Laws and Regulations General Rating criteria Disability evaluations are determined by the application of VA's Schedule for Rating Disabilities (Rating Schedule), 38 C.F.R. Part 4 (2013). The percentage ratings contained in the Rating Schedule represent, as far as can be practicably determined, the average impairment in earning capacity resulting from diseases and injuries incurred or aggravated during military service and the residual conditions in civil occupations. 38 U.S.C.A. § 1155; 38 C.F.R. §§ 3.321(a), 4.1 (2013). Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7 (2013). The Court held in Francisco v. Brown, 7 Vet. App. 55, 58 (1994), that "[c]compensation for service-connected injury is limited to those claims which show present disability" and held: "Where entitlement to compensation has already been established and an increase in the disability rating is at issue, the present level of disability is of primary importance." The Court later held that the above rule is not applicable to the assignment of an initial rating for a disability following an initial award of service connection for that disability, such as in the case of the Veteran's claims for initial compensable ratings for the service-connected seborrheic dermatitis of the scalp and MVP. At the time of an initial rating, separate ratings can be assigned for separate periods of time based on facts found, a practice known as "staged" ratings. Fenderson v. West, 12 Vet. App. 119, 126 (1999). III. Merits Analysis The Veteran seeks initial compensable disability ratings for service-connected seborrheic dermatitis of the scalp and MVP for the period from February 1, 2005 to January 2008. The Board will discuss each disability separately in its analysis below. (i) Seborrheic dermatitis of the scalp By the appealed April 2005 rating action, the RO granted service connection, in part, for seborrheic dermatitis of the scalp; an initial noncompensable disability was assigned, effective April 1, 2005--the date after the Veteran was discharged from military service. The RO assigned the above-cited noncompensable rating under the provisions of 38 C.F.R. § 4.118, Diagnostic Code 7806 (2004). The RO based its award of service connection for seborrheic dermatitis of the scalp on the Veteran's service treatment records reflecting that she was diagnosed with psoriasis of the scalp and treated with a new shampoo in 2002. The RO also based its determination on a September 2004 VA examination report. At that examination, the Veteran reported having occasionally small foci of itchiness on her head. She related that she had sought treatment from a dermatologist and that she had been prescribed topical solutions. A physical evaluation of the Veteran's head did not reveal any alteration of the scalp, skin or hair distribution or appearance. The September 2004 VA examiner diagnosed the Veteran with psoriasis by history. The examiner specifically noted that there was no identifiable skin pathology to support a skin diagnosis. (See September 2004 VA examination report). The noncompensable evaluation remained in effect until February 1, 2008, at which time the RO assigned an initial 10 percent disability rating as a result of a VA examination conducted on that date that showed an increase in severity of the service-connected seborrheic dermatitis of the scalp. The applicable rating criteria for skin disorders, found at 38 C.F.R. § 4.118 were amended effective August 30, 2002 and again in October 2008. The October 2008 revisions are applicable to application for benefits received by the VA on or after October 23, 2008. See 73 Fed. Reg. 54708 (September 23, 2008). In this case, the Veteran filed her claim in April 2005. Therefore, only the 2002 changes to 38 C.F.R. § 4.118 are applicable to the Veteran's claim. Diagnostic Code 7806 provides for the following levels of disability: A noncompensable rating is appropriate where less than 5 percent of the entire body or less than 5 percent of exposed areas are affected, and; no more than topical therapy is required during the past 12-month period. A 10 percent rating is warranted when at least 5 percent, but less than 20 percent, of the entire body, or at least 5 percent, but less than 20 percent, of exposed areas are affected, or; intermittent systemic therapy such as corticosteroids or other immunosuppressive drugs are required for a total duration of less than 6 weeks during the past 12-month period. A 30 percent disability rating is appropriate where 20 to 40 percent of the entire body or 20 to 40 percent of exposed areas are affected, or; systemic therapy such as corticosteroids or other immunosuppressive drugs are required for a total duration of six weeks or more, but not constantly, during the past 12 month period. A 60 percent disability rating is appropriate where more than 40 percent of the entire body or more than 40 percent of exposed areas are affected, or; constant or near-constant systemic therapy such as corticosteroids or other immunosuppressive drugs are required during the past 12-month period. See 38 C.F.R. § 4.118, Diagnostic Code 7806, as amended by 67 Fed. Reg. 49596 (July 31, 2002). The Veteran contends generally that a noncompensable (0 percent) disability rating does not represent the severity of her seborrheic dermatitis of the scalp during the above-cited time period. Having reviewed all the evidence of record, lay and medical, the Board finds that the preponderance of the evidence of record is against an initial compensable rating for seborrheic dermatitis of the scalp for the period from February 1, 2005 to January 31, 2008 because the symptomatology does not more nearly approximate that required for a compensable rating under Diagnostic Code 7806. As noted above, during a September 2004 VA examination, the Veteran reported having occasionally small foci of itchiness on her head. She related that she had been prescribed topical solutions by a private dermatologist. A physical evaluation of the Veteran's scalp in September 2004 did not reveal any alteration of the scalp, skin or hair distribution or appearance. The September 2004 VA examiner diagnosed the Veteran with psoriasis by history. The VA examiner specifically noted that there was no identifiable skin pathology to support a skin diagnosis. (See September VA examination report). A March 2006 VA treatment report reflects that there was no visible scarring on the Veteran' scalp and no scales. The Veteran was prescribed a daily ointment to apply to her scalp, and she was instructed to minimize scratching and rubbing. A September 2006 VA treatment report reflects that a physical evaluation of the Veteran's scalp revealed an annular patch of decreased follicular density in the posterior right parietal scalp. Overall, the Board finds that as the above-cited clinical evidence does not show that the service-connected seborrheic dermatitis of the scalp was at least 5 percent, but less than 20 percent, of the entire body, or at least 5 percent, but less than 20 percent, of exposed areas are affected, or; intermittent systemic therapy such as corticosteroids or other immunosuppressive drugs were required for a total duration of less than 6 weeks during a 12-month period during the period from April 1, 2005 to January 31, 2008, the preponderance of the evidence of record is against an initial compensable rating for the service-connected seborrheic dermatitis during this time. As for other potentially applicable Diagnostic Codes, as the Veteran's seborrheic dermatitis of the scalp was not shown to be unstable, tender, painful on objective demonstration during the above-cited VA examination, or productive of any limitation of function, a compensable evaluation under Diagnostic Codes 7803, 7804, or 7805 is not warranted for the prescribed period. For these reasons, the preponderance of the evidence is against the claim for a higher (compensable) disability rating for service-connected seborrheic dermatitis of the scalp for the period from February 1, 2005 to January 31, 2008. (ii) MVP The Veteran seeks an initial compensable disability rating for her service-connected MVP for the period from February 1, 2005 to January 31, 2008. As noted in the Introduction, by an April 2005 rating action, the RO granted service connection for MVP; an initial noncompensable disability rating was assigned, effective February 1, 2005--the date the RO received the Veteran's original claim for compensation for this disability. The RO based its award, in part, on the Veteran's service treatment records reflecting that she had been diagnosed with MVP in 1987. She was advised to take antibiotics prior to any dental treatment. The RO also based its determination on a September 2004 VA examination report. The Veteran also reported that she had been diagnosed with MVP during [military] service, and that she had been advised to take (4) four Amoxicillin tablets before any dental procedure. She related that she was unaware of any signs or symptoms related to cardiac incompetence, and that she was not on any follow-up or treatment program for her MVP. An examination of the heart showed no evidence of any murmurs or thrills. The apex beat was within the midclavicular line. "S1 and S2 were clearly audible at appropriate locations over the heart outline." An electrocardiogram (EKG) showed a normal sinus rhythm without any ectopic beats. The Veteran's metabolic equivalent (MET) was estimated to have been in excess of 10.2. The examiner diagnosed the Veteran with MVP by history with no evidence of current pathology on examination to render a diagnosis. (See September 2004 VA examination report). For the period from February 1, 2005 to January 31, 2008, the Veteran's service-connected MVP was assigned an initial noncompensable percent disability under 38 C.F.R. § 4.104 for the cardiovascular system, Diagnostic Code 7000, which is the diagnostic code for valvular heart disease, including rheumatic heart disease. 38 C.F.R. § 4.104, Diagnostic Code 7000. Under Diagnostic Code 7000, a 10 percent disability rating will be assigned where there is evidence of workload greater than 7 METs but not greater than 10 METs results in dyspnea, fatigue, angina, dizziness, or syncope, or: continuous medication required; A 30 percent rating is warranted if workload of greater than 5 METs but not greater than 7 METs results in dyspnea, fatigue, angina, dizziness, or syncope, or; evidence of cardiac hypertrophy or dilatation on electro-cardiogram, echocardiogram, or X-ray. A 60 percent disability rating is warranted if more than one episode of acute congestive heart failure in the past year, or; workload of greater than 3 METs but not greater than 5 METs results in dyspnea, fatigue, angina, dizziness, or syncope, or; left ventricular dysfunction with an ejection fraction of 30 to 50 percent; A 100 percent disability rating is warranted during active infection with valvular heart damage and for three months following cessation of therapy for active infection; thereafter, with valvular heart disease (documented by findings on physical examination and either echocardiogram, Doppler echocardiogram, or; cardiac catheterization) resulting in: chronic congestive heart failure, or; workload of 3 METs or less results in dyspnea, fatigue, angina, dizziness, or syncope, or; left ventricular dysfunction with an ejection fraction of less than 30 percent. Id. One MET (metabolic equivalent) is defined as the energy cost of standing quietly at rest and represents an oxygen uptake of 3.5 milliliters per kilogram of body weight per minute. When the level of METs at which dyspnea, fatigue, angina, dizziness, or syncope develops is required for evaluation, and a laboratory determination cannot be done for medical reasons, an estimation by a medical examiner of the level of activity (expressed in METs and supported by specific examples, such as slow stair climbing or shoveling snow) that results in dyspnea, fatigue, angina, dizziness, or syncope may be used. 38 C.F.R. § 4.104, Note (2). Regulations for diseases of the heart were amended effective from October 6, 2006. However, a review of the regulations both prior to and after the 2006 amendments reveals that the relevant provisions in Diagnostic Code 7000 remains essentially unchanged. See 71 Fed. Reg. 52,460 (Sept. 6, 2006). After carefully reviewing the record during the period from February 1, 2005 to January 31, 2008, the Board finds that the preponderance of the evidence of record is against an initial compensable disability rating for the service-connected MVP under Diagnostic Code 7000. The most important probative evidence during this period is provided by the above-cited VA examination report, as the remainder of the private and VA evidence of record during this time period did not provide any METs findings. As noted above, the above-cited September 2004 VA examination showed that the Veteran's METs were in excess of 10.2. There was no other cardiac pathology on examination, to include an EKG. Aside from having been instructed to take medication prior to a dental treatment, the Veteran had not been prescribed medication for her MVP on a continuous basis. A December 2005 VA treatment report also reflects that an examination of the Veteran's heart was without any murmur, rales or gallops. The point of maximal impulse (PMI) was nondisplaced. (See December 2005 VA treatment report). These findings clearly do not meet the next higher rating of 10 percent for the service-connected MVP under Diagnostic Code 7000 for the period from February 1, 2005 to January 31, 2008. As the evidence does not show evidence of workload greater than 7 METs but not greater than 10 METs that resulted in dyspnea, fatigue, angina, dizziness, or syncope, or continuous medication required, an initial compensable disability rating is not warranted for the service-connected MVP during the above-cited period. 38 C.F.R. § 4.104, Diagnostic Code 7000. In every instance where the schedule does not provide a zero percent evaluation for a diagnostic code, such as here, a zero percent evaluation shall be assigned when the requirements for a compensable evaluation are not met. 38 C.F.R. § 4.31 (2013). IV. Conclusion The Board also emphasizes that in addition to the medical evidence, the Board has considered the Veteran's personal assertions in support of the above-cited claims. The Veteran is competent, as a layperson, to report on that as to which she has personal knowledge, such as the existence of existence of skin rashes, fatigue and shortness of breath. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007); Barr v. Nicholson, 21 Vet. App. 303, 310 (2007); and 38 C.F.R. § 3.159(a)(2). As a layperson, without the appropriate medical training and expertise, she is not competent to provide a probative (persuasive) opinion on a medical matter, especially the severity of her skin and heart disabilities in terms of the applicable rating criteria. Rather, this necessarily requires appropriate medical findings regarding the extent and nature of his heart disability. There is absolutely no indication that she possesses the specialized medical expertise required to assess whether she has the numerical percentage of exposed skin area due to her seborrheic dermatitis or to evaluate her MVP workload in terms of METs. Since she is not competent to provide probative evidence in this regard, there is necessarily no need to additionally consider the credibility of her lay statements. See Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006). V. Fenderson consideration The Board has considered whether a "staged" rating is appropriate. Fenderson, supra. The record, however, shows the same level of seborrheic dermatitis of the scalp and MPV under the rating schedule for the period from February 1, 2005 to January 31, 2008. It does not support assigning different percentage disability ratings during this time period. VI. Extraschedular consideration The above determination continuing the initial noncompensable disability ratings assigned to the service-connected seborrheic dermatitis of the scalp and MVP for the period from February 1, 2005 to January 31, 2008 involves application of pertinent provisions of the VA's Schedule for Rating Disabilities, and is made on a schedular basis. One other avenue exists through which a higher evaluation can be obtained. Specifically, it is possible to assign an evaluation on an extraschedular basis. 38 C.F.R. § 3.321(b). Steps to be taken regarding extraschedular evaluations were set forth in Thun v. Peake, 22 Vet. App. 111 (2008). A determination of whether the evidence presents such an exceptional disability picture that the available applicable schedular evaluation criteria are inadequate because they do not contemplate the Veteran's level of disability and symptomatology first must be made by the RO or Board. If the evaluation criteria are inadequate, the RO or Board must proceed to determine whether the Veteran's exceptional disability picture exhibits other related factors such as marked interference with employment or frequent periods of hospitalization. If such related factors are exhibited, then referral must be made to the Under Secretary for Benefits or the Director of the Compensation and Pension Service for consideration of an extraschedular evaluation. Neither the Veteran nor her representative has argued for an extraschedular initial evaluations. There is no indication that her service-connected seborrheic dermatitis of the scalp and MVP cannot be contemplated adequately by the applicable schedular evaluation criteria discussed above. The predominant symptoms of the skin disability and MVP for the period from February 1, 2005 to January 31, 2008 are specifically are accounted for by the schedular evaluation criteria and associated statutes, regulations, and case law, as discussed by the Board in the preceding analysis. As explained above, the initial noncompensable evaluations accurately describe the severity of the Veteran's skin disability and MVP during the above-cite period because higher compensable evaluations are not warranted. In other words, the effect that they have on her is encompassed by the aforementioned evaluations. Given that the applicable schedular evaluation criteria are adequate, the Board finds that the Veteran does not manifest an exceptional skin or cardiovascular disability picture. Discussion of whether she exhibits related factors such as marked interference with employment or frequent periods of hospitalization accordingly is unnecessary. Further, referral for consideration of the assignment of an evaluation on an extraschedular basis is not warranted. See Thun, 22 Vet. App. at 111; see also Bagwell v. Brown, 9 Vet. App. 337 (1996); Floyd v. Brown, 9 Vet. App. 88 (1996); Shipwash v. Brown, 8 Vet. App. 218 (1995). VII. TDIU consideration Of final note is that "a request for entitlement to a total disability evaluation based on individual unemployability due to service-connected disabilities (TDIU), whether expressly raised by a [V]eteran or reasonably raised by the record, is not a separate claim for benefits, but rather involves an attempt to obtain an appropriate rating for a disability or disabilities ... as part of a claim for increased compensation." Rice v. Shinseki, 22 Vet. App. 447 (2009); see also Comer v. Peake, 552 F.3d 1662 (Fed. Cir. 2009); Roberson v. Principi, 251 F.3d 1378 (Fed. Cir. 2001). Here, during the period from February 1, 2005 to January 31, 2008, the Veteran was employed as a vocational rehabilitation counselor. (See January 2008 VA PTSD examination report). As such, consideration of a TDIU is unnecessary. ORDER An initial compensable evaluation for seborrheic dermatitis of the scalp for the period from February 1, 2005 to January 31, 2008 is denied. An initial compensable evaluation for MVP for the period from February 1, 2005 to January 31, 2008 is denied. REMAND Unfortunately, a remand is required for the issues of entitlement to initial disability ratings in excess of 10 percent for service-connected seborrheic dermatitis and MVP for the period from February 1, 2008; entitlement to an initial disability in rating in excess of 30 percent for service-connected PTSD; entitlement to an initial disability rating in excess of 10 percent for service-connected low back disability; entitlement to initial compensable disability ratings for service-connected GERD; fibroids, ovarian cysts, polyps and right (major) shoulder disorder; and entitlement to service connection for a bilateral hip disorder in order to obtain current VA examinations of these disabilities; obtain an examination and opinion as to the nature and etiology of the Veteran's claimed bilateral hip disorder; obtain outstanding private treatment records; issue a Supplemental Statement of the Case (SSOC) that addresses the above-cited issues and evidence received since issuance of a September 2009 SSOC; and issue a Statement of the Case (SOC) that address issues 11-20 listed on the title page of this decision. The Board sincerely regrets the additional delay, it is necessary to ensure that there is a complete record upon which to decide these claims so that she is afforded every possible consideration. (i)VA examinations-Initial Rating Claims The Veteran has maintained in testimony before the undersigned in June 2012 that her service-connected seborrheic dermatitis; MVP; PTSD; low back and right shoulder disabilities; and, GERD have increased in severity since her February 2008 VA examination, thus, current examinations are warranted in order to determine the above-cited disabilities current severity. (See June 2012 Transcript (T.) at pages (pgs.) 3, 5, 7-8, 25). The Veteran underwent a VA orthopedic examination in February 2008. At that examination, the examiner reported clinical findings relating to each of the above-cited service-connected disabilities. (See February 2008 VA orthopedic examination report). (Parenthetically, the Board observes that the Veteran was afforded VA Fee Basis examinations in December 2010 and January 2011, however, these examination reports do not contain clinical findings necessary upon which to evaluate the above-cited service connected disabilities under the appropriate schedular criteria). The Board finds that the above-cited VA February 2008 VA orthopedic examination is not contemporaneous because it was conducted over five (5) years ago and is of considerable age. As such, it might not portray the current state of the Veteran's service-connected seborrheic dermatitis of the scalp and MVP for the period from February 1, 2008; GERD; and, PTSD, low back and right shoulder disabilities. Absent current evidence, a fully informed evaluation of the Veteran's service-connected seborrheic dermatitis and MVP for the period from February 1, 2008 and service-connected PTSD, low back; GERD; and, right shoulder disorder cannot be performed. Thus, on remand, the Veteran should be schedule for appropriate VA examinations to determine the current severity of above-cited service-connected disabilities. A remand is necessary to accomplish this task. (ii) VA examination-Bilateral Hip Disorder The Veteran seeks service connection for a bilateral hip disorder. She maintains that her current bilateral hip disorder is the result of combat training during military service. (T. at pgs. 27-28). She maintains that she received rehabilitative treatment and medication for her hips during military service, as well as being placed on a limited profile. Id. The Veteran's service treatment records pertinently show that she complained of right gluteal pain in January 2001. X-rays of the pelvis and hips, performed in October and November 2001 revealed a minimal asymmetric appearance of the right ischial tuberosity, which was thought to have possibly represented bursitis or mild posttraumatic changes. In January 2002, the Veteran complained of right buttock pain. The examining clinician entered an assessment of chronic piriformis syndrome was entered. That same month, the Veteran's private physician diagnosed her with right sciatic neuropathy, ischial bursitis. She was instructed not to perform any high impact activities for one (1) month. A June 2004 pre-retirement examination reflects that reflects that the Veteran's lower extremities were evaluated as "abnormal" due to an unrelated orthopedic disability (left knee). In the Summary of Defects and Diagnoses portion of the examination report, the examining physician noted that the Veteran had had right hip pain (bursitis). On an accompanying Report of Medical Assessment, the Veteran indicated that she intended to seek VA benefits, in part, for "bursitis." The examining clinician indicated that she had had right hip pain. On a Report of Medical History, dated in June 2004, the Veteran indicated that she had had bursitis. The examining clinician reported that she had a history of having fractured her right hip in 2001 and that she had been prescribed the medication, Flexeril, for right hip pain. Post-service VA and private treatment and examination reports reflect that the Veteran was recently diagnosed with right hip strain at a December 2010 VA Fee basis examination. The examiner did not provide an opinion as to the etiology of the diagnosed right hip strain. (See December 2010 VA fee basis examination report, pg. 5). In view of the in-service clinical findings of right hip pain and bursitis per x-ray of the pelvis and hip and current diagnosis of right hip strain, the Board finds that there is sufficient information to warrant a VA examination with an opinion to better address the nature and etiology of the any diagnosed right and/or left hip disability. See McLendon v. Nicholson, 20 Vet. App. 79 (2006). (iii) Private Treatment records During the June 2012 hearing before the undersigned, the Veteran testified that she had undergone an oblation procedure by a private gynecologist in Atlanta, Georgia in March 2011. (T. at pgs. 18-19). The Veteran also testified that she was scheduled for a general medical examination by a private physician in August 2012. (T. at page (pg.) 6). These treatment records have not been obtained and associated with the claims files or uploaded to the Veteran's Virtual VA electronic claims file or Veterans Benefits Management System (VBMS). As the outstanding private treatment records might show an increase in severity of the Veteran's service-connected disabilities, namely the fibroids, ovarian cysts/fibroids, they are relevant to her initial evaluation claims. The Board notes that VA has a duty to make reasonable efforts to obtain relevant records not in the custody of a Federal department or agency, to include private medical records. See 38 U.S.C.A. § 5103A(b)(1) (West 2002); 38 C.F.R. § 3.159(c)(1) (2013). Accordingly, efforts should be made on remand to obtain a complete copy of all of the Veteran's outstanding treatment records from the above-cited private medical provider on remand. (iv) Issuance of SSOC As noted above, many VA and private medical records and copies of correspondence from her physicians, as well as internet articles from the University of Pennsylvania Health System Encyclopedia, have been received without a waiver of initial RO consideration after issuance of a September 2009 SSOC. Thus, the Agency of Original Jurisdiction must review these materials in the first instance. See 38 C.F.R. § 20.1304(c) (2013). (v) Issuance of SOC As noted in the Introduction, by a July 2011 rating action, the RO denied service connection for sleep apnea, metabolic syndrome, and DVT. The RO denied claims for service connection for osteomyleitis, Achilles tendonitis, and plantar aponeurosis enthesopathy, each to include as secondary to service-connected hallux valgus of the right and left feet. Finally, the RO continued noncompensable disability ratings assigned to the service-connected hallux valgus of the right and left feet, and assigned 10 percent disability ratings to the service-connected CTS of the right and left hands. (See July 2011 rating action). In September 2011, the RO received the Veteran's Notice of Disagreement with its denial of service connection for the above-cited disabilities and assignment of a 10 percent disability ratings to the CTS of the right and left hands. Under these circumstances, and as will be discussed in the remand below, the RO is required to issue a Statement of the Case that addresses the above-cited service connection and initial rating claims. See Manlicon v. West, 12 Vet. App. 238 (1999). The Board is required to remand, rather than refer, these issues. Id. Accordingly, the case is REMANDED to the RO/AMC for the following action: 1. Review the claims files and undertake any additional records development indicated. This shall include obtaining and associating with the claims files updated VA treatment records, if any, regarding the Veteran. This also shall include obtaining and associating with the claims files, after securing any necessary authorization, additional pertinent records identified by her during the course of the appeal. Specifically, obtain all medical records pertaining to a March 2011 oblation procedure performed by a private gynecologist in Augusta, Georgia, and an August 2012 general medical examination referenced by the Veteran at a July 2012 hearing before the undersigned. The RO/AMC should request the Veteran to identify any other medical treatment and take appropriate action to obtain the records of such treatment. If any records cannot be obtained after reasonable efforts have been made, issue a formal determination that such records do not exist or that further efforts to obtain such records would be futile, which should be documented in the claims files. The Veteran must be notified of the attempts made and why further attempts would be futile, and allowed the opportunity to provide such records herself, as provided in 38 U.S.C.A. § 5103A(b)(2) and 38 C.F.R. § 3.159(e). 2. Review the claims files and ensure that the foregoing requested development in paragraph one (1) has been conducted and completed in full. If any development is incomplete, appropriate corrective action is to be implemented. 3. After any additional treatment records are obtained and associated with the claims files, afford the Veteran an opportunity to attend VA examinations at an appropriate location to determine the current severity of her service-connected seborrheic dermatitis of the scalp; MVP; PTSD; low back and right shoulder disabilities; and, GERD. The following considerations will govern their respective examinations: a. The claims files and a copy of this remand shall be made available to the examiners in conjunction with the examinations. The examination reports shall reflect review of pertinent material in the claims files. All necessary tests and studies shall be conducted. b. After reviewing the claims files and conducting an interview with, and an examination of, the Veteran, the examiners must provide current findings: i. The skin examiner must indicate the extent of any rash and/or scarring due to the service-connected seborrheic dermatitis of the scalp, and describe any associated manifestations and/or discomfort that may accompany the disability, such as pain, itching, peeling, discoloration, disfigurement, etc. ii. The cardiovascular examiner must make specific findings as to the following: *Whether the Veteran has chronic congestive heart failure, or whether workload of 3 metabolic equivalents (METs) or less results in dyspnea, fatigue, angina, dizziness, or syncope, or whether he has left ventricular dysfunction with an ejection fraction of less than 30 percent or; *Whether the Veteran has had more than one episode of chronic congestive heart failure in the past year or whether a workload of 3 METs but not greater than 5 METs results in dyspnea, fatigue, angina, dizziness, or syncope or whether he has left ventricular dysfunction with an ejection fraction of 30 to 50 percent or; *Whether a workload greater than 5 METs but not greater than 7 METs results in dyspnea, fatigue, angina, dizziness, or evidence of cardiac hypertrophy or dilatation on electrocardiogram, echocardiogram, or X-ray or; *Whether a workload of greater than 7 METs but not greater than 10 METs results in dyspnea, fatigue, angina, dizziness, or syncope or continuous medication is required. iii. The psychiatric examiner shall evaluate the severity of the service-connected PTSD through a detailed mental status examination. This shall include the assignment of a Global Assessment of Functioning score for the Veteran's PTSD consistent with the American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition and explain the significance of the score. iv. The orthopedic examiner shall evaluate the severity of the Veteran's service-connected lumbar spine and right shoulder disability, utilizing all appropriate protocols for rating such disabilities, including the necessary range of motion studies. In regard to the bilateral hip disorder, diagnose any and all disables affecting each hip. For each hip disability diagnosed, provide an opinion as to whether it is at least as likely as not (i.e. a probability of 50 percent or greater) that any such hip disability was incurred in, as a result of, or aggravated by active duty service. * If the examiner finds that no diagnosis is warranted for either hip, it would be helpful for the examiner to discuss the legitimacy of the prior diagnoses of record, such as right hip strain entered by a VA fee basis examiner in December 2010. (See December 2010 VA fee basis examination report). v. The gastrointestinal disorders examiner shall evaluate the severity of the Veteran's service-connected GERD. This shall include the report of findings as to the presence of any persistently recurrent epigastric distress with dysphagia, pyrosis, and regurgitation, accompanied by substernal or arm or shoulder pain; or if any such symptoms, if present, are productive of considerable impairment of health. c. Each examiner must complete an independent review of the claims files and discuss the results of the last prior examinations (February 2008 orthopedic examination report) and any subsequent changes in severity of his or her respective disability. d. In all conclusions, the examiners must identify and explain the medical basis or bases, with identification of pertinent evidence of record. If any examiner is unable to provide such an opinion without resort to speculation or for any other reason, an adequate explanation should be provided as to why such an opinion cannot be provided. Such explanation may include, but are not limited to, limited experience in the specific medical field or the need for additional tests. e. All clinical findings must be reported in detail and correlated to a specific diagnosis. The reports prepared must be typed. 4. The Veteran must be given adequate notice of the date and place of the requested examinations. A copy of all notifications, including the address where the notice was sent, must be associated with the claims files. The Veteran is to be advised that failure to report for any scheduled VA examination without good cause shown may result in a denial of her claims in accordance with 38 C.F.R. § 3.655 (2013). 5. The RO should furnish a SOC that addresses the following issues: (i) Entitlement to service connection for sleep apnea; (ii) Entitlement to service connection for metabolic syndrome; (iii) Entitlement to service connection for DVT; (iv) Entitlement to a compensable disability rating for hallux valgus of the right foot; (v) Entitlement to a compensable disability rating for hallux valgus of the left foot; (vi) Entitlement to service connection for osteomyelitis, to include as secondary to service-connected hallux valgus of the feet; (vii) Entitlement to service connection for Achilles tendonitis, to include as secondary to service-connected hallux valgus of the feet; (viii) Entitlement to service connection plantar aponeurosis enthesopathy, to include as secondary to service-connected hallux valgus of the feet; (ix) Entitlement to a disability rating in excess of 10 percent for CTS of the right hand; and, (x) Entitlement to a disability rating in excess of 10 percent for service-connected CTS of the left hand. Only if the Veteran perfects an appeal as to these matters should they be certified and returned to the Board for the purpose of appellate review. 6. The RO/AMC shall then readjudicate the Veteran's claims of entitlement to initial disability ratings in excess of 10 percent for service-connected seborrheic dermatitis of the scalp and MVP for the period from February 1, 2008; entitlement to an initial disability rating in excess of 30 percent for service-connected PTSD; entitlement to an initial disability rating in excess of 10 percent for service-connected low back disability; and entitlement to initial compensable disability ratings for service-connected GERD; fibroids, ovarian cysts, polyps and right (major) shoulder disorder; and entitlement to service connection for a bilateral hip disorder. If the benefits sought on appeal remain denied, the Veteran and her representative should be provided with a SSOC that address all evidence received since issuance of a September 2009 SSOC. An appropriate period of time should be allowed for response. The Veteran has the right to submit additional evidence and argument on the matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). These claims must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2012). ______________________________________________ JONATHAN B. KRAMER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs