Citation Nr: 1338874 Decision Date: 11/26/13 Archive Date: 12/06/13 DOCKET NO. 10-45 779 ) DATE ) ) On appeal from the Department of Veterans Affairs (VA) Regional Office (RO) in Jackson, Mississippi THE ISSUES 1. Entitlement to an increased disability rating for adjustment disorder with anxiety and depression, in excess of 10 percent prior to October 7, 2010, in excess of 30 percent since October 7, 2010. 2. Entitlement to a disability rating for sinusitis with headaches in excess of 30 percent. REPRESENTATION Appellant (the Veteran) is represented by: Tiffany Hosey Brown, Attorney WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD L. Cramp, Counsel INTRODUCTION The Veteran had active service from March 1962 to March 1966. This appeal comes before the Board of Veterans' Appeals (Board) from a January 2009 rating decision of the RO in Jackson, Mississippi. In July 2013, the Veteran presented testimony at a Board hearing, which was chaired by the undersigned Veterans Law Judge in Washington, D.C. The Veteran submitted additional evidence subsequent to the most recent supplemental statement of the case. This consisted of an undated report of VA neuropsychological testing pertaining to a questioned diagnosis of Alzheimer's dementia. As Alzheimer's dementia is not a service-connected disability, and as all of the Veteran's memory impairment is being attributed to the Veteran's service-connected psychiatric disability, the Board finds that this report is not relevant to any issue on appeal and a remand to obtain a supplemental statement of the case or a waiver of RO consideration of this evidence is not necessary. The Board does consider this evidence as an effort by the Veteran to have his case adjudicated as quickly as possible, which the Board will do at this time. In reviewing this case the Board has reviewed the physical claims file as well as the electronic file to insure a total review of the evidence. FINDINGS OF FACT 1. For the entire period of this appeal, the Veteran's migraine headaches have been manifested by frequent completely prostrating and prolonged attacks productive of severe economic inadaptability. 2. For the entire period of this appeal, the Veteran's sinusitis has been manifested by more than six non-incapacitating episodes per year of sinusitis characterized by headaches, pain, and purulent discharge or crusting. 3. For the entire period of this appeal, the Veteran's adjustment disorder has been manifested by occupational and social impairment with reduced reliability and productivity. CONCLUSIONS OF LAW 1. The criteria for a separate disability rating of 50 for migraine headaches have been met for the entire appeal period; the criteria for a rating in excess of 50 percent are not met for any period. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107, 7104 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.3, 4.7, 4.10, 4.124a, Diagnostic Code 8100 (2013). 2. The criteria for a disability rating higher than 30 percent for sinusitis have not been met for any period. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107, 7104 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.3, 4.7, 4.10, 4.97, Diagnostic Code 6513 (2013). 3. The criteria for a disability rating of 50 percent for adjustment disorder have been met for the entire appeal period; the criteria for a rating in excess of 50 percent have not been met for any period. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107, 7104 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.3, 4.7, 4.10, 4.126, 4.130, Diagnostic Code 9440 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran is seeking increased disability ratings for his service-connected migraine headaches, sinusitis, and adjustment disorder. He maintains that each service-connected disability is of greater severity than currently evaluated. He has also made specific requests for separate ratings for his headaches and sinusitis, which are currently assigned a combined rating. Headaches and Sinusitis By way of history, service connection for the combined disability of allergic sinusitis and allergic rhinitis with headaches was granted in an August 2001 rating decision with a 10 percent rating assigned for the combined disability pursuant to Diagnostic Code 6513 (sinusitis), effective December 11, 1998. In a June 2006 rating decision, the RO separated the disability rating for rhinitis, which had previously been combined with the allergic sinusitis and headaches; however, this did not affect the overall rating, as a 0 percent rating was assigned for rhinitis, pursuant to Diagnostic Code 6522, effective January 9, 2001. The sinusitis and headaches continued to be assigned a single 10 percent rating pursuant to Diagnostic Code 6513. In a June 2007 rating decision, the RO increased the rating for sinusitis and headaches (still combined) to 30 percent, pursuant to Diagnostic Code 6513, effective December 11, 1998, and increased the rating for rhinitis (Diagnostic Code 6522) to 10 percent, effective January 19, 2001. The current appeal arises from a claim received at the RO on May 13, 2008. In a January 2009 rating decision, the RO denied a rating in excess of 30 percent for the combined headaches and sinusitis. In the July 2009 rating decision on appeal, the RO changed the diagnostic code for the combined sinusitis and headaches to Diagnostic Code 8100 (migraine headaches), but denied a disability rating in excess of 30 percent. Under Diagnostic Code 6513, chronic maxillary sinusitis is to be rated in accordance with the general rating formula for sinusitis. Under that schedule, a 50 percent rating is for application following radical surgery with chronic osteomyelitis, or; near constant sinusitis characterized by headaches, pain and tenderness of affected sinus, and purulent discharge or crusting after repeated surgeries. A 30 percent rating is for assignment with three or more incapacitating episodes per year of sinusitis requiring prolonged (lasting four to six weeks) antibiotic treatment, or; more than six non-incapacitating episodes per year of sinusitis characterized by headaches, pain, and purulent discharge or crusting. A 10 percent rating requires one or two incapacitating episodes per year of sinusitis requiring prolonged (lasting four to six weeks) antibiotic treatment, or; three to six non-incapacitating episodes per year of sinusitis characterized by headaches, pain, and purulent discharge or crusting. A 0 percent rating is for application where detected by X-ray only. An incapacitating episode of sinusitis means one that requires bed rest and treatment by a physician. 38 C.F.R. § 4.97. Under Diagnostic Code 8100, migraine headaches are assigned a 50 percent rating with very frequent completely prostrating and prolonged attacks productive of severe economic inadaptability. A 30 percent rating is for application with characteristic prostrating attacks occurring on an average once a month over last several months. A 10 percent rating is for application with characteristic prostrating attacks averaging one in 2 months over last several months. A 0 percent rating is for application with less frequent attacks. 38 C.F.R. § 4.124a, Diagnostic Code 8100. The Board finds that the symptomatology associated with the Veteran's sinusitis and migraine headaches does not substantially overlap, and therefore separate ratings are appropriate. While headaches are listed among the symptoms associated with sinusitis, it does not appear that they are essential to a rating at any particular level. Notably, the 30 percent level for sinusitis presents 2 alternative (disjunctive) scenarios for entitlement, one of which does not mention headaches. To the extent that headaches are considered an essential part of any rating for sinusitis, the Board finds that the evidence in this case has consistently demonstrated a distinction in the type of headaches associated with flares of sinusitis from those associated with migraines. In an April 2008 staff physician note, the symptoms were described as a chronic daily headache and a seasonal frontal headache associated with sinusitis. Thus, the types of headache associated with the service-connected migraines are distinct from those associated with the sinusitis. In this case, there does not appear to be a danger of pyramiding associated with the assignment of separate ratings for sinusitis and migraines. Accordingly, the Board finds that, as requested by the Veteran, separate compensable ratings are appropriate. After a review of all of the evidence, the Board finds that a 50 percent rating is warranted for the Veteran's migraine headaches. The Veteran's description of frequency of migraines is that they are constant. While not all of his constant headaches appear to be completely prostrating, the Veteran has asserted that approximately 50 percent are prostrating. He described to a September 2008 VA examiner that he had experienced 6 incapacitating headaches in the prior 6 months. A description of one such attack in April 2008 would appear to support this assertion as to incapacitation. The Veteran described a headache of 3 to 4 days duration with "crushing, gripping pain" rated at 10 out of 10. He described headaches of this severity occurring at a frequency of 3 to 4 per year. According to the Veteran, over-the-counter pain relievers provide no relief for these attacks. In October 2010, the Veteran described a headache lasting 4 to 5 days. At the time of a June 2012 sinus CT scan, the Veteran described dizziness on movement and nausea associated with headaches. In correspondence received in July 2012, the Veteran reported that he experiences debilitating migraines 7 times per year, which leave him unable to participate in daily routines and cause him to lie down for days. Moreover, the Veteran has described experiencing sudden increases in his headache pain associated with everyday activities such as pumping gasoline, as exposure to the fumes increases his pain "tenfold" (see July 30, 2012 correspondence). The Board notes that the presence of constant headache symptoms does not fit squarely into the rating schedule for migraines, which contemplates distinct attacks with intervening periods of relief. The Board finds that, although the Veteran has reported that he can generally tolerate the throbbing headaches he experiences, the constant frequency of these less-than-prostrating symptoms must also be taken into account. The Board finds that the symptoms associated with the Veteran's migraine headaches more nearly approximate very frequent completely prostrating and prolonged attacks productive of severe economic inadaptability than they do characteristic prostrating attacks occurring on an average once a month over last several months. As such, the Board finds that the criteria for a 50 percent rating for migraine headaches are met for the entire period of this appeal. The 50 percent rating assigned herein is the maximum schedular rating for migraine headaches. Accordingly, no higher schedular rating is available. To the extent any higher level of compensation is sought, the preponderance of the evidence is against this claim, and hence the benefit-of-the-doubt doctrine does not apply. 38 U.S.C.A. § 5107(b); 38 C.F.R. §§ 4.3, 4.7. Turning to the separately rated sinusitis, as the disability has primarily been rated under the diagnostic code for sinusitis, and as the description of the disability as sinusitis with headaches indicates that sinusitis has been the predominant disability, the Board finds that it is appropriate to maintain the 30 percent rating assigned by the RO despite the Board's decision here to assign a separate rating for headaches. As already discussed, the headaches related to sinusitis have been distinct from the constant migraine headaches, and the symptom of headaches is not essential to the rating for sinusitis. Accordingly, the Board begins its analysis with entitlement to a disability rating in excess of 30 percent under Diagnostic Code 6513. After a review of all of the evidence, the Board finds that the weight of the evidence demonstrates that a rating in excess of 30 percent under Diagnostic Code 6513 is not warranted. In essence, during the course of the appeal, the evidence demonstrates that there has not been radical surgery with chronic osteomyelitis. Indeed, there is no assertion that there has been radical surgery with chronic osteomyelitis. The evidence demonstrates that there has not been near constant sinusitis characterized by headaches that are distinct from his migraines, pain, and tenderness of the affected sinus and purulent discharge or crusting after repeated surgeries. While the Veteran has asserted that he experiences crusting, he has not described what he means by this. The criteria clearly refer to crusting after repeated surgeries. The evidence does not show, and the Veteran does not contend, that there have been any surgeries for sinusitis. Regarding near constant sinusitis, the Board acknowledges the testimony of the Veteran and his attorney (testifying in her capacity as the Veteran's daughter with first-hand knowledge of his symptoms), that the Veteran experiences constant sinusitis. However, the Veteran's assertion to medical treatment providers is that he experiences sinusitis and the specific headaches associated with sinusitis primarily during the winter season. Moreover, when examined in April 2009, sinus X-rays were normal and the examiner found no evidence of sinusitis. The examiner diagnosed only a mild vasomotor rhinitis. The Board notes that, in their testimony, the Veteran and his attorney did not distinguish the symptoms of sinusitis from the symptoms of rhinitis. The rating for rhinitis is not before the Board on appeal. The medical evidence is accorded greater probative weight on this point. When examined for rhinitis and sinusitis in June 2012, the radiologist interpreted X-rays as indicating maxillary sinusitis. However, the examiner disagreed with the radiologist and interpreted the X-rays as normal. The examiner then ordered a CT scan of the sinuses to clarify the issue, the results of which were interpreted as normal with no evidence of maxillary sinusitis or other sinus disease. Indeed, the examiner found no evidence of rhinitis at that time. The examiner opined that the reported sinusitis symptoms were actually due to a septal deformity. The Board does not dispute the validity of the diagnosis of sinusitis, nor has any examiner. Indeed, the Veteran has been treated for sinusitis, such as in October 2010 when he was prescribed antibiotics and nasal steroids. However, the findings of the June 2012 examiner and the April 2009 examiner are highly probative evidence regarding the question of "near constant" sinusitis. In this case, the weight of the evidence is against a finding of near constant sinusitis characterized by headaches, pain, and tenderness of the affected sinus and purulent discharge or crusting after repeated surgeries. Accordingly, the criteria for a 50 percent rating for sinusitis are not met and are not more nearly approximated than the criteria for the 30 percent rating currently assigned. To the extent any higher level of compensation is sought, the preponderance of the evidence is against this claim, and hence the benefit-of-the-doubt doctrine does not apply. 38 U.S.C.A. § 5107(b); 38 C.F.R. §§ 4.3, 4.7. Psychiatric Disability Service connection for adjustment disorder with mixed anxiety and depression was granted in an April 2004 rating decision with a 10 percent disability rating assigned pursuant to Diagnostic Code 9940, effective February 26, 2004. The current appeal arises from a claim received at the RO on May 13, 2008. The General Rating Formula for Mental Disorders at 38 C.F.R. § 4.130 provides the following ratings for psychiatric disabilities: A 10 percent rating is warranted if there is occupational and social impairment due to mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress, or; symptoms controlled by continuous medication. 38 C.F.R. 4.130, Diagnostic Code 9440. A 30 percent rating is warranted if there is occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, or mild memory loss (such as forgetting names, directions, recent events). 38 C.F.R. 4.130, Diagnostic Code 9440. A 50 percent rating is warranted if it is productive of occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to compete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships. 38 C.F.R. 4.130, Diagnostic Code 9440. A 70 percent rating, may be assigned for occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work-like setting); and inability to establish and maintain effective relationships. 38 C.F.R. 4.130, Diagnostic Code 9440. The criteria for a 70 percent rating are met if there are deficiencies in most of the areas of work, school, family relations, judgment, thinking, and mood. Bowling v. Principi, 15 Vet. App. 1, 11-14 (2001). A 100 percent rating contemplates total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. 38 C.F.R. 4.130, Diagnostic Code 9440. After a review of all of the evidence, the Board finds that the criteria for a 50 percent rating for the Veteran's adjustment disorder are met. The Board observes that the primary difference between the criteria for a 30 percent rating and those for a 50 percent rating appears to be the frequency with which functional impairment is experienced. The criteria for the 30 percent rating specify "occasional" decrease in work efficiency and "intermittent" periods of inability to perform occupational tasks. The criteria for a 50 percent rating contemplate impairment that is more constant and measurable, i.e., reduced reliability and productivity. In this case, throughout the period on appeal, the impairment due to the Veteran's adjustment disorder would appear to be closer to constant than intermittent or occasional. This impairment is primarily manifested by disturbances of motivation and mood demonstrated by suspiciousness and irritability, but also demonstrated by impairment of short- and long-term memory. The Board notes that, throughout the appeal period, the Veteran has presented to VA treatment providers as irritable and argumentative. In a January 2007 treatment note, the Veteran began yelling at the clinician until he eventually walked out of the treatment room. The Veteran has expressed suspicion regarding doctors, VA employees, and other government employees. A March 2007 examiner described him as ruminant and suspicious, as well as conspiracy focused. An October 2008 VA examiner noted that the Veteran became angry, irritable, and agitated at the start of the evaluation when asked to give details about past military/psychiatric and treatment history. He stated, "you are treating me like a child." The Veteran reported that he would be doing fine if he did not have to deal with "these people." More recently, in October 2010, the Veteran reported that he was having difficulty interacting with others due to his constant irritability. He reported feeling angry and that he has moments where he becomes vocally aggressive. The Veteran reported isolating to a greater degree. He reported moments of anxiety that appear spontaneously and that are not correlated to any particular event. When seen for headache complaints in October 2010, the examiner noted that he was very agitated and irritated. He refused a CT scan stating "I am not a kid." A January 2007 clinical note reveals that the Veteran presented with stomach problems. A clinician explained that he would need to see another doctor and there would be a wait. The Veteran then began yelling that he had already waited an hour and he wanted to see a specific doctor. The clinician informed him that the doctor could not see him. The Veteran began to yell and eventually walked out of treatment room. The Veteran's attorney asserted at the hearing that the Veteran's level of agitation has increased and he experiences a lot of anxiety. The Veteran testified that he loses patience in social and business interactions and responds with anger. He also testified that he increasingly forgets things such as when to take medications or what to bring with him when he is on errands. Thus, throughout the period on appeal, the Veteran has demonstrated ongoing symptoms that directly and negatively impact his social interactions. This would naturally extend to his occupational functioning as well. These constant or near-constant symptoms would reasonably be expected to result in reduced reliability and productivity. The Board acknowledges that there is some conflicting evidence regarding entitlement to a rating in excess of 30 percent. The Veteran was afforded a VA examination in June 2012. When presented with the descriptions provided under the various rating levels, the examiner specifically found that the Veteran's overall impairment most closely approximated occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although generally functioning satisfactorily, with normal routine behavior, self care and conversation, which are the criteria for the 30 percent rating. However, this is balanced against clinical findings by the same examiner that the Veteran experiences disturbances of motivation and mood, which is a symptom example for the 50 percent rating, as well as a finding that he experiences difficulty in adapting to stressful circumstances, including work or a worklike setting, which is a symptom example for the 70 percent rating. The Board finds that the presence of these symptom examples, balanced against the examiner's estimation that the criteria for a 30 percent rating were most closely approximated, supports a 50 percent rating. The Board also notes that, with a few exceptions, GAF scores assigned throughout the appeal period are consistent with a 50 percent rating. Global Assessment of Functioning (GAF) score is a scale reflecting the "psychological, social, and occupational functioning on a hypothetical continuum of mental health-illness." Richard v. Brown, 9 Vet. App. 266, 267 (1996) (citing DIAGNOSTIC AND STATISTICAL MANUAL OF MENTAL DISORDERS, 4th ed. (DSM-IV) at 32). The October 2008 VA examiner assigned a GAF score of 60. A GAF score of 51-60 indicates moderate symptoms (e.g., flat affect and circumstantial speech, occasional panic attacks) or moderate difficulty in social, occupational, or school functioning, (e.g., few friends, conflicts with peers or co-workers). These examples appear consistent with the examples given for the 50 percent rating. While the June 2012 VA examiner assigned a GAF score of 65, reflective of mild symptoms, psychiatric outpatient notes from October 2010 through March 2012 contain GAF scores of 50, which are reflective of serious symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent shoplifting) or any serious impairment in social, occupational, or school functioning (e.g., no friends, unable to keep a job). On balance, the Board finds that the GAF scores support a 50 percent rating for the entire period on appeal. While the Board has found that a 50 percent rating is supported for the entire appeal period, the Board also finds that the weight of the evidence demonstrates that a rating in excess of 50 percent is not warranted during any portion of the appeal period. In essence, the Board finds that, while the Veteran's symptoms may occasionally impact most areas, they do not result in deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood. The report of VA examination in October 2008 reveals that the Veteran denied any depressive symptoms at that time. He denied loss of interest in activities, and denied any past or recent history of suicidal ideation/attempts or homicidal ideation. The Veteran denied any recent or past history of violent or physically aggressive behavior. The Veteran denied a history of auditory/visual hallucinations, paranoia, delusions, or other thought disorders. The Veteran also denied any anxiety or panic attacks. While the Veteran's symptoms were described as constant, they were also categorized as mild. The Veteran also denied any current effect of his psychiatric condition on social and industrial functioning. On a social level, the Veteran reported that he lived alone, but he denied any significant problems with social interaction. The examiner found that communications and sensorium were clear. Speech was spontaneous with normal volume, rate, and regular rhythm, but loud at the beginning of the evaluation. The Veteran's mood was described as irritable. His affect was stable and congruent to mood. Thought content revealed no active suicidal/homicidal ideation and no paranoia. There were no delusions or active auditory/visual hallucinations. Thought processes were coherent, logical, and goal directed. The Veteran was alert and oriented in time and place. Recent/past memory was grossly intact. Judgment was adequate for basic needs. Cognitive evaluation was grossly intact. The Board acknowledges an October 2008 report of a vague visual hallucination where the Veteran was seeing snakes that were not there. A February 2007 mental health note makes reference to paranoia, suspiciousness, and delusional thinking, described as suspiciousness regarding the government. Nevertheless, these limited examples does not suggest "persistent" delusions or hallucinations as contemplated for a rating at the 100 percent level. The Board notes that even these limited symptoms have not been noted recently, and that recent psychiatric outpatient notes have consistently reported the absence of delusions. As discussed above, findings such as those regarding delusions, have been weighed against the absence of other symptoms at the 50 percent level in order to elevate the rating from 30 percent to 50 percent. The Board reiterates the absence of such symptoms as flattened affect, circumstantial, circumlocutory, or stereotyped speech, panic attacks, difficulty in understanding complex commands, impaired judgment, and impaired abstract thinking. The Board also reiterates the finding of the October 2008 examiner that the Veteran's psychiatric symptoms have a minimal effect on his social functioning. If it were not for the presence of some symptomatology above the 50 percent level to balance the otherwise milder findings, a 50 percent rating would not be warranted. The Board also emphasizes the specific finding of the June 2012 VA examiner that the Veteran did not have occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking and/or mood, and that the Veteran did not have total occupational and social impairment. This is probative and persuasive evidence against the assignment of any rating in excess of 50 percent. In sum, the Board finds that, despite the absence of certain symptomatology associated with a 50 percent rating, the evidence reveals specific symptom examples associated with ratings above 50 percent. In balance, the Board finds that the Veteran's symptomatology more nearly approximates the criteria for a 50 percent rating for the entire appeal period. However, the weight of the evidence is against a rating in excess of 50 percent for portion of the appeal period. To the extent any higher level of compensation is sought, the preponderance of the evidence is against the claim, and hence the benefit-of-the-doubt doctrine does not apply. 38 U.S.C.A. § 5107(b); 38 C.F.R. §§ 4.3, 4.7. The Board acknowledges a request by the Veteran in his May 2008 claim for application of 38 C.F.R. § 3.350(f)(3) (2013) for an "increase of my rating to intermediate under 38 C.F.R. § 3.350(f) or the next higher rate." A review of the rating sheets throughout the appeal period indicates that there have been no ratings assigned under the quoted provisions, which govern special monthly compensation for specific enumerated disabilities and combinations of disabilities. As there are no ratings assigned under 38 C.F.R. § 3.350, the provisions governing assignment of an intermediate or next higher rating under that section do not apply. To the extent this request can be considered a claim for application of the provisions of 38 C.F.R. § 3.350, the Veteran has not specified any of the particular disabilities or combinations of disability that would warrant application of this section. The Board emphasizes that 38 C.F.R. § 3.350(f)(3) does not apply to all service-connected disabilities, but only to the disabilities and combinations of disabilities specified under 38 C.F.R. § 3.350. The potential application of the various other provisions of Title 38 of the Code of Federal Regulations have also been considered, including 38 C.F.R. § 3.321(b)(1) (2013), which provides procedures for referral or assignment of an extraschedular evaluation. Schafrath v. Derwinski, 1 Vet. App. 589, 593 (1991). The question of an extraschedular rating is a component of a claim for an increased rating. See Bagwell v. Brown, 9 Vet. App. 337, 339 (1996). Although the Board may not assign an extraschedular rating in the first instance, it must specifically adjudicate whether to refer a case for extraschedular evaluation when the issue either is raised by the claimant or is reasonably raised by the evidence of record. Barringer v. Peake, 22 Vet. App. 242 (2008). The VA Compensation and Pension Service is authorized to approve an extraschedular evaluation if the case "presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization as to render impractical the application of the regular schedular standards." 38 C.F.R. § 3.321(b)(1). If the evidence raises the question of entitlement to an extraschedular rating, the threshold factor for extraschedular consideration is a finding that the evidence before VA presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. Therefore, initially, there must be a comparison between the level of severity and symptomatology of the claimant's service-connected disability with the established criteria found in the rating schedule for that disability. If the criteria reasonably describe the claimant's disability level and symptomatology, then the claimant's disability picture is contemplated by the rating schedule, the assigned schedular evaluation is, therefore, adequate, and no referral is required. Thun v. Peake, 22 Vet. App. 111, 115 (2008), aff'd 572 F.3d 1366 (Fed. Cir. 2009). In this case, the Board finds that the schedular rating criteria contemplate the Veteran's service-connected sinusitis and migraine headaches. Regarding headaches, the criteria specifically provide for ratings based on the presence of incapacitating headaches which are the Veteran's primary symptom. Moreover, the Board has applied the rating schedule in such a way as account for certain variations in the Veteran's reported symptoms and those specifically contemplated by the rating schedule. In other words, despite a symptom frequency that more nearly approximates the criteria for the 30 percent level, the Board has granted a 50 percent rating to account for the constant nature of the Veteran's symptoms. Regarding sinusitis, the criteria specifically provide for the symptomatology reported by the Veteran as well as additional symptomatology that has not been reported. The criteria provide for higher ratings where symptoms such as near constant sinusitis and the necessity of surgery are demonstrated, as well as symptoms such as chronic osteomyelitis, pain, tenderness, purulent discharge, crusting, incapacitating episodes, and antibiotic treatment. Such factors are explicitly part of the schedular rating criteria. In addition, all the Veteran's adjustment disorder symptoms are either explicitly part of the schedular rating criteria under the general formula for rating mental disorders at 38 C.F.R. § 4.130; are analogous to the schedular rating criteria (see 38 C.F.R. §§ 4.20, 4.21), or are "like or similar to" the schedular rating criteria (see Mauerhan at 442-43). The schedular rating criteria, Diagnostic Code 9440, specifically provides for disability ratings based on a combination of history and clinical findings. The Veteran's symptoms of irritability, social withdrawal, depressed mood, anxiety, suspiciousness, and memory loss are specifically included in the rating schedule, and the assigned 50 percent disability rating specifically rates based on the degree of occupational and social impairment, including due to specific symptomatology. The GAF scores indicated in the DSM-IV, which reflect overall degree of impairment due to psychiatric disorders, and which the Board weighed and considered in this case, are part of the schedular rating criteria. Because the schedular rating criteria are adequate to rate the disabilities, there is no exceptional or unusual disability picture to render impractical the application of the regular schedular standards. For these reasons, the Board finds that the criteria for referral for extraschedular rating have not been met. 38 C.F.R. § 3.321(b)(1). The Veterans Claims Assistance Act of 2000 (VCAA) and implementing regulations impose obligations on VA to provide claimants with notice and assistance. 38 U.S.C.A. §§ 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2011); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2013). The Veteran has not asserted any deficiencies in the notice provided by the RO. Moreover, there do not appear to be any specific assertions regarding a failure to assist the Veteran in obtaining pertinent records. The information and evidence that has been associated with the claims file includes the Veteran's service treatment records, post-service VA treatment records, records from the Social Security Administration, and the Veteran's written assertions and personal hearing testimony. In addition, the Veteran was afforded VA examinations to address the manifestations and severity of each service-connected disability. These examinations are adequate because each was performed by a medical professional based on solicitation of history and symptomatology from the Veteran and a thorough examination of the Veteran, and each includes findings pertinent to the rating schedule as applied above. Nieves-Rodriguez v. Peake, 22 Vet. App 295 (2008). When conducting a hearing, a VA hearing officer, to include a Veterans Law Judge, must suggest that a claimant submit evidence on any issue material to substantiating the claim when the record is missing any evidence on that issue or when the testimony at the hearing raises an issue for which there is no evidence in the record. See Bryant v. Shinseki, 23 Vet. App. 488 (2010); 38 C.F.R. § 3.103 (2013). The hearing officer also must suggest the submission of evidence when testimony during the hearing indicates that it exists (or could be reduced to writing) but is not of record. Here, during the hearing, the Veteran's symptomatology was discussed in detail, and testimony concerning his level of impairment was elicited. Such actions supplement the VCAA and comply with 38 C.F.R. § 3.103. ORDER For the entire period on appeal, a disability rating of 50 percent, but not higher, for adjustment disorder with anxiety and depression, is granted. For the entire period on appeal, a disability rating in excess of 30 percent for sinusitis is denied. For the entire period on appeal, a disability rating of 50 for migraine headaches is granted. ____________________________________________ JOHN J. CROWLEY Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs