Citation Nr: 1339787 Decision Date: 12/03/13 Archive Date: 12/18/13 DOCKET NO. 07-21 665 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Muskogee, Oklahoma THE ISSUES 1. Entitlement to an initial compensable rating for a skin disorder. 2. Entitlement to an initial rating in excess of 10 percent for headaches prior to January 29, 2013, and a rating in excess of 30 percent thereafter. 3. Entitlement to an initial rating in excess of 10 percent for a gastrointestinal disorder. 4. Entitlement to an initial rating in excess of 10 percent for a cervical spine disorder, to include consideration of a temporary total rating due to convalescence under 38 C.F.R. § 4.30. 5. Entitlement to an initial compensable rating for a right shoulder disorder prior to January 29, 2013, and a rating in excess of 10 percent thereafter. REPRESENTATION Veteran represented by: Virginia Girard-Brady, Attorney at Law WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD E. Woodward Deutsch, Counsel INTRODUCTION The Veteran had active service from May 1992 to August 2003. This case has a complex procedural history, arising from April 2007, October 2011, and April 2012 rating decisions issued by the Department of Veterans Affairs (VA) Regional Office in Muskogee, Oklahoma, and the Appeals Management Center. The Veteran testified in support of her skin and right shoulder disorder claims at a June 2009 hearing before the undersigned. In an ensuing September 2009 decision, the Board, in pertinent part, denied the Veteran's claim for a compensable right shoulder rating. After switching her representation from the Oklahoma Department of Veterans Affairs to the attorney listed on the title page, the Veteran appealed the September 2009 denial to the United States Court of Appeals for Veterans Claims (Veterans Court). That denial was later vacated pursuant to a December 2010 joint motion for remand (JMR), and the underlying issue was remanded to the Board for reconsideration. Thereafter, in May 2012, the Board remanded that issue for additional evidentiary development. The Board concurrently found that further development was required with respect to the Veteran's skin disorder claim, notwithstanding the fact that this issue had been previously remanded in September 2009 and February 2010. While the above development was pending, the Veteran perfected an appeal of the RO's denial of her claims for initial increased ratings for gastrointestinal, headache, and cervical spine disorders. Although originally assigned to a separate docket number, those three issues have now been merged with the prior appeal for collective consideration by the Board. Indeed, consolidation of the pending claims is proper as the Veteran is represented by same attorney with respect to all five issues and the fundamentals of due process do not otherwise prohibit their consideration in a single decision. As a final introductory matter, the Board recognizes that the fourth issue on appeal was originally construed as entitlement to an initial rating in excess of 10 percent for degenerative disc disease of the cervical spine. However, as discussed in further detail below, the representative for the Veteran has submitted medical documentation indicating that she has recently undergone surgery to address that service-connected disability, which has been followed by an extensive period of convalescence. The Board considers such evidence sufficient to constitute an implicit claim of entitlement to a temporary total rating for surgery warranting convalescence pursuant to 38 C.F.R. § 4.30. That issue is part and parcel of the Veteran's pending claim for an initial rating in excess of 10 percent for a cervical spine disorder, which, in conjunction with her claim for an initial compensable rating for a right shoulder disorder prior to January 29, 2013, and a rating in excess of 10 percent thereafter, are addressed in the REMAND portion of the decision below and REMANDED to the Regional Office. Employability The Board notes that the Veterans Court held in Rice v. Shinseki, 22 Vet. App. 447 (2009) that every claim for a higher evaluation includes a claim for a total rating based on individual unemployability (TDIU) where the Veteran claims that his or her service-connected disabilities prevent him or her from working. The Board notes that the Veteran is employed on a full-time basis. As such, the Board finds that Rice is not applicable to the current appeal. There must be cogent evidence of unemployability in the record. See Rice, 22 Vet. App. 447, citing Comer v. Peake, 552 F.3d 1362 (Fed. Cir. 2009). Thus, any further discussion of an issue of entitlement to TDIU is not necessary. See Rice, supra. FINDINGS OF FACT 1. Since the effective date of service connection (February 9, 2005), the Veteran's skin disorder (identified as eczema, but also including psoriasis and dermatitis) has affected roughly five percent of her entire body and five percent of the exposed areas therein. However, it has not required intermittent systemic therapy, such as corticosteroids or other immunosuppressive drugs, nor resulted in characteristic disfigurement of the head, face, or neck, or the loss of all body hair. 2. Since the effective date of service connection (February 9, 2005), the Veteran's headaches have been manifested by characteristic prostrating attacks occurring at an average frequency of once per month over the last several months. 3. Since the effective date of service connection (February 9, 2005), the Veteran's gastrointestinal disorder (initially identified as gastroenteritis, but later recharacterized as celiac disease) has most closely approximated moderately severe irritable colon syndrome, manifested by frequent episodes of bowel disturbance and abdominal distress. 4. Since the effective date of service connection, the evidence has not shown that the Veteran's service-connected skin, headache, and gastrointestinal disorders are so exceptional or unusual that referral for extraschedular consideration by designated authority is required. (CONTINUED ON NEXT PAGE) CONCLUSIONS OF LAW 1. The criteria for an initial schedular rating of 10 percent, but no higher, for a skin disorder have been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.321(a), 4.1, 4.2, 4.3, 4.7, 4.10, 4.118, Diagnostic Codes (DCs) 7800, 7801, 7802, 7803, 7804, 7805, 7806, 7813 (effective August 30, 2002 to October 23, 2008). 2. The criteria for an initial schedular rating of 30 percent, but no higher, for headaches have been met for the period prior to January 29, 2013. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.321(a), 4.1, 4.2, 4.3, 4.7, 4.10, 4.124a, DC 8100 (2013). 3. The criteria for a schedular rating in excess of 30 percent for headaches have not been met for the period since January 29, 2013. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.321(a), 4.1, 4.2, 4.3, 4.7, 4.10, 4.124a, DC 8100 (2013). 4. The criteria for an initial schedular rating in excess of 10 percent for a gastrointestinal disorder have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.321(a), 4.1, 4.2, 4.3, 4.7, 4.10, 4.114, DC 7319, 7327 (2013). 5. Application of the extraschedular provisions is not warranted in this case. 38 C.F.R. § 3.321(b) (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Board has thoroughly reviewed all of the evidence in the Veteran's paper and electronic claims files. Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss every modicum of evidence submitted by the Veteran or on her behalf. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (holding that the Board must review the entire record, but does not have to discuss each piece of evidence). The analysis below focuses on the most salient evidence and on what such evidence shows, or fails to show, with respect to the claims. The Veteran must not assume that the Board has overlooked pieces of evidence that are not explicitly discussed herein. See Timberlake v. Gober, 14 Vet. App. 122 (2000) (noting that the law requires only that the Board address its reasons for rejecting evidence favorable to the Veteran). The Board must assess the credibility and weight of all evidence, including the medical evidence, to determine its probative value, accounting for evidence that it finds to be persuasive or unpersuasive, and providing reasons for rejecting any evidence favorable to the Veteran. Equal weight is not accorded to each piece of evidence contained in the record; every item of evidence does not have the same probative value. When all the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the Veteran prevailing in either event, or whether a preponderance of the evidence is against a claim, in which case, the claim must be denied. See Gilbert v. Derwinski, 1 Vet. App. 49 (1990). I. VA's Duties to Notify and Assist With respect to the issues decided herein, VA has met all notice and duty to assist provisions outlined in the Veterans Claims Assistance Act of 2000 (VCAA) and its implementing regulations. See 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126 (West 2002); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326 (2012). Under the VCAA, when VA receives a complete or substantially complete application for benefits, it is required to notify the claimant and his representative, if any, of the information and medical or lay evidence that is necessary to substantiate the claim. See 38 U.S.C.A. § 5103(a) (West 2002); 38 C.F.R. § 3.159(b) (2012); Quartuccio v. Principi, 16 Vet. App. 183 (2002). In Pelegrini v. Principi, 18 Vet. App. 112, 120-21 (2004) (Pelegrini II), the Veterans Court held that VA must inform the claimant of any 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. The Court subsequently ruled that VCAA notice requirements apply to all five elements of a service-connection claim, including claimant status, existence of a disability, a connection between service and the disability, degree of disability, and effective date of the disability. See Dingess v. Nicholson, 19 Vet. App. 473, 484-86 (2006). In this case, notice letters dated in March 2005 and August 2010 collectively advised the Veteran of the evidence needed to establish service connection for a skin disorder (identified as eczema), headaches, and a gastrointestinal disorder (identified as gastroenteritis), and as well as her responsibilities, and those of VA, for obtaining such evidence. Thereafter, rating decisions issued in April 2007 and October 2011 granted service connection and assigned initial ratings for those disabilities. The Veteran contested the assigned ratings by filing timely Notices of Disagreement, and her perfected claims were later merged into the current appeal. Where, as here, service connection has been established and the claimant is appealing the initially assigned rating, VCAA notice obligations are considered satisfied. Moreover, any further notice and assistance requirements are covered by 38 U.S.C.A. §§ 5104(a), 7105(d)(1), and 5103A as part of the appeals process, which is triggered by a timely Notice of Disagreement, as was received in this case. In light of the above provisions, the Board finds that the Veteran has received sufficient notice in advance of appealing the initial ratings assigned for her skin, headache, and gastrointestinal disorders. Tellingly, she has not alleged that the notice provided with respect to any of those issues has been inadequate. See Goodwin v. Peake, 22 Vet. App. 128 (2008) (holding, in pertinent part, that where a claim has been substantiated after the enactment of the VCAA, the Veteran bears the burden of demonstrating any prejudice from defective VCAA notice with respect to the downstream elements"). As such, the Board finds there has been sufficient compliance with the duty to notify with respect to those issues. The Board likewise finds that there has been sufficient compliance with the VCAA duty to assist in the development of those issues. In this regard, the Board observes that the Veteran's service and post-service treatment records have been associated with her claims file. She has not contended, and the record has not otherwise shown, that any other service or post-service records remain outstanding that are necessary to decide her skin, headache, and gastrointestinal disorder claims. In addition to eliciting pertinent records, the agency of original jurisdiction (AOJ) has assisted the Veteran by affording her multiple VA examinations in support of the above claims. Notably, she has not contested the validity of those examinations, nor alleged that they are otherwise inadequate to rate her claims. Additionally, there is nothing in the record that indicates that the Veteran's skin, headache, and gastrointestinal disorders have worsened since they were last examined. See Palczewski v. Nicholson, 21 Vet. App. 174 (2007); VAOPGCPREC 11-95 (1995), 60 Fed. Reg. 43186 (1995) (holding that the mere passage of time is not a sufficient basis to remand for a new VA examination in an increased rating claim where there is no evidence that the underlying disability has worsened in severity). As such, the Board considers it unnecessary to obtain a new examination or opinion with respect to those issues. See Barr v. Nicholson, 21 Vet. App. 303, 312 (2007) (finding that VA must provide an examination that is adequate for rating purposes). The Board also considers it unnecessary to otherwise delay adjudication of the Veteran's skin, headache, and gastrointestinal disorder claims. While, as noted in the Introduction, the first of those issues has been thrice remanded, the Board is now satisfied that its requests for evidentiary development have met with substantial compliance. See Stegall v. West, 11 Vet. App. 268, 271 (1998). Indeed, the AOJ has not only undertaken appropriate steps to elicit medical records pertinent to the Veteran's skin disorder claim but has also afforded her a January 2013 VA examination with respect to that issue. As previously noted, the Veteran has not contested the results of that examination, nor has the record otherwise suggested that it is inadequate to rate her claim. Therefore, the Board finds that there has been substantial, if not total, compliance with the terms of its most recent remand. See Dyment v. West, 13 Vet. App. 141, 146-47 (1999); D'Aries v. Peake, 22 Vet App. 97, 105 (2008) (discussing situations when it is acceptable to have 'substantial' compliance, even if not 'total' compliance, per se). In further compliance with the Board's May 2012 remand, the Veteran's skin disorder claim have been readjudicated in a March 2013 Supplemental Statement of the Case (SSOC). In that readjudication, the AOJ has expressly addressed the January 2013 VA examiner's findings and the other clinical and lay evidence introduced since the previous SSOC. As such, the AOJ has substantially complied with VA's governing regulatory provisions that the SSOC consider all evidence added to the record since the most recent adjudication. 38 C.F.R. § 19.31 (2013). Even if the March 2013 SSOC had not specifically mentioned the newly received evidence of record, another remand would not be warranted on those grounds alone. To the contrary, "[t]here is a presumption of regularity that public officers perform their duties 'correctly, fairly, in good faith, and in accordance with law and governing regulations.'" Marsh v. Nicholson, 19 Vet. App. 381, 385 (2005) (quoting Alaska Airlines, Inc. v. Johnson, 8 F.3d 791, 795 (Fed. Cir. 1993)). Courts presume that, "'in the absence of clear evidence to the contrary,'" public officers have "'properly discharged their official duties.'" Ashley v. Derwinski, 2 Vet. App. 62, 64 (1992) (quoting United States v. Chem. Found., Inc., 272 U.S. 1, 14-15 (1926)). Therefore, the Board presumes that the AOJ has reviewed all of the pertinent additions to the record when readjudicating the Veteran's claims, absent any evidence to contrary. No such evidence has been presented here. The Board therefore concludes that the March 2013 SSOC has substantially complied with its remand directives to readjudicate the Veteran's skin disorder claim and that there has been substantial compliance with the entirety of its remand instructions related to that issue. See Stegall, 11 Vet. App. at 271. As a final matter with respect to the duty to assist, the Veteran has been afforded a hearing before the undersigned in support of her skin disorder claim. During that June 2009 proceeding, the undersigned explained the underlying issue to the Veteran, as well as the elements required to substantiate her claim. The undersigned also participated in the thorough presentation by the Veteran's then-representative, and asked additional questions necessary to illuminate the matter on appeal, as related to the elements needed to establish that claim. Through such actions, the undersigned satisfied the duties incumbent on a Veterans Law Judge to explain fully the issue and to suggest the submission of evidence that may have been overlooked. See Bryant v. Shinseki, 23 Vet. App. 488, 492 (2010) (holding that the provisions of 38 C.F.R. § 3.103(c)(2) apply to a hearing before the Board). Although the Veteran has since appointed a new representative, she has not elected to testify at another hearing with respect to her skin disorder claim. Nor has she requested a hearing in support of the other claims decided herein. Accordingly, absent any evidence to the contrary, the Board finds that the duties to notify and assist have been satisfied with respect to the Veteran's skin, headache, and gastrointestinal disorder claims such that appellate review of those issues may now proceed. See Bernard v. Brown, 4 Vet. App. 384, 394 (1993). II. Increased Disability Ratings The Veteran contends that her service-connected skin, headache, and gastrointestinal disorders are more severe than indicated by her currently assigned ratings and that increased disability evaluations are therefore warranted. Disability evaluations are determined by the application of the 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 their residual disorders in civil occupations. See 38 U.S.C.A. § 1155 (West 2002); 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. See 38 C.F.R. § 4.7 (2013). Pertinent regulations do not require that all cases show all findings specified by the Rating Schedule, but that findings sufficiently characteristic to identify the disease and the resulting disability and above all, coordination of rating with impairment of function will be expected in all cases. See 38 C.F.R. § 4.21 (2013). Moreover, the assignment of a particular diagnostic code is "completely dependent on the facts of a particular case." See Butts v. Brown, 5 Vet. App. 532, 538 (1993). One diagnostic code may be more appropriate than another based on such factors as an individual's relevant medical history, the current diagnosis, and demonstrated symptomatology. Any change in diagnostic code by a VA adjudicator must be specifically explained. See Pernorio v. Derwinski, 2 Vet. App. 625, 629 (1992). Mindful of the above guidelines, the Board has considered the potential application of various provisions of the regulations governing VA benefits, whether or not they were raised by the Veteran, as well as the entire history of her service-connected disabilities in reaching its decision. See Schafrath v. Derwinski, 1 Vet. App. 589, 595 (1991). The Board has also considered applying diagnostic codes in addition to those that were initially used to decide the Veteran's claims. See Tedeschi v. Brown, 7 Vet. App. 411, 414 (1995). Because the Veteran has perfected an appeal as to the assignment of initial ratings following original awards of service connection, the Board is required to evaluate all the evidence of record reflecting the period of time between the effective dates of those initial grants of service connection until the present. The Board will also consider probative evidence prior to this date, to the extent that this evidence sheds additional light on the Veteran's overall disability picture. This could result in "staged ratings" based upon the facts found during the period in question. See Fenderson v. West, 12 Vet. App. 119, 126 (1999). That is to say, the Board must consider whether there have been times when his disabilities have been more severe than at other times throughout the appeal. Id. Under the anti-pyramiding provision of 38 C.F.R. § 4.14, the evaluation of the "same disability" or the "same manifestation" under various diagnoses is to be avoided. Indeed, the Veterans Court has held that, for purposes of determining whether a claimant is entitled to separate ratings for different problems or residuals of an injury, such that separate evaluations do not violate the prohibition against pyramiding, the critical element is that none of the symptomatology for any one of the conditions is duplicative of, or overlapping with, the symptomatology of the other conditions. 38 C.F.R. §§4.14, 4.25; Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994). As a final point before proceeding to the specific facts underlying the Veteran's claims, the Board emphasizes that it has considered all relevant, competent evidence of record, both medical and lay. Competent medical evidence is essentially evidence provided by a person who is qualified through education, training, or experience to offer medical diagnoses, statements, or opinions. Competent medical evidence may also comprise statements conveying sound medical principles found in medical treatises, as well as statements contained in authoritative writings, such as medical and scientific articles and research reports or analyses. See 38 C.F.R. § 3.159(a)(1) (2013). In contrast, competent lay evidence encompasses any evidence not requiring that the proponent have specialized education, training, or experience. Lay evidence is considered competent if the proponent has knowledge of the facts or circumstances and conveys matters that are capable of lay observation or description. See 38 C.F.R. § 3.159(a)(2) (2013). In essence, lay testimony is deemed competent when it pertains to the readily observable features or symptoms of injury or illness. See Layno v. Brown, 6 Vet. App. 465, 469 (1994). In this case, the Board finds that the record supports the assignment of an initial 10 percent rating for the Veteran's skin disorder for the entire period on appeal, and an initial 30 percent rating for her headaches prior to January 13, 2013. Conversely, the Board finds that the Veteran's headaches have not met the requirements for a higher rating since January 13, 2013, and that her gastrointestinal disorder has been adequately compensated since the date of service connection and, thus, has not warranted the assignment of an increased initial rating. The Board's specific reasons and bases for each finding are set forth, below. A. Skin Disorder Since the effective date of service connection (February 9, 2005), the Veteran's service-connected skin disorder has been rated noncompensably disabling under the diagnostic code pertaining to dermatitis or eczema. 38 C.F.R. § 4.118, DC 7806. That code provides for a noncompensable rating where less than 5 percent of the entire body or less than 5 percent of exposed areas are affected, or no more than topical therapy is required during a past 12-month period; a 10 percent rating where 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 six weeks during a 12-month period; a 30 percent rating where 20 to 40 percent of the entire body or 20 to 40 percent of exposed areas are affected, or; where systemic therapy such as corticosteroids or other immunosuppressive drugs are required for a total duration of six weeks or more, but not constantly, during a 12-month period; and a maximum 60 percent rating where more than 40 percent of the entire body or more than 40 percent of the exposed areas are affected; or where there is constant or near-constant systemic therapy such as corticosteroids or other immunosuppressive drugs required during the past 12-month period. 38 C.F.R. § 4.118, DC 7806 (2013). Parenthetically, the Board acknowledges that the subsections of 38 C.F.R. § 4.118 that pertain to scars have been revised during the pendency of this appeal. However, the Veteran has not expressly requested evaluation under those amended provisions and, thus they need not be considered here. See 73 Fed. Reg. 54,708 (September 23, 2008; effective October 23, 2008). In any event, the Board observes that the primary skin code implicated in this claim (DC 7806) has not substantively changed since August 30, 2002. See 67 Fed. Reg. 49,590-95 (effective August 30, 2002). Accordingly, the Board will now apply the version of DC 7806 that took effect on August 30, 2002, to the pertinent evidence of record. Such evidence includes the Veteran's VA medical records, which reflect a history of outpatient treatment and prescribed oral and topical medications for skin problems alternately diagnosed as eczema and dermatitis of the hands and psoriasis of the scalp. Also of record are written statements and hearing testimony in which the Veteran has attested to itchy "little spots" and pustules on her hands and crusting on her scalp, which is associated with hair loss. See Board Hearing Tr. at 19-20. She has further testified that these symptoms were initially treated with steroid medications, which aggravated her digestive system, thereby forcing her to switch to a different prescription regimen. Id. at 25. Significantly, however, the Veteran has not reported that her skin disorder is productive of scarring. Nor has she alleged a seasonal pattern of outbreaks. Accordingly, the Board has no cause for concern that the VA skin examinations conducted during this appeal have failed to address the true frequency and duration of that service-connected disability. See Ardison v. Brown, 6 Vet. App. 405, 407 (1994) (noting that the frequency and duration of skin outbreaks and the appearance and virulence of symptoms during such outbreaks must be addressed). During the Veteran's initial VA skin examination in March 2007, eczema was observed on both of her middle fingers. However, no measurement of the rash was provided. Nor was there any discussion of the diagnoses of dermatitis and psoriasis, which were also implicated in her skin disorder claim. Consequently, the Board remanded that claim for a follow-up VA examination to more comprehensively assess her skin disability picture. Unfortunately, the requested examination, administered in August 2010, also failed to fully account for the Veteran's skin disorder. Despite indicating that this service-connected disability affected approximately four percent of her body, the August 2010 examiner declined to quantify the impact to the Veteran's scalp, notwithstanding her own detailed testimony in this regard. In light of that evidentiary omission, the Board determined that there had not been substantial compliance with its prior remand directive and that another VA examination was therefore needed. During this third and final VA examination, in January 2013, the Veteran was revealed to have symptoms consistent with eczema or dermatitis, which affected both of her hands, as well as psoriasis, which impacted her lower occipital scalp and was "also a manifestation of eczema." Overall, the Veteran's skin disorder was found to impact approximately five percent of her total body and five percent of exposed areas. While that service-connected disability was also found to warrant the use of corticosteroids for six weeks or more in the past year, the examining clinician expressly noted that the cream prescribed (clobetasol) was a topical, rather than a systemic or immunosuppressive drug. That clinician also determined that the Veteran's skin disorder did not require any other therapy or treatment, apart from over-the-counter lotions, and was not productive of any debilitating or nondebilitating episodes of urticaria, primary cutaneous vasculitis, erthema multiforme, or toxic epidermal necrolysis. Similarly, that clinician found that service-connected disability was not associated with any tumors or neoplasms, or any specific skin conditions apart from those described above. Notably, neither the Veteran nor her representative has raised any specific objections to the January 2013 VA examiner's findings. Nor has either party introduced any additional medical evidence in support of the Veteran's skin disorder claim. Accordingly, the Board finds that the January 2013 VA examination report, in tandem with the other pertinent evidence summarized above, is sufficient to rate that claim. Based on the foregoing evidence, the Board finds that the Veteran's skin disorder most closely approximates the criteria for a 10 percent rating under DC 7806. 38 C.F.R. § 4.118, DC 7806. As discussed, such an evaluation is warranted for a service-connected disability that affects 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, or requires intermittent systemic therapy such as corticosteroids or other immunosuppressive drugs for a total duration of less than six weeks during a 12-month period. Here, the January 2013 VA examiner determined that the Veteran's skin disorder affects roughly five percent her body and five percent of all exposed areas. While such comprehensive measurements were not obtained previously in the appeals period, there is nothing in the record that suggests a significant change in the Veteran's overall level of disability. Accordingly, after resolving all reasonable doubt in the Veteran's favor, the Board finds that she is entitled to an initial 10 percent rating, effective the date of service connection. Conversely, the Board finds that a higher evaluation is not warranted under DC 7306. That code provides for a 30 percent rating where 20 to 40 percent of the entire body or 20 to 40 percent of exposed areas are affected, or; where systemic therapy such as corticosteroids or other immunosuppressive drugs are required for a total duration of six weeks or more, but not constantly, during a 12-month period. 38 C.F.R. § 4.118, DC 7806 (2013). Here, there is no evidence that the Veteran's skin disorder has exceeded five percent of her entire body, or five percent of exposed areas, at any time since the date of service connection. Nor has that disability been shown to require systemic therapy such as corticosteroids or other immunosuppressive drugs for a total duration of six weeks or more during any 12-month period. To the contrary, while the January 2013 VA examination report indicates that the Veteran used corticosteroids for six weeks or more in the past year, it expressly notes that prescribed mediation (clobetasol) was a topical cream and not an systemic or immunosuppressive drug. That report further specifies that the Veteran did not use any systemic corticosteroids or other immunosuppressive medications in the past year, and she has not contended otherwise. Moreover, there is no other evidence that suggests that her skin disorder meets, or has ever met, the criteria for a rating above 10 percent under DC 7806. Similarly, the record does not show that the Veteran's service-connected disability has ever warranted a higher rating under any other applicable diagnostic code. In this regard, the Board acknowledges that the Veteran has complained of hair loss associated with her scalp psoriasis. She is competent to describe such a symptom, which is capable of lay observation. See Washington v. Nicholson, 19 Vet. App. 362, 368 (2005) (holding that a lay person is competent to testify as to factual matters of which he has first-hand knowledge through observation or experience). Moreover, the Veteran's hair loss has not been clinically dissociated from the effects of her skin disorder and, thus, may be considered in evaluating that service-connected disability. See Mittleider v. West, 11 Vet. App. 181, 182 (1998) (citing 61 Fed. Reg. 52,698 (1996)) (holding that, when considering the appropriate rating to assign in a particular case, when the effects of a service-connected disability have not been clinically disassociated from those of a nonservice-connected disorder, all relevant signs and symptoms must be attributed to the service-connected disability.) Further, as such hair loss is distinguishable from the skin symptoms encompassed in DC 7806, it could conceivably warrant an evaluation separate from the 10 percent rating assigned herein. 38 C.F.R. §§4.14, 4.25; Esteban, 6 Vet. App. at 261-62. While mindful of the dictates of Mittleider and Esteban, however, the Board finds that a separate compensable rating is not assignable for the Veteran's reported hair loss. Indeed, while such symptomatology is contemplated by DC 7811, the particular skin disorder addressed in that code (alopecia areata) has been expressly ruled out by the January 2013 VA examiner. 38 C.F.R. § 4.118, DC 7831. Moreover, even if such a diagnosis were appropriate in the Veteran's case, she would need to demonstrate the loss of all body hair to qualify for a separate compensable rating under DC 7831. Such extensive hair loss has neither been contended nor shown and, thus, no additional compensation is warranted under that particular diagnostic code. Nor is any additional compensation warranted under any of the other provisions of 38 C.F.R. § 4.118. While the Board has considered the applicability of DCs 7800-7805, the criteria contained in those codes are expressly contemplated by DC 7806 and, thus, may not support a separate rating in this case. 38 C.F.R. §§4.14, 4.25; Esteban, 6 Vet. App. at 261-62. Nor may DCs 7800-7805 serve as the basis for a rating higher than the 10 percent assigned herein. To qualify for such a rating, the Veteran would need to demonstrate one or more of the following: visible or palpable tissue loss and either gross distortion or asymmetry of one feature or paired set of features, or; with two or three characteristics of disfigurement (DC 7800, effective from Aug. 30, 2002); or scarring, other than on the head, face, or neck, that is deep or that causes limited motion and affects an area or areas exceeding 12 square inches (77 sq. cm.) (DC 7801, effective from Aug. 30, 2002). Such a significant level of skin disability has neither been contended nor shown. Moreover, the Board observes that the Veteran is already in receipt of the highest schedular rating available under the versions of DC 7802, 7803, 7804, and 7805, in effect on August 30, 2002. Accordingly, the Board finds that a higher rating is not warranted under any of those applicable scar codes. 38 C.F.R. § 4.118, DCs 7800-05 (effective from Aug. 30, 2002). In considering the applicability of the remaining codes pertaining to the skin, the Board acknowledges that the Veteran has been diagnosed with psoriasis, which is listed under DC 7816. However, that code espouses the same criteria as DC 7806 and, thus, may not be used to support a rating in excess of that which has already been assigned. 38 C.F.R. § 4.118, DCs 7806, 7816. Additionally, the Veteran has not been diagnosed with any of the disabilities covered by DCs 7815 (bullous disorders), 7817 (exfoliative dermatitis), 7818 malignant skin neoplasms), 7819 (benign skin neoplasm); 7820 (cutaneous manifestations of collagen-vascular diseases), 7822 (papulosquamous disorders), 7823 (Vitiligo) 7824 (keratinization), 7825 (urticaria), 7826 (vasculitis, primary cutaneous), 7827 (erythema multiforme; toxic epidermal necrolysis), 7828 (acne), 7829 (chloracne), 7830 (scarring alopecia), 7831 (alopecia areata), 7832 (hyperhidrosis), or 7833 (malignant melanoma). 38 C.F.R. § 4.118, DCs 7815-7818, 7820-7833 (2009). Nor is her current skin disorder more analogous to one of those particular codes than to DC 7806, under which she is presently rated. Accordingly, a rating under any of those diagnostic codes would not be appropriate. In summary, the Board finds that the evidence collectively establishes that the Veteran is entitled to an initial compensable rating of no more than 10 percent under the applicable schedular criteria. The Board's analysis does not end here as it must also consider whether to refer the Veteran's skin disorder claim for a higher evaluation outside the Rating Schedule. Rather than proceeding directly to this question, however, the Board will defer its extraschedular analysis, for the sake of economy, until it assesses the Veteran's headaches and gastrointestinal disorder under the relevant schedular criteria. B. Headaches This service-connected disability has been rated by analogy under DC 8100, which contemplates migraine headaches. 38 C.F.R. § 4.124a, DC 8100. However, while the Veteran's headaches have been classified as non-migraineous, DC 8100 still appears to be the diagnostic code that best encapsulates her underlying symptoms. Indeed, the Veteran has neither contended nor otherwise shown that a different diagnostic code would be more appropriate to rate her headaches. Accordingly, while cognizant that the assignment of a particular diagnostic code is "completely dependent on the facts of a particular case," the Board finds that, in this case, the Veteran's service-connected headaches are best contemplated by the criteria set forth in DC 8100. See Butts, 5 Vet. App. at 538. As such, the Board will now consider whether a higher rating is warranted under that code. DC 8100 provides for a 10 percent rating for characteristic prostrating headache attacks occurring an average of once every two months over the last several months. A 30 percent rating is warranted for characteristic prostrating attacks occurring on an average of once a month over the last several months. A maximum 50 percent rating is warranted for very frequent completely prostrating attacks productive of severe economic inadaptability. 38 C.F.R. § 4.124a, DC 8100. Significantly, for purposes of this appeal, the use of the conjunctive "and" in a statutory provision means that all of the conditions listed in the provision must be met. See Melson v. Derwinski, 1 Vet. App. 334 (1991); compare Johnson v. Brown, 7 Vet. App. 95 (1994) (holding that only one disjunctive 'or' requirement must be met in order for an increased rating to be assigned). Hence, because of the successive nature of DC 8100's criteria -- such that the evaluation for each higher disability rating includes the criteria of each lower disability rating -- each criterion listed in the 50 percent rating must be satisfied in order to warrant that maximum schedular evaluation. See Tatum v. Shinseki, 23 Vet. App. 152, 156 (2009). Additionally, while cognizant that neither the VA Rating Schedule nor the Veterans Court has specifically defined the term "prostrating," the Board notes that it has been defined by Webster's New World Dictionary of American English, Third College Edition (p. 1080, 3rd College Ed. (1986)), as "utter physical exhaustion or helplessness." A similar interpretation has been presented in Dorland's Illustrated Medical Dictionary (p. 1554, 31st Ed. (2007)), which has defined "prostration" as "extreme exhaustion or powerlessness." The term "productive of severe economic inadaptability" is also not defined in VA law. However, the Veteran's Court has held that this term is not synonymous with being unable to work and VA has conceded that the phrase "productive of" could be read to mean either "producing" or "capable of producing" economic inadaptability. See Pierce v. Principi, 18 Vet. App. 440, 446-7 (2004). The Board recognizes that the AOJ has relied upon the above criteria to assign an initial 10 percent rating for the Veteran's headaches prior to January 29, 2013, and a 30 percent rating thereafter. Significantly, however, that rating increase has been predicated on a January 2013 VA headaches examination, which has yielded findings similar to those shown earlier during the appeal. Indeed, while the Veteran reported to the January 2013 examiner that her headaches were productive of "pulsating or throbbing pain on both sides of [her] head; accompanied by heightened sensitivity to light and sound," she had previously complained of such symptoms during VA examinations conducted in August 2010 and March 2011. Moreover, while the Veteran indicated during her initial VA examination that her headaches had worsened in recent years, she has not since reported any significant change in symptomatology. Nor does the record otherwise suggest that such a change has transpired. To the contrary, the Veteran's VA examination reports and treatment records indicate that she has consistently complained of frequent, non-migraine headaches, which limit her concentration and thereby interfere with her ability to work as an administrative professional. Further, while the January 2013 examining clinician has provided details regarding the frequency and duration of the Veteran's prostrating attacks of head pain, which were not previously of record, the Board attributes these new findings to the increased specificity of the VA examination template, rather than to any worsening of her headache symptoms. As such, the Board presumes that the Veteran's service-connected disability - which, by her own account, is currently manifested by "prostrating attacks" that routinely occur each month - has also been productive of a similar pattern of exacerbation throughout the rating period. Accordingly, the Board finds that, since the date of service connection, the Veteran's headaches have most closely approximated the criteria for a higher 30 percent rating under DC 8100. As discussed, those criteria contemplate characteristic prostrating attacks occurring an average of once a month over a period of several months. Such a disability picture corresponds to the findings of the January 2013 VA examiner and is also consistent with the Veteran's own lay statements throughout the appeal. In contrast, there is nothing in the record that shows that the Veteran's migraine symptoms rise to the level of very frequent completely prostrating attacks that are productive of severe economic inadaptability. To the contrary, the January 2013 VA examiner has expressly determined that the Veteran's incapacitating headache episodes occur at an average frequency of once per month, rather than "more frequently than once per month," as would be consistent with the criteria for a 50 percent rating. Moreover, the Veteran herself has acknowledged that, while occupationally and socially debilitating, her headache symptoms are responsive to medication and rest, and are generally no longer than one day in duration. See January 2013 VA Examination Report. This suggests that, by the Veteran's own admission, her headaches do not cause such "utter physical exhaustion or helplessness," or "extreme exhaustion or powerlessness," as to either produce, or be capable of producing, severe economic inadaptability. Further, the Board considers it significant that, as discussed below, the Veteran remains employed fulltime and that her recent absences from work have been less due to her headaches than to her service-connected cervical spine disorder. As such, while mindful that her current employment, standing alone, does not preclude the assignment of a 50 percent rating under DC 8100, the Board finds that such a maximum schedular evaluation is not warranted in this instance. In addition to DC 8100, the Board has considered whether other diagnostic codes might serve as the basis for separate or higher ratings. As discussed, however, the Veteran herself has not alleged that such evaluations are warranted under other provisions of the Rating Schedule. Moreover, there is nothing of record that otherwise suggests that DC 8100 is insufficient to account for the Veteran's headache symptoms. Further, while the Veteran has also reported flare-ups of pain throughout her neck and upper extremities, such symptomatology is expressly encompassed in her service-connected cervical spine and right shoulder disorders, discussed below. 38 C.F.R. § 4.97, DC 6513. Accordingly, to rely on that symptomatology as the basis for awarding higher compensation for the Veteran's service-connected headaches would constitute unlawful pyramiding. 38 C.F.R. §§ 4.14, 4.25; Esteban, 6 Vet. App. at 261-62. In summary, the Board finds that, throughout the pendency of this appeal, the Veteran's headaches have most nearly approximated the criteria for a 30 percent rating under DC 8100 and have not warranted a separate or higher evaluation under any other diagnostic code. Accordingly, the Board will now consider whether a higher schedular evaluation for the Veteran's gastrointestinal disorder is warranted before addressing whether to refer that issue and the aforementioned initial increased-rating claims for extraschedular consideration. C. Gastrointestinal Disorder Since the effective date of service connection, the Veteran's gastrointestinal disorder has been alternately classified as gastroenteritis, gastroesophageal reflux disorder (GERD), irritable bowel disorder (IBS), and celiac disease. Notwithstanding those variable diagnoses, however, the service-connected disability has been consistently rated under DC 7399-7319. Such a hyphenated diagnostic code is used when an unlisted disease, injury, or residual condition is encountered, requiring rating by analogy. In that instance, the first two digits are selected from the part of the schedule most closely identifying the part, or system of the body involved -- in this case, the digestive system - and the last two digits are designated as "99," to represent all unlisted conditions. Then, the underlying disability is rated by analogy under a diagnostic code that most closely approximates its anatomical functions and symptomatology. 3 8 C.F.R. §§ 4.20, 4.27 (2013). In accordance with the above guidelines, the AOJ has determined that the Veteran's gastrointestinal disorder is best approximated by the diagnostic code pertaining to irritable colon syndrome (spastic colitis, mucous colitis, etc.). 38 C.F.R. § 4.114, DC 7319. In considering the applicability of other diagnostic codes, the Board is constrained by the specific regulations precluding the assignment of separate ratings for certain diseases of the digestive system. 38 C.F.R. §§ 4.14, 4.113 (2013). Specifically, ratings under DCs 7301 to 7329, inclusive, 7331, 7342, and 7345 to 7348, inclusive, are not be combined with each other without violating the fundamental principle against pyramiding. Instead, a single rating is to be assigned under the diagnostic code which reflects the predominant disability picture, with elevation to the next higher evaluation where the severity of the overall disability warrants such an increase. 38 C.F.R. § 4.114 (2013). Notwithstanding VA's anti-pyramiding provisions, it is possible for a claimant to have separate manifestations attributable to the same digestive disease or injury, which would permit ratings under several diagnostic codes. However, no such distinct symptomatology has been presented in the instant case. To the contrary, while the Veteran has been afforded different diagnoses at various stages of the appeal, her underlying gastrointestinal symptoms have remained essentially unchanged. Moreover, those symptoms have been confined to frequent bowel movements, with episodic diarrhea, and abdominal distress. Such symptoms are squarely contemplated by the criteria in DC 7319. Indeed, there appears to be no other diagnostic code that better encapsulates the complaints and clinical findings surrounding the Veteran's gastrointestinal disorder, and she has not alleged otherwise. Accordingly, the Board finds that it need not further consider the application of other schedular criteria and will instead focus its analysis on DC 7319. 38 C.F.R. § 4.114, DC 7319 (2013). That diagnostic code directs that a minimal compensable (10 percent) rating be assigned for moderate irritable colon syndrome and related symptoms, to specifically include frequent episodes of bowel disturbance with abdominal distress. The code envisions a maximum 30 percent rating for severe diarrhea, or alternating diarrhea and constipation, with more or less constant abdominal distress. 38 C.F.R. § 4.114, DC 7319 (2013). The terms mild, moderate, and severe, as used in DC 7319 and in other diagnostic codes, are not defined in the Rating Schedule. Thus, rather than applying a mechanical formula, the Board must evaluate all the pertinent evidence to the end that its decision is equitable and just. 38 C.F.R. § 4.6 (2010). Here, the pertinent evidence consists of a 2008 colonoscopy summary, which was devoid of any abnormalities, as well as subsequent VA medical records, showing treatment for episodic diarrhea and related gastrointestinal complaints. Also of record are reports of VA and private examinations, administered in August 2010, October 2010, January 2012, and January 2013. During the Veteran's initial VA examination, in August 2010, she complained of "fecal urgency" dating back to her in-service hospitalization in Turkey. The Veteran reported that her current symptoms included episodic diarrhea, occurring "a couple of times" each year and lasting for several weeks. During such episodes, the Veteran indicated that she experienced " 2-3 bowel movements daily that [we]re explosive and urgent," accompanied by frequent gas and abdominal discomfort. However, the Veteran denied any significant weight changes or other gastrointestinal abnormalities. Concurrent clinical testing revealed mild abdominal gurgling and tenderness to palpation. Such findings, in tandem with the Veteran's reported symptoms, were deemed consistent with a diagnosis of IBS. A follow-up VA examination, conducted in October 2010, focused on a genitourinary disorder not at issue in this appeal. Nevertheless, that examination was noteworthy for expressly negating any history of incontinence or anemia. Conversely, the Veteran has complained of abnormalities consistent with GERD and celiac disease. Indeed, she reported a history of those disorders during a private examination in January 2012. At that time, the Veteran also indicated that she had been prescribed medication and a gluten-free diet, which had collectively resulted in a dramatic improvement of her irritable bowel symptoms and abdominal distress. Moreover, while she reported a recent increase in GERD symptoms, she attributed this to "forgetting to take [her medication] while sick" with a different ailment. The record thereafter shows that, during her most recent VA examination in January 2013, the Veteran reprised her complaints of gluten-related digestive ailments. As on her private evaluation, she indicated that those ailments were generally controlled through medication and a gluten-free diet. Nevertheless, she emphasized that, even with such intervention, she continued to experience intermittent flare-ups of diarrhea, which occurred "anywhere from every 2 months to 6 months" for a duration of "2-3 months." The Veteran added that, during such flare-ups, she experienced "loose stools up to six times per day," which were "explosive and watery with urgency." She further indicated that her flare-ups included bouts of incontinence, which marked a departure from her reported history during the October 2010 VA examination. Conversely, the Veteran echoed her prior denial as to any history of anemia. She likewise denied any history of constipation and indicated that, while she experienced frequent episodes (i.e., at least seven annual attacks) of diarrhea, accompanied by nausea, belching, and increased flatulence, her symptoms did not approximate "more or less constant abdominal distress." In addition to conducting a clinical interview, the January 2013 VA examiner reviewed the Veteran's pertinent medical history - including an April 2011 endoscopy report that was significant for celiac disease - and conducted diagnostic testing, which was demonstrative of mild abdominal tenderness, but no other digestive abnormalities. Following the above examination, the Veteran submitted written argument and clinical findings with respect to other issues on appeal. However, she declined to provide any additional substantive evidence in support of her gastrointestinal claim. Nor did she provide any information that would enable VA to obtain such evidence on her behalf. See Wood v. Derwinski, 1 Vet. App. 190, 193 (1991) (holding that the duty to assist is "not a one-way street"). Having thus ruled out the existence of additional, relevant evidence concerning the Veteran's gastrointestinal disorder, the Board finds that the totality of the record does not support an increased rating for that service-connected disability. Although the Veteran has complained of frequent and prolonged bouts of diarrhea and abdominal distress, she has not alleged, and the record has not otherwise shown, that her symptoms include alternating diarrhea and constipation. Moreover, during her most recent VA examination, the Veteran has expressly denied experiencing "more or less constant abdominal distress," and at no other time since the date of service connection has she reported such symptoms. Accordingly, the Board has no evidentiary basis to assign a higher rating of 30 percent pursuant to DC 7319. Instead, the Board finds that the Veteran's gastrointestinal disability picture is more accurately contemplated by the criteria for a 10 percent rating under that diagnostic code. As discussed, those criteria encompass moderate irritable colon syndrome, manifested by frequent episodes of bowel disturbance with abdominal distress. The Veteran has exhibited such manifestations throughout this appeal. It follows that, even though no VA or private clinician has described the Veteran's gastrointestinal disability as "moderate" in degree - and while she herself may disagree with that qualitative description -- the Board finds that this corresponds to the most equitable and just level of compensation within the context of the Rating Schedule. 38 C.F.R. § 4.6. III. Extraschedular Consideration Now that the Board has considered the Veteran's claims under the applicable schedular criteria, it recognizes that exceptional or unusual factors may arise that would render the application of such criteria impractical. See Fisher v. Principi, 4 Vet. App. 57, 60 (1993). According to the applicable regulation, an extraschedular disability rating is warranted upon a finding that the case presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization that would render impractical the application of the regular schedular standards. See 38 C.F.R. § 3.321(b)(1) (2013), Fanning v. Brown, 4 Vet. App. 225, 229 (1993). Under Thun v. Peake, 22 Vet. App. 111, 115 (2008), there is a three-step inquiry for determining whether a veteran is entitled to an extraschedular rating. First, the Board must determine whether the evidence presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. Second, if the schedular evaluation does not contemplate the level of disability and symptomatology and is found to be inadequate, the Board must then determine whether the claimant's disability picture exhibits other related factors such as those provided by the regulation as "governing norms." Third, if the Rating Schedule is inadequate to evaluate a claimant's disability picture and that picture has attendant thereto related factors such as marked interference with employment or frequent periods of hospitalization, then the case must be referred to the VA Under Secretary for Benefits or the Director of the Compensation and Pension Service to determine whether, to accord justice, the veteran's disability picture requires the assignment of an extraschedular rating. In applying the Thun criteria to the facts of the instant case, the Board acknowledges that the Veteran has complained of occupational impairment due, in part, to her skin, headache, and gastrointestinal disorders. Additionally, the Board recognizes that the most recent VA examiners to address those service-connected disabilities have concluded that they all interfere with the Veteran's employability. Indeed, those examiners have collectively indicated that the Veteran's skin disorder renders her unfit for jobs "which would require frequent immersion of her hands in water such as bar tending, waitressing or hair dressing," while her headaches limit her ability to work "approximately one time per month" during prostrating attacks, and her gastrointestinal disorder requires "special [workplace] accommodations [including] nearby bathroom facilities." Notwithstanding those documented restrictions, however, the record indicates that the Veteran has remained capable of fulltime employment throughout the relevant appeals period. Moreover, her only extensive absence from work during that period has been due to her cervical disk surgery, and not to her skin, headache, or gastrointestinal disorders. Next, the Board observes that neither the Veteran nor her representative has expressly raised the matter of entitlement to an extraschedular rating in connection with the claims decided herein. To the contrary, their contentions have been limited to those discussed above, i.e., that her skin, headache, or gastrointestinal disorders are more severe than reflected by the currently assigned schedular ratings. See Brannon v. West, 12 Vet. App. 32 (1998) [while the Board must interpret a claimant's submissions broadly, the Board is not required to conjure up issues that were not raised by the claimant]. Moreover, the Veteran and her representative have not identified any factors that may be considered to be exceptional or unusual with respect to those service-connected disabilities and the Board has been similarly unsuccessful. Further, the record does not show that the Veteran has required frequent hospitalizations for those disabilities . There is no unusual clinical picture presented, nor is there any other factor which takes the disabilities outside the usual rating criteria. Accordingly, the Board finds that the evidence does not reflect that the Veteran's skin, headache, and gastrointestinal disorders present such an exceptional or unusual disability picture as to render impractical the application of the regular schedular standards and warrant the assignment of an extraschedular rating under 38 C.F.R. § 3.321(b)(1) (2013). IV. Conclusion In summary, the Board concludes that, since the effective dates of service connection, the Veteran has qualified for initial increased ratings of 10 percent and 30 percent for her skin disorder and headaches, respectively. Conversely, she has not met the criteria for a headache rating above the 30 percent assigned for the period since January 29, 2013. Nor has she satisfied the requirements for an initial increased rating for her gastrointestinal disorder at any time throughout the appeal. In making these determinations, the Board has considered the assignment of staged ratings, but has concluded that the above evaluations most closely approximate the Veteran's service-connected disabilities since the effective dates of service connection. See Fenderson, 12 Vet. App. at 126. All reasonable doubt has been resolved in the Veteran's favor in rendering this decision. See 38 U.S.C.A. § 5107(b) (West 2002); 38 C.F.R. §§ 3.102, 3.400 (2012); see also Gilbert v. Derwinksi, 1 Vet. App. 49 (1990). (CONTINUED ON NEXT PAGE) ORDER Entitlement to initial rating in excess of 10 percent for a skin disorder is granted, subject to the laws and regulations governing the payment of VA compensation. For the period prior to January 29, 2013, entitlement to an initial rating of 30 percent, but no higher, for headaches is granted, subject to the laws and regulations governing the payment of VA compensation. For the period since January 29, 2013, entitlement to a rating in excess of 30 percent for headaches is denied. Entitlement to an initial rating in excess of 10 percent for a gastrointestinal disorder is denied. REMAND The Board is mindful that this case has been pending for a significant time, and has been remanded in the past. Nevertheless, the Board finds that an additional remand is necessary to ensure a full and fair adjudication of the issues remaining on appeal. The Board will explain each of its reasons for remand in turn. 38 C.F.R. § 19.9. I. VA Examination The record reflects that the Veteran was last afforded a VA examination with respect to her service-connected degenerative disc disease of the cervical spine in January 2013. Since that time, she has undergone cervical disc fusion surgery, as evidenced by private medical documentation, which her representative has submitted in connection with her appeal. While the representative has not expressly waived initial AOJ consideration of that documentation, the Board has reviewed it solely for the purpose of remanding the Veteran's claim - an outcome that is fully favorable to her. The above documentation strongly suggests that the Veteran's degenerative disc disease of the cervical spine may have materially changed since her January 2013 VA examination. As such, notwithstanding the relative recency of that examination, the Board finds that a new examination is needed to assess the current nature, extent and severity of her service-connected cervical spine disability. See 38 C.F.R. §§ 3.326, 3.327 (reexaminations will be requested whenever VA determines there is a need to verify the current severity of a disability, such as when the evidence indicates there has been a material change in a disability or that the current rating may be incorrect.); Snuffer v. Gober, 10 Vet. App. 400, 403 (1997); VAOPGCPREC 11-95 (1995), 60 Fed. Reg. 43,186 (1995). A new VA examination is likewise warranted with respect to the Veteran's right shoulder bursitis. This service-connected disability was examined concurrently with the Veteran's degenerative disc disease of cervical spine in January 2013. However, it is unclear whether the Veteran's intervening surgery may have impacted her right shoulder symptoms, which have been clinically linked to her service-connected cervical spine disability. See, e.g., August 2010 Examination Report of "R.S.F., D.O." (noting that Veteran's right shoulder and cervical spine disorders are related insofar as her "pain aris[es] from the shoulder joint or from irritation of the nerves of the cervical spine that innervate the shoulder muscles"). Accordingly, the Board finds that, on remand, the VA clinician who assesses the current nature, extent and severity of the Veteran's service-connected cervical spine disability should also provide an updated examination of her right shoulder symptoms. Moreover, that clinician should distinguish, to the extent possible, which symptoms are attributable to the Veteran's cervical spine and which are more closely associated with her right shoulder. This will enable VA to more accurately adjudicate the symptoms underlying each service-connected disability without violating the rule against pyramiding. 38 C.F.R. §§4.14, 4.25; Esteban, 6 Vet. App. at 261-62. Further, the Board wishes to emphasize that such clarification is crucial to ensure substantial compliance with the terms of its May 2012 remand, and, by extension, the December 2010 JMR, which indicated that the Veteran should undergo a VA examination to "disassociate any symptomatology related to [her] cervical spine from [her] service-connected right shoulder bursitis." See Stegall v. West, 11 Vet. App. 268 (1998) (holding that a remand by the Veterans Court or the Board confers on the Veteran or other claimant, as a matter of law, the right to compliance with the remand orders). Even if an additional examination were not otherwise warranted with respect to the Veteran's right shoulder claim, such a follow-up assessment would be needed to resolve the questions left open by the previous VA examiner, who indicated that she was "unable to express an opinion regarding the degree of additional [right shoulder] motion loss or favorable, intermediate or unfavorable ankylosis due to pain on use or during flare-ups as the examiner is not present when the Veteran is experiencing a flare up and this would leave the examiner unable to provide the opinion without resorting to speculation." See January 2013 VA Joints Examination. Such inherently speculative medical findings are of little value to the Board in assessing the overall nature and severity of the Veteran's right shoulder disorder. See Tirpak v. Derwinski, 2 Vet. App. 609, 611 (1992) (observing that evidence which is speculative, general or inconclusive in nature cannot support a claim). Moreover, the Board is precluded from arriving at its own unsubstantiated medical conclusions in this regard. See Colvin v. Derwinski, 1 Vet. App. 171, 175 (1991) (VA may only consider independent medical evidence to support its findings and is not permitted to base decisions on its own unsubstantiated medical conclusions). Accordingly, to ensure that there is sufficient medical evidence upon which to rate the Veteran's right shoulder claim - and, in particular, to allow for adequate consideration of the provisions governing functional loss due to pain under 38 C.F.R. § 4.40 and functional loss due to weakness, fatigability, incoordination or pain on movement of a joint under 38 C.F.R. § 4.45 - an additional VA examination is needed. See Mitchell v. Shinseki, 25 Vet. App. 32 (2011); DeLuca v. Brown, 8 Vet. App. 202, 205-206 (1995). II. Records Procurement The medical documentation submitted by the representative for the Veteran shows that she was scheduled to return to a modified work schedule on August 13, 2013, and thereafter undergo further evaluation of her post-surgery cervical spine disability on September 6, 2013. See August 12, 2013, Return to Work Status Statement signed by Oklahoma Sports & Orthopedics Physician. However, no subsequent records from that private clinic have yet been associated with the claims file. Accordingly, as such records may provide further insight into the current nature and severity of the Veteran's service-connected cervical spine and right shoulder disorders, reasonable efforts to obtain them should be made on remand. Pertinent VA records also appear to be outstanding. A review of the paper and electronic claims file reflects a history of recent VA treatment for "neck pain" and "right shoulder arthralgia." Significantly, however, the last attempt to obtain any records of such treatment was undertaken on May 2, 2013. Therefore, to ensure that the file is complete for rating purposes, all relevant VA treatment records dated since May 2, 2013, should also be obtained on remand. 38 C.F.R. § 3.159(c)(2) (2013); Bell v. Derwinski, 2 Vet. App. 611 (1992). Accordingly, the case is REMANDED for the following actions: 1. After eliciting any necessary authorization from the Veteran, request and obtain all records pertaining to her service-connected cervical spine and right shoulder disorders generated by the Oklahoma Sports & Orthopedics Institute since August 12, 2013. Pursuant to 38 U.S.C.A. § 5103A(2)(B), two attempts should be made to obtain these relevant treatment records, unless a formal finding can be made that a second request for such records would be futile. See Pub. L. No. 112-154, § 505, 126 Stat. 1165, 1193 (2013). All requests and responses, positive and negative, should be associated with the Veteran's paper or electronic claims file. The Veteran should also be requested to provide copies of any outstanding medical records in her own possession that are pertinent to her pending claims. 2. Obtain and associate with the paper or electronic claims file all treatment records from the Oklahoma City, Oklahoma VA Medical Center dated since May 2, 2013. If any of the requested VA records are unavailable, notify the Veteran in accordance with 38 C.F.R. § 3.159(e). Also advise the Veteran to submit any additional treatment records in her own possession in support of his appeal. 3. After completing items 1 and 2, schedule the Veteran for one or more appropriate VA examinations to assess the current extent and severity of her degenerative disc disease of the cervical spine and right shoulder bursitis. The examiner should conduct all clinically-indicated tests and studies. In addition, the examiner should render findings responsive to the following, to the extent feasible: a) Set forth all current complaints, findings, and diagnoses pertaining to the Veteran's cervical spine and right shoulder disorders and clearly distinguish which symptomatology corresponds to each service-connected disability. b) Provide range-of-motion and repetitive motion findings for the Veteran's cervical spine and right shoulder. c) Describe any pain, weakened movement, excess fatigability, or incoordination resulting from the Veteran's cervical spine and right shoulder disorders. 38 C.F.R. §§ 4.40, 4.45 (2013); Mitchell v. Shinseki, 25 Vet. App. 32 (2011); DeLuca v. Brown, 8 Vet. App. 202 (1995). d) State whether the Veteran's cervical spine and right shoulder disorders are manifested by any painful flare-ups, and, if so, the frequency and duration of such flare-ups. e) Specify whether any flare-ups with respect to the Veteran's cervical spine and right shoulder disorders are accompanied by any additional limitation of motion. Any determination should be portrayed in terms of the degree of additional range of motion loss. f) State the length of time during the past twelve months that the Veteran has had incapacitating episodes due to her cervical spine disorder. Incapacitating episodes are periods of acute signs and symptoms due to intervertebral disc syndrome that require rest prescribed by a physician and treatment by a physician. g) State whether the Veteran's service-connected cervical spine and right shoulder disorders are manifested by any neurological impairment, and, if so, which nerves are involved, and the extent of the impairment. The diagnostic criteria applicable to nerve impairment distinguish the types of paralysis as complete or incomplete. Under incomplete paralysis, the degree of paralysis is further divided into the categories of mild, moderate, and severe. With those categories in mind, classify any low back disorder neurological pathology, distinguishing among the categories and using the results of all pertinent testing of record. Conduct all necessary sensory, reflex, and motor testing, to specifically include EMG or nerve conduction velocity studies. Explain, in terms meaningful to a layperson, the base line results of those tests versus the results obtained for the Veteran. Explain the meaning of any abnormal results obtained. h) Discuss the degree of occupational impairment attributable to the Veteran's cervical spine and right shoulder disorders. In particular, describe what types of employment activities would be limited because of each service-connected disability, what types of employment would not be limited (if any), and whether any limitation on employment is likely to be permanent. i) Finally, provide detailed findings as to whether the Veteran's July 2013 cervical spine surgery has: (1) necessitated at least one month of convalescence; (2) resulted in severe postoperative residuals such as incompletely healed surgical wounds, stumps of recent amputations, therapeutic immobilization of one major joint or more, application of a body cast, or the necessity for house confinement, or the necessity for continued use of a wheelchair or crutches (regular weight-bearing prohibited; or, (3) immobilization by cast, without surgery, of one major joint or more. A report of the examination should be prepared and associated with the Veteran's claims file. A complete rationale must be provided for all opinions rendered. If the examiner cannot provide any of the requested opinions without resorting to speculation, he or she should expressly indicate this and provide a supporting rationale as to why an opinion cannot be made without resorting to speculation. 4. Thereafter, and following any other appropriate development, the remanded claims should be readjudicated, taking into account all pertinent evidence of record, including all evidence obtained pursuant to this remand. Ratings for any indicated periods of convalescence, pursuant to 38 C.F.R. § 4.30, during the appeals period should also be expressly considered . If any aspect of the appeal remains denied, the Veteran and her attorney should be furnished an appropriate SSOC and be afforded an opportunity to respond. Thereafter, the case should be returned to the Board for appellate review. 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. 2013). _________________________________________________ K. A. KENNERLY Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs