Citation Nr: 1511484 Decision Date: 03/18/15 Archive Date: 03/27/15 DOCKET NO. 12-13 096 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Anchorage, Alaska THE ISSUES 1. Whether new and material evidence has been received in order to reopen a claim of service connection for right arm numbness, to include carpal tunnel syndrome. 2. Whether new and material evidence has been received in order to reopen a claim of service connection for left arm numbness, to include carpal tunnel syndrome. 3. Entitlement to service connection for right arm numbness, to include carpal tunnel syndrome, claimed as secondary to the service-connected cervical spine disability. 4. Entitlement to service connection for left arm numbness, to include carpal tunnel syndrome, claimed as secondary to the service-connected cervical spine disability. 5. Entitlement to a rating in excess of 10 percent for a cervical spine disability, to include cervical strain. 6. Entitlement to a rating in excess of 10 percent for temporomandibular joint disorder (TMJ), with headaches. REPRESENTATION Appellant represented by: Veterans of Foreign Wars of the United States WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD A. Lindio, Counsel INTRODUCTION The Veteran served on active duty from April 1986 to April 1989. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a rating decision issued in March 2010 by the Department of Veterans Affairs (VA) Regional Office (RO) in Anchorage, Alaska. The Board recognizes that the Veteran has previously claimed service connection for carpal tunnel syndrome of the bilateral upper extremities, but in her current claim requested service connection for "bilateral numbness in arms". A change in diagnosis or specificity of the claim must be carefully considered in determining the etiology of a potentially service-connected condition and whether the new diagnosis is a progression of the prior diagnosis, correction of an error in diagnosis, or development of a new and separate condition. See 38 C.F.R. §§ 4.13, 4.125; see also Boggs v. Peake, 520 F.3d 1330 (Fed. Cir. 2008); Velez v. Shinseki, 23 Vet. App. 199 (2009). In determining whether new and material evidence is required, the focus of the Board's analysis must be on whether the evidence presented truly amounts to a new claim "based upon distinctly diagnosed diseases or injuries" (Boggs, 520 F.3d at 1337 ), or whether it is evidence tending to substantiate an element of a previously adjudicated matter. See Velez, 23 Vet. App. at 204. Multiple theories pertaining to the same benefit constitute the same claim. See Roebuck v. Nicholson, 20 Vet. App. 307, 313 (2006). In her prior claims, the Veteran similarly claimed that her arm numbness, then claimed as due to carpal tunnel syndrome, was due to her service-connected cervical spine disability. The Board finds that the record fails to show a new factual basis upon which the claim for service connection for arm numbness is based. Therefore, new and material evidence is necessary to reopen the claim. Accordingly, the issues have been recharacterized as such. The Board also finds that adjudicating the new and material evidence issue in the first instance is not prejudicial to the Veteran as the Board finds that there is new and material evidence of record to reopen the claim. In May 2013, the Veteran testified during a hearing before the undersigned Veterans Law Judge at the RO; a transcript of that hearing is of record. In September 2013, the Veteran submitted additional evidence and argument in support of her claims on appeal. In February 2015, the Veteran's representative waived RO consideration of such evidence. As such, there is no prejudice in the Board reviewing this evidence in the first instance. See 38 C.F.R. § 20.1304. The Board notes that, in addition to the paper claims file, the Veteran also has electronic Virtual VA and Veteran Benefits Management System (VBMS) paperless claims files. A review of the documents in such files reveals that they are either duplicative of the evidence in the paper claims file or are irrelevant to the issues on appeal, or were considered by the RO in the August 2012 supplemental statement of the case. Additionally, in February 2015, the Veteran, through his representative, submitted a waiver of the RO's review of the additional evidence submitted. FINDINGS OF FACT 1. In a final decision issued in June 2008, the RO determined that new and material evidence sufficient to reopen a claim of entitlement to service connection for carpal tunnel syndrome had not been received. 2. Evidence added to the record since the final June 2008 denial is not cumulative or redundant of the evidence of record at the time of the decision and raises a reasonable possibility of substantiating the Veteran's claim of entitlement to service connection for numbness of the right and left arms. 3. Right arm numbness is not shown to be causally or etiologically related to any disease, injury, or incident in service or due to or aggravated by a service-connected disability. 4. Left arm numbness is not shown to be causally or etiologically related to any disease, injury, or incident in service or incident in service or due to or aggravated by a service-connected disability. 5. For the entire appeal period, the Veteran's cervical spine disability is manifested by flexion greater than 30 degrees, combined range of motion of greater than 170 degrees, no muscle spasm or guarding severe enough to result in abnormal gait or spinal contour, and no ankylosis. 6. Giving the Veteran the benefit of the doubt, for the entire appeal period, the Veteran's TMJ is manifested by pain on chewing, popping, and limited range of motion. 7. For the entire appeal period, the Veteran's headaches are not manifested by prostrating attacks. CONCLUSIONS OF LAW 1. The June 2008 rating decision that determined that new and material evidence sufficient to reopen a claim of entitlement to service connection for carpal tunnel syndrome (right and left upper extremity) had not been received is final. 38 U.S.C.A. § 7105(c) (West 2014); 38 C.F.R. §§ 3.104, 20.302, 20.1103 (2014). 2. New and material evidence has been received to reopen the claim of entitlement to service connection for numbness of the right and left arms, also claimed as carpal tunnel syndrome. 38 U.S.C.A. § 5108 (West 2014); 38 C.F.R. § 3.156(a) (2014). 3. Right arm numbness was not incurred in or aggravated by the Veteran's active duty military service, including as secondary to service-connected cervical spine disability. 38 U.S.C.A. §§ 1110, 1131, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.309, 3.310 (2014). 4. Left arm numbness was not incurred in or aggravated by the Veteran's active duty military service, including as secondary to service-connected cervical spine disability. 38 U.S.C.A. §§ 1110, 1131, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.309, 3.310 (2014). 5. For the entire appeal period, the criteria for a rating in excess of 10 percent for cervical spine disability have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.3, 4.7, 4.71a, Diagnostic Code 5237 (2014). 6. Giving the Veteran the benefit of the doubt, for the entire appeal period, the criteria for a rating of 20 percent, and no higher, for TMJ have been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.3, 4.7, 4.150, Diagnostic Code 9905 (2014). 7. For the entire appeal period, the criteria for a separate, compensable rating for headaches have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.3, 4.7, 4.124a, Diagnostic Code 8100 (2014). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. VA's Duties to Notify and Assist 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 (West 2014); 38 C.F.R §§ 3.102, 3.156(a), 3.159, 3.326(a) (2014). Proper VCAA notice must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b)(1). In addition, the notice requirements of the VCAA apply to all five elements of a service-connection claim, including: (1) Veteran status; (2) existence of a disability; (3) a connection between the Veteran's service and the disability; (4) degree of disability; and (5) effective date of the disability. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). Further, this notice must include information regarding the disability rating and effective date for the award of benefits if service connection is awarded. Id. at 486. In Pelegrini v. Principi, 18 Vet. App. 112 (2004), the Court held that a VCAA notice, as required by 38 U.S.C.A. § 5103(a), must be provided to a claimant before the initial unfavorable AOJ decision on the claim for VA benefits. The U.S. Court of Appeals for the Federal Circuit previously held that any errors in notice required under the VCAA should be presumed to be prejudicial to the claimant unless VA shows that the error did not affect the essential fairness of the adjudication. See Sanders v. Nicholson, 487 F.3d 881 (Fed. Cir. 2007). Under Sanders, VA bore the burden of proving that such an error did not cause harm. Id. In the case Shinseki v. Sanders, 129 S.Ct. 1696 (2009), however, the U.S. Supreme Court held that the Federal Circuit's blanket presumption of prejudicial error in all cases imposed an unreasonable evidentiary burden upon VA. Rather, in Shinseki v. Sanders, the Supreme Court suggested that determinations concerning prejudicial error and harmless error should be made on a case-by-case basis. Id. As such, in conformance with the precedents set forth above, on appellate review the Board must consider, on a case-by-case basis, whether any potential VCAA notice errors are prejudicial to the claimant. In Kent v. Nicholson, 20 Vet. App. 1 (2006), the Court held that the VCAA notice requirements in regard to new and material evidence claims require VA to send a specific notice letter to the claimant that: (1) notifies him or her of the evidence and information necessary to reopen the claim (i.e., describes what is meant by new and material evidence); (2) identifies what specific evidence is required to substantiate the element or elements needed for service connection that were found insufficient in the prior denial on the merits; and (3) provides general VCAA notice for the underlying service connection claim. The RO provided a November 2009 letter with information consistent with those requirements. However, VA has since determined that such requirements are not necessary as they are inconsistent with the subsequent Federal Circuit decisions in Vazquez-Flores v. Shinseki, 580 F.3d 1270, 1277 (Fed. Cir. 2009) ("Vazquez-Flores II') and Wilson v. Mansfield, 506 F.3d 1055, 1059 (Fed. Cir. 2007). See VAOPGCREC 6-2014 (2014). Additionally, the November 2009 letter, issued prior to the initial March 2010 rating decision, advised the Veteran of the evidence and information necessary to substantiate her service connection claims, to include on a secondary basis, as well as her and VA's respective responsibilities in obtaining such evidence and information. That letter also included notice of the evidence and information necessary to establish a disability rating and an effective date in accordance with Dingess/Hartman, supra. Under these circumstances, the Board finds that the notification requirements of the VCAA have been satisfied as to both timing and content. Therefore, adequate notice was provided to the Veteran prior to the transfer and certification of her case to the Board and VA has complied with the requirements of 38 U.S.C. § 5103(a) and 38 C.F.R. § 3.159(b). VA has a duty to assist the Veteran in developing her claim, which includes assisting the Veteran in obtaining any outstanding records of identified VA or private medical treatment relevant to his claim, and affording him an examination when appropriate. Relevant to the duty to assist, the Veteran's service treatment records as well as post-service VA and private treatment records have been obtained and considered. To the extent that more recent VA medical records have not been associated with the claims file, the Veteran has not reported that such evidence should be obtained or is relevant. Rather, she appears to have already provided the new relevant evidence, in September 2013, and waived RO consideration of such evidence in February 2015. Therefore, the Board finds that VA has met its duty to assist the Veteran in obtaining relevant records. The Veteran also received multiple VA examinations, including in February 2010 and March 2012 for her spine and upper extremities claims, as well as, in January 2010, May and June 2012 for her TMJ, and February 2010 and June 2012 for headaches. The Board finds that such VA examinations and accompanying opinions are adequate to decide the issues as they are predicated on an interview with the Veteran; a review of the record, to include her available service treatment records; and a physical examination. The opinions proffered considered all of the pertinent evidence of record, to include the statements of the Veteran, and provided a complete rationale, relying on and citing to the records reviewed. Moreover, the examiners offered clear conclusions with supporting data as well as reasoned medical explanations connecting the two. In regards to the increased rating claim, the VA examiners also addressed the relevant rating criteria. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008); Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007) ("[A]medical opinion ... must support its conclusion with an analysis that the Board can consider and weigh against contrary opinions"). To the extent that the last VA examination for TMJ has been unclear as to his findings, as the Board is giving the Veteran the benefit of the doubt as to those findings, she is not prejudiced by its consideration of such evidence. Accordingly, the Board finds that VA's duty to assist with respect to obtaining a VA examination and opinion regarding the issue decided herein has been met. Additionally, in May 2013 the Veteran had the opportunity to set forth her contentions during the hearing before the undersigned Veterans Law Judge. In Bryant v. Shinseki, 23 Vet. App. 488 (2010), the Court held that 38 C.F.R. § 3.103(c)(2) requires that the Decision Review Officer or Veterans Law Judge who chairs a hearing to fulfill two duties: (1) the duty to fully explain the issues and (2) the duty to suggest the submission of evidence that may have been overlooked. Here, during the Veteran's hearing, the undersigned noted the issues on appeal and the type of evidence needed to support her claims. Additionally, testimony regarding the Veteran's theory that her numbness of the right and left arms developed due to her cervical spine disability, as well as the severity of the symptoms that she relates to her service-connected disabilities. She further read a statement into the hearing outlining her allegations. Therefore, not only were the issues "explained . . . in terms of the scope of the claim for benefits," but "the outstanding issues material to substantiating the claim," were also fully explained. See Bryant, 23 Vet. App. at 497. As such, the Board finds that, consistent with Bryant, the undersigned complied with the duties set forth in 38 C.F.R. § 3.103(c)(2) and that the Board may proceed to adjudicate the claim based on the current record. Thus, the Board finds that VA has fully satisfied the duty to assist. In the circumstances of this case, additional efforts to assist or notify the Veteran in accordance with the VCAA would serve no useful purpose. See Soyini v. Derwinski, 1 Vet. App. 540, 546 (1991) (strict adherence to requirements of the law does not dictate an unquestioning, blind adherence in the face of overwhelming evidence in support of the result in a particular case; such adherence would result in unnecessarily imposing additional burdens on VA with no benefit flowing to the appellant); Sabonis v. Brown, 6 Vet. App. 426, 430 (1994) (remands which would only result in unnecessarily imposing additional burdens on VA with no benefit flowing to the appellant are to be avoided). VA has satisfied its duty to inform and assist the Veteran at every stage in this case, at least insofar as any errors committed were not harmful to the essential fairness of the proceeding. Therefore, she will not be prejudiced as a result of the Board proceeding to the merits of hers claims. II. New and Material Evidence Claims The Veteran contends that her numbness of the right and left arms, previously claimed as carpal tunnel syndrome, developed secondary to her service-connected cervical spine disability. A November 2007 rating decision originally denied the claim for service connection for carpal tunnel syndrome. At the time of such decision, the Veteran's service treatment, as well as post-service VA and private treatment records and a July 2007 VA examination were of record. The RO found that the VA examiner found that her carpal tunnel syndrome was not caused by her cervical spine disability. In a June 2008 rating decision, the RO found that new and material evidence had not been submitted to reopen the claims of service connection for carpal tunnel syndrome, (right and left numbness of the upper extremities). The Veteran did not appeal the November 2007 and June 2008 RO decisions. Rating actions are final and binding based on evidence on file at the time the claimant is notified of the decision and may not be revised on the same factual basis except by a duly constituted appellate authority. 38 C.F.R. § 3.104(a). The claimant has one year from notification of an RO decision to initiate an appeal by filing a notice of disagreement with the decision, and the decision becomes final if an appeal is not perfected within the allowed time period. 38 U.S.C.A. § 7105(b) and (c); 38 C.F.R. §§ 3.160(d), 20.200, 20.201, 20.202, and 20.302(a). In November 2007, the RO advised the Veteran of the rating decision and her appellate rights. She did not submit a notice of disagreement within one year of the rating decision. The Board has considered the applicability of 38 C.F.R. § 3.156(b), which provides that, when new and material evidence is received prior to the expiration of the appeal period, it will be considered as having been filed in connection with the claim which was pending at the beginning of the appeal period. That regulation is applicable here, as she subsequently submitted private medical evidence within a year of her decision. See also Bond v. Shinseki, 659 F.3d 1362, 1367 (Fed. Cir. 2011); Roebuck v. Nicholson, 20 Vet. App. 307, 316 (2006); Muehl v. West, 13 Vet. App. 159, 161-62 (1999). The RO subsequently issued another rating decision in June 2008; however, given that the Veteran had submitted evidence in conjunction with her November 2007 rating decision, the Board finds that the November 2007 rating decision had continued to be on appeal at that time. Thereafter, the RO issued a September 2009 statement of the case. The Veteran, however, did not file a substantive appeal with that decision. Therefore, the November 2007 and June 2008 rating decisions are final. 38 U.S.C.A. § 7105(c); 38 C.F.R. §§ 3.104, 20.302, 20.1103. Generally, a claim which has been denied in an unappealed Board decision or an unappealed RO decision may not thereafter be reopened and allowed. 38 U.S.C.A. §§ 7104(b), 7105(c). The exception to this rule is 38 U.S.C.A. § 5108, which provides that, if new and material evidence is presented or secured with respect to a claim which has been disallowed, the Secretary shall reopen the claim and review the former disposition of the claim. New evidence means existing evidence not previously submitted to agency decision makers. Material evidence means existing evidence that, by itself or when considered with previous evidence of record, relates to an unestablished fact necessary to substantiate the claim. New and material evidence can be neither cumulative nor redundant of the evidence of record at the time of the last prior final denial of the claim sought to be reopened, and must raise a reasonable possibility of substantiating the claim. 38 C.F.R. § 3.156(a). The Court has held that the determination of whether newly submitted evidence raises a reasonable possibility of substantiating the claim should be considered a component of the question of what is new and material evidence, rather than a separate determination to be made after the Board has found that evidence is new and material. See Shade v. Shinseki, 24 Vet. App. 110 (2010). The Court further held that new evidence would raise a reasonable possibility of substantiating the claim if, when considered with the old evidence, it would at least trigger the Secretary's duty to assist by providing a medical opinion. Id. For the purpose of establishing whether new and material evidence has been submitted, the credibility of the evidence is to be presumed. Justus v. Principi, 3 Vet. App. 510, 513 (1992). Since the June 2008 rating decision, additional evidence consisting of private and VA treatment records and lay statements have been received. In this regard, February 2010 and March 2012 VA examinations provided etiological medical opinions regarding the claimed disorders. The Board concludes that the evidence received since the prior final denial is new in that it was not previously of record. It is material because it relates to unestablished facts necessary to substantiate the claim. Therefore, the Board finds that such evidence is new and material evidence, as it relates to the underlying claims of service connection. Accordingly, the claims of entitlement to service connection for numbness of the right and left arms are reopened. III. Service Connection of the Right and Left Arms The Veteran contends that she has numbness of both the right and left arms, previously claimed as carpal tunnel syndrome, due to her service-connected cervical spine disability. Service connection is warranted where the evidence of record establishes that a particular injury or disease resulting in disability was incurred in the line of duty in the active military service or, if pre-existing such service, was aggravated thereby. 38 U.S.C.A. 1110, 1131 (West 2014); 38 C.F.R. 3.303(a) (2014). Generally, in order to prove service connection, there must be competent, credible evidence of (1) a current disability, (2) in-service incurrence or aggravation of an injury or disease, and (3) a nexus, or link, between the current disability and the in-service disease or injury. See, e.g., Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009); Pond v. West, 12 Vet. App. 341 (1999). In some cases, service connection may also be established under 38 C.F.R. § 3.303(b) by (a) evidence of (i) a chronic disease shown as such in service (or within an applicable presumptive period under 38 C.F.R. § 3.307) and (ii) subsequent manifestations of the same chronic disease, or (b) if the fact of chronicity in service in not adequately supported, by evidence of continuity of symptomatology. However, the United States Court of Appeals for the Federal Circuit has held that the provisions of 38 C.F.R. § 3.303(b) relating to continuity of symptomatology can be applied only in cases involving those conditions explicitly recognized as chronic under 38 C.F.R. § 3.309(a). Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Service connection may be established on a secondary basis for a disability which is proximately due to or the result of service-connected disease or injury. 38 C.F.R. § 3.310(a). Establishing service connection on a secondary basis requires evidence sufficient to show (1) that a current disability exists and (2) that the current disability was either (a) proximately caused by or (b) proximately aggravated by a service-connected disability. Allen v. Brown, 7 Vet. App. 439, 448 (1995) (en banc). The Board notes that effective October 10, 2006, before the Veteran filed her claim, the provisions of 38 C.F.R. § 3.310 were changed to state that service connection may not be awarded on the basis of aggravation without establishing a pre-aggravation baseline level of disability and comparing it to the current level of disability. 38 C.F.R. § 3.310(b). The Veteran has not claimed, and the Board does not find, that the Veteran has numbness of the right and left arms directly related to service. The medical evidence of record does not support making such a finding. Rather, the service treatment records are negative for any complaints of, or treatment for, such a disorder. Indeed, they include negative findings of neurological problem (June 1987 service treatment record) and a specific denial of radiation and paresthesia (August 1987 service treatment record). Additionally, post-service records are negative for any complaints of, or treatment for, numbness of the right and left arms for years following service. Indeed, following her April 1989 separation from service, the Veteran underwent an April 1993 VA examination. On that examination, she denied having any neurological weakness and paresthesias; the examiner found no neurologic findings. The examiner found that she had a thoracic compression fracture, without evidence of spinal cord or neurological involvement. The Veteran herself has also denied having problems with numbness of the right and left arms until years following her discharge from service. (May 2013 Board hearing). Also, the only medical opinion to address this question was that of the March 2012 VA examiner. That physician opined that the claimed condition was less likely than not (less than 50 percent probability) incurred in or caused by the claimed in-service injury, event, or illness. She noted the Veteran's in-service car accident that caused her cervical spine disability, but noted that service treatment records were negative for radiculopathy. She further noted that the Veteran did not have recorded symptoms until after she began working at Kaladi Brothers Coffee Company, at which time she developed symptoms of carpal tunnel syndrome. The examiner also diagnosed her with distal bilateral ulnar dysfunction (wrist level) and right carpal tunnel syndrome based on prior examination and testing), the ulnar and median nerve findings. However, the examiner determined that given the distance in time between the 1987 in-service accident and the development or first documentation, almost 20 years later, she was unable to establish a nexus for such disabilities and service. The Board finds that there is no probative medical evidence supportive of finding that service connection on a direct or presumptive basis for numbness of the right and left arms. Rather, such evidence indicates that the disorder developed many years following service and did not develop due to service. As such, service connection on a direct basis or presumptive basis is not warranted for either right or left arm numbness. The Board further finds that service connection for numbness of the right and left arms secondary to the service-connected cervical spine disability is not warranted. The most probative evidence of record does not support the Veteran's contentions. The Veteran filed her initial claim regarding the arms, then characterized as carpal tunnel syndrome, in June 2007. The medical evidence of record support current findings of carpal tunnel syndrome, but such evidence does not support finding that it developed secondary to the cervical spine disability. VA medical records generally document complaints of, or treatment for, numbness, with a diagnosis of carpal tunnel syndrome. (July 6, 2007). A September 2013 MRI report noted a clinical history of neck pain with radiculopathy, but the actual findings were a normal signal within the cervical cord and no findings regarding radiculopathy were made. A May 2007 EMG report, from Alaska Rehabilitation Medicine, showed normal studies without electrodiagnostic evidence of a focal peripheral median or ulnar neuropathy nor cervical radiculopathy. Rather, the EMG found that the Veteran's symptoms were consistent with mild carpal tunnel syndrome. A July 2007 VA examiner also diagnosed her with mild, bilateral carpal tunnel syndrome, with normal nerve conduction. She noted that the Veteran reported it began around 2002. She opined that the carpal tunnel syndrome was not caused by or a result of the back condition and limited motion of the cervical spine. The physician explained that electrodiagnostic testing had been normal and there was no evidence of cervical or thoracic radiculopathy. Similarly, a February 2010 VA examiner, following examination, opined that bilateral numbness in the arms was less likely as not caused by or a result of cervical strain. That physician explained that even without available electrodiagnostic testing and recent MRI of the spine, her clinical presentation since 2007 supported a diagnosis of carpal tunnel syndrome. She further explained that bilateral carpal tunnel syndrome is a peripheral neuropathy, not related to cervical neuropathy or radiculopathy. A March 2012 VA examiner diagnosed the Veteran with distant bilateral ulnar neuropathy and distal right median nerve neuropathy (carpal tunnel syndrome right hand). On examination, the examiner found no radicular pain or other signs or symptoms due to radiculopathy. The examiner opined that the Veteran's disorders were not caused or aggravated by her service-connected cervical spine disability. Rather, she found that the cervical spine disability and distal carpal tunnel syndrome/ulnar dysfunction symptoms were independent and separate conditions. She explained that the symptoms did not develop until the Veteran began working at the coffee shop. Also, at the time of examination, the examiner found that the Veteran had a biomechanical cervical strain only. Also, based on clinical findings and supported by prior examination and testing, the ulnar and median nerve findings are distal and independent from the biomechanical strain of the cervical spine. Specifically, the peripheral nerve symptoms are distal (at wrist level) and independent for the cervical condition. Furthermore, the examiner determined there was bilateral distal nerve dysfunction (wrist level -ulnar and carpal tunnel signs). The only medical evidence supportive of her claim is from her private chiropractor, C.V. Garden and Dr. K.R. Pervier. In an October 2007 statement, C.V. Garden, noted that the Veteran had nerve impingement syndrome that is replicating carpal tunnel syndrome like symptoms. In a May 2009 letter, he reported that she had cervical nerve root compression complicated by cervical disc degeneration and arthritis, as well as, carpal tunnel syndrome. In May 2009, Dr. K.R. Pervier noted that the Veteran had mild-to-moderate carpal tunnel syndrome of the right wrist and Martin-Gruber anastomosis with median conduction response carried by the ulnar nerve, as well as ulnar nerve impingement at the wrist and around the elbow. He found that the Veteran "has multiple areas of impingement of the ulnar and median nerve...likely some inflammation and scissoring of the brachial plexi...shoulder and lower neck". It is the responsibility of the Board to assess the credibility and weight to be given the evidence. See Hayes v. Brown, 5 Vet. App. 60, 69-70 (1993) (citing Wood v. Derwinski, 1 Vet. App. 190, 192-93 (1992)). The probative value of medical evidence is based on the physician's knowledge and skill in analyzing the data, and the medical conclusion the physician reaches; as is true of any evidence, the credibility and weight to be attached to medical opinions are within the province of the Board. See Guerrieri v. Brown, 4 Vet. App. 467, 470-71 (1993). When reviewing such medical opinions, the Board may appropriately favor the opinion of one competent medical authority over another. See Owens v. Brown, 7 Vet. App. 429, 433 (1995). However, the Board may not reject medical opinions based on its own medical judgment. Obert v. Brown, 5 Vet. App. 30 (1993); see also Colvin v. Derwinski, 1 Vet. App. 171 (1991). In assessing medical opinions, the failure of the physician to provide a basis for his opinion goes to the weight or credibility of the evidence in the adjudication of the merits. See Hernandez-Toyens v. West, 11 Vet. App. 379, 382 (1998). Other factors for assessing the probative value of a medical opinion are the physician's access to the claims file and the thoroughness and detail of the opinion. See Prejean v. West, 13 Vet. App. 444, 448-49 (2000). However, a medical opinion may not be discounted solely because the examiner did not review the claims file. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). The Board finds that the multiple negative medical opinions by the VA examiners are more probative than the positive medical opinions of C.V. Garden and Dr. K.R. Pervier. The VA examiners, especially the March 2012 VA examiner, provided the most thorough and detailed medical opinions. C.V. Garden merely noted that the Veteran had nerve impingement syndrome that is replicating carpal tunnel syndrome like symptoms (October 2007 statement) and cervical nerve root compression complicated by cervical disc degeneration and arthritis, as well as, carpal tunnel syndrome (May 2009 letter). Additionally, his findings are inconsistent with the objective medical evidence of record. The September 2013 VA MRI report specifically found that the signal within the cervical cord was normal. The Board further notes that although C.V. Garden reported nerve impingement syndrome and cervical nerve root compression, the private medical records from Garden Chiropractic generally indicate only treatment for carpal tunnel syndrome. Indeed, in a May 27, 2009 record, the chiropractor noted that the neurologist, "Dr. P." [presumably Dr. K.R. Pervier who provided the May 2009 EMG study] had done a nerve condition needle and diagnosed her with carpal tunnel syndrome. He did not indicate that the EMG findings were consistent with radiculopathy. As to Dr. K.R. Pervier's finding that the Veteran had "likely some inflammation and scissoring of the brachial plexi...shoulder and lower neck", the examiner did not provide as complete an explanation as the VA examiners in reaching his determination. He also did not provide an opinion relating the numbness to the specific, service-connected disability. In contrast, the VA examinations, especially the March 2012 examination, were based on interview and examination of the Veteran; a thorough review of the record, including the Veteran's comprehensive treatment records and claims file; and a thoughtful analysis of the Veteran's entire history. Furthermore, the findings of the examiners are generally consistent with the Veteran's medical history and objective testing. The only other evidence of record supportive of the Veteran's claim is her contention that the numbness of the right and left arms developed due to her service-connected cervical spine disability. Although lay persons are competent to provide opinions on some medical issues, see Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011), as to the specific issues in this case, i.e., whether the Veteran has a medically diagnosed disorder disability etiologically related to a specific medical disability, such questions falls outside the realm of common knowledge of a lay person as they involve a medical subject concerning an internal physical process extending beyond an immediately observable cause-and-effect relationship. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007) (lay persons not competent to diagnose cancer); see also Woehlaert v. Nicholson, 21 Vet. App. 456 (2007) (although the claimant is competent in certain situations to provide a diagnosis of a simple condition such as a broken leg or varicose veins, the claimant is not competent to provide evidence as to more complex medical questions). The Board notes that the Veteran's husband provided a January 2010 lay statement, to the effect that the Veteran would wake up at night with numbness and tingling in her arms and hands and that she reported pain and numbness through her day. The Board notes that such a report is not a medical opinion, but an observation of symptoms. Additionally, in May 2009, Dr. K.R. Pervier noted that the Veteran "has a tendency to have her hands go numb...with use...also wake up...arms numb, which is quite typical of either carpal tunnel syndrome and/or chronic inflammatory changes in the muscles at the base of the neck and shoulder." As such, those observed symptoms could be related to the Veteran's carpal tunnel syndrome, which none of the VA examiners or private medical providers have related to the service-connected cervical spine disability. The weight of the most probative medical evidence demonstrates that the Veteran does not have a disability manifested by right and/or left arm numbness, to include carpal tunnel syndrome, due to service or her service-connected cervical spine disability. As the preponderance of the evidence is against this claim, the benefit of the doubt rule does not apply. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Service connection for right and left arm numbness is denied. IV. Increased Rating Law Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities, found in 38 C.F.R., Part 4. The Rating Schedule is primarily a guide in the evaluation of disability resulting from all types of diseases and injuries encountered as a result of or incident to military service. The ratings are intended to compensate, as far as can practicably be determined, the average impairment of earning capacity resulting from such diseases and injuries and their residual conditions in civilian occupations. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. 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 for that rating. Otherwise the lower rating will be assigned. 38 C.F.R. § 4.7. All benefit of the doubt will be resolved in the Veteran's favor. 38 C.F.R. § 4.3. However, the Court has held that in determining the present level of a disability for any increased evaluation claim, the Board must consider the application of staged ratings. See Hart v. Mansfield, 21 Vet. App. 505 (2007). In other words, where the evidence contains factual findings that demonstrate distinct time periods in which the service-connected disability exhibited diverse symptoms meeting the criteria for different ratings during the course of the appeal, the assignment of staged ratings would be necessary. A. Law Specific to the Cervical Spine Disability Cervical spine disabilities are rated on the basis of limitation of motion, with evaluations assigned under the General Rating Formula for Diseases and Injuries of the Spine. The General Rating Formula for Diseases and Injuries of the Spine assigns evaluations with or without symptoms such as pain (whether or not it radiates), stiffness, or aching in the area of the spine affected by the residuals of the injury or disease. A note following the schedular criteria indicates that, for VA compensation purposes, normal forward flexion of the cervical spine is from 0 to 45 degrees, extension from 0 to 45 degrees, left and right lateral flexion from 0 to 45 degrees, and left and right lateral rotation from 0 to 80 degrees. C.F.R. § 4.71a. In the alternative, an evaluation can be assigned under the Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes. Diagnostic Codes 5235-5243. The General Rating Formula for Diseases and Injuries of the Spine provides that a 20 percent rating is assigned for forward flexion of the cervical spine greater than 15 degrees but not greater than 30 degrees; or a combined range of motion of the cervical spine not greater than 170 degrees; or muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. A disability evaluation of 30 percent would be warranted upon a showing of favorable ankylosis of the entire cervical spine or forward flexion of the cervical spine of 15 degrees or less. A 40 percent evaluation would only be warranted if there is unfavorable ankylosis of the entire cervical spine. A 50 percent rating requires unfavorable ankylosis of the entire thoracolumbar spine. A 100 percent rating is granted if the Veteran has unfavorable ankylosis of the entire spine. 38 C.F.R. § 4.71a. B. Law Specific to TMJ, with Headaches Under Diagnostic Code 9905, a 10 percent rating is warranted when the range of lateral excursion is limited from 0 to 4 millimeters (mm) or the inter-incisal range is limited to 31 to 40 mm. A 20 percent evaluation is applicable when the inter-incisal range is limited to 21 to 30 mm, and a 30 percent rating is for contemplation when the inter-incisal range is limited to 11 to 20 mm. A 40 percent rating is assigned when the inter-incisal range is limited to 0 to 10 mm. 38 C.F.R. § 4.150, Diagnostic Code 9905. Under Diagnostic Code 8100, migraine headaches are evaluated as follows: a 50 percent rating is assigned with very frequent completely prostrating and prolonged attacks productive of severe economic inadaptability; a 30 percent rating is assigned with characteristic prostrating attacks occurring on an average once a month over last several months; a 10 percent rating is assigned with characteristic prostrating attacks averaging one in 2 months over last several months; and, a non- compensable rating is assigned with less frequent attacks. 38 C.F.R. § 4.124a, Diagnostic Code 8100. V. Cervical Spine Disability Increased Rating Claim The Veteran contends that her cervical spine disability, to include strain, is more severe than indicated by her current 10 percent disability rating. The Board finds that evidence of record does not support finding that her cervical spine disability warrants a disability rating in excess of 10 percent. During the current appeal period, the only medical evidence to provide findings necessary for rating purposes were the February 2010 and March 2012 VA examinations. In order to warrant a 20 percent rating, forward flexion of the cervical spine should be greater than 15 degrees but not greater than 30 degrees; or a combined range of motion of the cervical spine not greater than 170 degrees; or muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. Both the VA examiners found forward flexion greater than 30 degrees; there was 45 degrees in February 2010 and 45 degrees or greater in March 2012, without objective evidence of pain or loss of motion with repetition. Also, the combined range of motion was consistently greater than 170 degrees; there was 300 degrees in February 2010 and 330 degrees in March 2012, without significant change following repetition. Additionally, although the February 2010 VA examiner noted an abnormal spinal contour, of kyphosis and lumbar lordosis, she did not indicate that such conditions were due to muscle spasm or guarding. Rather, she found that the Veteran did not have any muscle spasms on examination. The March 2012 VA examiner specifically found that the Veteran did not have guarding or muscle spasm of the cervical spine, to include spasm that would result in abnormal gait or abnormal spinal contour. That VA examiner also noted a normal gait. Moreover, the September 2013 MRI noted some mild curvature to the right, but only noted straightening of normal cervical lordosis, rather than find an abnormal spinal contour. Even higher ratings were also not demonstrated by the record, which would require ankylosis of the spine or flexion less than 15 degrees. Both VA examiners found no ankylosis and flexion that was much greater than 15 degrees. The VA examiners did not indicate that the Veteran reported painful motion with the full range of motion; however, to the extent that the Veteran may be reporting pain associated with her full range of motion, the Court has recently held that "pain itself does not rise to the level of functional loss as contemplated by VA regulations applicable to the musculoskeletal system." Mitchell v. Shinseki, 25 Vet. App. 32, 42 (2011). Indeed, the Court found that nothing in its case law supports an appellant's contentions that she should be given the maximum disability ratings under Diagnostic Code 5260 and 5261 simply because she experienced pain throughout the range of motion of her left knee. Id. at 11. It is necessary to consider, along with the schedular criteria, functional loss due to flare-ups of pain, fatigability, incoordination, pain on movement and weakness. See DeLuca v. Brown, 8 Vet. App. 202 (1995). The Board finds that there is evidence of functional impairment as a result of flare-ups of symptomatology, but that this functional impairment was contemplated by the RO when granting the 10 percent disability evaluations. The Board notes that even following repetitive motion, the Veteran's range of motion was still consistently well above what would be necessary to qualify for a disability rating in excess of 10 percent. Indeed, both VA examiners noted that the Veteran did not demonstrate objective evidence of pain on motion. Also, ankylosis for an even higher rating was not of record. The Board must also evaluate any associated objective neurological abnormalities separately under an appropriate diagnostic code. Under Note 1, any associated objective neurologic abnormalities, including, but not limited to, bowel or bladder impairment, should be separately rated under an appropriate diagnostic code. As discussed above, the Board has found that she does not have a neurological disorder of either upper extremity due to her cervical spine disability. Additionally, in both her VA examinations, she denied having bowel or bladder impairment. With respect to intervertebral disc syndrome, under Diagnostic Code 5243, based on incapacitating episodes, a 20 percent rating, would require incapacitating episodes of a total duration of at least two weeks but less than four weeks during the past 12 months, with an "incapacitating episode" defined as a period of acute signs and symptoms due to intervertebral disc syndrome that required bed rest prescribed by a physician and treatment by a physician. 38 C.F.R. § 4.71a. Even higher ratings would require more episodes of incapacitation. No evidence shows that the Veteran had incapacitating episodes prescribed by a physician or as part of a physician's treatment for her service-connected back disability. The February 2010 and March 2012 VA examiners both found that she did not have intervertebral disc syndrome of the cervical spine. There is also no evidence that the Veteran was ever hospitalized for her disability. In light of the foregoing, the Board that the preponderance of the evidence is against a disability rating in excess of 10 percent for cervical spine disability. VI. TMJ, with Headaches The Veteran contends that her service-connected TMJ, with headaches, is more severe than indicated by her current 10 percent disability rating. A January 1999 rating decision granted service connection for TMJ with headaches, with a 10 percent disability rating. The Veteran has reported difficulty performing activities with her mouth, not being able to enjoy chewy foods, and a jaw dislocation once at work. She has also reported having headaches three to four times a week, light sensitivity, blurred vision and eye twitching. (May 2013 Board hearing and submitted written statement). In regards to the TMJ, during the appeal period, the Veteran underwent VA examinations in January 2010 and June 2012, with an October 2012 addendum. A July 2012 VA medical record also provides information relevant to rating the disability. The January 2010 VA examiner noted complaints of popping, clicking, crepitus. The examiner noted intercisional openings ranging from 31 to 41mm, for an average of 36mm. There was also a small deviation to the left and movement was not smooth. The examiner found that her intercisional and other movements had not lessened since her last examination, and was actually less restrictive in some cases. However, he found that given her episode of dislocation and report of increased pain, it was more likely than not that her TMJ had worsened. The June 2012 VA examiner found popping on left, with the first sounds at 14 mm then 20 mm. Range of motion testing revealed findings of 20, 16 and 20 mm with no pain; her jaw shook as she opened it. However, the examiner further noted that when he examined her and was talking to her, she produced much more range of motion. The examiner found her to have a limited range of motion, but noted that the measurements are "practiced"; in conversation and my exam, she opens much more. In July 2012, the RO contacted the June 2012 VA examiner for clarification regarding his finding of "practiced" range of motion. The examiner reported that the Veteran did not appear to provide effort during the objective measuring portion of the examination; it was reduced compared to how far she was able to open her mouth during other portions of the examiner. In an October 2012 addendum, the June 2012 VA examiner reported he reported that he wished to edit the Veteran's record regarding range of motion. He indicated that he did not state that her motions were "practiced". The June 2012 VA examiner also provided subsequent dental treatment to the Veteran. In an August 2012 VA medical record addendum, he reported that during her appointment the Veteran had been able to open her mouth 42-45 mm based on my knuckle, measured instruments, and insertion of impression trays for models. Per the January 2010 VA examination and August 2012 VA medical record, the Veteran's inter-incisal range is greater than 21 to 30 mm needed to warrant a 20 percent rating or higher (which would require an even greater level of limitation), under Diagnostic Code 9905. The June 2012 VA examiner, however, noted findings of 20, 16 and 20 mm, which would be consistent with a 30 percent disability rating, under Diagnostic Code 9905. Those findings are more questionable, given his initial reported of a "practiced" range of motion, essentially confirmed by the RO's contact with the examiner in July 2012, but then withdrawn by the examiner in October 2012. The majority of the evidence, though, is consistent with a 10 percent disability rating. Although the majority of the medical evidence does not support finding a disability rating in excess of 10 percent, the Board notes that she has reported symptoms of her TMJ and the January 2010 VA examiner noted that it had worsened since her last examination. Although the June 2012 VA examination had questionable findings, giving the Veteran the benefit of the doubt, they could be considered to indicate a more severe level of limitation than previously indicated. Giving the Veteran the benefit of the doubt, the Board finds that a 20 percent disability rating, and no higher, is warranted for the TMJ. A disability rating in excess of 20 percent, however, is not warranted. As previously noted, the only medical evidence of record supportive of such a finding is the June 2012 VA examination, but that examination is unclear as to the true level of her limitation. In contrast, the January 2010 VA examination provided clear findings consistent with a 10 percent disability rating. Also, the most recent evidence of record, the August 2012 VA medical record also documents findings consistent with a 10 percent disability rating. The Board has also considered whether a higher disability rating is warranted under other applicable diagnostic code provisions during either period on appeal. However, as the Veteran did not exhibit any nonunion of the mandible at any time period on appeal, a higher disability rating pursuant to Diagnostic Code 9903 and 9904 is not warranted. The Veteran also did not have ramus, loss of condyloid process, or loss of hard palate. See 38 C.F.R. § 4.150, Diagnostic Codes, 9907, 9909, 9912. Additionally, the Veteran has never been diagnosed with, nor does she contend, that her jaw disability manifests in chronic osteomyelitis or osteoradionecrosis of the maxilla or mandible, any loss of the mandible, any loss of the ramus, any loss of the condyloid, or any loss or malunion of the maxilla. Therefore, the Veteran is not entitled to a higher rating under Diagnostic Codes 9900-9902, 9906, 9908, 9911, and 9914-9916 during either period on appeal. 38 C.F.R. § 4.150. The potential disabling effects of pain have also been considered in evaluating the Veteran's service-connected TMJ. While she has complained of difficulty chewing, popping, clicking, and pain, the Board finds that this is already contemplated in the 20 percent rating granted. As previously noted, although some of the medical evidence does not support granting a disability rating in excess of 10 percent, the Board is giving her the benefit of the doubt as to a worsening of her condition. See DeLuca, 8 Vet. App. at 202. There is no showing of any other functional impairment which would warrant a higher rating for the complaints of pain. 38 C.F.R. §§ 4.7, 4.20, 4.40, 4.59, 4.130. In short, there is no showing of additional limitation of functional such as to enable a finding that the Veteran's disability picture most nearly approximates the disability rating in excess of 20 percent. As such, the Board finds that the evidence of record does not support finding a rating in excess of 20 percent. As to her headaches, the Veteran is not in receipt of a separate rating for that disability. The assignment of a particular diagnostic code is "completely dependent on the facts of a particular case." 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 diagnosis, and demonstrated symptomatology. Any change in a diagnostic code by a VA adjudicator must be specifically explained. Pernorio v. Derwinski, 2 Vet. App. 625, 629 (1992). In this case, the Veteran is essentially seeking a separate compensable rating for her service-connected headaches. Headaches are generally rated under Diagnostic Code 8100, for migraines. Under that code, a compensable rating would require prostrating attacks, with increasing frequency for higher ratings. However, the code also specifically states that a non-compensable rating is assigned with less frequent attacks. Her September 2008 VA medical records generally found that the Veteran's headaches appeared to be more stress related. She denied visual changes, nausea/vomiting, increased weakness, and photophobia. In February 2010, she underwent a headaches VA examination. She described her headaches pain as constant and "numbing" radiating from her jaws, with intermittent flare ups. She complained of daily pain, but denied having migraine headaches and associated symptoms of visual changes, nausea/vomiting, increased weakness. The VA examiner diagnosed her with chronic bitemporal headaches, related to TMJ. The June 2012 VA examiner for the TMJ noted that the Veteran had headaches that are muscular and easily tempered using standard therapy. She also underwent a June 2012 headaches VA examination. That VA examiner reported that she had chronic bitemporal headaches, related to TMJ. The examiner found that the Veteran's symptoms were directly related to her lack of medical treatment, and that her condition and symptoms were subject to improvement; her symptoms could not be considered permanent and are subject to change. The Veteran denied having constant head pain, pulsating or throbbing head pain, pain localized to one side of the head, and pain on both sides of the head. She reported she had constant bilateral temporomandibular joint pain that lasted all day. She also denied having nausea, vomiting, sensitivity to light or sound, changes in vision, and sensory changes. The examiner determined that the Veteran did not have characteristic prostrating attacks of migraine headache pain. The medical evidence of record consistently shows that the Veteran does not have prostrating headaches warranting a compensable, separate disability rating for her headaches. Both the February 2010 and June 2012 VA examiners found the contrary. As such, the Board finds that a separate rating for headaches, of a compensable degree, is not warranted. As for the lay assertions of record, the Board notes that the Veteran is certainly competent to report her own symptoms, or matters within her personal knowledge. See Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007); Buchanan v. Nicholson, 451 F.3d 1331, 1336 (Fed. Cir. 2006). See also Routen v. Brown, 10 Vet. App. 183, 186 (1997) ("a layperson is generally not capable of opining on matters requiring medical knowledge"). Giving the Veteran the benefit of the doubt and taking into consideration the Veteran's lay evidence as well as the objective medical findings, the Board finds that a disability rating of 20 percent, for TMJ, with headaches, is warranted. However, a separate, compensable rating for headaches, as well as, a disability rating in excess of 20 percent for TMJ, with headaches, is not warranted. VII. Extra-schedular Consideration Additionally, the Board has contemplated whether either the increased rating claim should be referred for extra-schedular consideration. An extra-schedular disability rating is warranted 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 that application of the regular schedular standards would be impracticable. 38 C.F.R. § 3.321(b)(1). In Thun v. Peake, 22 Vet. App. 111, 115-16 (2008), the Court explained how the provisions of 38 C.F.R. § 3.321 are applied. Specifically, the Court stated that the determination of whether a claimant is entitled to an extra-schedular rating under § 3.321 is a three-step inquiry. First, it must be determined whether the evidence presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. In this regard, the Court indicated that 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. Under the approach prescribed by VA, 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. Second, if the schedular evaluation does not contemplate the claimant's level of disability and symptomatology and is found inadequate, the RO or Board must determine whether the claimant's exceptional disability picture exhibits other related factors such as "marked interference with employment" and "frequent periods of hospitalization." Third, when an analysis of the first two steps reveals that 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 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 extra-schedular rating. Id. The Board has carefully compared the level of severity and symptomatology of the Veteran's service-connected disabilities of cervical spine disability and TMJ, with headaches. In this regard, the Board finds that the Veteran's symptomatology associated with each disability is fully addressed by the rating criteria. Specifically, the rating criteria address the severity of cervical spine disability, include change in spinal contour, gait, range of motion, and incapacitation. Also, the TMJ also considers limitation of movement and thus ability to perform functions. The headaches criteria considers level of incapacitation. As such, the rating schedule is adequate to evaluate the Veteran's disability picture for each disability. Therefore, the Board need not proceed to consider the second factor, viz., whether there are attendant thereto related factors such as marked interference with employment or frequent periods of hospitalization. Consequently, the Board concludes that referral of this case for consideration of an extra-schedular rating is not warranted. Id.; Bagwell v. Brown, 9 Vet. App. 337, 338-39 (1996); Floyd v. Brown, 9 Vet. App. 88, 96 (1996). In Rice v. Shinseki, 22 Vet. App. 447 (2009), the Court held that a claim for a total disability rating based on individual unemployability (TDIU) is part of an increased rating claim when such claim is expressly raised by the Veteran or reasonably raised by the record. The Court further held that when evidence of unemployability is submitted at the same time that the Veteran is appealing the initial rating assigned for a disability, the claim for TDIU will be considered part and parcel of the claim for benefits for the underlying disability. Id. In this case, the evidence does not suggest that the Veteran's service-connected disabilities render her unable to secure or follow gainful employment. Both VA examiners specifically found that the cervical spine disability condition would not impact her ability to work. The June 2012 VA examiner found that her headaches do not impact her ability to work. Also, the Veteran has repeatedly reported working and/or going to school with her disabilities. Therefore, the Board finds that the issue of entitlement to a TDIU is not expressly raised by the Veteran or reasonably raised by the record and, consequently, further consideration of such is not necessary. ORDER New and material evidence having been received, the claim of entitlement to service connection for right arm numbness is reopened. New and material evidence having been received, the claim of entitlement to service connection for left arm numbness is reopened. Service connection for right arm numbness, to include carpal tunnel syndrome, to include as secondary to the service-connected cervical spine disability, is denied. Service connection for left arm numbness, to include carpal tunnel syndrome, to include as secondary to the service-connected cervical spine disability, is denied. A rating in excess of 10 percent for cervical spine disability, to include strain, is denied. A rating of 20 percent, and no higher, for TMJ, with headaches, is granted subject to the laws and regulations governing the payment of monetary benefits. ____________________________________________ K. OSBORNE Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs