Citation Nr: 1635737 Decision Date: 09/13/16 Archive Date: 09/20/16 DOCKET NO. 10-14 085 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Atlanta, Georgia THE ISSUES 1. Entitlement to service connection for a hysterectomy, claimed as pelvic pain, menometrorrhagia, fibroid uterus, and anemia. 2. Entitlement to an increased rating in excess of 30 percent for hypothyroidism. 3. Entitlement to service connection for major depressive disorder. 4. Entitlement to service connection for suppressed nerves of the right upper extremity. 5. Entitlement to service connection for suppressed nerves of the right lower extremity. 6. Entitlement to service connection for post tubal ligation syndrome. 7. Entitlement to service connection for an abdominal scar. 8. Whether new and material evidence has been submitted to reopen service connection for a right shoulder disability. REPRESENTATION Appellant represented by: Penelope E. Gronbeck, Attorney ATTORNEY FOR THE BOARD Christine C. Kung, Counsel INTRODUCTION The Veteran served on active duty from January 1998 to August 2005. This matter comes on appeal before the Board of Veterans' Appeals (Board) from October 2008 and September 2015 rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in Waco, Texas and the RO in Atlanta, Georgia. Jurisdiction of the appeal is currently with to the RO in in Atlanta, Georgia. The Veteran was scheduled for a December 2013 Board videoconference hearing, but did not appear. The hearing request was, therefore, withdrawn. The Board remanded the appeal in January 2014 for additional development, which included a request for outstanding medical records and a VA examination to address hypothyroidism. The Board finds that the agency of original jurisdiction (AOJ) substantially complied with the remand order in obtaining outstanding medical records and an examination and the Board finds that it may proceed with a decision at this time. See Dyment v. West, 13 Vet. App. 141, 146-47 (1999) (remand not required under Stegall v. West, 11 Vet. App. 268 (1998), where the Board's remand instructions were substantially complied with), aff'd, Dyment v. Principi, 287 F.3d 1377 (Fed. Cir. 2002). The issues of entitlement to service connection for major depressive disorder, suppressed nerves of the right upper extremity, suppressed nerves of the right lower extremity, post tubal ligation syndrome, and an abdominal scar; and whether new and material evidence has been submitted to reopen service connection for a right shoulder disability are addressed in the REMAND portion of the decision below and are REMANDED to the Agency of Original Jurisdiction (AOJ). FINDINGS OF FACT 1. The Veteran had anemia due to a fibroid uterus in service. 2. A post-service hysterectomy due to anemia, due to fibroid uterus and menometrorrhagia, is etiologically related to service. 3. The Veteran's hypothyroidism is manifested by symptoms which include weight gain, but not muscular weakness or mental disturbance and do not met or more nearly approximate the criteria for a 60 percent rating under Diagnostic Code 7903. CONCLUSIONS OF LAW 1. Resolving reasonable doubt in the Veteran's favor, the criteria for service connection for a hysterectomy have been met. 38 U.S.C.A. §§ 1110, 5107 (West 2015); 38 C.F.R. §§ 3.102, 3.303, 3.304 (2016). 2. The criteria for an evaluation in excess of 30 percent for hypothyroidism are not met. 38 U.S.C.A. §§ 1155, 5107 (West 2015); 38 C.F.R. §§ 4.7, 4.119, Diagnostic 7903 (2016). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS 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 in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5102, 5103, 5103A, 5107, 5126 (West 2015); 38 C.F.R. §§ 3.102, 3.156(a), 3.326(a) (2016). The Board finds VCAA notice letters dated in November 2007 provided adequate preadjudicatory notice to the Veteran. The Board is also satisfied that VA has made reasonable efforts to obtain relevant records and evidence. Specifically, the information and evidence that has been associated with the record includes VA and private treatment records, treatment records from the William Beaumont Army Medical Center, VA examinations and opinions, and lay evidence. The Board finds that the AOJ substantially complied with a January 2014 Board remand order in obtaining VA examinations and opinions to address the Veteran's hypothyroidism. The Board finds that the VA examinations and opinions obtained in May 2014, June 2014, and October 2014 are adequate because the examinations were performed by medical professionals, and the opinions were based on a review and discussion of the evidence of record and history and symptomatology from the Veteran, and the Board finds that physical examinations are sufficient for rating purposes. Accordingly, the Board finds that VA's duty to assist with respect to obtaining a VA examination or opinion has been met. 38 C.F.R. § 3.159 (c)(4). Moreover, because the Board is granting service connection for a hysterectomy, the Board finds that no additional notice or development is necessary to address that claim. For these reasons, the Board finds that VA has fulfilled the duties to notify and assist the Veteran. (CONTINUED ON NEXT PAGE) Service Connection Law and Analysis Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active military, naval, or air service. 38 U.S.C.A. § 1110; 38 C.F.R. § 3.303(a). Service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). As a general matter, service connection for a disability requires evidence of: (1) the existence of a current disability; (2) the existence of the disease or injury in service, and; (3) a relationship or nexus between the current disability and any injury or disease during service. Shedden v. Principi, 381 F.3d 1163 (Fed. Cir. 2004); see also Hickson v. West, 12 Vet. App. 247, 253 (1999), citing Caluza v. Brown, 7 Vet. App. 498, 506 (1995), aff'd, 78 F.3d 604 (Fed. Cir. 1996). A hysterectomy, claimed as due to pelvic pain, menometrorrhagia, fibroid uterus, and anemia, is not a "chronic disease" listed under 38 C.F.R. § 3.309(a); therefore, the presumptive service connection provisions of 38 C.F.R. § 3.303(b) based on chronic in service symptoms and continuous post-service symptoms do not apply in this case. Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013); Fountain v. McDonald, 27 Vet. App. 258 (2015). The Board is charged with the duty to assess the credibility and weight given to evidence. Wensch v. Principi, 15 Vet. App. 362, 367 (2001); Wood v. Derwinski, 1 Vet. App. 190, 193 (1991). In weighing credibility, VA may consider interest, bias, inconsistent statements, bad character, internal inconsistency, facial plausibility, self interest, consistency with other evidence of record, malingering, desire for monetary gain, and demeanor of the witness. Caluza v. Brown, 7 Vet. App. 498 (1995). The Board may weigh the absence of contemporaneous medical evidence against the lay evidence in determining credibility, but the Board cannot determine that lay evidence lacks credibility merely because it is unaccompanied by contemporaneous medical evidence. Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006). The Veteran contends that symptoms of abdominal pain, anemia, and excessive uterine bleeding subsequent to a 2004 cesarean section, performed in service, led up to the need for a post-service hysterectomy. Service treatment records and VA and private treatment records indicate that the Veteran had symptoms of abdominal pain, anemia, and vaginal bleeding both in service and post-service leading up to a February 2008 hysterectomy. Service treatment records show that the Veteran had a cesarean section in July 2004. The Veteran had some complaints of abdominal pain during her pregnancy, and was assessed with chronic abdominal pain in August 2004, subsequent to delivery. February 2005 lab work showed iron deficiency anemia. A history of anemia during pregnancy was also noted. Post-service VA treatment records dated in December 2007 show that the Veteran was referred to a local gynecologist for evaluation for a possible hysterectomy. A reported history shows that the Veteran delivered a healthy baby girl in July 2004 but had vaginal bleeding on a constant basis since that time. She was seen at the William Beaumont Army Medical Center and was diagnosed with uterine fibroid, and this was assumed to be the cause of the bleeding. Because of marked anemia, a hysterectomy was recommended. The Veteran underwent dilation and curettage in November 2007 and was started on birth control pills in an attempt to regulate her menstrual cycle. The Veteran was assessed with iron deficiency anemia secondary to profuse chronic vaginal bleeding, improved after having dilation and curettage, and with fibroid uterine tumors. The Veteran was seen again, after the dilation and curettage, for vaginal bleeding in January 2008. She underwent an abdominal hysterectomy in February 2008. A February 2008 pre-surgical hysterectomy report from Sierra Medical Center shows that the Veteran was initially referred by VA in September 2007 for evaluation for fibroids, abnormal bleeding, anemia, and hysterectomy. She had a laparoscopic cholecystectomy at the William Beaumont Army Medical Center in August 2006, and a laparoscopy was done in June 2007 because of abdominal pain and bleeding. She was offered a hysterectomy, but did not want to do it at that time. The history also noted that the Veteran had normal periods until her last delivery in 2004 when they became heavy with clots, lasting up to 25 days. She was admitted with menorrhagia, possible fibroid uterus, and anemia, with an abdominal hysterectomy scheduled that day. A February 2008 VA hematology note shows that the Veteran had a history of menorrhagia since her last cesarean section in 2004, that she became severely anemic in 2006, that she continued bleeding and underwent a hysterectomy in February 2008. She had a diagnosis of iron deficiency anemia due to menorrhagia, status post hysterectomy in February 2008. The Board finds that May 2008, July 2008, and August 2008 VA medical opinions, when considered together, indicate that the Veteran had the onset of anemia in service due to a fibroid uterus, and indicate that the anemia due to menometrorrhagia and a fibroid uterus resulted in the need for a hysterectomy. A May 2008 VA gynecological examination shows that the Veteran had excessive and prolonged vaginal bleeding secondary to fibroid uterus. The examiner noted that findings from a September 2007 diagnostic dilation and curettage and hysteroscopy, and pathology report were consistent with placental site nodule. The Veteran continued to have bleeding and anemia and had a total abdominal hysterectomy in February 2008 for menorrhagia and bleeding. The VA examiner opined that chronic anemia may be related to fibroid uterus and it was service-related. A May 2008 VA general medical examination indicates that the Veteran had been anemic since 1998 and had been treated with iron. The Veteran reported that anemia got worse after her pregnancy in 2004. She was diagnosed with current anemia. A July 2008 VA gynecological examination noted a history of vaginal bleeding, tiredness, and anemia secondary to fibroid uterus. The September 2007 pathology report showing a placental site nodule was stated to be an incidental finding related to her past caesarian section. A total abdominal hysterectomy was done for menometrorrhagia, secondary to the fibroid uterus, but not due to the placental nodule. The VA examiner opined that chronic anemia may be secondary to fibroid uterus, and was not caused by a placental nodule from her fourth pregnancy, but did not provide an opinion as to whether a fibroid uterus was incurred or otherwise had its onset in service. The Board finds that an August 2008 VA supplemental medical opinion relates that Veteran's anemia, fibroid uterus and menometrorrhagia to service. The VA examiner stated that anemia was most likely caused by the Veteran's fibroid uterus and menometrorrhagia, based on findings from service treatment records and private treatment notes showing that the Veteran had an abdominal hysterectomy in February 2008 as a result of fibroid uterus and menometrorrhagia. Additionally, the VA examiner reasoned that the Veteran had a diagnosis of anemia in 1998 and dysfunctional uterine bleeding, with additional diagnoses of anemia in February 1999 and February 2000, and he opined that this resulted in her hysterectomy. May 2008 VA examinations indicate that anemia had its onset in service. A July 2008 VA examination indicates that anemia and menometrorrhagia were due to a fibroid uterus, and that a hysterectomy was done because of anemia and menometrorrhagia. Finally, an August 2008 VA supplemental medical opinion relates in-service diagnoses of anemia, most likely caused by fibroid uterus and menometrorrhagia, to a post-service hysterectomy. Resolving the benefit of the doubt in favor of the Veteran, the Board finds that service connection for residuals of a hysterectomy is warranted. See 38 U.S.C.A. § 5107(b) (West 2015); 38 C.F.R. §§ 4.3, 4.7 (2016). Increased Rating Law and Analysis Disability ratings are determined by applying the criteria set forth in VA's Schedule for Rating Disabilities. The percentage ratings are based on the average impairment of earning capacity and individual disabilities are assigned separate diagnostic codes. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1 (2016). If two evaluations are potentially applicable, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that evaluation; otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7 (2016). Any reasonable doubt regarding a degree of disability will be resolved in favor of the veteran. 38 C.F.R. § 4.3 (2016). The United States Court of Appeals for Veterans Claims (Court) has also held that staged ratings are appropriate for an increased rating claim when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. Hart v. Mansfield, 21 Vet. App. 505 (2007). The relevant temporal focus for adjudicating an increased rating claim is on the evidence concerning the state of the disability from the time period one year before the claim was filed until VA makes a final decision on the claim. Id. The Board finds that symptoms related to the Veteran's hypothyroidism has not changed in severity over the course of the appeal period to warrant a staged rating. Pyramiding, that is the evaluation of the same disability, or the same manifestation of a disability, under different diagnostic codes, is to be avoided when evaluating a veteran's service-connected disability. 38 C.F.R. § 4.14 (2016). However, it is possible for a veteran to have separate and distinct manifestations from the same injury which would permit rating under several diagnostic codes; the critical element in permitting the assignment of several evaluations under various diagnostic codes is that none of the symptomatology for any one of the conditions is duplicative or overlapping with the symptomatology of the other condition. See Esteban v. Brown, 6 Vet. App. 259, 261- 62 (1994). In rendering a decision on appeal the Board must also analyze the credibility and probative value of the evidence, account for the evidence which it finds to be persuasive or unpersuasive, and provide the reasons for its rejection of any material evidence favorable to the claimant. Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994); Gilbert v. Derwinski, 1 Vet. App. 49, 57 (1990). The Veteran is currently in receipt of a 30 percent rating for hypothyroidism under Diagnostic Code 7903. Under Diagnostic Code 7903, a 30 percent rating assigned with evidence of fatigability, constipation, and mental sluggishness. A higher 60 percent rating is assigned with evidence of muscular weakness, mental disturbance, and weight gain; and a total 100 percent rating assigned where there is cold intolerance, muscular weakness, cardiovascular involvement, mental disturbance (dementia, slowing of thought, depression), bradycardia (less than 60 beats per minute), and sleepiness. The rating criteria for Diagnostic Code 7903 are not conjunctive, cumulative, or successive. See Tatum v. Shinseki, 23 Vet. App. 152 (2009). The Veteran contends in April 2010 and July 2010 statements that a higher evaluation is warranted for hypothyroidism based on symptoms of muscle weakness, weight gain, fatigue, insomnia, constipation, forgetfulness, and mental sluggishness. She also contends that diagnosed depression and anxiety are related to hypothyroidism. After a review of the evidence, lay and medical, the Board finds that the Veteran's hypothyroidism is manifested by symptoms of fatigability, sleepiness, constipation, mental sluggishness, cold intolerance, and weight gain, but not muscular weakness or mental disturbance. VA treatment records dated from 2007 to 2016 identify a diagnosis of hypothyroidism, managed with medication. A January 2015 VA treatment report noted that the Veteran had an elevated TSH level and her medications were increased. The Veteran reported constipation. A physical examination shows that the Veteran had a normal heart rate and the clinician identified no significant weight changes. The Veteran was provided a VA endocrinology examination to address hypothyroidism in April 2014 with an addendum opinion in June 2014, and a second examination was conducted in October 2014. The April 2014 VA examination shows that the Veteran had a diagnosis of hypothyroidism treated with medication. Signs and symptoms of hypothyroidism were stated to include fatigability, constipation, depression, need for continuous medication, weight gain, and cold intolerance. Physical examination shows that the Veteran's pulse was regular and the Veteran had a heart rate of 74. A reflex examination was normal in the upper and lower extremities. The examiner indicated that there were no other pertinent physical findings, complications, conditions, signs, or symptoms associated with hypothyroidism. The examiner also opined that hypothyroidism did not impact the Veteran's ability to work and opined that it was less likely than not that hypothyroidism interfered with the Veteran's obtain or maintain employment, reasoning that patients with hypothyroidism do have frequent fluctuation in thyroid function tests due to multiple factors, and those fluctuations rarely caused symptoms. In a June 2014 addendum opinion, the VA examiner opined that the Veteran's hypothyroidism was, less likely than not, a reason for or attributable to any of her mental disease symptoms. The examiner reasoned that her thyroid function was not decreased to a degree that it could cause significant hypothyroid symptoms, and that she was on supplements with TSH levels ranging from 1.76 to 8.37 with T4 very mildly reduced. A second VA examination was conducted in October 2014. During examination, the Veteran reported treatment with medication, and attributed her diagnosed depression and anxiety to her thyroid condition. The VA examiner noted that a separate VA psychiatric examination was being conducted. Findings from the October 2014 VA endocrinology examination were consistent with findings from the earlier April 2014 examination. The VA examiner continued to identify current symptoms of fatigability, constipation, and weight gain, use of continuous medication, sleepiness, and cold intolerance. Physical examination shows that the Veteran's pulse was regular and the Veteran had a heart rate of 72. A reflex examination was normal in the upper and lower extremities. The examiner indicated that there were no other pertinent physical findings, complications, conditions, signs, or symptoms associated with hypothyroidism. Hypothyroidism did not impact her ability to work. With respect to the Veteran's current psychiatric diagnoses or claimed mental problems, the VA examiner opined that these were less likely than not related to her hypothyroidism, reasoning that symptoms of depression and anxiety had not worsened over the past year even though her free T4 had fluctuated from low too high to low with in the past year. He reasoned that one would expect that her symptoms of depression versus anxiety would fluctuate along with her thyroid hormone levels, and this was not noted to occur. An October 2014 VA psychiatric evaluation included a detailed interview of the Veteran, a discussion of her psychiatric history, and a mental examination. The VA examiner indicated that the Veteran met the criteria for a diagnosis of major depressive disorder but opined that it was less likely than not that her depression was related to her thyroid disorder. The examiner reasoned that the Veteran reported that her depression had always been about her sister's murder and feelings of guilt about her death. There were also noted contributing factors of emotional abuse by her mother, childhood sexual abuse, marital difficulties, financial stress, and an impending foreclosure. Based on the evidence discussed, the Board finds that hypothyroidism results in symptoms of fatigability, sleepiness, constipation, mental sluggishness, cold intolerance, and weight gain, but not muscular weakness or mental disturbance. The Board finds that the Veteran's symptoms fatigability, constipation, mental sluggishness are consistent with the currently assigned 30 percent rating under Diagnostic Code 7903. While the Veteran was also shown to have weight gain, the preponderance of the evidence does not establish muscular weakness or mental disturbance associated with hypothyroidism. June 2014 and October 2014 opinions from two different VA endocrinology examiners and an October 2014 VA psychologist's opinion show that the Veteran's diagnosed psychiatric disorder and mental symptoms are not related to her hypothyroidism. The Board finds that the rational provided for the opinions are well reasoned and probative, and the Board finds that the VA examiners' opinions outweigh the Veteran's own assertions, attempting to relate her psychiatric diagnoses to hypothyroidism. While the Veteran has reported symptoms of fatigability, insomnia, and forgetfulness, the Board finds that this is contemplated by symptoms of fatigability and mental sluggishness identified in her currently assigned 30 percent rating under Diagnostic Code 7903. In a July 2010 statement, made for compensation purposes, the Veteran contends that she has muscular weakness, including her legs giving out on her. Muscular weakness, however, was not identified during April 2014 or October 2014 VA endocrinology examination and all reflexes were tested as normal. The record also includes a May 2015 VA orthopedic examination, which included muscle strength testing of the lower extremities. On examination, the Veteran had normal strength (5/5) in the bilateral hips, knees, ankles, and feet. VA treatment records do not otherwise identify any complaints related to muscle weakness. The Board finds that objective findings, showing full muscle strength in the lower extremities, and the lack of clinical complaints of muscle weakness shown by the medical record outweigh the Veteran's own assertions of muscular weakness made in connection with the compensation claim outside of the clinical environment. This is because when an individual is before a medical professional for the purpose of medical evaluation or treatment, any statements made about current health status in inherently more reliable so that the proper care may be rendered. Accordingly, the Board finds that the Veteran is not credible in identifying muscular weakness due to hypothyroidism, and the weight of the evidence does not show the Veteran has either muscular weakness or mental disturbance due to hypothyroidism at any time during the rating period. Accordingly, the Board finds that symptoms associated with hypothyroidism do not more nearly approximate the criteria for an increased 60 percent rating. The Board notes that April 2014 and October 2014 VA examinations identified symptoms of cold intolerance and sleepiness, which are symptoms included in a 100 percent rating for hypothyroidism. The Board finds, however, that the criteria for neither a 60 percent, nor a 100 percent rating have been met or more nearly approximated in this case. A 100 percent rating is assigned under Diagnostic Code 7903 where there is evidence of cold intolerance, muscular weakness, cardiovascular involvement, mental disturbance (dementia, slowing of thought, depression), bradycardia (less than 60 beats per minute), and sleepiness. The Board finds that the Veteran has not exhibited other symptoms described for the next higher 100 percent rating, including muscular weakness, cardiovascular involvement, mental disturbance, such as dementia, slowing of thought, or depression, or bradycardia due to service-connected hypothyroidism. See 38 C.F.R. § 4.119, Diagnostic Code 7903. As discussed above, the Veteran does not have muscular weakness, and diagnosed depression is unrelated to hypothyroidism. Additionally, April 2014 and October 2014 VA examinations show no cardiovascular involvement, and the Veteran had normal heart sinus rate and rhythm (recorded at above 60 beats per minute) on physical examination. The Veteran did not have dementia diagnosed or slowing of thought identified on an October 2014 VA psychiatric examination or in VA treatment records. Accordingly, the Board finds that the Veteran's symptoms do not approximate the criteria for a higher 100 percent rating for hypothyroidism. For the reasons discussed above, the preponderance of the evidence is against the appeal for increased rating, in excess of 30 percent for hypothyroidism; therefore, the appeal must be denied, and the benefit of the doubt doctrine is not for application. See 38 U.S.C.A. § 5107; 38 C.F.R. §§ 4.3, 4.7 (2016). Extraschedular Consideration The Board has considered whether referral for an extraschedular evaluation is warranted. In exceptional cases an extraschedular rating may be provided. 38 C.F.R. § 3.321 (2016). The threshold factor for extraschedular consideration is a finding that the evidence before VA presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. Therefore, initially, there must be a comparison between the level of severity and symptomatology of the claimant's service-connected disability with the established criteria found in the rating schedule for that disability. Thun v. Peake, 22 Vet. App. 111 (2008). 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. In the second step of the inquiry, however, 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 those provided by the regulation as "governing norms." 38 C.F.R. 3.321(b)(1) (related factors include "marked interference with employment" and "frequent periods of hospitalization"). When the rating schedule is inadequate to evaluate a claimant's disability picture and that picture has 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 for completion of the third step-a determination of whether, to accord justice, the claimant's disability picture requires the assignment of an extraschedular rating. Id. Turning to the first step of the extraschedular analysis, the Board finds that for the entire rating period, the symptomatology and impairment caused by service-connected hypothyroidism are specifically contemplated by the schedular rating criteria, and no referral for extraschedular consideration is required. The schedular rating criteria specifically provide for disability ratings based on symptoms such as under Diagnostic Code 7903. See 38 C.F.R. § 4.114. The Board finds that the Veteran's symptoms of fatigability, sleepiness, constipation, mental sluggishness, cold intolerance, and weight gain are specifically contemplated by Diagnostic Code 7903, and the Veteran's overall level of functional impairment is contemplated by the assigned 30 percent rating. Higher ratings are available under the available Diagnostic Code, and under other provisions of the code, to include based on findings of weight gain, mental disturbance, and muscular weakness; and despite weight gain, the Veteran is not shown to approximate the criteria for a higher rating. For these reasons, the Board finds that the schedular rating criteria are adequate to rate service-connected hypothyroidism. The schedule is intended to compensate for average impairments in earning capacity resulting from service-connected disability in civil occupations. 38 U.S.C.A. § 1155. "Generally, the degrees of disability specified [in the rating schedule] are considered adequate to compensate for considerable loss of working time from exacerbations or illnesses proportionate to the severity of the several grades of disability." 38 C.F.R. § 4.1 (2016). In this case, the problems reported by the Veteran are specifically contemplated by the criteria discussed above, and this includes the effect of her disability on occupational or daily functioning. Moreover, VA examinations indicate, in this case, that hypothyroidism did not impact the Veteran's ability to work did not interfere with her ability to obtain or maintain employment. According to Johnson v. McDonald, 762 F.3d 1362 (Fed. Cir. 2014), a veteran may be entitled to "consideration [under 38 C.F.R. § 3.321(b)] for referral for an extra-schedular evaluation based on multiple disabilities, the combined effect of which is exceptional and not captured by schedular evaluations." In this case, the Veteran has not asserted, and the evidence of record has not suggested, any such combined effect or collective impact of multiple service-connected disabilities that create such an exceptional circumstance to render the schedular rating criteria inadequate. In this case, there is neither allegation nor indication that the collective impact or combined effect of more than one service-connected disability presents an exceptional or unusual disability picture to render inadequate the schedular rating criteria. In the absence of exceptional factors associated with service-connected hypothyroidism, the Board finds that the criteria for referral for consideration of an extraschedular rating pursuant to 38 C.F.R. § 3.321(b)(1) are not met. See Bagwell v. Brown, 9 Vet. App. 337 (1996); Shipwash v. Brown, 8 Vet. App. 218, 227 (1995). ORDER Service connection for a hysterectomy is granted. An increased rating in excess of 30 percent for hypothyroidism is denied. REMAND The Veteran submitted a November 2015 notice of disagreement to a September 2015 rating decision which denied service connection for major depressive disorder, suppressed nerves of the right upper extremity, suppressed nerves of the right lower extremity, post tubal ligation syndrome, an abdominal scar; and a right shoulder disability. Because service connection for a right shoulder disability was previously denied in a November 2005 rating decision, the Board has recharacterized that issue as a claim to reopen service connection. The AOJ has not issued a statement of the case addressing the appeal of the September 2015 rating decision. The filing of a notice of disagreement places a claim in appellate status. The failure to issue a statement of the case in such a circumstance renders a claim procedurally defective and necessitates a remand. See 38 C.F.R. §§ 19.9, 20.200, 20.201 (2016); see also Manlincon v. West, 12 Vet. App. 238 (1999). The purpose of the remand is to give the AOJ an opportunity to cure this defect by issuing a statement of the case. Accordingly, the case is REMANDED for the following action: The AOJ should issue a statement of the case addressing entitlement to service connection for major depressive disorder, suppressed nerves of the right upper extremity, suppressed nerves of the right lower extremity, post tubal ligation syndrome, an abdominal scar, and the claim to reopen service connection for a right shoulder disability. The Veteran should be given an opportunity to perfect an appeal by submitting a timely substantive appeal. The AOJ should advise the Veteran that the appeal will not be returned to the Board for appellate consideration following the issuance of the statement of the case unless he perfects his appeal. The Veteran has the right to submit additional evidence and argument on the matter or matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board 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 2015). ______________________________________________ JONATHAN B. KRAMER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs