Citation Nr: 1623445 Decision Date: 06/13/16 Archive Date: 06/29/16 DOCKET NO. 12-17 792 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Denver, Colorado THE ISSUES 1. Entitlement to an initial evaluation in excess of 40 percent prior to March 4, 2015 for complex partial seizures. 2. Entitlement to an evaluation in excess of 30 percent for a hysterectomy with a history of endometriosis. 3. Entitlement to an initial evaluation in excess of 30 percent for depressive disorder associated with hysterectomy prior to March 2, 2015 and in excess of 50 percent from then onwards. 4. Entitlement to an effective date prior to July 2, 2010 for service connection of depressive disorder. 5. Entitlement to service connection for a heart condition as secondary to a seizure disorder. REPRESENTATION Veteran represented by: Ralph J. Bratch, Esquire ATTORNEY FOR THE BOARD N.K., Associate Counsel INTRODUCTION The Veteran served on active duty from March 1995 to March 1999. This matter is before the Board of Veterans' Appeals (Board) on appeal from September 2010 and October 2012 rating decisions of the Denver, Colorado Regional Office (RO) of the Department of Veterans Affairs (VA). In March 2015, the RO increased the Veteran's disability rating for complex seizures to 100 percent from March 2015, onward. As the increase does not satisfy this appeal in full, the issue remains on appeal. AB v. Brown, 6 Vet. App. 35, 38 (1993). The issues of an increased evaluation for complex seizures and service connection for a heart condition 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 hysterectomy removed the uterus, and there have been no signs of lesions involving the bowel or bladder confirmed by laparoscopy or heavy or irregular bleeding not controlled by treatment. 2. Since the award of service connection in July 2010 to March 2, 2015, the Veteran's service-connected depressive disorder has been manifested by symptoms such as disturbances of mood and motivation, depression, anxiety, and fatigue and has been productive of occupational and social impairment with an occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, but not reduced reliability and productivity. 3. From March 2, 2015 onward, the Veteran's service connected depressive disorder has been manifested by symptoms such as depression and anxiety, fatigue, impaired judgement and difficulty establishing and maintaining relationships, productive of occupational and social impairment with reduced reliability and productivity, but not deficiencies in most areas. 4. On July 2, 2010 the Veteran filed a claim for service connection for depression; no earlier record constitutes a formal or informal claim for this benefit. CONCLUSIONS OF LAW 1. The criteria for a rating higher than 30 percent for endometriosis with hysterectomy have not been met. 38 U.S.C.A. § 1155, 5107 (West 2014); 38 C.F.R. §§ 4.7, 4.116, Diagnostic Codes 7618, 7629 (2015). 2. The criteria for an initial evaluation in excess of 30 percent for depressive disorder prior to March 2, 2015 and in excess of 50 percent onward, have not been met. 38 U.S.C.A. §§ 1155 , 5107 (West 2014); 38 C.F.R. § 4.130, Diagnostic Code 9434 (2015). 3. The criteria for an effective date earlier than July 2, 2010 for the award of service connection for depressive disorder are not met. 38 U.S.C.A. §§ 5107, 5110 (West 2014); 38 C.F.R. §§ 3.102 , 3.400 (2015). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Increased Ratings A disability rating is determined by the application of VA's Schedule for Rating Disabilities (Rating Schedule). The percentage ratings contained in the Rating Schedule represent, as far as can be practicably determined, the average impairment in earning capacity resulting from diseases and injuries incurred or aggravated during military service and the residual conditions in civil occupations. Separate Diagnostic Codes identify the various disabilities. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. If 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. The Board will consider whether separate ratings may be assigned for separate periods of time based on facts found, a practice known as "staged ratings," whether it is an initial rating case or not. Fenderson v. West, 12 Vet.App. 119, 126-27(1999); Hart v. Mansfield, 21 Vet.App. 505 (2007). Entitlement to an Increased Rating for a Hysterectomy with Endometriosis The Board notes that the Veteran was granted service connection for a hysterectomy with endometriosis in April 2004 and assigned a 30 percent rating effective June 2003. In July 2010 the Veteran filed a claim for an increased evaluation in her gynecological disorder. In October 2012 the RO denied her the increase; the Veteran filed a notice of disagreement to this denial, and perfected an appeal as to the issue. Endometriosis with hysterectomy is currently rated 30 percent under Diagnostic Codes 7618 and 7629. 38 C.F.R. § 4.116, Diagnostic Code 7618, 7629. Diagnostic Code 7618 provides ratings for removal of the uterus. A 100 percent rating is warranted for three months after removal and a 30 percent rating is warranted thereafter. Diagnostic Code 7629, provides ratings for endometriosis. A 30 percent rating is warranted for pelvic pain or heavy or irregular bleeding not controlled by treatment. A 50 percent rating is warranted for lesions involving bowel and bladder confirmed by laparoscopy, pelvic pain or heavy or irregular bleeding not controlled by treatment, and bowel and bladder symptoms. In 2009 and early 2010 the Veteran sought treatment for her post hysterectomy and endometriosis at the Tucson VAMC. Specifically, in December 2009 the Veteran was afforded a gynecology follow up at which point the examiner noted the Veteran had never had an abnormal pap smear and had no noted discharge. The Veteran sought treatment for her gynecological conditions at the Phoenix VAMC in 2010. Specifically, in August 2010 the Veteran sought treatment from a gynecologist at Phoenix who noted she reported pain in right ovary. The Veteran reporting needing medication to help her sleep. See August 20, 2010 Phoenix VAMC Treatment Record. In November 2010 the Veteran was referred to the Women's Clinic for consultation regarding her gynecological conditions. The Board notes that the Veteran sought treatment for her gynecological conditions at the Denver VAMC between 2011 to 2015. Specifically regarding those records, the Veteran sought management of her pain in May 2011. She reported continued heavy periods with clots and cyclic cramping and pain. The Veteran denied experiencing constipation and diarrhea. The examining medical professional noted a history of endometriosis and planned for the Veteran to start taking Lupron and Agestin for monthly cramps and to return to re-evaluate the pain. See May 27, 2011 Denver VAMC Treatment Record. In July 2011 the Veteran was afforded a general VA examination at which point she discussed her gynecological issues in detail. At that examination, the Veteran noted that she had prior diagnoses of dysmenorrhea and menorrhagia with abdominal cramping. She noted that she was diagnosed with endometriosis with heavy periods, clots and cramping in 2003. The Veteran reported at that examination that after her hysterectomy she continued to have cyclic cramping pain. She had her left ovary removed in 2006 without improvement of her symptoms. The Veteran was sexually active at the time of the examination, but reported dyspareunia with deep penetration. The examiner noted the Veteran's treatment at the Denver VAMC in 2011 for her pelvic pain. The examiner noted further that the Veteran's pelvic pain occurred at the end of the month, and that her cycle was normally only 3-4 days long. Her pelvic discomfort limited what she was able to wear and made her feel bloated and uncomfortable. She rated her pain level at a 10/10. Upon examination, the examiner noted the Veteran's reports of pelvic pain, abdominal pain, abnormal abdominal bleeding, a history of endometriosis confirmed by laparoscopy as well as intermittent blood in stools related to endometriosis. The Veteran noted that she was unemployed at the time but not retired. She reported that her duration of unemployment was 5 to 10 years and that she was unable to sustain a job due to her seizures. The examiner diagnosed the Veteran with endometriosis with persistent pelvic pain. She found that the Veteran's pelvic pain/endometriosis did not limit her ability to be employed. The examiner noted the Veteran's history of working as a paralegal and found that her gynecological diagnosis should not limit her ability to work in that field or any other field. In March 2015 the Veteran was afforded another VA examination for her gynecological conditions. At that examination, upon review of the Veteran's claims folder, the examiner noted the Veteran's reports that her symptoms of endometriosis remained the same as they had been three years prior to this examination. Specifically, she noted that she had pelvic pain each month lasting 3-4 days; however, as she previously had a hysterectomy, she no longer has periods. The examiner noted that the Veteran currently takes hydrocodone for her chronic back pain, but reported that it helps with her pelvic pain too. The Veteran was not noted to have any uterine fibroids, enlargement of the uterus or displacement of the uterus. She has further not been diagnosed with any diseases, injuries, adhesions or other conditions of the fallopian tubes to include pelvic inflammatory disease. The Veteran was not noted to have uterine incontinence or leaking and further did not have any rectovaginal fisulas, urethrovaginal fistulas or complications resulting from obstetrical or gynecological conditions or procedures. The examiner noted that the Veteran had symptoms of endometriosis not requiring continuous treatment. The examiner noted that the Veteran had previously had a laparoscopy for her endometriosis. The examiner noted that the Veteran would be able to work despite her pelvic pain due to her hysterectomy and endometriosis, as she was able to adequately manage the pain with medication. The Veteran seeks a rating higher than 30 percent for endometriosis with hysterectomy. Based on the evidence presented, the Board finds that the preponderance of the evidence is against a rating higher than 30 percent for the Veteran. It is undisputed that the hysterectomy removed the uterus. In this regard, a 30 percent is the highest rating assignable under Diagnostic Code 7618 for the Veteran's appeal. Since her service connection for hysterectomy and associated endometriosis, the Veteran has been assigned a rating of 30 percent, the maximum rating under Diagnostic Code 7618. The Board also considered whether a higher rating was warranted under any other Diagnostic Code. Diagnostic Code 7629 is the only potentially applicable code under the rating schedule for gynecological conditions. Under Diagnostic Code 7629, a 50 percent rating, the next higher rating, requires lesions involving bowel and bladder confirmed by laparoscopy, pelvic pain or heavy or irregular bleeding not controlled by treatment, and bowel and bladder symptoms. In this regard, the Board finds that the Veteran's treatment at the Tucson, Phoenix and Denver VAMCs do not reflect any bowel or bladder lesions confirmed by laparoscopy. The Board notes that the Veteran underwent a prior laparoscopy, but that such did not result in diagnosis of bowel or bladder lesions. The Board takes note of the Veteran's July 2011 examination, at which point she reported that she had intermittent blood in stools. Although the Board notes that bowel and/or bladder symptoms are listed criteria for a 50 percent rating for endometriosis, the criteria also states that such must be present with heavy or irregular bleeding not controlled by treatment. The Board finds that the Veteran has noted at her March 2015 VA examination that she is taking pain medication, specifically hydrocodone, to relieve her pelvic discomfort. Therefore, she is treating her endometriosis symptoms. As noted in the Denver, Tucson and Phoenix medical treatment records, in addition to the Veteran's VA examinations, the Veteran has consistently reported experiencing pelvic pain, heavy bleeding and clots during periods. However, the Board notes that these symptoms warrant a 30 percent rating, and not a higher 50 percent one. Therefore, the Board concludes that as the Veteran has managed her pelvic pain with medication and furthermore did not have any reported bowel or bladder related lesions, the preponderance of the evidence is against the claim for a rating higher than 30 percent for endometriosis under Diagnostic Codes 7618 and 7629 during the pendency of the appeal. The Board finds that as there is no other potentially applicable Diagnostic Code, the preponderance of the evidence is against the claim of entitlement to an evaluation in excess of 30 percent for hysterectomy with endometriosis; therefore, the benefit-of-the-doubt standard of proof does not apply. 38 U.S.C.A. § 5107(b). Entitlement to a Higher Evaluation for Depressive Disorder The Board notes that the Veteran filed a claim for service connection for depressive disorder in July 2010. In an October 2012 rating decision she was granted service connection and assigned a 10 percent rating from her date of claim. The Veteran filed a timely notice of disagreement to the issue and perfected an appeal. In April 2015 the RO increased the Veteran's rating to 30 percent from date of claim to March 2, 2015 and 50 percent thereafter. The Board notes that as this increase does not constitute a full grant of benefits, the claim is still on appeal before the Board. AB v. Brown, 6 Vet. App. 35, 38 (1993). Applying the facts in this case to the applicable legal criteria, the Board finds that an initial rating prior to March 2, 2015 in excess of 30 percent for depressive disorder is not warranted and in excess of 50 percent thereafter is not warranted. Major depressive disorder is evaluated under the General Rating Formula for Mental Disorders. See 38 C.F.R. § 4.130, Diagnostic Code 9434 (2015). A 30 percent rating is assigned when a veteran's psychiatric disorder causes occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, or mild memory loss (such as forgetting names, directions, recent events). 38 C.F.R. § 4.130, Diagnostic Code 9411. A 50 percent rating is assigned when a veteran's psychiatric disorder causes occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short-term and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; or difficulty in establishing and maintaining effective work and social relationships. 38 C.F.R. § 4.130, Diagnostic Code 9411. A 70 percent evaluation is assigned when a veteran's psychiatric disorder causes occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work like setting); or an inability to establish and maintain effective relationships. A 100 percent rating is assigned when a veteran's psychiatric disorder causes total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; danger of hurting self or others; intermittent inability to perform activities of living (including maintenance of minimal hygiene); disorientation to time or place; or, memory loss for names of close relatives, occupation, or own name. 38 C.F.R. § 4.130, Diagnostic Code 9411. The criteria set forth in the rating formula for mental disorders do not constitute an exhaustive list of symptoms, but rather are examples of the type and degree of the symptoms, or their effects, that would justify a particular rating. Mauerhan v. Principi, 16 Vet. App. 436 (2002). Nevertheless, the Veteran must demonstrate the particular symptoms associated with that percentage, or others of similar severity, frequency, and duration. Vazquez-Claudio v. Shinseki, 713 F.3d 112, 116-17 (Fed. Cir. 2013) (also explaining that VA intended the General Rating Formula to provide a regulatory framework for placing veterans on the disability spectrum based upon their objectively observable symptoms). Global Assessment of Functioning (GAF) scores are a scale reflecting the "psychological, social, and occupational functioning on a hypothetical continuum of mental health- illness." See Carpenter v. Brown, 8 Vet. App. 240, 242 (1995); see also Richard v. Brown, 9 Vet. App. 266, 267 (1996) [citing the American Psychiatric Association's DIAGNOSTIC AND STATISTICAL MANUAL FOR MENTAL DISORDERS, Fourth Edition (DSM-IV), p. 32]. Effective August 4, 2014, VA amended the portion of the Rating Schedule dealing with mental disorders and its adjudication regulations that define the term "psychosis" to remove outdated references to the DSM-IV and replace them with references to the recently updated Fifth Edition (DSM-5). See 79 Fed. Reg. 149, 45094. The provisions of the interim final rule apply to all applications for benefits that are received by VA or that were pending before the AOJ on or after August 4, 2014. Id. VA adopted as final, without change, the interim final rule and clarified that the provisions of this interim final rule do not apply to claims that have been certified for appeal to the Board or are pending before the Board as of August 4, 2014. See 80 Fed. Reg. 53, 14308 (March 19, 2015). The RO certified the Veteran's appeal to the Board in February 2014, and therefore the claim is governed by DSM-IV. The Board notes that the use of GAF scores has been abandoned in the DSM-5 because of, among other reasons, "its conceptual lack of clarity" and "questionable psychometrics in routine practice." See Diagnostic and Statistical Manual for Mental Disorders, Fifth edition, p. 16 (2013). In this case, however, the Veteran's claim is governed by DSM-IV and DSM-IV was in use at the time the medical entries of record were made. Thus, the GAF scores assigned remain relevant for consideration in this appeal. GAF scores ranging between 61 to 70 reflect some mild symptoms (e.g., depressed mood and mild insomnia) or some difficulty in social, occupational, or school functioning (e.g., occasional truancy, or theft within the household), but generally functioning pretty well, and has some meaningful interpersonal relationships. Scores ranging from 51 to 60 reflect more moderate symptoms (e.g., flat affect and circumstantial speech, occasional panic attacks) or moderate difficulty in social, occupational, or school functioning (e.g., few friends, conflicts with peers or co- workers). Scores ranging from 41 to 50 reflect serious symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent shoplifting) or any serious impairment in social, occupational, or school functioning (e.g., no friends, unable to keep a job). See 38 C.F.R. § 4.130. The Board notes that the Veteran sought treatment at the La Junta Community Based Outpatient Clinic in 2011. Specifically, in February 2011 the Veteran walked into the clinic seeking treatment for stress due to the alcoholism of her husband. She continued to have difficulties in social, familial and occupational areas. Upon examination, her speech was normal but her mood was depressed and anxious. She had good insight and judgement and her memory was intact. At the time she denied suicidal and homicidal ideations. The examiner planned to continue the Veteran with individual therapy. In April 2011 the licensed clinical social worker (LCSW) noted in the La Junta COBC records that the Veteran failed to appear for her scheduled mental health appointment. She noted that the Veteran was not on high risk for suicide, but that the Veteran had rescheduled her appointment multiple times for mental health consult. In May 2011 the Veteran attended a therapy session at which the LCSW noted that she continued to have anxiety regarding her husband and her seizure disorder. The Veteran continued to have significant difficulties socially occupationally and familially. Her mood was depressed but she had appropriate insight and judgement with intact memory. The Veteran agreed to follow up in two weeks, but then failed to appear for her follow up appointment. The Board notes that the Veteran made intermittent visits to outpatient VAMCs following these detailed visits. At the majority of her visits, she discussed her difficulties with her service-connected seizures and her husband's alcoholism. The Board notes that multiple times the Veteran rescheduled her therapy visits or failed to appear. In October 2011 the Veteran was afforded a VA examination for her mental health disorders. At that examination the Veteran reported that she first sought mental health treatment in 2003 for 6 months and then again in 2004 for one and a half years. In 2009 she sought more mental health treatment. The Veteran noted at the examination that she was not taking any medication at that time. The Veteran reported that she did not drink, that she had never gotten into trouble due to alcohol or received any treatment for alcohol abuse. She also denied drug use. The Veteran denied psychiatric history of her family. Upon examination, the examiner noted that the Veteran reported to the clinic dressed casually with no grooming or hygiene deficits observed. Her attitude toward the examiner was cooperative and she did not exhibit any unusual movements or psychomotor changes. Her speech was within normal limits and her though processes were goal oriented. She denied current or past suicidal or homicidal thoughts. She was oriented to person, place and time and demonstrated no problems with cognitive ability. The Veteran noted that she had felt depressed since the time of her hysterectomy, specifically because she was no longer able to have children. She reported that she had some good days and some bad days and that she had trouble sleeping, trouble concentrating and feeling fatigued in addition to the frequently depressed mood. Her depression impacted her social life in that she isolated herself when she felt low, but did not affect her occupationally. The examiner found that the Veteran's symptoms best met the criteria for depressive disorder. The examiner noted that the Veteran was in therapy and was not taking any medication. Her behavior was appropriate and her thought processes were not impaired. She had no other mental health conditions and she was competent to handle her VA funds. The examiner diagnosed the Veteran with depressive disorder not otherwise specified (NOS) and assigned an overall GAF score of 61-70. In addition to receiving treatment at the La Junta CBOC, the Veteran also received treatment at the Denver VAMC. Specifically in December 2014, the Veteran was afforded a mental health consult at which point she planned to continue individual therapy. At that consult the Veteran noted that she was underemployed due to her disabilities, and stressed due to her husband's unemployment. She noted symptoms of little interest or pleasure in participating in activities, feeling down or hopeless, trouble sleeping, low energy, poor appetite, feelings of failure and motor retardation. The social worker at the consult assigned the Veteran a GAF score of 55. The Veteran continued consults with the Denver VAMC throughout the end of 2014 and 2015 for her mental health disability. She sought treatment in March 2015 for her depression at which time she made detailed descriptions of her history of abuse and neglect. She reported poor sleep hygiene, fatigue and depressed mood nearly every day. She noted constant low self-esteem. The social worker at that consult assigned her a GAF score of 55. In March 2015 the Veteran was afforded another VA examination for her psychiatric disorder. The Veteran reported at that time that she had moved recently and she was setting up her new house. She stated that for hobbies she liked to scrapbook and noted that she raised funds for her Cancer Society. The Veteran reported that her highest degree was a bachelor's degree and that she also had an associate's degree as a paralegal. She stated that she was unemployed from a full time position since she was 26 years old. The Veteran reported that she had never been hospitalized for mental health reasons. She had never attempted suicide and hadn't expressed any suicidal or homicidal ideations. She noted that she had been working with a therapist in Phoenix, Arizona. She claimed that she was also diagnosed with PTSD due to domestic violence issues in her home. Upon examination, the examiner noted that the Veteran only had one mental disorder diagnosed. The examiner noted that the Veteran's occupational and social impairment was best described as with reduced reliability and productivity. The Veteran's speech was a normal tone, rate and pressure. Her eye contact was good and her thought process was linear and goal oriented. She reported that she suffered from insomnia and that her mind would race. She reported being unable to exercise due to her high levels of fatigue. Her activity levels ranged from average to low depending on her health status. She noted that she was not able to take antidepressants as they caused side effects, specifically causing her to be very groggy. The Veteran noted that she had a depressed mood almost every day, diminished interest in activities, weight gain, insomnia, psychomotor agitation, high levels of fatigue, low self-esteem and difficulty concentrating. She noted no suicidal ideations at the time. The Veteran reported that she believed her symptoms had increased as her physical health issues had gone unresolved and she was unable to achieve her dream of attending law school. The Veteran claimed that she did not drink alcohol. She used no illegal substances and stated she did not smoke cigarettes. The examiner selected that the Veteran experienced the symptoms of depressed mood, anxiety, chronic sleep impairment, mild memory loss, disturbances of motivation and mood and difficulty in adapting to stressful circumstances. The examiner noted that the Veteran's mental health issues in and of themselves did not preclude or prevent her from all types of employment. After a thorough review of the claims file, the Board finds that the Veteran does not meet the criteria for a schedular rating in excess of 30 percent prior to March 2, 2015 or in excess of 50 percent from then onward. While the Veteran clear has problems, the Veteran's reported symptoms at her VAMC consults and VA examinations prior to March 2, 2015 do not warrant a rating in excess of 30 percent. Specifically, the Veteran has not demonstrated that she experiences social and occupational impairment with reduced reliability and productivity due to such symptoms as (for example only) flattened affect, panic attacks more than once a week or impaired abstract thinking. The Veteran reported experiencing some memory loss and isolation as well as depressed moods; however, the Board finds that these symptoms are not severe enough to warrant a higher 50 percent rating prior to March 2, 2015. It is clear based on the Veteran's reports that she does not experience social and occupational impairment with reduced reliability and productivity. The Board noted at her October 2011 examination that she did not report experiencing hallucinations or delusions and she did not demonstrate a desire to hurt herself or others. The Veteran noted that she was married and that she managed her house and finances as her husband had problems with alcohol abuse. Moreover, during her mental health treatment she reported scheduling and attending therapy sessions. Therefore, higher ratings of 70 and 100 percent are not warranted as the Veteran's depressive disorder symptoms do not reflect occupational and social impairment with deficiencies in most areas, or total occupation and social impairment. The Board notes that from March 2, 2015 onward the Veteran's symptoms do not warrant a rating in excess of 50 percent. At her March 2015 VA examination the Veteran experienced the symptoms of depressed mood, anxiety, chronic sleep impairment, mild memory loss, disturbances of motivation and mood and difficulty in adapting to stressful circumstances. The examiner noted that the Veteran's occupational and social impairment was best described as with reduced reliability and productivity. It is clear based on the Veteran's reports that she does not experience social and occupational impairment with deficiencies in most areas. As noted above, the criteria set forth in the rating formula for mental disorders do not constitute an exhaustive list of symptoms, but rather are examples of the type and degree of the symptoms, or their effects, that would justify a particular rating. Mauerhan v. Principi, 16 Vet. App. 436 (2002). The Board notes the Veteran's reported symptoms of isolation, difficulty sleeping, trouble concentrating and fatigue. However, the impact of these symptoms are generally more congruent with the assigned disability ratings of 30 and 50 percent than they would with higher ratings. As such, the Veteran's claims for schedular ratings in excess of 30 and 50 percent prior to March 2, 2015 and from then onward for depression is denied. Extraschedular Considerations As to consideration of referral for an extraschedular rating, such consideration requires a three-step inquiry. See Thun v. Peake, 22 Vet. App. 111 (2008), aff'd sub nom. Thun v. Shinseki, 572 F.3d 1366 (Fed. Cir. 2009). The first question is whether the schedular rating adequately contemplates the claimant's disability picture. Thun, 22 Vet. App. at 115. 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. If the schedular evaluation does not contemplate the claimant's level of disability and symptomatology and is found inadequate, then the second inquiry is whether the claimant's exceptional disability picture exhibits other related factors such as those provided by the regulation as governing norms. If the claimant's disability picture meets the second inquiry, then the third step is to refer the case to the Under Secretary for Benefits or the Director of the Compensation and Pension Service to determine whether an extraschedular rating is warranted. Here, regarding the Veteran's claims for increased ratings for hysterectomy and depressive disorder the rating criteria for the disability at issue reasonably describe and assess the Veteran's disability levels and symptomatology. The discussion above reflects that the symptoms of the Veteran's hysterectomy with endometriosis and depression are fully contemplated by the applicable rating criteria, as they address the following: pelvic pain and psychiatric symptoms that result in social and occupational functioning. As shown above, the criteria include both the symptoms listed and the overall level of impairment. Hence, consideration of whether the Veteran's disability picture exhibits other related factors such as those provided by the regulations as "governing norms" is not required. Referral for consideration of an extraschedular rating for these disabilities is therefore not warranted. 38 C.F.R. § 3.321(b)(1). In this regard, the Veteran is currently at 100% disabled. Entitlement to an Earlier Effective Date for Depressive Disorder In July 2010 the Veteran filed a claim of service connection for depressive disorder, which she claimed resulted from her endometriosis and hysterectomy. An October 2012 rating decision granted service connection for depressive disorder as associated with such, and assigned a 10 percent evaluation, effective July 2, 2010. The Board acknowledges that the Veteran listed June 21, 2010 on the date of her claim. However, the RO acknowledged through time stamp receipt of the claim on July 20, 2010. Although the RO noted receipt on the 20th of July, it issued an effective date of July 2, 2010 when it granted service connection for the Veteran's depressive disorder in the October 2012 rating decision. In November 2013, the Veteran submitted a notice of disagreement with the October 2012 rating decision, stating that she was appealing the rating and effective date for depressive disorder. She later perfected this appeal to the Board. Generally, the effective date of an evaluation and award of compensation for an increased rating claim is the date of receipt of the claim or the date entitlement arose, whichever is the later. 38 U.S.C.A. § 5110(a); 38 C.F.R. § 3.400(o)(1). A claim is "a formal or informal communication in writing requesting a determination of entitlement, or evidencing a belief in entitlement, to a benefit." 38 C.F.R. § 3.1(p) (2015). An informal claim is "[a]ny communication or action indicating intent to apply for one or more benefits." 38 C.F.R. § 3.155(a) (2015). VA must look to all communications from a claimant that may be interpreted as applications or claims - formal and informal - for benefits and is required to identify and act on informal claims for benefits. Servello v. Derwinski, 3 Vet. App. 196, 198 (1992). In some cases, a report of examination or hospitalization may be accepted as an informal claim for benefits. 38 C.F.R. § 3.157(b) (2015). The date of outpatient or hospital examination or date of admission to a VA hospital will be accepted as the date of receipt of a claim when such reports relate to examination or treatment of a disability for which service-connection has previously been established or when a claim specifying the benefit sought is received within one year from the date of such examination, treatment or hospital admission. 38 C.F.R. § 3.157(b). A report of examination implies that the medical record describes the results of a specific, particular examination and reflects a worsening of the condition. Massie v. Shinseki, 25 Vet. App. 123, 133-34 (2011) (noting that a letter from a VA physician generated for a pending Social Security claim was not a report of examination). Additionally, where new and material evidence is submitted prior to the expiration of the appeal period, or prior to the appellate decision if a timely appeal has been filed, it is considered as having been filed in connection with the claim which was pending at the beginning of the appeal period. 38 C.F.R. § 3.156(b). In an October 2012 rating decision, the RO granted service connection for depressive disorder and assigned a 10 percent evaluation, effective from July 2, 2010. The RO noted that such was the date of the Veteran's claim; although the Veteran's claim was in actuality received by the RO on July 20, 2010, the Board will not prejudice the Veteran by assigning such later effective date. The Veteran has never disputed the fact that this was the earliest claim of record for service connection for depressive disorder. In her November 2013 notice of disagreement the Veteran argued that an earlier effective date for depression should be assigned. Through her attorney, she provided the following statement: "the Veteran disagrees with all adjudicative determinations in that decision. This includes ratings and effective dates assigned." See November 2013 Notice of Disagreement. The Board notes that the Veteran's depression arose as early as August 2000, at which point she visited the Oregon Health Sciences University (HSU) for mental health treatment related to her endometriosis and tubal ligation in 1999. See Oregon HSU Progress Record Dated August 2000. As the date of the Veteran's claim (July 2, 2010) is clearly later in time than the date the disability arose, the currently assigned effective date of July 2, 2010 for the grant of service connection for depressive disorder is proper. As the preponderance of the evidence is against the Veteran's claim for an effective date earlier than July 2, 2010, for the grant of service connection for depressive disorder, the claim must be denied. 38 U.S.C.A. § 5107(b). Duties to Notify and Assist VA's duty to notify was satisfied by letters in June 2003 and July 2010. See 38 U.S.C.A. §§ 5102, 5103, 5103A (West 2014); 38 C.F.R. § 3.159 (2015); see also Scott v. McDonald, 789 F.3d 1375 (Fed. Cir. 2015). The Board further notes that the issues adjudicated in this decision stem from an appeal of an initial disability rating assigned following an award of compensation. Once a decision awarding compensation and assigning a disability rating and an effective date has been made, section 5103(a) notice has served its purpose, and its application is no longer required because the claim has been substantiated. Dingess/Hartman v. Nicholson, 19 Vet. App. 473, 490 (2006). The Board further notes that the record does not show, nor has the Veteran contended, that there are any notification deficiencies which have resulted in prejudice to her. See Goodwin v. Peake, 22 Vet. App. 128 (holding that the Veteran bears the burden of demonstrating any prejudice from defective VCAA notice with respect to the downstream elements such as the disability rating and effective date). With respect to VA's duty to assist, the record shows that VA has undertaken all necessary development action. 38 U.S.C.A. § 5103A(West 2014); 38 C.F.R. § 3.159(2015). The Veteran's service treatment records are on file, as are all available post-service clinical records which the Veteran has specifically identified and authorized VA to obtain. 38 U.S.C.A. § 5103A(c) (West 2014); 38 C.F.R. § 3.159(c)(2), (3)(2015). The Veteran has also been afforded a series of VA medical examinations in connection with her claims. 38 C.F.R. § 3.159(c) (4) (2015). The Board finds that the examination reports, together with the other evidence of record, contain the necessary findings upon which to decide these issues. See Massey v. Brown, 7 Vet. App. 204 (1994) (holding that VA medical examination reports must provide sufficient reference to the pertinent schedular criteria). The Board also notes that the record does not show, nor has the Veteran contended, that her service-connected disabilities have increased in severity or otherwise materially changed since the most recent examinations were conducted. Palczewski v. Nicholson, 21 Vet. App. 174, 182 (2007). In his regard, the Veteran is already at 100% disabled by VA. For the reasons set forth above, and given the facts of this case, the Board finds that no further notification or development action is necessary on the issues now being decided. ORDER An evaluation in excess of 30 percent for a hysterectomy with a history of endometriosis is denied. An initial evaluation in excess of 30 percent for depressive disorder associated with hysterectomy prior to March 2, 2015 and in excess of 50 percent from then onwards is denied. An effective date prior to July 2, 2010 for the award of service connection of depressive disorder is denied. REMAND Regarding entitlement to an increased evaluation for complex seizures, the Board notes that remand is required to obtain private treatment records. In March 2010, the Veteran submitted a private medical opinion in support of her claim from Dr. D.T. This opinion focused on elements of service connection, but Dr. D.T. noted in the opinion that he was treating the Veteran for her seizure disorder. The Board notes that no records by Dr. T.P. are associated with the claims folder. Therefore, it would appear that there are outstanding, private treatment records. On remand, the AOJ should request the Veteran's authority to obtain any outstanding private treatment records. With regard to the Veteran's claim of service connection for a heart condition, through her attorney, the Veteran has alleged that it is secondary to her service connected seizure disorder. See Attorney Submission of Addition Evidence September 2010. At her March 2015 VA examination, the examiner concluded that the Veteran's heart condition was less likely than not related to her service connected seizure disorder, but did not address whether such could have been aggravated by her service connected disability. The Board notes that secondary service connection claims may be granted based on a service-connected disability causing or aggravating another disorder. 38 C.F.R. § 3.310 (2015); Allen v. Brown, 7 Vet. App. 439, 449 (1995). Accordingly, the case is REMANDED for the following action: 1. Contact the Veteran and afford her the opportunity to identify by name, address, and dates of treatment or examination any relevant medical records. A specific request should be made for records from Dr. D.T. (see the Veteran's March 2010 submission), and any other specialist who has treated her for her seizure disorder. Subsequently, and after securing the proper authorizations where necessary, arrange to obtain all the records of treatment or examination from all the sources listed by the Veteran that are not already on file. All information obtained must be made part of the file. All attempts to secure this evidence must be documented in the claims file, and if, after making reasonable efforts to obtain named records, they are not able to be secured, provide the required notice and opportunity to respond to the Veteran and her attorney. 2. After any additional records are associated with the claims file, obtain an addendum opinion regarding the Veteran's heart condition from the examiner who conducted the March 2015 VA examination. If the same examiner is not available, provide the Veteran a new examination to determine the nature and etiology of her heart condition. The entire claims file should be made available to and be reviewed by the examiner. Any indicated tests and studies must be accomplished. All clinical findings must be reported in detail and correlated to a specific diagnosis. An explanation for all opinions expressed must be provided. The examiner must opine whether it is at least as likely as not (50 percent or greater probability) that: 1) the Veteran's heart condition was caused by service-connected seizure disorder; and 2) such disorder was aggravated by the service-connected seizure disorder. 3. Review each examination report to ensure that it is in complete compliance with the directives of this remand. If a report is deficient in any manner, the AOJ must implement corrective procedures. Stegall v. West, 11 Vet. App. 268, 271 (1998). 4. After completing the above action, and any other development as may be indicated by any response received as a consequence of the actions taken in the paragraphs above, the claims must be readjudicated. If the claims remain denied, a supplemental statement of the case must be provided to the Veteran and her attorney. After the Veteran and her attorney have had an adequate opportunity to respond, the appeal must be returned to the Board for appellate review. The Veteran has the right to submit additional evidence and argument on the matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). 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 2014). ______________________________________________ JOHN J. CROWLEY Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs