Citation Nr: 1756729 Decision Date: 12/07/17 Archive Date: 12/15/17 DOCKET NO. 13-30 513 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Lincoln, Nebraska THE ISSUES 1. Whether new and material evidence sufficient to reopen the claim for entitlement to service connection for headaches has been submitted. 2. Whether new and material evidence sufficient to reopen the claim for entitlement to service connection for a left lower extremity (possible radiculopathy) condition has been submitted. 3. Whether new and material evidence sufficient to reopen the claim for entitlement to service connection for musculoligamentous strain, right knee, has been submitted. 4. Whether new and material evidence sufficient to reopen the claim for entitlement to service connection for fibromyalgia has been submitted. 5. Whether new and material evidence sufficient to reopen the claim for entitlement to service connection for cervical strain has been submitted. 6. Whether new and material evidence sufficient to reopen the claim for entitlement to service connection for a right upper extremity condition has been submitted. 7. Entitlement to service connection for urinary frequency. 8. Entitlement to service connection for fibromyalgia. 9. Entitlement to service connection for a right upper extremity disability, to include neuropathy. 10. Entitlement to service connection for a cervical spine disability, to include cervical strain. 11. Entitlement to service connection for a headache disability. 12. Entitlement to service connection for a left lower extremity disability, to include radiculopathy. 13. Entitlement to service connection for a right knee disability, to include musculoligamentous strain. 14. Entitlement to an effective date prior to September 22, 2015, for the grant of entitlement to service connection for right lower extremity radiculopathy. 15. Entitlement to an initial rating greater than 10 percent for right lower extremity radiculopathy. 16. Entitlement to an increased rating greater than 10 percent for chronic constipation (claimed as gastrointestinal condition). 17. Entitlement to an increased rating greater than 10 percent for tendonitis and bursitis of the right shoulder. 18. Entitlement to an increased rating greater than 10 percent for bilateral sacroiliac joint dysfunction. 19. Entitlement to a compensable rating for hemorrhoids. 20. Entitlement to an increased rating greater than 50 percent for a mood disorder. REPRESENTATION Appellant represented by: John Berry, Attorney at Law ATTORNEY FOR THE BOARD C. J. Houbeck, Counsel INTRODUCTION The Veteran had active service from May 2004 to October 2004. This matter comes to the Board of Veterans' Appeals (Board) on appeal from February 2013, September 2014, and January 2016 rating decisions from the Department of Veterans Affairs (VA) Regional Office (RO) in Lincoln, Nebraska. The September 2014 rating decision and subsequent adjudications reopened the majority of the above new and material evidence issues and denied the claims on the merits. Regardless of the RO's actions, the Board is required to consider whether new and material evidence has been received warranting the reopening of the previously denied claims. See Barnett v. Brown, 83 F.3d 1380 (Fed. Cir. 1996); Jackson v. Principi, 265 F.3d 1366 (Fed. Cir. 2001); see also Wakeford v. Brown, 8 Vet. App. 237 (1995) (VA failed to comply with its own regulations by ignoring issue of whether any new and material evidence had been submitted to reopen the Veteran's previously and finally denied claims). In May 2016, the Board remanded the Veteran's increased rating claim for a mood disorder for further development and consideration. Based on the VA treatment records, a May 2016 letter to the Veteran, the October 2016 VA examination, and the subsequent readjudication of the claim, the Board finds that there has been substantial compliance with its remand directives. See Stegall v. West, 11 Vet. App. 268, 271 (1998). In addition to the mood disorder claim, the Board remand included the issue of entitlement to a total disability rating based on individual unemployability (TDIU). The RO subsequently granted entitlement to TDIU in an October 2016 rating decision, effective September 1, 2012, the month following the last date worked by the Veteran. The Veteran has not expressed disagreement with that determination and the record from that point does not otherwise include argument from the Veteran or her attorney representative that the service-connected disabilities currently on appeal render the Veteran unable to work. See Rice v. Shinseki, 22 Vet. App. 447, 454 (2009) (noting in a footnote that claims for increased evaluations and TDIU claims may be separately adjudicated). This appeal was processed using the Veteran's Benefits Management System (VBMS) and Virtual VA paperless claims processing systems. Accordingly, any future consideration of the case should take into consideration the existence of these electronic records. All the above-listed claims for service connection, as well as the increased rating claims for the low back, right shoulder, and right lower extremity radiculopathy are addressed in the REMAND portion of the decision below and are REMANDED to the Agency of Original Jurisdiction (AOJ). FINDINGS OF FACT 1. Unappealed July 2012 and November 2012 rating decisions denied entitlement to service connection for musculoligamentous strain right knee, fibromyalgia, right upper extremity condition (neuropathy), headaches, cervical strain, and bilateral lower extremity (possible radiculopathy). 2. Evidence received since the July 2012 and November 2012 rating decisions raises a reasonable possibility of substantiating the Veteran's musculoligamentous strain right knee, fibromyalgia, right upper extremity condition (neuropathy), headaches, cervical strain, and bilateral (now only left) lower extremity (possible radiculopathy) claims. 3. The Veteran's original claim for entitlement to service connection for a right lower extremity disability was filed in October 2007, more than one year after her separation from service, and entitlement to service connection for this disability was denied by the RO in multiple final rating decisions, including in November 2012. 4. A submission from the Veteran was received by VA on April 4, 2014, requesting that her claim for entitlement to service connection for a bilateral lower extremity (possible radiculopathy) condition be reopened. 5. Affording the Veteran the benefit of the doubt, she has had a diagnosis of right lower extremity radiculopathy from April 4, 2014. 6. The Veteran's chronic constipation disability is not manifested by severe diarrhea or alternating diarrhea and constipation. 7. The Veteran's hemorrhoid disability is manifested by primarily internal hemorrhoids, with no evidence of hemorrhoids that are large or thrombotic, irreducible, with excessive redundant tissue, evidencing frequent recurrences; and with no evidence of persistent bleeding with secondary anemia or with fissures. 8. The Veteran's mood disorder is manifested by depressed mood, anxiety, chronic sleep impairment, problems with immediate recall, disturbances of motivation and mood, anhedonia, anergia, feelings of worthlessness and hopelessness, and concentration problems, as well as intermittent reports of suicidal thoughts without plans or intent, all resulting in deficiencies in most areas, but less than total social and occupational impairment. CONCLUSIONS OF LAW 1. The July 2012 and November 2012 rating decisions that denied entitlement to service connection for musculoligamentous strain right knee, fibromyalgia, right upper extremity condition (neuropathy), headaches, cervical strain, and bilateral (now only left) lower extremity (possible radiculopathy) is final. 38 U.S.C. § 7105 (2012); 38 C.F.R. § 20.1103 (2017). 2. Evidence received since the July 2012 and November 2012 rating decisions in relation to the Veteran's claims for entitlement to service connection for musculoligamentous strain right knee, fibromyalgia, right upper extremity condition (neuropathy), headaches, cervical strain, and bilateral (now only left) lower extremity (possible radiculopathy) is new and material, and, therefore, the claims may be reopened. 38 U.S.C. §§ 5108, 7104 (2012); 38 C.F.R. § 3.156 (2017). 3. The criteria for an effective date of April 4, 2014, but no earlier, for the grant of entitlement to service connection for right lower extremity radiculopathy have been met. 38 U.S.C. §§ 1155, 5110 (2012); 38 C.F.R. §§ 3.1, 3.151, 3.152, 3.153, 3.155, 3.400 (2017). 4. The criteria for an increased rating greater than 10 percent for chronic constipation have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.159, 3.321, 4.7, 4.114, Diagnostic Code (DC) 7399-7319 (2017). 5. The criteria for a compensable disability rating for hemorrhoids have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.159, 3.321, 4.59, 4.114, DC 7336 (2017). 6. The criteria for an increased rating of 70 percent, but no higher, for a mood disorder have been met. 38 U.S.C. §§ 1155, 5107 (2012), 38 C.F.R. §§ 3.159, 3.321, 4.1, 4.3, 4.7, 4.126, 4.130, DC 9435 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duty to Notify and Assist Neither the Veteran nor her representative has identified any shortcomings in fulfilling VA's duty to notify and assist. See Scott v. McDonald, 789 F.3d 1375 (Fed. Cir. 2015). For the above reasons, the Board finds the duties to notify and assist have been met, all due process concerns have been satisfied, and the appeal may be considered on the merits. New and Material Evidence The Veteran has one year from notification of a RO decision to initiate an appeal by filing a notice of disagreement (NOD) with the decision, and the decision becomes final if an appeal is not perfected within the allowed time period. 38 U.S.C. § 7105(b) and (c) (2012); 38 C.F.R. §§ 3.160(d), 20.201, and 20.302(a) (2017). The Veteran originally or most recently was denied entitlement to service connection for musculoligamentous strain right knee, fibromyalgia, right upper extremity condition (neuropathy), headaches, cervical strain, and bilateral lower extremity (possible radiculopathy) in July 2012 and November 2012 rating decisions. The Veteran did not appeal the denial by submitting a timely NOD or other indication of disagreement with the rating decision within one year. The denial of her claims consequently became final. See 38 C.F.R. §§ 20.302, 20.1103 (2017). As a result, the claims of service connection may now be considered on the merits only if new and material evidence has been received since the time of the last final adjudication. 38 U.S.C. § 5108 (2012); 38 C.F.R. § 3.156 (2017); Manio v. Derwinski, 1 Vet. App. 140, 145 (1991); Evans v. Brown, 9 Vet. App. 273 (1996). Under 38 C.F.R. § 3.156(a), evidence is considered "new" if it was not of record at the time of the last final disallowance of the claim. 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. Finally, 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. In determining whether evidence is new and material, the "credibility of the evidence is to be presumed." Justus v. Principi, 3 Vet. App. 510, 513 (1992). Additionally, when determining whether the Veteran has submitted new and material evidence to reopen a claim, consideration must be given to all the evidence since the last final denial of the claim. Evans v. Brown, 9 Vet. App. 273 (1996). Moreover, the Veteran need not present evidence as to each element that was a specified basis for the last disallowance, but merely new and material evidence as to at least one of the bases of the prior disallowance. See Shade v. Shinseki, 24 Vet. App. 110 (2010) (holding that it would be illogical to require that a claimant submit medical nexus evidence when he has provided new and material evidence as to another missing element). Since the time of the last final rating decision, the Veteran has submitted an April 2014 letter from a private physician opining that each of the claimed disabilities discussed above were due to a fall in service and/or a service-connected disability. Pursuant to the Court's holding in Shade and presuming the credibility of the evidence for the sole purpose of determining whether the claims should be reopened, the Board concludes that the above medical evidence suggests a possible association between the claimed musculoligamentous strain right knee, fibromyalgia, right upper extremity condition (neuropathy), headaches, cervical strain, and bilateral (now only left) lower extremity (possible radiculopathy) and service or a service-connected disability. At the very least, this new evidence raises a reasonable possibility of substantiating the claims and constitutes new and material evidence sufficient to reopen the Veteran's service connection claims. However, as will be discussed more fully below, the Board finds that additional development is necessary prior to adjudication of the service connection claims. Earlier Effective Date The Veteran seeks an effective date prior to September 22, 2015, for the grant of service connection for right lower extremity radiculopathy. In general, where a claim for service connection is filed more than one year after separation from active service, the effective date for the grant of service connection is the date of receipt of claim, or the date entitlement arose, whichever is later. 38 U.S.C. § 5110(b) (2012); 38 C.F.R. § 3.400(b) (2017). In this case, the Veteran separated from active service in October 2004. She did not submit a claim of entitlement to service connection for a right lower extremity disorder within one year from his discharge. Therefore, assignment of an effective date back to the day following discharge is not possible. Instead, the appropriate effective date is the date of receipt of claim or the date entitlement arose, whichever is later. The terms "claim" and "application" mean a formal or informal communication in writing requesting a determination of entitlement or evidencing a belief in entitlement to a benefit. See 38 C.F.R. § 3.1(p) (2017). A specific claim in the form prescribed by VA must be filed in order for benefits to be paid or furnished to any individual under the laws administered by VA. See 38 U.S.C. § 5101(a) (2012); 38 C.F.R. § 3.151(a) (2017). An April 2014 letter from the Veteran's private treating physician noted treatment from 2008 and listed a diagnosis of bilateral lower extremity peripheral neuropathy. A contemporaneous treatment record from the same physician included an assessment of sciatica, pain in limb, and pain in joint involving lower leg. (The Board also notes that January 2010 straight leg raising testing was mildly positive and a November 2010 treatment record from the same provider included a diagnosis of sciatica.) An April 2014 Fibromyalgia Disability Benefits Questionnaire completed by treatment providers from the same facility included diagnoses of fibromyalgia, migraine, and sciatica. A September 22, 2015, VA examination report included a finding of right lower extremity radiculopathy involving the sciatic nerve and based on this finding service connection was granted. In a June 2016 statement, the Veteran's attorney pointed to the April 2014 private physician's statement noting a diagnosis of bilateral lower extremity radiculopathy and treatment for such problems and that the physician was competent to provide evidence of such diagnosis and treatment. The Board acknowledges that multiple prior VA examinations were negative for radiculopathy, including in January 2011, June 2012, February 2013, and July 2014; however, given the multiple specific findings of sciatica and radiculopathy the Board will afford the Veteran the benefit of the doubt and presume that she had a diagnosis of right lower extremity radiculopathy at the time of her April 4, 2014, petition to reopen the finally denied claim for entitlement to service connection for a bilateral lower extremity disability. As such, entitlement to service connection is warranted from that date. The Board has considered whether an effective date prior to April 4, 2014, is warranted. The Board finds that an effective date prior to April 4, 2014, is not warranted. Rating actions are final and binding based on evidence on file at the time the Veteran 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) (2017). The Veteran has one year from notification of a RO decision to initiate an appeal by filing a notice of disagreement (NOD) with the decision, and the decision becomes final if an appeal is not perfected within the allowed time period. 38 U.S.C. § 7105(b) and (c) (2012); 38 C.F.R. §§ 3.160(d), 20.201, 20.302(a) (2017). Multiple prior rating decisions, including in November 2012, denied entitlement to service connection for a bilateral lower extremity (possible radiculopathy) condition. The Veteran did not submit a timely notice of disagreement with the November 2012 determination and it became final. As noted above, the effective date for a grant of service connection for an initial claim or on the basis of the receipt of new and material evidence following a final prior disallowance is the date of receipt of the application to reopen, or the date entitlement arose, whichever is later. Thus, April 4, 2014, is the earliest effective date possible under the relevant laws and regulations for the Veteran's right lower extremity radiculopathy claim. Ratings Disability evaluations are determined by evaluating the extent to which a veteran's service-connected disability adversely affects his or her ability to function under the ordinary conditions of daily life, including employment, by comparing his or her symptomatology with the criteria set forth in the Schedule for Rating Disabilities. The percentage ratings represent as far as can practicably be determined the average impairment in earning capacity resulting from such diseases and injuries and the residual conditions in civilian occupations. Generally, the degree of disabilities specified are considered adequate to compensate for considerable loss of working time from exacerbation or illness proportionate to the severity of the several grades of disability. 38 U.S.C. § 1155 (2012); 38 C.F.R. § 4.1 (2017). Separate DCs identify the various disabilities and the criteria for specific ratings. If two disability evaluations are potentially applicable, the higher evaluation will be assigned to the disability picture that more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7 (2017). Any reasonable doubt regarding the degree of disability will be resolved in favor of the Veteran. 38 C.F.R. § 4.3 (2017). The Veteran's entire history is reviewed when making a disability determination. See 38 C.F.R. § 4.1 (2017). VA must consider whether the Veteran is entitled to "staged" ratings to compensate when his or her disability may have been more severe than at other times during the course of his or her appeal. The evaluation of the same disability under various diagnoses, known as pyramiding, is generally to be avoided. 38 C.F.R. § 4.14 (2017). The critical element in permitting the assignment of several ratings under various DCs is that none of the symptomatology for any one of the disabilities is duplicative or overlapping with the symptomatology of the other disability. See Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994). Chronic Constipation The Veteran's chronic constipation currently is rated at 10 percent under DC 7399-7319 as analogous to irritable colon syndrome. The Veteran claims the current 10 percent rating does not accurately reflect the severity of her condition. DC 7319 provides ratings for irritable colon syndrome (spastic colitis, mucous colitis, etc.). Mild irritable colon syndrome, with disturbances of bowel function with occasional episodes of abdominal distress, is rated noncompensably (0 percent) disabling. Moderate irritable colon syndrome, with frequent episodes of bowel disturbance with abdominal distress, is rated 10 percent disabling. Severe irritable colon syndrome, with diarrhea, or alternating diarrhea and constipation, with more or less constant abdominal distress, is rated 30 percent disabling. 38 C.F.R. § 4.114, DC 7319. The Board observes that the words "mild," "moderate," "moderately severe," and "severe" as used in the various DCs are not defined in the VA Schedule for Rating Disabilities. Rather than applying a mechanical formula, the Board must evaluate all of the evidence, to the end that its decisions are "equitable and just." 38 C.F.R. § 4.6. In her April 2014 claim, the Veteran asserted that she had periods of alternating constipation and diarrhea. On occasion, her stomach would swell up to the point that she appeared to be 7 months pregnant. The Veteran underwent a VA examination in July 2014. The examiner noted review of the claims file. There was a diagnosis of chronic constipation. The Veteran had irregular bowel movements and used an enema twice per week with intermittently successful results. There was bloating and she used polyethylene glycol powder orally, as well as docusate sodium. The Veteran also had increased her water intake. There was no weight loss or episodes of abdominal disturbance with abdominal distress. There was no evidence of malnutrition or tumors. The Veteran was afforded a VA examination in September 2015 for her chronic constipation. She described experiencing only 1 to 2 bowel movements per month and took over-the-counter stool softeners, laxatives, magnesium citrate, docusate and enemas. Her last bowel movement was approximately one week prior to the examination. Occasionally, she experienced some loose stools, but often they were hard and solid. The Veteran also experienced abdominal bloating and cramping accompanying the constipation. She had not undergone any surgery for the symptoms. The examiner described her problems as involving frequent episodes of bowel disturbance with abdominal distress. There was no associated weight loss, malnutrition, or tumors. The Veteran's VA treatment records document regular complaints of chronic constipation. With regard to assigning an increased rating under DC 7319, the Board finds that there is no evidence of record reflecting that the Veteran's chronic constipation results in severe diarrhea or alternating diarrhea and constipation. The evidence indicates that the Veteran occasionally has loose stools, but generally has hard stools that occur infrequently. There is evidence of bloating. In light of the foregoing, the Board finds no medical evidence of record reflecting that the Veteran's chronic constipation currently meets the criteria for a 30 percent rating under DC 7319. As such, an increased rating is not warranted under this DC. The Board has reviewed the remaining DCs relating to disabilities of the digestive system but finds that they are inapplicable in this case - other than with respect to the separate rating under DC 7336 for hemorrhoids as discussed below. See 38 C.F.R. § 4.114 (2017). In summary, the Board concludes that the preponderance of the evidence is against the claim for an increased rating. The benefit of the doubt rule enunciated in 38 U.S.C. § 5107(b) is not for application as there is not an approximate balance of evidence. Assignment of staged ratings has been considered and is not for application. Hemorrhoids A noncompensable evaluation is assigned for the Veteran's service-connected hemorrhoids under DC 7336. The Veteran contends that the rating does not reflect the severity of her symptoms. Under DC 7336, a noncompensable evaluation is assigned for mild to moderate hemorrhoids. A 10 percent evaluation is assigned for external or internal hemorrhoids, large or thrombotic, irreducible, with excessive redundant tissue, evidencing frequent recurrences. A 20 percent evaluation is assigned for external or internal hemorrhoids, with persistent bleeding and with secondary anemia, or with fissures. 38 C.F.R. § 4.114, DC 7336. In her April 2014 claim for an increased rating, the Veteran claimed to have bleeding and excess tissue as symptoms of the hemorrhoids. The Veteran underwent a VA rectal and anus examination in July 2014. The examiner noted review of the claims file. The Veteran reported irregular bowel movements and approximately twice per week there was bright red blood (pink tinge) on the toilet paper. She used an enema twice a week for her hard stools. There was not any current treatment for the hemorrhoids. The Veteran declined an examination for privacy reasons and the examiner determined that the Veteran's described symptoms were in the mild or moderate range. The Veteran was afforded a VA examination for her hemorrhoids in September 2015. The examiner noted review of the claims file and the diagnosis of hemorrhoids. The Veteran reported ongoing flare-ups, primarily of internal hemorrhoids. The flare-ups could occur 1 to 2 times per month and would last for 1 or 2 days. Symptoms during flare-ups included burning, bleeding, itching, swelling, and discomfort. She did not use any medication or other treatment remedies. The Veteran had not undergone any surgeries for hemorrhoids and the last flare-up occurred 1.5 to 2 weeks prior to the examination. The Veteran did not describe any periods of complete incapacity or sphincter impairment. The Veteran declined an examination, since the hemorrhoids were not currently flaring. With regard to assigning an increased rating under DC 7336, the Board finds that there is no evidence of record reflecting that the Veteran has hemorrhoids that are large, thrombotic, or irreducible. The Veteran has alleged that the hemorrhoids cause excessive redundant tissue and result in intermittent bleeding, but without evidence suggestive of anemia or fissures. The Veteran's hemorrhoids have been described as mild or moderate in severity, consistent with a noncompensable rating. The evidence also indicates that the hemorrhoids do not impact the Veteran's ability to work. Therefore, upon review of the claims file, the Board finds no medical evidence of record reflecting that the Veteran's hemorrhoids currently meet the criteria for a 10 or 20 percent rating under DC 7336. As such, an increased rating is not warranted under this DC. The Board has reviewed the remaining DCs relating to disabilities of the digestive system but finds that they are inapplicable in this case. See 38 C.F.R. § 4.114 (2017); see also Copeland v. McDonald, 27 Vet. App. 333 (2015) (holding that rating by analogy is not permitted when, as in this case, there is a DC that is specifically labeled with the name of a particular condition). In summary, the Board concludes that the preponderance of the evidence is against the claim for an increased rating. The benefit of the doubt rule enunciated in 38 U.S.C. § 5107(b) is not for application as there is not an approximate balance of evidence. Assignment of staged ratings has been considered and is not for application. Mood Disorder Currently the Veteran's disability rating is 50 percent for her service-connected mood disorder. The Veteran claims the rating does not accurately depict the severity of her condition. The General Rating Formula for Mental Disorders provides, in pertinent part: Occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships . . . . . . . . . . . . . . . . . . . . . . . 50 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 worklike setting); inability to establish and maintain effective relationships . . . .. . . . . . . . . . . . . . . . . . . . . . . . . 70 Total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or name . . . . . . . . . . . . . . . . . . . . 100 38 C.F.R. § 4.130, DC 9435. When determining the appropriate disability evaluation under the general rating formula, the Board's primary consideration is a veteran's symptoms, but it must also make findings as to how those symptoms impact the Veteran's occupational and social impairment. See Vazquez-Claudio v. Shinseki, 713 F.3d 112, 116-17 (Fed. Cir. 2013). Because the use of the term "such as" in the rating criteria demonstrates that the symptoms after that phrase are not intended to constitute an exhaustive list. Nevertheless, as all ratings in the general rating formula are also associated with objectively observable symptomatology and the plain language of the regulation makes it clear that the Veteran's impairment must be "due to" those symptoms, a veteran may only qualify for a given disability rating under the general rating formula by demonstrating the particular symptoms associated with that percentage, or others of similar severity, frequency, and duration. Id at 117-18. Additionally, a Global Assessment of Functioning (GAF) score is often used by treating examiners to reflect the "psychological, social, and occupational functioning on a hypothetical continuum of mental health-illness." See Richard v. Brown, 9 Vet. App. 266 (1996). A GAF score is highly probative as it relates directly to the Veteran's level of impairment of social and industrial adaptability, as contemplated by the rating criteria for mental disorders. See Massey v. Brown, 7 Vet. App. 204, 207 (1994). The Board recognizes that GAF scores are not utilized in the DSM-5. The Veteran underwent a VA mental health examination in September 2012. The examiner noted review of the claims file and a diagnosis of mood disorder due to general medical condition, with depressive features. The examiner described the Veteran as having occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although generally functioning satisfactorily, with normal routine behavior, self-care, and conversation. The Veteran was working as a self-employed childcare provider. Her major complaint was that she had "a lot of stressors in my life." She had been experiencing depression for over one year, which had worsened as her pain had increased. Symptoms included anhedonia, anergia, feelings of worthlessness and hopelessness, and concentration problems at work. She also had a depressed mood, chronic sleep impairment, disturbances of motivation and mood, and difficulty in establishing and maintaining effective work and social relationships. The Veteran denied suicidal or homicidal ideation or audio or visual hallucinations. The Veteran had sleep problems and intermittent anxiety and irritability. She was not taking psychiatric medication, but would consider medication when she stopped breastfeeding her youngest child. The Veteran was living with her youngest child's father and her 4 children. She had contact with her extended family, but otherwise limited social activities because while part of her wanted to be involved with others another part of her did not want to go to see friends. The Veteran currently was a student at the local university and was taking 4 classes for 12 credit hours. She was not currently employed and last worked in March 2010 doing telephone work, customer service, and billing. Her current activities included playing games, going for walks, spending time with the family, and getting her children to activities. On examination, the Veteran was fully oriented and also had intact attention, insight, judgment, memory, and concentration. In an October 2012 statement, the Veteran indicated that the pain from her service-connected orthopedic disabilities caused significant depression and sleep problems. She did not believe that she would be able to work due to the pain and indicated that she had "given up." Her psychiatrist wanted to put her on medication and the Veteran was considering medication, but was concerned about the side effects. An October 2012 letter from the Veteran's then-fiancé indicated that the Veteran was experiencing significant depression and did not "feel like I am worth anything" because she was unable to do simple things around the house due to pain. The Veteran underwent another VA mental health examination in February 2013. The examiner described the Veteran as having occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although generally functioning satisfactorily, with normal routine behavior, self-care, and conversation. The Veteran had recently gotten married and was living with her husband and 4 children. Her husband forced her to go to social events because she did not want to attend. Her mother called 4 times per day. The Veteran had not taken any educational classes since the last examination and was not employed. The Veteran spent her time watching television and would like to read except that books were expensive. At present, she was not receiving any mental health treatment or medication. On examination, the Veteran was fully oriented and had intact concentration and attention. She reported becoming depressed very easily and some irritability. Insight, memory, and judgment were intact. A March 2013 statement from the Veteran indicated that she could "barely leave my room[.] Honestly it has gotten so bad that my kids have to be in my room with me just so we spend more time together. The Veteran also indicated that suicidal thoughts crossed her mind "more times than not." She got past her dark thoughts by thinking about her amazing family and what her suicide would do to them. She felt depressed due to how difficult daily tasks had become. The Veteran's mother called her multiple times per day and her friends tried to get her to go out, but she did not want to go out. She also described memory problems. A June 2016 VA Social Work and Industrial Survey noted that the Veteran was appropriately dressed for the examination, was cooperative, had a good grasp of reality, and had no difficulty with communication. She had intermittent eye contact and appeared sad. She cried a few times during the interview and a few pauses during the interview suggesting some difficulties with attention span. The Veteran stated that when her pain was severe or mood down that it affected her concentration and focus. Due to pain and lack of motivation she did not socialize outside her immediate family, but was living with her husband and 4 children. The Veteran had just started in-person and online courses and had some prior college courses. Mental status examination was similar to the below September 2016 examination findings. A GAF score of 50 was assigned. The Veteran had significant depression and anxiety due to overall physical and mental issues, which also affected her ability to focus and maintain the pace of employment. She was attempting college classes for the third time and found it extraordinarily difficult to focus and concentrate. The Veteran was afforded a VA examination in September 2016. The examiner noted a diagnosis of depressive disorder, not otherwise specified, and review of the claims file and medical records. The examiner determined that the Veteran's occupational and social impairment resulted in reduced reliability and productivity. The Veteran had 4 marriages and 3 divorces. She had 4 children and was expecting a fifth around September 2016. She last was employed in administration at VA. Prior to that the Veteran had tried to work in daycare. She had not pursued any education after high school. The examiner noted that the Veteran had been in a depressive study at VA, but dropped out. She was not on medication at the time of examination. Mental health symptoms included depressed mood, anxiety, chronic sleep impairment, and disturbances of motivation and mood. On evaluation, the Veteran was fully oriented and demonstrated relevant thought processes. She denied psychotic symptoms or suicidal ideation. Short and long term memory was intact, but there were problems with immediate recall after 5 minutes. The Veteran's mood was depressed / anxious and she had a congruent affect. The Board concludes that the objective medical evidence and the Veteran's and other lay statements regarding her symptomatology show disability that more nearly approximates that which warrants the assignment of a 70 percent disability rating. See 38 C.F.R. § 4.7. In reaching that conclusion, the Board notes that the Veteran's symptoms include multiple reports of suicidal thoughts, without specific plan or intent; memory and concentration problems; depressed mood; anxiety; chronic sleep impairment; problems with immediate recall; disturbances of motivation and mood; anhedonia; anergia; and feelings of worthlessness and hopelessness. In summary, the Board finds that the above symptoms most closely approximate the higher 70 percent rating. The Board recognizes that all of the above-listed symptoms have not been noted at all times or in all records. That said, the severity of the Veteran's mood disorder overall appears to have been essentially consistent for the entire appellate time period. For this reason, staged ratings are not applicable. Therefore, as explained above, the medical and lay evidence supports the Board's conclusion that a 70 percent rating is warranted for the entire appeal period. However, a rating greater than 70 percent is not appropriate for any period of time on appeal because the Veteran does not have total social and occupational impairment. Although the Veteran clearly has a serious disability, the evidence does not show that there is total occupational and social impairment. She does not have symptoms such as gross impairment of thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others (while she reported suicidal thoughts she has denied plans or intent because of her amazing family); intermittent inability to perform activities of daily living due to mental health problems, as her difficulties with such activities are due to her pain problems; disorientation to time or place; or memory loss for names of close relatives, own occupation, or own name. As noted, while the Veteran has expressed suicidal thoughts, she has denied any actual intent to harm herself. As such, her symptoms more closely approximate those for a 70 percent rating, specifically suicidal or homicidal ideation, but without rising to the level required for a 100 percent rating, specifically a persistent danger of hurting self or others. As to the Veteran's reported concentration and memory problems, there is no indication or suggestion that these problems rise to the level of severity contemplated for a 100 percent rating, namely forgetting one's own name or those of family or close friends. As to occupational and social functioning, medical professionals have indicated that the Veteran would have some difficulty in the workplace, due to her psychiatric symptoms. The vast majority of the evidence, however, indicates that the basis for the Veteran's ongoing unemployment is due to non-psychiatric disorders, to include multiple service-connected disabilities that served as the basis for the grant of entitlement to TDIU. Similarly, during her appeal, the Veteran married and has maintained good relationships with several family members. She is withdrawn socially outside of her family, but maintains a strong relationship with her husband and children, as well as more extended family. Thus, the Veteran does not have total social and occupational impairment sufficient to warrant a total schedular rating. She does have some deficiencies in several areas, but the greater weight of evidence demonstrates that it is to a degree that is contemplated by the 70 percent rating assigned herein. In determining that a rating in excess of 70 percent is not warranted, the Board has considered the Veteran's complaints regardless of whether they are listed in the rating criteria, but for the reasons discussed above concludes that the Veteran's level of social and occupational impairment does not warrant a rating in excess of the currently assigned 70 percent rating. In summary, for the reasons and bases set forth above, the Board concludes that an increased rating of 70 percent, but no more, is warranted for the entire period of time that is covered by this claim. Neither the Veteran nor her representative has raised any other issues, nor have any other issues been reasonably raised by the record. See Doucette v. Shulkin, 28 Vet. App. 366 (2017) (confirming that the Board is not required to address issues unless they are specifically raised by the claimant or reasonably raised by the evidence of record). ORDER The application to reopen a claim for headaches is granted. The application to reopen a claim for a left lower extremity (possible radiculopathy) condition is granted. The application to reopen a claim for musculoligamentous strain, right knee, is granted. The application to reopen a claim for fibromyalgia is granted. The application to reopen a claim for cervical strain is granted. The application to reopen a claim for a right upper extremity condition is granted. Entitlement to an effective date of April 4, 2014, but no earlier, for the grant of entitlement to service connection for right lower extremity radiculopathy is granted, subject to the laws and regulations controlling the award of monetary benefits. Entitlement to an increased rating greater than 10 percent for chronic constipation (claimed as gastrointestinal condition) is denied. Entitlement to a compensable rating for hemorrhoids is denied. Entitlement to an increased rating of 70 percent, but no greater, for a mood disorder is granted, subject to the laws and regulations controlling the award of monetary benefits. REMAND The Board finds that further development is necessary prior to the adjudication of the remaining claims. The Veteran was last afforded a VA examination for her low back and right shoulder disabilities in September 2015. Since the time of that examination, the United States Court of Appeals for Veterans Claims (Court) held in Correia v. McDonald, 28 Vet. App. 158 (2016) that to be adequate a VA examination of the joints must, wherever possible, include the results of range of motion testing on both active and passive motion, in weight-bearing and nonweight-bearing and, if possible, with the range of the opposite undamaged joint in compliance with 38 C.F.R. § 4.59. The September 2015 VA examination reports for the Veteran's back and right shoulder failed to include any discussion or delineation of passive versus active range of motion or weight bearing and non-weight bearing testing. The shoulder examination also did not include examination of the left shoulder for comparison. As the Veteran is not in receipt of the maximum ratings available for limitation of motion of the back or right shoulder, the Board finds that the VA examination reports of record do not comply with Correia and that new examinations are warranted. In addition, the Board finds that the increased rating claim for right lower extremity radiculopathy and entitlement to service connection for left lower extremity radiculopathy are inextricably intertwined with the remanded low back issue, as the ordered examination will include testing for radiculopathy of the left lower extremity (which has been denied based on the absence of a confirmed diagnosis) and discuss the severity of the right lower extremity radiculopathy. For the same reason, adjudication of the right upper extremity disability claim (claimed as neuropathy) is deferred, as the Veteran asserts that she has neuropathy due to the right shoulder disability and the claim has been denied based on the absence of a current diagnosis. As such, adjudication of these issues is deferred pending the above development. As to the Veteran's headache claim, she was afforded a VA examination in June 2012 and in the resulting examination report the examiner concluded that the headaches were due to her cervical strain, which was not a service-connected disability. As will be discussed in greater detail below, the cervical strain claim is remanded herein and the headache claim is inextricably intertwined with that issue. Moreover, the June 2012 VA examination report failed to discuss whether the headache disorder was caused or aggravated by any of the Veteran's already service-connected disabilities. As such, an additional medical opinion is necessary. The evidence indicates that the Veteran's urinary frequency claim is the result of excessive water intake due to symptoms of dry mouth associated with the Veteran's migraine medication (Topomax). As such, the urinary frequency claim is inextricably intertwined with the headache claim and final adjudication is deferred. As to the cervical spine and right knee claims, the Veteran was afforded VA examinations in June 2012, with an August 2014 medical opinion of record with respect to the cervical spine. These opinions focused solely on whether these disabilities were secondary to any of the Veteran's service-connected disabilities. The above failed, however, to consider or discuss whether either disability was directly related to service. In that regard, an April 2014 opinion from the Veteran's private treating physician indicated that cervical spine, right knee, and other problems were due to an in-service fall suffered by the Veteran. The service treatment records fail to document the fall or complaints regarding the cervical spine or right knee, but the RO in June 2008 determined that the records were incomplete. In light of the foregoing, the Board finds that a medical opinion is necessary regarding whether the cervical spine and right knee disabilities were incurred in or are otherwise the result of an in-service fall in 2004. As to the Veteran's fibromyalgia claim, she was afforded a VA examination in June 2012 at which time she was diagnosed with fibromyalgia. The private and VA medical records otherwise are replete with multiple diagnoses of fibromyalgia. The April 2014 private physician's letter (referenced above) concluded that the Veteran's fibromyalgia was due to her 2004 in-service fall. The RO sought an addendum opinion to address that theory of entitlement. The subsequent January 2016 opinion, however, without examination of the Veteran concluded that she did not meet the criteria for a diagnosis of fibromyalgia. The medical professional provided a negative opinion as to a relationship between the claimed fibromyalgia and the 2004 fall based in part on the conclusion that she did not meet the criteria for fibromyalgia. The Board finds such a determination extremely problematic as it was not based on a physical examination and is at odds with the findings of multiple medical professionals who have examined the Veteran. As such, a remand for a new examination is necessary. Accordingly, the case is REMANDED for the following action: 1. Associate with the electronic claims file all VA treatment records from September 2016 to the present. 2. Schedule the Veteran for an appropriate VA examination for her claimed fibromyalgia disability. The electronic claims file must be provided to the appropriate examiner for review, and the examiner should note that it has been reviewed. After reviewing the claims file, eliciting a history directly from the Veteran, and conducting a thorough examination, as well as any diagnostic studies deemed necessary, the examiner must offer an opinion as to whether any currently diagnosed fibromyalgia or fibromyalgia diagnosed during the appellate time period was incurred in service or is otherwise the result of service, to include as the result of a fall in 2004. In reaching that conclusion the examiner is requested to consider, and reconcile to the extent necessary, the April 2014 private physician's letter and the June 2012 VA examination and January 2016 addendum. If the examiner concludes that the Veteran does not have a current diagnosis of fibromyalgia, the examiner is requested to reconcile such a finding with the numerous diagnoses of fibromyalgia in the record, to include both private and VA records. The term "at least as likely as not" does not mean "within the realm of medical possibility." Rather, it means that the weight of medical evidence both for and against a conclusion is so evenly divided that it is as medically sound to find in favor of that conclusion as it is to find against it. The examiner must provide the underlying reasons for any opinion provided. If the examiner determines that an opinion cannot be made without resort to mere speculation, then it should be clear in the remarks whether it cannot be determined from current medical knowledge that a specific in-service injury or disease can possibly cause the claimed disorder, or whether the actual cause is due to multiple potential causes. In other words, simply stating that an opinion cannot be provided without resort to mere speculation is not acceptable without a detailed reason as to why this is so. 3. Obtain a supplemental opinion from the examiner who conducted the June 2012 VA cervical spine and right knee examinations. If the examiner is not available, obtain an opinion from another appropriate medical professional. If the examiner/reviewer determines that additional examination of the Veteran is necessary to provide a reliable opinion, such examination should be scheduled. However, the Veteran should not be required to report for another examination as a matter of course, if it is not found to be necessary. The electronic claims file must be made available to and reviewed by the reviewer/examiner. The reviewer/examiner is asked to provide an opinion regarding whether it is as least as likely as not (50 percent probability or more) that the diagnosed cervical spine and/or right knee disabilities were incurred in or are otherwise related to the Veteran's service, to include as a result of a fall in 2004. Review of the entire file is required; however, attention is invited to the April 2014 letter from the Veteran's private treating physician opining that the cervical spine and right knee problems were due to the 2004 fall, as the Veteran had not been experiencing problems prior to the fall and such problems were reasonable to expect as the result of a jarring injury after a fall. The Board recognizes that the service treatment records do not include specific references to right knee or cervical spine problems as the result of a fall; however, the service treatment records have been deemed to be incomplete. The medical professional is asked to explain the reasons behind any opinions expressed and conclusions reached. The medical professional is reminded that the term "as likely as not" does not mean "within the realm of medical possibility," but rather that the evidence of record is so evenly divided that, in the medical professional's expert opinion, it is as medically sound to find in favor of the proposition as it is to find against it. 4. Obtain a supplemental opinion from the examiner who conducted the June 2012 VA headache examination. If the examiner is not available, obtain an opinion from another appropriate medical professional. If the examiner/reviewer determines that additional examination of the Veteran is necessary to provide a reliable opinion, such examination should be scheduled. However, the Veteran should not be required to report for another examination as a matter of course, if it is not found to be necessary. The electronic claims file must be made available to and reviewed by the reviewer/examiner. The reviewer/examiner is asked to provide an opinion regarding whether it is as least as likely as not (50 percent probability or more) that the diagnosed headache disabilities were caused OR aggravated by one or more of the Veteran's service-connected disabilities. Review of the entire file is required; however, attention is invited to the June 2012 examination report findings that the Veteran was unaware of any triggers to the headaches, whereas in an October 2012 statement she specifically indicated that her headaches were triggered by pain from her service-connected back and other areas. The medical professional is asked to explain the reasons behind any opinions expressed and conclusions reached. The medical professional is reminded that the term "as likely as not" does not mean "within the realm of medical possibility," but rather that the evidence of record is so evenly divided that, in the medical professional's expert opinion, it is as medically sound to find in favor of the proposition as it is to find against it. 5. Schedule the Veteran for VA examinations to determine the current nature and severity of her lumbar spine and right shoulder disabilities. The electronic claims file should be made available to and reviewed by the examiner(s). Full range of motion testing must be performed where possible. The joint(s) involved should be tested in both active and passive motion, in weight-bearing and non weight-bearing and, if possible, with the range of the opposite undamaged joint in compliance with 38 C.F.R. § 4.59. If the examiner(s) is unable to conduct the required testing or concludes that the required testing is not necessary in this case, he or she should clearly explain the basis for this decision. 6. After the above is complete, readjudicate the claims. If a complete grant of the benefits requested for each claim is not granted, issue a supplemental statement of the case (SSOC) to the Veteran and her representative. The appellant 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 2014). ______________________________________________ MICHAEL LANE Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs