Citation Nr: 18140661 Decision Date: 10/04/18 Archive Date: 10/03/18 DOCKET NO. 16-60 247 DATE: October 4, 2018 ORDER Entitlement to service connection for bilateral hearing loss is denied. Entitlement to service connection for sleep apnea is denied. Entitlement to service connection for low blood pressure is denied. Entitlement to service connection for blisters is denied. Entitlement to an initial rating in excess of 10 percent for osteoporosis is denied. Entitlement to an initial rating in excess of 10 percent for left hip sacroiliac stress fracture with residual pain, limitation of extension, is denied. REMANDED Entitlement to an initial rating in excess of 10 percent for lumbar degenerative disc disease L3-L4, prior to July 31, 2017, and in excess of 20 percent thereafter, is remanded. Entitlement to an initial rating in excess of 10 percent for left lumbar radiculopathy prior to July 31, 2017, and in excess of 20 percent thereafter, is remanded. Entitlement to an initial compensable rating for left hip sacroiliac stress fracture with residual pain, limitation of flexion, is remanded. Entitlement to an initial rating in excess of 10 percent for left hip sacroiliac stress fracture with residual pain, impairment of the hip, is remanded. Entitlement to an initial compensable rating for tibial plateau stress fracture and osteoporosis, left knee, is remanded. Entitlement to an initial rating in excess of 10 percent for tibial plateau stress fracture and osteoporosis, right knee, is remanded. Entitlement to an initial compensable rating for metatarsal stress fracture, right foot, is remanded. Entitlement to an initial compensable rating for constipation is remanded. Entitlement to an initial compensable rating for peripheral vestibular disorder prior to May 21, 2015, and in excess of 10 percent thereafter, is remanded Entitlement to an initial rating in excess of 30 percent for depressive disorder, not otherwise specified, with anxiety, prior to May 19, 2016, and in excess of 50 percent thereafter, is remanded. Entitlement to an initial rating in excess of 30 percent for migraine headaches is remanded. Entitlement to service connection for gastroesophageal reflux disease (GERD) is remanded. FINDINGS OF FACT 1. The appellant does not currently have a bilateral hearing loss disability for VA compensation purposes. 2. Sleep apnea has not been present during the period of this claim. 3. The appellant does not have a current disability manifested by low blood pressure which was incurred in or is otherwise causally related to her active service. 4. The appellant does not have a current disability manifested by blisters which was incurred in or is otherwise causally related to her active service. 5. The appellant is in receipt of the maximum schedular rating for limitation of extension of the left hip. 6. The appellant is in receipt of separate compensable ratings for her joints affected by osteoporosis: her left hip, bilateral knees, and right foot. CONCLUSIONS OF LAW 1. The criteria for entitlement to service connection for bilateral hearing loss have not been met. 38 U.S.C. §§ 1110, 5107 (2012); 38 C.F.R. §§ 3.303, 3.304, 3.307, 3.309, 3.385 (2017). 2. The criteria for service connection for sleep apnea have not been met. 38 U.S.C. §§ 1110, 5107 (2012); 38 C.F.R. §§ 3.303, 3.304 (2017). 3. The criteria for entitlement to service connection for low blood pressure have not been met. 38 U.S.C. §§ 1110, 5107 (2012); 38 C.F.R. §§ 3.303, 3.304 (2017). 4. The criteria for entitlement to service connection for blisters have not been met. 38 U.S.C. §§ 1110, 5107 (2012); 38 C.F.R. §§ 3.303, 3.304 (2017). 5. The criteria for entitlement to an initial rating in excess of 10 percent for left hip sacroiliac stress fracture with residual pain, limitation of extension, have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.40, 4.45, 4.71a, DC 5251 (2017). 6. The criteria for entitlement to an initial rating in excess of 10 percent for osteoporosis, separate from the separate compensable ratings for her affected left hip, bilateral knees, and right foot disabilities, have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.40, 4.45, 4.71a, DC 5310-5003 (2017). INTRODUCTION The appellant served on active duty in the Army from October 2012 to April 2013. This matter comes before the Board of Veterans’ Appeals (Board) from January 2014, two August 2016, and September 2016 rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in San Juan, Puerto Rico. Following issuance of the January 2014 rating decision, a timely Notice of Disagreement (NOD) was received in February 2014. A Statement of the Case (SOC) was issued in September 2016. A timely substantive appeal was received in November 2016. A Supplemental Statement of the Case (SSOC) was issued in April 2018. Two rating decisions were issued in August 2016; and a rating decision was issued in September 2016. A timely NOD was received in November 2016. An SOC with respect to the constipation issue was issued in April 2018. A timely substantive appeal was received in June 2018. The former August 2016 rating decision also increased the rating of depressive disorder to 50 percent, effective May 19, 2016. A September 2016 rating decision, inter alia, increased the rating of peripheral vestibular disorder to 10 percent, effective May 21, 2015. An April 2018 rating decision increased the ratings of lumbar degenerative disc disease to 20 percent, effective July 31, 2017, and left lumbar radiculopathy to 20 percent, effective July 31, 2017. These issues remain in appellate status, as the maximum schedular ratings were not assigned for the entire period on appeal. See AB v. Brown, 6 Vet. App. 35, 38 (1993). The appellant was afforded an informal conference before a Decision Review Officer (DRO) in May 2017. A summary is of record. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Service Connection Applicable Law Service connection may be established for disability resulting from personal injury suffered or disease contracted in the line of duty from active military, naval, or air service. 38 U.S.C. §§ 1110, 1131. “To establish a right to compensation for a present disability, a Veteran must show: ‘(1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service’—the so-called ‘nexus’ requirement.” Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2010) (citing Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004)). Service connection may also be granted for any disease diagnosed after discharge, when all the evidence, including that which is pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Service connection for certain chronic diseases, including cardiovascular-renal disease and an organic diseases of the nervous system such as sensorineural hearing loss, may also be established on a presumptive basis by showing that such a disease manifested itself to a degree of 10 percent or more within one year from the date of separation from service. 38 U.S.C. § 1112; 38 C.F.R. §§ 3.307(a) (3), 3.309(a). In such cases, the disease is presumed under the law to have had its onset in service even though there is no evidence of such disease during the period of service. 38 C.F.R. § 3.307(a). To establish service connection under this provision, there must be: evidence of a chronic disease shown as such in service (or within an applicable presumptive period under 38 C.F.R. § 3.307), and subsequent manifestations of the same chronic disease; or if the fact of chronicity in service is not adequately supported, by evidence of continuity of symptomatology after service. The provisions of 38 C.F.R. § 3.303(b) relating to continuity of symptomatology, however, can be applied only in cases involving those conditions explicitly enumerated under 38 C.F.R. § 3.309(a). Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Bilateral Hearing Loss In addition to the criteria set forth above, service connection for impaired hearing is subject to the additional requirement of 38 C.F.R. § 3.385, which provides that impaired hearing will be considered to be a disability only if at least one of the thresholds for the frequencies of 500, 1000, 2000, 3000, or 4000 Hertz is 40 decibels or greater; the thresholds for at least three of the frequencies are greater than 25 decibels; or speech recognition scores using the Maryland CNC Test are less than 94 percent. See also Hensley v. Brown, 5 Vet. App. 155 (1993). The appellant’s November 2010 enlistment Report of Medical Examination states that pure tone threshold testing revealed: HERTZ 500 1000 2000 3000 4000 RIGHT 5 5 10 15 5 LEFT 5 0 0 5 5 On her November 2010 Report of Medical History, the appellant denied ear, nose, or throat trouble, and she denied having hearing loss or wearing a hearing aid. The appellant’s hearing acuity was tested during her January 2013 Medical Board examination. Pure tone threshold testing revealed: HERTZ 500 1000 2000 3000 4000 RIGHT 0 -5 5 10 10 LEFT 5 -10 0 0 0 On her accompanying January 2013 Report of Medical History, she denied ear, nose, or throat trouble, and denied having hearing loss or wearing a hearing aid. The appellant was provided a notice, based on the report of her January 2013 examination, that her hearing had some numbers which indicated the potential for problems. It was recommended that she take very liberal precautions with protecting her hearing. A January 2013 clinical note states that, during review of systems, the appellant denied hearing loss. The appellant was afforded a VA examination in September 2013. The claims file was reviewed. Pure tone threshold testing revealed: HERTZ 500 1000 2000 3000 4000 RIGHT 10 10 15 20 20 LEFT 15 10 10 25 20 The 1000-4000 Hertz average was 16 decibels in the right ear and 16 in the left. Speech recognition using the Maryland CNC word list was 100 percent in the right ear and 100 percent in the left. She was diagnosed with left ear sensorineural hearing loss, while she had normal hearing in the right ear. The examiner opined that it was less likely than not that the appellant’s hearing loss was causally related to her active service because her audiological evaluations were consistent with bilateral normal hearing while on active duty. In October 2014, the appellant reported that there had been no change in her hearing. A May 2015 primary care note states that, during review of systems, the appellant reported that her hearing was okay. She denied decreased hearing in May 2016, June 2016, and January 2017. After reviewing the record, the Board concludes that the preponderance of the evidence is against the claim of service connection for bilateral hearing loss. The appellant contends that she developed bilateral hearing loss as a result of her active service. As described above, the appellant’s service treatment records and the VA examination report show that her hearing acuity both in service and since that time does not meet the criteria for a bilateral hearing loss disability for VA purposes. 38 C.F.R. § 3.385 dictates that service connection may not be established for disability due to impaired hearing unless the auditory threshold in any of the frequencies 500, 1000, 2000, 3000, or 4000 Hertz is 40 decibels or greater; or when the auditory threshold for at least three of the frequencies are 26 decibels or greater; or when speech recognition scores using the Maryland CNC Test are less than 94 percent. The appellant’s speech recognition scores using the Maryland CNC Test of 100 percent in September 2013; no frequency had an auditory threshold of greater than 25 decibels; and the auditory threshold for at least three frequencies was not 26 decibels or greater. Her right ear was noted to be normal in September 2013, while she was diagnosed with left ear sensorineural hearing loss. There is no other post-service clinical evidence establishing a current hearing loss disability for VA purposes. Although the appellant has a diagnosis of left ear sensorineural hearing loss, she does not meet the criteria under 38 C.F.R. § 3.385 to have hearing loss in either ear for VA compensation purposes at this time. Moreover, the record on appeal shows that the appellant has never had a hearing loss disability in either ear for VA purposes. The appellant’s statement that she has experienced worsening hearing bilaterally has been considered. Although the appellant is competent to describe symptoms of difficulty hearing, she is not competent to state that her hearing acuity is severe enough to meet the specific criteria set forth in section 3.385. Under these circumstances, entitlement to service connection for bilateral hearing loss must be denied because the most probative evidence shows that the appellant does not currently have a bilateral hearing loss disability for VA purposes. In her November 2016 substantive appeal, the appellant expressed displeasure with regard to how her examinations were conducted. She stated that “[t]here is plenty of medical evidence of record that shows how [her claimed disabilities] have worsened.” She indicated that the examiner did not report “the proper measurements” as the appellant described, and reported that the examiner did not use any instruments or look at the appellant during examination. Rather, the examiner only wrote down the appellant’s answers to questions which were asked. While it is unclear whether this objection was with regard to the September 2013 audiological examination in particular, the Board observes that there is a well-established presumption of regularity under which it is presumed that government officials “have properly discharged their official duties.” United States v. Chemical Foundation, Inc., 272 U.S. 1, 14-15 (1926). Therefore, it must be presumed that the Secretary properly discharged his official duties by properly handling claims submitted by the appellant, including having the September 2013 VA examiner perform audiological testing and accurately report the results of such. Mere lay statements are not the type of clear evidence to the contrary which would be sufficient to rebut the presumption of regularity. Jones v. West, 12 Vet. App. 90 (1999), Mindenhall v. Brown, 7 Vet. App. 271, 274 (1994); Ashley v. Brown, 2 Vet. App. 62, 64 (1992). Congress specifically limits entitlement for service-connected disease or injury to cases where in-service incidents have resulted in a disability. See 38 U.S.C. §§ 1110, 1131; see also Brammer v. Derwinski, 3 Vet. App. 223 (1992); Gilpin v. West, 155 F.3d 1353 (Fed. Cir. 1998) (holding VA’s interpretation of the provisions of 38 U.S.C.A § 1110 to require evidence of a present disability to be consistent with congressional intent). In other words, the law limits entitlement to compensation to cases where the underlying in-service incident has resulted in a current disability. Degmetich v. Brown, 104 F.3d 1328 (Fed. Cir. 1997). VA has promulgated regulations specifically defining a hearing loss disability. See 38 C.F.R. § 3.385. The record contains audiometric test results which establish that the decreased hearing acuity she perceives does not meet the criteria set forth in section 3.385, a necessary prerequisite to an award of service connection for bilateral hearing loss. Although the appellant is competent to describe her decreased hearing acuity, she is not competent to state that his hearing acuity meets the required pure tone thresholds, in decibels. However, the Board notes that she has denied worsening of her hearing in multiple clinical visits since the September 2013 examination. Again, absent probative evidence of a current hearing loss disability, the claim must be denied. As the preponderance of the evidence is against the claim of service connection for bilateral hearing loss, the benefit of the doubt doctrine is not for application. 38 U.S.C. § 5107; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Sleep Apnea The appellant contends that service connection is warranted for sleep apnea. As an initial matter, the record on appeal indicates that service connection for insomnia has been denied previously. See e.g. October 2014 rating decision denying service connection for insomnia, claimed as sleep disorder. That issue is not currently in appellate status. Because sleep apnea is a distinctly and differently diagnosed disease from insomnia, however, the claim of service connection for sleep apnea is being considered on a de novo basis. See e.g. Boggs v. Peake, 520 F.3d 1330 (Fed. Cir. 2008). Service treatment records are negative for treatment for or a diagnosis of sleep apnea. However, the appellant endorsed trouble sleeping on numerous occasions, and was prescribed Ambien and Trazodone at various times. See e.g. January 2013 and March 2013 notes. A February 2013 psychiatric note indicates that the appellant endorsed sleep disturbances, among other symptoms. Her January 2013 Report of Medical Examination was essentially normal, save for musculoskeletal and identifying body marks. On her accompanying January 2013 Report of Medical History, she endorsed frequent trouble sleeping. The appellant was afforded a VA examination in September 2013. The claims file was reviewed. The appellant denied history of sleep apnea. She complained of difficulty with catching up and maintaining sleep. Such had been present since October 2012 and had been diagnosed as insomnia. The appellant attributed her sleep difficulties to emotional stress. During the examination, she denied trouble breathing during sleep or snoring. The examiner stated that there was no evidence of sleep apnea symptoms or a diagnosis of such. There was no reason to suspect that she had sleep apnea. VA and private clinical records are likewise negative for complaints or a diagnosis of sleep apnea. The appellant has competently reported difficulty sleeping throughout the period on appeal. She described her sleep problems as insomnia in a statement received in June 2015. Also received in June 2015 was a statement from her spouse, which stated that he believed the appellant’s psychiatric medications were causing her to experience insomnia. The Board also observes that the appellant’s chronic sleep impairment has been noted as a symptom of her service-connected psychiatric disorder. See e.g. May 2016 VA examination. The Board has reviewed the record on appeal and can find no indication that the appellant currently has sleep apnea, nor has she identified any such evidence. Congress specifically limits entitlement for service-connected disease or injury to cases where such incidents have resulted in a disability. See 38 U.S.C. § 1110; see also Brammer v. Derwinski, 3 Vet. App. 223 (1992); Gilpin v. West, 155 F.3d 1353 (Fed. Cir. 1998). Although the appellant and her husband reported that the appellant has experienced sleep impairment, there is no indication that such symptoms are related to sleep apnea. Rather, the clinical evidence indicates that at least some of the sleep-related symptoms reported by the appellant and her spouse are related to her service-connected psychiatric disorder. While the appellant and her spouse are certainly competent to report symptoms and observations because this requires only personal knowledge as it comes through an individual’s senses. Layno v. Brown, 6 Vet. App. 465, 470 (1994). The appellant and her spouse in this case are not competent to determine the cause of her symptoms because it would involve medical inquiry into biological processes, anatomical relationships, and physiological functioning. Such internal physical processes are not readily observable and are not within the competence of the appellant in this case, who has not been shown by the evidence of record to have medical training or skills. Absent probative evidence that the appellant currently has sleep apnea, or has had sleep apnea at any time since military service, there is no basis upon which to grant the claim of service connection for sleep apnea. McClain v. Nicholson, 21 Vet. App. 319, 321 (2007). Absent any indication that the appellant currently has sleep apnea, the Board finds that the preponderance of the evidence is against the claim. 38 U.S.C. § 5107; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Low Blood Pressure The appellant has claimed service connection for low blood pressure. An October 25, 2012, clinical note states that the appellant complained of dizziness. She felt light-headed when first standing up from bed. She sat down and the episode resolved within one minute. There was no loss of consciousness. It was noted that she did not hydrate following physical training the night before. The assessment was dizziness. EKG and orthostatics were negative. The appellant was noted to be asymptomatic. The impression was mild dehydration, resolved. In her January 2013 Report of Medical History, she denied high or low blood pressure. The appellant was afforded a VA examination in September 2013. The claims file was reviewed. It was noted that the appellant experienced a single episode of syncope on October 25, 2012. She “passed out” while awaiting transportation. She was taken by ambulance to the urgent clinic. Low blood pressure of 100/65 was noted. The assessment was “dizziness due to mild dehydration.” She was treated with IV saline solution. Following negative cardiac, metabolic, and neurologic examinations, which included EKG and labs, she was discharged. The appellant reported that she had not eaten breakfast when such incident occurred. She denied any recurrences. There was no history of a cardiac or neurologic disease. During the instant examination, blood pressure was measured at 106/71 and 102/71. Heart rate was 71. Blood pressure and heart rate were noted to be normal. Normal heart and lung auscultation, and normal neurological examination were noted. The appellant was found to be asymptomatic. The Board observes that the appellant’s systolic pressure has primarily been measured as 100 or greater, and diastolic has primarily been measured as 60 or greater, throughout the period on appeal. There have been some outlier measurements, such as 107/55 in December 2013, 97/63 in April 2014, and 88/68 in January 2017. However, no clinician has diagnosed the appellant with a disability characterized by low blood pressure or hypotension, nor is there any indication that additional testing or observation was considered warranted by clinicians based upon observation of such measurements. Indeed, there is no indication that any isolated post-service reading of blood pressure, which may be lower than others, is causally related to an injury or disease incurred while on active duty. The Board has considered the appellant’s lay history of symptomatology related to his claimed disorder throughout the appeal period. She is competent to report such symptoms and observations because this requires only personal knowledge as it comes through an individual’s senses. Layno v. Brown, 6 Vet. App. 465, 470 (1994). The appellant in this case is not competent to determine the cause of her symptoms because it would involve medical inquiry into biological processes, anatomical relationships, and physiological functioning. Such internal physical processes are not readily observable and are not within the competence of the appellant in this case, who has not been shown by the evidence of record to have medical training or skills. The Board finds the VA examination report to be of greater probative weight than the appellant’s lay assertions. Congress has specifically limited entitlement to service connection for disease or injury to cases where such incidents have resulted in disability. See 38 U.S.C. § 1131. Thus, where the collective lay and medical evidence indicates that, fundamentally, the appellant does not have a current disability for which service connection is sought, there can be no valid claim for service connection. See Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992); Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004); Gilpin v. West, 155 F.3d 1353, 1356 (Fed. Cir. 1998). The Board notes the recent holding of the Court of Appeals for the Federal Circuit (Federal Circuit) in Saunders v. Wilkie, 886 F.3d 1356 (Fed. Cir. 2018), that the term disability, as used in 38 U.S.C. § 1110, “refers to the functional impairment of earning capacity, not the underlying cause of said disability.” Thus, “pain alone can serve as a functional impairment and therefore qualify as a disability.” Id. While such case focused exclusively on pain unattributed to a diagnosis or an identifiable underlying malady or condition, the same reasoning could apply to low blood pressure unrelated to a diagnosed condition. However, even under the Federal Circuit’s holding in Saunders, the Board finds that the appellant in the present case has not presented evidence to demonstrate that her claimed disability characterized by low blood pressure reaches the level of functional impairment of earning capacity sufficient to be reasonably interpreted as a current disability under the governing statutes and regulations. Notably, the September 2013 VA examiner considered the appellant’s contentions, reviewed her service treatment records, and measured blood pressure, finding it to be normal. In any event, the Board emphasizes there is no indication that any isolated post-service readings of blood pressure which may be lower than others are causally related to an injury or disease incurred while on active duty. As the evidence preponderates against the claim, the benefit of the doubt doctrine is not for application. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). Blisters The appellant contends that service connection is warranted for blisters. An October 4, 2012, clinical note states that the appellant had blisters on the heels. On October 9, 2012, an open blister on the left heel was observed to be healing. A blister on the heel was present on October 24, 2012. The appellant’s January 2013 Report of Medical Examination was negative for foot blisters. On her accompanying January 2013 Report of Medical History, she endorsed foot trouble; however, such was in reference due to a right foot stress fracture. The appellant was afforded a VA examination in September 2013. The claims file was reviewed. The appellant reported that she has foot blisters during the first weeks of training. However, there were no sequelae or scars, and her feet were non-tender. Examination was normal with intact skin. There were no marks, scars, or changes in coloration. There was no evidence of blisters. It was noted that the blisters diagnosed in October 2012 had resolved. The clinician noted that the appellant had been found with blisters on her feet without infection in October 2012. She reported that her boots were causing the blisters. She was provided simple local care and records indicated that he blisters had resolved. The instant examination of her feet revealed that there was no evidence of blisters. Thus, such had resolved. Clinical records thereafter are negative for complaints, observations, treatment, or diagnoses regarding blisters. Indeed, the appellant herself has not contended that she has experienced foot blisters, or any residuals of such, since separation. Congress has specifically limited entitlement to service connection for disease or injury to cases where such incidents have resulted in disability. See 38 U.S.C. § 1131. Thus, where the collective lay and medical evidence indicates that, fundamentally, the appellant does not have a current disability for which service connection is sought, there can be no valid claim for service connection. See Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992); Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004); Gilpin v. West, 155 F.3d 1353, 1356 (Fed. Cir. 1998). As the evidence preponderates against the claim, the benefit of the doubt doctrine is not for application. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). Increased Evaluations Applicable Law Disability evaluations are determined by the application of a schedule of ratings which is based on average impairment of earning capacity. 38 U.S.C. § 1155; 38 C.F.R. Part 4. Separate diagnostic codes identify the various disabilities. Where there is a question as to which of two evaluations should be applied, the higher evaluation will be assigned if that disability picture more nearly approximates the criteria required for that rating. 38 C.F.R. § 4.7. Any reasonable doubt regarding the degree of disability is resolved in favor of the veteran. 38 C.F.R. § 4.3. In considering the severity of a disability, it is essential to trace the medical history of the veteran. 38 C.F.R. §§ 4.1, 4.2, 4.41. Consideration of the whole recorded history is necessary so that a rating may accurately reflect the elements of disability present. 38 C.F.R. § 4.2; Peyton v. Derwinski, 1 Vet. App. 282 (1991). Where a claimant appeals the initial rating assigned following an award of service connection, evidence contemporaneous with the claim for service connection and with the rating decision granting service connection would be most probative of the degree of disability existing at the time that the initial rating was assigned and should be the evidence “used to decide whether an [initial] rating on appeal was erroneous. . . .” Fenderson v. West, 12 Vet. App. 119, 126 (1999). If later evidence obtained during the appeal period indicates that the degree of disability increased or decreased following the assignment of the initial rating, “staged” ratings may be assigned for separate periods of time based on facts found. Id. Left Hip Extension The appellant is in receipt of three ratings for her service-connected left hip sacroiliac stress fracture with residual pain. While entitlement to increased initial ratings for limitation of flexion of the thigh, under DC 5252, and impairment of the thigh, under DC 5253, are remanded for the reasons discussed infra, the Board finds that adjudication of the issue of entitlement to an initial rating in excess of 10 percent for limitation of extension of the thigh, rated under DC 5251, is warranted at the present time. Diagnostic Code (DC) 5251 directs that a maximum 10 percent rating is warranted for extension of the thigh limited to 5 degrees. 38 C.F.R. § 4.71a. The appellant has in receipt of a 10 percent rating for limitation of extension of the thigh since April 27, 2013, the entire period on appeal. When evaluating disabilities of the musculoskeletal system based on loss of range of motion, 38 C.F.R. § 4.40 allows for consideration of functional loss due to pain and weakness causing additional disability beyond that reflected on range of motion measurements. DeLuca v. Brown, 8 Vet. App. 202, 206-07 (1995). Further, 38 C.F.R. § 4.45 provides that consideration also be given to weakened movement, excess fatigability, and incoordination. Because the appellant is already in receipt of the maximum schedular rating available, consideration of 38 C.F.R. § 4.40 and 4.45, and the accompanying case law, is not required, despite her competent and credible reports of flare-ups of her left hip disability. Johnston v. Brown, 10 Vet. App. 80 (1997). Again, the Board emphasizes that entitlement to initial increased ratings for the appellant’s service-connected left hip disability under DCs 5252 and 5253, for limitation of flexion of the thigh and impairment of the hip, are remanded for an appropriate examination. The denial of entitlement to an initial rating in excess of 10 percent for limitation of extension, under DC 5251, does not preclude the possibility of increased ratings under these other diagnostic codes. As the evidence preponderates against the claim, the benefit of the doubt doctrine is not for application. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). Osteoporosis The appellant’s osteoporosis is rated by analogy under DC 5013-5003. DC 5013 is for osteoporosis, with joint manifestations. Diseases under DC 5013 are to be rated on limitation of motion of affected parts, as arthritis, degenerative. 38 C.F.R. § 4.71. DC 5003 is for degenerative arthritis. Arthritis established by X-ray findings is rated on the basis of limitation of motion under the appropriate diagnostic codes for the specific joint or joints involved. 38 C.F.R. § 4.71, DC 5003. When the limitation of motion of the specific joint or joints involved is noncompensable under the appropriate diagnostic codes, a rating of 10 percent is for application for each such major joint or group of minor joints affected by limitation of motion. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. Id. In the January 2014 rating decision on appeal, the RO assigned an 10 percent rating for osteoporosis, as well as separate compensable ratings for disabilities of the low back, right knee, and left hip, all effective April 27, 2013. The Board observes that in a September 2016 rating decision, the RO determined that its assignment of a separate compensable rating for osteoporosis was clearly and unmistakably erroneous. The RO proposed to remove the separate 10 percent rating for osteoporosis because all of the affected joints had been assigned separate ratings under applicable diagnostic codes. As the RO has not yet undertaken the proposed action, that issue is not ripe for adjudication by the Board. Thus, the Board will limit its consideration to whether the appellant is entitlement to an initial rating in excess of 10 percent for osteoporosis. Turning to the merits of the issue of entitlement to a rating in excess of 10 percent for osteoporosis, the Board concludes that there is no basis to award a higher rating for any portion of the period on appeal. VA’s rating schedule has no separate rating criteria specific to osteoporosis; rather, this disease is rated under the criteria for arthritis. The criteria for rating arthritis, however, make clear that ratings for arthritis will not be combined with ratings based on limitation of motion. See 38 C.F.R. § 4.71a, Diagnostic Code 5003, Note(1). Moreover, the Board may not violate the rule against pyramiding, meaning that the evaluation of the same manifestation under different diagnoses is to be avoided. 38 C.F.R. § 4.16. The Board observes that, as directed by the rating criteria for DC 5013, the appellant is already in receipt of separate ratings for joints affected by osteoporosis: the left hip, the bilateral knees, and the right foot. In short, the appellant’s joint symptoms are being considered in their entirety in those ratings. There are no separate manifestations of osteoporosis that would warrant a rating in excess of 10 percent. As the evidence preponderates against the claim, the benefit of the doubt doctrine is not for application. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). REASONS FOR REMAND Remand for adequate examinations is warranted for the claims of entitlement to increased evaluations for (1) lumbar degenerative disc disease L3-L4; (2) left lumbar radiculopathy; (3) left hip sacroiliac stress fracture with residual pain, limitation of flexion; (4) left hip sacroiliac stress fracture with residual pain, impairment of the hip; (5) tibial plateau stress fracture and osteoporosis, left knee; (6) tibial plateau stress fracture and osteoporosis, right knee; (7) metatarsal stress fracture, right foot; (8) constipation; (9) peripheral vestibular disorder; and (10) depressive disorder. Remand for the issuance of a Statement of the Case (SOC) is warranted for the claims of entitlement to an initial rating in excess of 30 percent for migraine headaches and entitlement to service connection for GERD. Examinations The Board notes that the DRO stated in the May 2017 informal conference summary that it was agreed that the appellant should be afforded “VA examinations for all increase disability” claims. She underwent examination for her left hip, back, radiculopathy, peripheral vestibular disorder, bilateral knees, and depression in July 2017. However, she was not afforded a new examination for her right foot disability. Since her July 2016 VA examination for constipation, the appellant reported in her June 2018 substantive appeal that such had worsened. In the August 2018 informal hearing presentation, the appellant’s representative indicated that the appellant was dissatisfied with her most recent examinations. It was argued that the severity, in the form of restrictions and limitations, of her disabilities were not being accurately captured by the examinations. In particular, the appellant does not believe that the examination reports have accurately addressed the limitations she experiences during flare-ups. It was noted that, when multiple disabilities flare up at the same time, the appellant has a great deal of trouble with simple functioning, self-care, and employability. The Board observes that the appellant has reported flare-ups with respect to her back, bilateral knees, and left hip disabilities in the July 2017 examinations. Based upon the August 2018 informal hearing presentation reporting the appellant’s dissatisfaction with the examinations capturing the functional impairment caused by her service-connected depression and peripheral vestibular disorder, she should also be afforded appropriate examinations to determine the current severity of such. The Board observes that United States Court of Appeals for Veterans Claims (Court) held in Sharp v. Shulkin, 29 Vet. App. 26 (2017), that, pursuant to VA regulations and the VA Clinician’s Guide, when conducting evaluations for musculoskeletal disabilities, VA examiners are obligated to inquire whether there are periods of flare-ups and, if so, to state their “severity, frequency, and duration; name the precipitating and alleviating factors; and estimate, ‘per [the] veteran,’ to what extent, if any, they affect functional impairment.” Id. at 32. The Court further explained that, in the event an examination is not conducted during a flare-up, the “critical question” in assessing the adequacy of the examination was “whether the examiner was sufficiently informed of and conveyed any additional or increased symptoms and limitations experienced during flares.” Id. at 34 (quoting Mitchell v. Shinseki, 25 Vet. App. 32, 44 (2011)). Statement of the Case As noted above, an August 2016 rating decision granted service connection for migraine headaches and assigned an initial 30 percent rating; and a September 2016 rating decision denied service connection for GERD. The appellant filed a timely NOD in November 2016 with respect to, inter alia, the initial rating assigned for migraine headaches and the denial of service connection for GERD. While the Veterans Appeals Control and Locator System (VACOLS) indicates that the appellant withdrew the GERD claim in July 2017, the Board’s review of the claims file is negative for any indication that she wished to do so. As a Statement of the Case has not been issued with respect to these claims, the Board is required to remand this matter to the RO for the issuance of a Statement of the Case. See Manlincon v. West, 12 Vet. App. 238 (1999). The matters are REMANDED for the following action: 1. Issue an appropriate Statement of the Case with respect to the issues of entitlement to (a) an initial rating in excess of 30 percent for migraine headaches and (b) entitlement to service connection for GERD. The appellant and her representative should be advised of the time afforded for perfecting an appeal in this matter, and given opportunity to do so. If that occurs, these matters should also be returned to the Board for appellate review. 2. Schedule the appellant for appropriate examinations to ascertain the current severity and manifestations of her service-connected (a) lumbar degenerative disc disease L3-L4; (b) left lumbar radiculopathy; (c) left hip sacroiliac stress fracture with residual pain, limitation of flexion; (d) left hip sacroiliac stress fracture with residual pain, impairment of the hip; (e) tibial plateau stress fracture and osteoporosis, left knee; (f) tibial plateau stress fracture and osteoporosis, right knee; and (g) metatarsal stress fracture, right foot. Access to records in the appellant’s electronic claims file should be made available to the examiner for review. The examination should be conducted in accordance with the current disability benefits questionnaire. The examiner must also address at what point in the arc of motion pain limits function both regularly and during flare-ups, even if a flare-up is not observed on that day. In addressing the nature of any disability during a flare-up the examiner must address the severity of the flare-up, the frequency and duration of the flare-up, and all precipitating and alleviating factors. 3. Schedule the appellant for appropriate examination to determine the current severity and manifestations of her constipation. Access to records in the appellant’s electronic claims file should be made available to the examiner for review. The examination should be conducted in accordance with the current and appropriate disability benefits questionnaire. All examination findings/testing results, along with complete, clearly-stated rationale for any conclusions reached, must be provided. 4. Schedule the appellant for appropriate examination to determine the current severity and manifestations of her peripheral vestibular disorder. Access to records in the appellant’s electronic claims file should be made available to the examiner for review. The examination should be conducted in accordance with the current and appropriate disability benefits questionnaire. All examination findings/testing results, along with complete, clearly-stated rationale for any conclusions reached, must be provided. 5. Schedule the appellant for appropriate examination to determine the current severity and manifestations of her depressive disorder, not otherwise specified, with anxiety. Access to the appellant’s VA claims file should be made available to the examiner for review in connection with the examination. The examiner should report all signs and symptoms necessary for rating the appellant’s psychiatric disorder under the General Rating Formula for Mental Disorders. The examiner should address the level of social and occupational impairment attributable to the appellant’s depressive disorder, NOS, with anxiety. K. Conner Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD R. Behlen, Associate Counsel