Citation Nr: 18150082 Decision Date: 11/14/18 Archive Date: 11/14/18 DOCKET NO. 16-26 573 DATE: November 14, 2018 ORDER Service connection for an acquired psychiatric disability (to include posttraumatic stress disorder (PTSD) and depression) is granted. Service connection for a low back disability is denied. Service connection for a left knee disability is denied. Service connection for a right knee disability is denied. Service connection for toxemia is denied. Service connection for urinary tract infection (UTI) is denied. Service connection for a disability manifested by fatigue is denied. Service connection for a left shoulder disability is denied. Service connection for a right shoulder disability is denied. Service connection for a left hip disability is denied. Service connection for a right hip disability is denied. An effective date earlier than June 6, 2012 for the award of service connection for migraine headaches is denied. A higher initial rating for migraine headaches (currently evaluated as noncompensable prior to June 1, 2015 and 30 percent disabling from June 1, 2015) is denied. REMANDED The issue of service connection for anemia is remanded. The issue of service connection for menorrhagia, claimed as severe menstrual bleeding, is remanded. The issue of a total disability rating based on individual unemployability due to service-connected disability (TDIU) is remanded. FINDINGS OF FACT 1. The Veteran has been diagnosed with acquired psychiatric disabilities (including PTSD and depression); she has provided competent and credible reports that she experienced an in-service sexual assault; and VA treatment records establish that her acquired psychiatric conditions were caused by the in-service sexual assault. 2. The most probative evidence of record does not demonstrate that it is at least as likely as not that the Veteran has a low back disability that is causally related to an in-service injury, event or disease. 3. The most probative evidence of record does not demonstrate that it is at least as likely as not that the Veteran has a left knee disability that is causally related to an in-service injury, event or disease. 4. The most probative evidence of record does not demonstrate that it is at least as likely as not that the Veteran has a right knee disability that is causally related to an in-service injury, event or disease. 5. The competent evidence of record does not demonstrate a diagnosis of toxemia proximate to the claim, or during the appeal period. 6. The competent evidence of record does not demonstrate a diagnosis of UTI proximate to the claim, or during the appeal period. 7. The competent evidence of record does not demonstrate a diagnosis of any disability related to or manifested by fatigue proximate to the claim, or during the appeal period. 8. The most probative evidence of record does not demonstrate that it is at least as likely as not that the Veteran has a bilateral shoulder disability that is causally related to an in-service injury, event or disease. 9. The most probative evidence of record does not demonstrate that it is at least as likely as not that the Veteran has a bilateral hip disability that is causally related to an in-service injury, event or disease. 10. The earliest effective date for the award of service connection for migraine headaches is June 6, 2012, the date that VA received the Veteran’s claim for service connection. 11. There is no probative evidence of record that the Veteran experienced characteristic prostrating headache attacks at any time during the rating period prior to June 1, 2015. 12. The evidence of record does not show that, from June 1, 2015, the Veteran’s migraine headaches were manifested by very frequent completely prostrating and prolonged attacks that produced severe economic inadaptability. CONCLUSIONS OF LAW 1. The criteria for service connection for an acquired psychiatric disability (to include PTSD and depression) have been met. 38 U.S.C. §§ 1101, 1131, 5103, 5103A, 5107 (b) (2012); 38 C.F.R. §§ 3.102, 3.159, 3.303 (2017). 2. The criteria for service connection for a low back disability have not been met. 38 U.S.C. §§ 1101, 1131, 5103, 5103A, 5107 (b) (2012); 38 C.F.R. §§ 3.102, 3.159, 3.303 (2017). 3. The criteria for service connection for a left knee disability have not been met. Id. 4. The criteria for service connection for a right knee disability have not been met. Id. 5. The criteria for service connection for toxemia have not been met. Id. 6. The criteria for service connection for UTI have not been met. Id. 7. The criteria for service connection for a disability manifested by fatigue have not been met. Id. 8. The criteria for service connection for a bilateral shoulder disability have not been met. Id. 9. The criteria for service connection for a bilateral hip disability have not been met. Id. 10. The criteria for an effective date earlier than June 6, 2012 for the award of service connection for migraine headaches have not been met. 38 U.S.C. § 5110 (2012); 38 C.F.R. §§ 3.156 (c) (1), 3.400 (2017). 11. The criteria for an increased initial rating for migraine headaches, rated as noncompensable prior to June 1, 2015, and 30 percent disabling from June 1, 2015, have not been met. 38 U.S.C. §§ 1155, 5103A, 5107 (2012); 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.4, 4.7, 4.124a, Diagnostic Code 8100 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from February 1984 to July 1986. These matters come before the Board of Veterans’ Appeals (Board) on appeal of December 2014 and May 2016 rating decisions by the Department of Veterans Affairs (VA) Regional Office (RO) in Sioux Falls, South Dakota. In a May 2016 rating decision, the Agency of Original Jurisdiction (AOJ) increased the rating for the Veteran’s migraine headache disability to 30 percent, effective June 1, 2015. As the increase did not satisfy the appeal in full, the issue remains on appeal and has been characterized as shown on the title page of this decision. See AB v. Brown, 6 Vet. App. 35 (1993). The Veteran initially submitted a claim for service connection for depression and anxiety. See VA Form 21-526EZ, Application for Disability Compensation and Related Compensation Benefits, received January 2016. The medical evidence of record includes diagnoses for psychiatric disabilities in addition to depression and anxiety. Although the Veteran sought service connection only for depression and anxiety, a claim “cannot be a claim limited only to that diagnosis, but must rather be considered a claim for any mental disability that may be reasonably encompassed.” Clemons v. Shinseki, 23 Vet. App. 1, 5 (2009). In essence, a veteran does not file a claim to receive benefits for a particular psychiatric diagnosis that is named on a claims form, such as depression and anxiety, but instead makes a general claim for compensation for the difficulties posed by the mental condition. Id. Accordingly, the Board has reframed the issue on appeal, as shown on the title page. A claim for TDIU is part of a claim for a higher rating when such claim is raised by the record or asserted by the Veteran. Rice v. Shinseki, 22 Vet. App. 447 (2009). When evidence of unemployability is submitted at the same time that the Veteran is appealing the rating assigned for a disability, the claim for TDIU will be considered part and parcel of the claim for benefits for the underlying disability. Id. at 452-54. In this case, a March 2016 VA treatment record reflects that the Veteran stated she has been unemployed for two years because she started to get sick, had headaches, and could not pass a physical to be able to work. The Board interprets this statement as an indication that the Veteran feels she is unable to secure or follow a substantially gainful occupation as a result of the service-connected disability at issue on appeal. Accordingly, the Board finds that a claim for TDIU has been raised as part and parcel to the increased rating claim. Therefore, the issue of TDIU is before the Board on appeal and is properly included in the list of issues before the Board. Service Connection Service connection may be established for disability resulting from disease or injury incurred in or aggravated by active military service. 38 U.S.C. § 1110 (2012); 38 C.F.R. § 3.303 (2017). To establish service connection for a disability, the 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. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). 1. Service Connection for Acquired Psychiatric Conditions The Veteran contends that her acquired psychiatric conditions are directly related to her active military service. See Correspondence, received May 2017. There are specific regulations describing alternative methods for how to establish service connection for PTSD. However, these regulations do not preclude a Veteran from establishing service connection for an acquired psychiatric condition on a direct basis. In this case, the Veteran submitted a May 2017 letter describing an in-service sexual assault and identifying this as the stressor that caused her acquired psychiatric conditions. The Veteran reported that she has suffered from nightmares since the in-service assault. VA treatment records show diagnoses of depression and PTSD. Additionally, the VA treatment records indicate that the Veteran’s depression and PTSD are related to the in-service sexual assault. The Board finds the Veteran’s statements are competent and credible evidence of an in-service injury (sexual assault) and that the medical evidence (VA treatment records) establishes that her currently diagnosed acquired psychiatric conditions were caused by her in-service sexual assault. Accordingly, service connection for these acquired psychiatric conditions is warranted. 2. Service Connection for a Low Back Disability and Bilateral Knee Disability The Veteran contends that she has a current low back disability and bilateral knee disability that is directly related to her active military service. The evidence of record shows that the Veteran has a current diagnosis of chronic arthralgia of the low back and bilateral knees. See, e.g., VA treatment record dated April 2016. Therefore, there is evidence of a current disability. As to an in-service event, injury or disease, a review of the Veteran’s service treatment records does not reflect any symptoms, complaints or treatment for a low back disability or bilateral knee disability. The earliest indication in the record that the Veteran suffers from a low back disability or bilateral knee disability is a February 2014 VA treatment record reflecting that the Veteran complained of low back pain and a December 2012 VA treatment record reflecting that the Veteran complained of knee pain. In summary, the service treatment records do not reflect in-service complaints of a low back disability or bilateral knee disability. The earliest evidence of record of a low back disability is a February 2014 VA treatment record noting that the Veteran complained of back pain and a December 2012 VA treatment record noting that the Veteran complained of knee pain. The VA treatment records are more than 25 years after the Veteran separated from active service. Therefore, there is evidence of a current low back disability and bilateral knee disability, but there is no evidence of an in-service injury, illness or disease to which the current low back disability and bilateral knee disability may be medically attributed. Rather, the evidence suggests that the Veteran did not have a low back disability or bilateral knee disability until more than two decades after her active military service. The only evidence indicating an association between the current low back disability and bilateral knee disability and her active service are the Veteran’s own assertions. In her December 2013 application for disability compensation and related compensation benefits, the Veteran stated that her low back disability and bilateral knee disability are related to her active military service. It is well established that a layperson without medical training is not qualified to render a medical opinion regarding the diagnosis or etiology of certain disorders and disabilities. See 38 C.F.R. § 3.159 (a) (1). In certain instances, lay testimony may be competent to establish medical etiology or nexus. See Jandreau v. Nicholson, 492 F. 3d 1372, 1377 (Fed. Cir. 2007). However, the origin or cause of chronic arthralgia is not a simple question that can be determined based on personal observation by a lay person. It is not shown that the Veteran is qualified through specialized education, training, or experience to offer a medical opinion as to the etiology of chronic arthralgia. Grottveit v. Brown, 5 Vet. App. 91, 93 (1993). Hence, the Veteran has submitted statements but the Veteran is not qualified (competent) to establish medical causation (nexus) because she does not have specialized medical training or experience. Id. As such, the Board finds the question of whether the Veteran’s current low back disability and bilateral knee disability are related to her active service does not lie within the range of common experience or common knowledge but requires special experience or special knowledge. The Board acknowledges that the Veteran was not afforded a VA examination relating directly to her low back and bilateral knee disabilities. On these facts, however, an examination is not required. VA will provide a medical examination or obtain a medical opinion if the evidence indicates the existence of a current disability or persistent or recurrent symptoms of a disability that may be associated with an event, injury, or disease in service, but the record does not contain sufficient medical evidence to decide the claim. 38 U.S.C. § 5103A (d) (2); 38 C.F.R. § (c) (4) (i); McLendon v. Nicholson, 20 Vet. App. 79 (2006). In this case, the claim does not meet these requirements for obtaining a VA medical opinion. Because the weight of the evidence demonstrates no low back disability or bilateral knee disability in service, and that the symptoms of a low back disability and bilateral knee disability were not present for many years thereafter, no examination is required. Absent evidence that indicates that the Veteran has a current claimed disability that is related to an injury or symptoms in service, the Board finds that an additional VA examination or opinion is not necessary for disposition of the claims. Accordingly, the Board finds that VA’s duty to assist with respect to obtaining a VA examination or opinion with respect to the Veteran’s claims for service connection for a low back disability and service connection for a bilateral knee disability have been met. 38 C.F.R. § 3.159 (c) (4). In view of the foregoing, the Board concludes that the preponderance of the evidence is against the claim for service connection for a low back disability and service connection for a bilateral knee disability. Because the preponderance of the evidence is against the claims, the benefit-of-the-doubt doctrine is not for application, and the claims must be denied. 38 U.S.C. § 5107 (b); see also Gilbert v. Derwinski, 1 Vet. App. 49 (1990). 3. Service Connection for Toxemia, UTI, and a Disability Manifested by Fatigue The Veteran contends that she has toxemia, UTI and a disability manifested by fatigue that are directly related to her active military service. The existence of a current disability is the cornerstone of a claim for VA disability compensation. 38 U.S.C. § 1110; see Degmetich v. Brown, 104 F.3d 1328, 1332 (1997) (holding that interpretation of 38 U.S.C. §§ 1110 and 1131 as requiring the existence of a present disability for VA compensation purposes cannot be considered arbitrary). In the absence of proof of a present disability, there can be no valid claim. Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). In this case, the evidence of record does not contain probative evidence of toxemia UTI, and/or a medical diagnosis of any disability manifested by or related to fatigue at any time proximate to, or during, the claim. During the pendency of the claim the Veteran was provided a private gynecological examination and received VA treatment, which do not demonstrate that the Veteran was diagnosed with toxemia or a UTI. The VA treatment records do reflect that the Veteran has reported experiencing extreme fatigue despite not being very active. See, e.g., VA treatment record dated March 2016. However, neither the VA treatment records nor the private treatment records contain a medical diagnosis related to the Veteran’s reported fatigue. Thus, the most probative evidence fails to demonstrate that it is at least as likely as not that the Veteran has a toxemia, UTI, or a fatigue disability that had its onset during active service or that there is a current toxemia, UTI, or a fatigue disability that is otherwise causally related to her active service. As such, service connection for toxemia, UTI, and fatigue is not warranted. Degmetich, 104 F. 3d at 1333. The Board acknowledges that the Veteran was not afforded a VA examination relating directly to her toxemia, UTI, and fatigue claims. On these facts, however, an examination is not required. In this case, the claims do not meet the requirements for obtaining a VA medical opinion. Because the weight of the evidence demonstrates no indication of a current disability, no examination is required. Absent evidence that indicates that the Veteran has a current claimed disability that is related to an injury or symptoms in service, the Board finds that a VA examination or opinion is not necessary for disposition of the claims. Accordingly, the Board finds that VA’s duty to assist with respect to obtaining a VA examination or opinion with respect to the Veteran’s claims for service connection for toxemia, UTI, and fatigue have been met. 38 C.F.R. § 3.159 (c) (4). The Board acknowledges the Veteran’s assertions that she has toxemia, UTI, and a disability related to or manifested by fatigue. However, she has not been shown to have the medical training and knowledge required to diagnose such condition. See Jandreau v. Nicholson, 492 F. 3d 1372, 1377 (Fed. Cir. 2007). Therefore, her assertions are not considered competent and do not weigh against the probative value of the medical treatment records, including the private treatment records and VA treatment records, which do not show a diagnosis of toxemia, UTI, or a disability manifested by fatigue. As noted above, the threshold requirement for service connection is competent evidence of the existence of the claimed disability at some point during the course of the appeal or in proximity to the claim. See Romanowsky v. Shinseki, 26 Vet. App. 289 (2013). While the Veteran has reported symptoms, this does not count as a “disability” for VA compensation purposes. The Board cannot grant service connection for a symptom. Although the Board recognizes the Veteran’s sincere belief in her claim, the most probative evidence of record does not show that she had toxemia, UTI, or a diagnosed fatigue disability at any point during (or in proximity to) the appeal period. In the absence of proof of a current disability, there can be no valid claim. Brammer, 3 Vet. App. at 225. In this case there is an absence of proof of toxemia, UTI, and fatigue during or in proximity to the appeal period. Without evidence of a current diagnosis of toxemia, UTI, and/or a fatigue disability, the Board need not address the other elements of service connection. The preponderance of the evidence is therefore against the claims, the benefit-of-the-doubt doctrine is not for application, and the claims must be denied. 38 U.S.C. § 5107 (b); see also Gilbert v. Derwinski, 1 Vet. App. 49 (1990). 4. Service Connection for Bilateral Shoulder and Bilateral Hip Disabilities The Veteran contends that she has a bilateral shoulder and bilateral hip disability that is directly related to her active service. Specifically, the Veteran has asserted that she fell during her active service and suffered injuries to her upper and lower extremities. See Correspondence, received May 2017. The evidence of record shows that the Veteran has a current diagnosis of bilateral shoulder strain and right shoulder subacromial/subdeltoid bursitis. See, e.g., December 2014 VA examination. Additionally, the Veteran has a current diagnosis of bilateral hip strain. See, e.g., December 2014 VA examination. Therefore, there is evidence of a current bilateral shoulder and bilateral hip disability. As to an in-service event, injury or disease, the Veteran’s service treatment records reveal that in May 1985 she reported that her shoulder was tender. Additionally, in May 1984 the Veteran stated that she injured her hip while running. Additionally, a December 2015 buddy statement reflects that during her active service the Veteran was hospitalized and she had bruising on her shoulders and upper hips. A second buddy statement received December 2015 reflects that after the Veteran was hospitalized she was unable to lift more than 35 pounds. Accordingly, there is also evidence of an in-service injury in the form of shoulder tenderness and hip pain, and the issue remaining for consideration as to direct service connection is whether the Veteran’s current bilateral hip disability and bilateral shoulder disability are causally related to the in-service injury. With respect to a nexus (causal link) between the current disabilities and in-service event, the only competent medical opinions of record are the December 2014 VA examinations and opinions, which weigh against the Veteran’s claims. Relating to the Veteran’s claim for service connection for a bilateral shoulder disability the VA examiner reviewed the record, interviewed the Veteran and conducted an in-person examination. The Veteran reported that she has bilateral shoulder pain. She further stated that she has had problems with her shoulders since 1984 but does not remember the in-service injury. The VA examiner opined that the Veteran’s bilateral shoulder disability is less likely than not incurred in or caused by treatment received during active service. The VA examiner explained that the Veteran’s service treatment records reflect shoulder tenderness during a headache examination in 1985. The VA examiner further noted that the Veteran’s medical records after her separation from active service are negative for treatment or complaints relating to a bilateral shoulder disability. Relating to the Veteran’s claim for service connection for a bilateral hip disability the VA examiner reviewed the record, interviewed the Veteran and conducted an in-person examination. The Veteran reported that she has had bilateral hip pain for 20 years. She further reported that she had difficulty running during her active service. The VA examiner opined that the Veteran’s bilateral hip disability is less likely than not incurred in or caused by treatment received during active service. As rationale, the VA examiner noted that the Veteran’s service treatment records reflect a diagnosis of left hip tensor lata strain after running. The VA examiner further noted that the Veteran’s medical records after her separation from active service are negative for treatment or complaints relating to a bilateral hip disability. The only evidence indicating an association between the current bilateral shoulder disability and bilateral hip disability and active duty are the Veteran’s own assertions. A layperson without medical training is not qualified to render a medical opinion regarding the diagnosis or etiology of medically complex disorders and disabilities. See 38 C.F.R. § 3.159 (a) (1). In certain instances, lay testimony may be qualified to establish a diagnosis or a causal link to a specific event. See Jandreau, 492 F. 3d at 1377. However, as the origin or cause of shoulder and hip strains are not simple questions that can be determined based on personal observation by a lay person. Therefore, unfortunately, the Veteran’s statements and the buddy statements relating to the Veteran’s in-service injuries are not qualified evidence that could establish a causal link to service. Id. As such, the Board finds the question of whether the Veteran’s current bilateral shoulder strain and bilateral hip strain had their onset during active duty does not lie within the range of common experience or common knowledge but requires special experience or special knowledge. There is no evidence that the Veteran is qualified through specialized education, training, or experience to offer a medical opinion as to the cause of her shoulder or hip strain. Grottveit v. Brown, 5 Vet. App. 91, 93 (1993). As such, the lay statements provided by the Veteran and her family are not qualified evidence as to whether the Veteran’s current hip and shoulder disabilities are related to active service. Moreover, such a finding is not supported by the record. Specifically, the December 2014 VA examiner opined that the Veteran’s current disabilities are not related to her active military service. Additionally, the VA treatment records do not contain reports of shoulder pain until November 2012, more than two decades after the Veteran’s separation from active service. With respect to assertions of continuity of symptoms since active service, this theory of establishing service connection only applies to certain listed chronic conditions. Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013) (interpreting 38 C.F.R. § 3.309 (a)). The diagnosis for the Veteran’s shoulder and hip disabilities (strain and subacromial/subdeltoid bursitis) are not on this list. However, service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disability was incurred in service. 38 C.F.R. § 3.303 (d). Here, the service medical treatment records reflect diagnoses and notations concerning the shoulders and right hip, not the left hip. Additionally, a right shoulder MRI from January 2014 did not reflect any degenerative changes. Indeed, the voluminous records associated with the records do not reflect reports relating to the Veteran’s shoulder and hip disabilities until November 2012. The Board finds that it is not credible that the Veteran would be experiencing chronic symptoms and not have reported these symptoms at any point during active service or when she received VA treatment. See AZ v. Shinseki, 731 F.3d at 1315-18 (the absence of evidence can be negative evidence if it is likely to have been recorded); Buczynski v. Shinseki, 24 Vet. App. at 224 (lack of noted medical condition or symptoms where such notation would normally be expected may be considered evidence that the condition or symptoms did not exist). The Board finds that the service medical treatment records, VA treatment records and VA opinions are more credible, and therefore more probative, than the more recent statements of the Veteran concerning chronic shoulder and hip disabilities. See Caluza v. Brown, 7 Vet. App. 498, 510-11 (1995) (Board must evaluate credibility of all evidence; lay statements may be evaluated based on, inter alia, inconsistent statements, facial plausibility, and consistency with other evidence of record). In summary, the most probative evidence of record does not support a finding that it is at least as likely as not that there is a causal relationship between the Veteran’s current shoulder and hip disabilities and her active military service. In light of the above, the preponderance of the evidence is against the claims and the benefit-of-the-doubt doctrine does not apply. The claims therefore must be denied. Earlier Effective Date The assignment of effective dates of awards is governed by 38 U.S.C. § 5110 and 38 C.F.R. § 3.400. Generally, the effective date of an award of pension, compensation, or dependency and indemnity compensation based on an original claim or a claim reopened after final disallowance, will be the date of receipt of the claim or the date entitlement arose, whichever is later. 38 U.S.C. § 5110 (a) (2012); 38 C.F.R. § 3.400 (2017). The effective date of an award of service connection is not based upon the date of the earliest medical evidence demonstrating entitlement, but on the date that the application upon which service connection was ultimately awarded was filed with VA. The mere presence of a disability does not establish intent on the part of a claimant to seek service connection. See KL v. Brown, 5 Vet. App. 205 (1993). The Veteran contends that she is entitled to an effective date earlier than June 6, 2012 for her service-connected migraine headaches. See Notice of Disagreement, received May 2015. A review of the claims folder shows that a claim for service connection for migraine headaches was first received by VA on June 6, 2012. See VA Memo, dated July 15, 2013. There are no earlier documents or communication in the claims folder that may be construed as a formal or informal claim. Therefore, by law, June 6, 2012 is the earliest date VA can assign for service connection for migraine headaches. See 38 C.F.R. § 3.400. Increased Rating Disability ratings are determined by the application of VA’s Schedule for Rating Disabilities (Schedule), which is based on the average impairment of earning capacity. Separate diagnostic codes identify the various disabilities. 38 U.S.C. § 1155 (2012); 38 C.F.R. Part 4 (2017). Pertinent regulations do not require that all cases show all findings specified by the Schedule, but that findings sufficient to identify the disease and the resulting disability and, above all, coordination of the rating with impairment of function will be expected in all cases. 38 C.F.R. § 4.21; see also Mauerhan v. Principi, 16 Vet. App. 436 (2002). When after careful consideration of all procurable and assembled data, a reasonable doubt arises regarding the degree of disability such doubt will be resolved in favor of the claimant. 38 C.F.R. § 4.3. Where there is a question as to which of two ratings shall be applied, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. The Board will consider whether separate ratings may be assigned for separate periods of time based on facts found, a practice known as “staged ratings,” in all claims for increased ratings. Fenderson v. West, 12 Vet. App. 119, 126-27 (1999). Analysis The Veteran seeks a higher initial rating for her service-connected migraine headaches. The Veteran’s service-connected migraine headaches are rated as noncompensable prior to June 1, 2015, and 30 percent disabling from June 1, 2015, under 38 C.F.R. § 4.124a, Diagnostic Code 8100, effective from June 6, 2012. The applicable rating period is from June 6, 2012, the effective date for the award of service connection for migraine headaches, through the present. See 38 C.F.R. § 3.400. Under Diagnostic Code 8100, a noncompensable rating is assigned for headaches with characteristic prostrating attacks averaging less than one in two months over the last several months. A 10 percent rating is assigned for headaches with characteristic prostrating attacks averaging one in two months over the last several months. A 30 percent rating is assigned for headaches with characteristic prostrating attacks occurring on an average once a month over the last several months. A maximum schedular 50 percent rating is assigned for headaches with very frequent completely prostrating and prolonged attacks productive of severe economic inadaptability. The rating criteria do not define “prostrating.” By way of reference, the Board notes that DORLAND’S ILLUSTRATED MEDICAL DICTIONARY 1531 (32nd Ed. 2012), defines “prostration” as “extreme exhaustion or powerlessness.” Turning to the relevant evidence of record, the Veteran was provided a VA Headaches examination in December 2014. The VA examiner reviewed the record, interviewed the Veteran and conducted an in-person examination. The VA examiner noted that the Veteran takes medication related to her migraine headaches. The Veteran stated that she experiences headache pain. She reported symptoms of constant head pain, pulsating or throbbing head pain, pain on both sides of the head, pain that worsens with physical activity, and that her headaches are usually frontal and behind both eyes. Additionally, the Veteran stated that she experiences additional symptoms including sensitivity to light and sound, changes in vision, sensory changes and that she gets dizzy with her headaches. The Veteran reported that her head pain typically lasts one to two days. The VA examiner opined that the Veteran has characteristic prostrating attacks of migraines averaging fewer than one in two months over the previous several months. In June 2015, a VA headaches examiner reviewed the record, examined and interviewed the Veteran, and noted that she took migraine headache medication. The Veteran reported pulsating or throbbing headache pain on both sides of her head, sensitivity to light and sound, and changes in vision. The headaches typically lasted less than one day and occurred, on average, once a month over the previous several months. The Veteran’s VA treatment records reflect occasional reports of headaches. See, e.g., VA treatment record dated March 2016. Additionally, at a March 2016 VA evaluation the Veteran stated that she has not been employed for two years because she “started to get sick, had headaches—dizzy and black out – couldn’t pass a physical to be able to work.” In view of the relevant evidence of record, the Board concludes that the Veteran was not entitled to a compensable initial rating for her service-connected migraine headaches prior to June 1, 2015. The December 2014 VA examination report indicates that the Veteran experienced constant headache pain that lasted one to two days. However, the report does not indicate that the headaches were “characteristic prostrating attacks.” Rather, the Veteran described symptoms of constant head pain, pulsating or throbbing head pain, pain on both sides of the head, pain that worsened with physical activity, and pain that was usually frontal and behind both eyes. Although these symptoms are significant, they do not fit the criteria for a compensable rating under 38 C.F.R. § 4.124a, Diagnostic Code 8100, because they do not manifest with the severity or occur with the frequency required for a compensable rating (a minimum of characteristic prostrating attacks averaging one in two months over the last several months). There is no probative evidence that the Veteran experienced prostrating headache attacks at any time during the rating period prior to the December 2014 VA examination. Accordingly, the record does not show that at any time prior to June 1, 2015, was the Veteran entitled to a compensable initial rating for headaches. From June 1, 2015, the Board concludes that the Veteran was not entitled to a rating in excess of 30 percent. The June 2015 VA examination report indicates that the Veteran experienced headaches that typically lasted less than one day and were located on both sides of the head. Additionally, the VA examiner noted that the Veteran experienced characteristic prostrating attacks that occurred on an average once per month. However, the report does not indicate that the headaches were characteristic prostrating attacks of more than one per month. These symptoms do not meet the requirements for a 50 percent rating (very frequent completely prostrating and prolonged attacks that produce severe economic adaptability). Accordingly, the record does not show that at any time from June 1, 2015, was the Veteran entitled to a disability rating in excess of 30 percent for her service-connected migraine headaches. In light of the above, the preponderance of the evidence is against the claim. The benefit-of-the-doubt rule does not apply and the claim must be denied. 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102. In addition, there is no probative evidence of record or allegation in support of application of any other diagnostic code for the Veteran’s service-connected migraine headaches. Therefore, no diagnostic code will be applied other than Diagnostic Code 8100. See Butts v. Brown, 5 Vet. App. 532, 538 (1993) (choice of diagnostic code should be upheld if it is supported by explanation and evidence). The Board has carefully considered the Veteran’s reports with respect to the nature and severity of her service-connected migraine headaches and notes that her lay testimony is qualified to describe her headache symptoms. The Veteran’s history and symptom reports have been considered, including as presented in the medical evidence discussed above, and are noted to be contemplated by the criteria for the disability rating for which the Veteran has been found entitled by the Board. The Board therefore finds that the criteria for a compensable initial rating, prior to June 1, 2015, and a rating in excess of 30 percent from June 1, 2015, for the Veteran’s service-connected migraine headaches have not been met at any time during the rating period. Neither the Veteran nor her representative has raised any other issues, nor have any other issues been reasonably raised by the record. See Yancy v. McDonald, 27 Vet. App. 484, 495 (2016); Doucette v. Shulkin, 38 Vet. App. 366, 369-70 (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). The Board notes that this decision does not leave the Veteran without recourse; if her headaches become more severe in the future, she is free to file a new claim for an increased rating at that time. REASONS FOR REMAND 1. Service Connection for Anemia The Veteran seeks service connection for anemia. The Veteran was provided a VA gynecological examination in December 2014. VA has a duty to ensure that any medical examination or opinion it provides is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). A medical opinion is adequate where it is based upon consideration of the full medical history and describes a disability in sufficient detail so that the Board’s evaluation will be fully informed. Stefl v. Nicholson, 21 Vet. App. 120, 123 (2007). Here, the December 2014 VA examiner noted that the Veteran has a current diagnosis of anemia. However, the VA examiner did not provide an opinion as to whether the Veteran’s diagnosed anemia is causally related to her active service. As the examination is not adequate for decision-making purposes, the Veteran must be provided an addendum opinion to address whether her anemia is causally related to her active service. 2. Service Connection for Menorrhagia The Veteran contends that she has menorrhagia, claimed as severe menstrual bleeding, that had its onset during her active service and has continued to the present. The Veteran was provided a VA gynecological examination in December 2014. The VA examiner noted that the Veteran was diagnosed with irregular menstrual bleeding in 1984 and 2014. The examiner opined that the Veteran’s condition is less likely than not incurred in or caused by treatment received during her active military service. However, the Board finds that the examiner’s opinion is entitled to little probative value as the examiner did not address whether it was a developmental defect or disease. For example, a developmental or congenital disease, even if hereditary, can be found to be service connected if it first manifests during active service. See VAOPGCPREC 67-90. On the other hand, a developmental or congenital defect cannot be service connected, but if there is a superimposed injury or disease, service connection can be warranted for the additional disability. See VAOPGCPREC 82-90 (July 18, 1990); 38 C.F.R. §§ 3.303 (c), 4.9, 4.127. The Board finds that a VA addendum opinion must be obtained. The examiner must address whether the Veteran’s condition is a congenital or developmental disease which first manifest in service, or a congenital or developmental defect and, if so, whether the menorrhagia was subject to a superimposed injury or disease during service that resulted in additional disability. If it is not a congenital or developmental defect or disease, then the examiner must address whether the disability is related to active service. 3. TDIU As noted above, TDIU has been raised as part and parcel to the Veteran’s claim for a higher initial disability rating. See Rice, 22 Vet. App. 447. As the RO has not yet considered whether the Veteran is entitled to TDIU, the issue must be remanded to the RO for appropriate development and initial adjudication. Additionally, the Board notes that the record for review may be incomplete. The most recent VA treatment records are from May 2016. VA treatment records, even if not in the claims file, are considered part of the record on appeal because they are within VA’s constructive possession. See 38 U.S.C. § 5103A (2012); Bell v. Derwinski, 2 Vet. App. 611 (1992). On remand, updated VA treatment records must be obtained and associated with the record. The matters are REMANDED for the following action: 1. Obtain all outstanding treatment records relevant to the matters being remanded, to include from May 2016. 2. Send the Veteran a notification letter with respect to her claim for TDIU. The letter should include a VA Form 21-8940, Veterans Application for Increased Compensation Based on Unemployability, and a VA Form 21-4142, Authorization and Consent to Release Information to VA, for completion and return to VA. 3. Complete any necessary development in view of the Veteran’s response to the above notification letter, to include the scheduling of any additional VA examinations deemed warranted. 4. After the first remand directive, forward the record and a copy of this remand to the examiner who conducted the December 2014 VA examination, or if the examiner is unavailable, another suitably qualified examiner, for completion of an addendum opinion. If the examiner determines that another in-person examination of the Veteran is required to provide the below-requested information, then such an examination should be scheduled. Following review of the record, the examiner should express an opinion as to: (a.) Whether it is at least as likely as not (50 percent or greater probability) that the Veteran’s anemia is related to her active service. 5. After the first remand directive, forward the record and a copy of this remand to the examiner who conducted the December 2014 VA examination, or if the examiner is unavailable, another suitably qualified examiner, for completion of an addendum opinion. If the examiner determines that another in-person examination of the Veteran is required to provide the below-requested information, then such an examination should be scheduled. Following review of the record, the examiner should express an opinion as to: (a.) Is the Veteran’s menorrhagia a congenital or developmental defect? If so, is it at least as likely as not (50 percent probability or more) that the menorrhagia was subject to a superimposed disease or injury during service that resulted in additional disability. If so, identify the additional disability. (b.) If the menorrhagia is a congenital or developmental disease, is it at least as likely as not (50 percent probability or higher) that the menorrhagia was incurred in or otherwise related to active service? 6. After completion of the above, review the expanded record, including the evidence entered since the most recent statement of the case, and determine whether service connection for an acquired psychiatric disability, anemia, and/or menorrhagia may be granted and whether TDIU may be granted. If any benefit sought remains denied, furnish the Veteran and her representative with a supplemental statement of the case. The appropriate period should be allowed for response before the appeal is returned to the Board. VICTORIA MOSHIASHWILI Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD B. G. LeMoine, Associate Counsel