Citation Nr: 1821292 Decision Date: 04/11/18 Archive Date: 04/19/18 DOCKET NO. 14-40 730 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Milwaukee, Wisconsin THE ISSUES 1. Entitlement to service connection for shingles. 2. Entitlement to service connection for urinary tract infections. 3. Entitlement to service connection for kidney stones as secondary to urinary tract infections. 4. Entitlement to service connection for a left shoulder strain. 5. Entitlement to service connection for hypertension, to include as secondary to migraines, and posttraumatic stress disorder (PTSD). 6. Entitlement to service connection for a low back disability. 7. Entitlement to service connection for upper face numbness, to include as secondary to migraines. 8. Entitlement to service connection for diabetes, to include as secondary to migraines, PTSD, and/or bulimia. 9. Entitlement to a compensable evaluation for bulimia. 10. Entitlement to an increased rating in excess of 30 percent prior to August 28, 2015, an in excess of 50 percent thereafter, for migraine headaches. 11. Entitlement to an earlier effective date for the award of service connection for posttraumatic stress disorder (PTSD). REPRESENTATION Veteran represented by: New York State Division of Veterans' Affairs WITNESS AT HEARING ON APPEAL Veteran ATTORNEY FOR THE BOARD E. Skiouris, Associate Counsel INTRODUCTION The appellant is a Veteran who served on active duty from March 1983 to October 1998. This matter is before the Board of Veterans' Appeals (Board) on appeal from January 2014, April 2015, and September 2015 rating decisions of a Department of Veterans Affairs (VA) Regional Office (RO). In July 2017, a Board hearing was held before the undersigned. A transcript of the hearing is associated with the Veteran's claims file. The issues of service connection for hypertension, service connection for diabetes, and service connection for face numbness, are addressed in the REMAND portion of the decision below and are REMANDED to the Agency of Original Jurisdiction (AOJ). FINDINGS OF FACT 1. On the record at the July 2017 hearing, prior to the promulgation of a decision in the appeal, the Veteran stated that she wished to withdraw her appeals of service connection for shingles, urinary tract infections, and kidney stones as secondary to urinary tract infections. 2. The Veteran's left shoulder strain, was not manifested during her active military service, and is not shown to be causally or etiologically related to her active military service. 3. The Veteran's lumbar spine sprain (claimed as low back disability), was not manifested during her active military service, and is not shown to be causally or etiologically related to her active military service. 4. After resolving reasonable doubt in her favor, the Veteran's bulimia nervosa is manifested by symptoms of self-induced vomiting with a diagnosis of an eating disorder, and incapacitating episodes. 5. For the period prior to August 28, 2015, the Veteran's headaches were not productive of severe economic inadaptability. 6. From August 28, 2015, the Veteran's headaches have not been shown to be of such severity so as to preclude substantially gainful employment. 7. The Veteran's informal claim of service connection for PTSD was received by VA on August 30, 2014. CONCLUSIONS OF LAW 1. The criteria for withdrawal of an appeal for service connection for shingles are met. 38 U.S.C. § 7105 (2012); 38 C.F.R. § 20.204 (2017). 2. The criteria for withdrawal of an appeal for service connection for urinary tract infections are met. 38 U.S.C. § 7105 (2012); 38 C.F.R. § 20.204 (2017). 3. The criteria for withdrawal of an appeal for service connection for kidney stones as secondary to urinary tract infections are met. 38 U.S.C. § 7105 (2012); 38 C.F.R. § 20.204 (2017). 4. The criteria to establish service connection for a left shoulder strain have not been met. 38 U.S.C. §§ 1131, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.310(a) (2017). 5. The criteria to establish service connection for a low back disability have not been met. 38 U.S.C. §§ 1131, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303 (2017). 6. The criteria for a 10 percent rating, but no higher, for bulimia nervosa have been met. 38 U.S.C. §§ 1154, 5107(b) (2012); 38 C.F.R. §§ 3.321, 4.3, 4.7, 4.130, Diagnostic Code 9521 (2017). 7. Prior to August 28, 2015, the criteria for a disability rating in excess of 30 percent for migraines have not been met; and a rating in excess of 50 percent from that time is the maximum schedular rating . 38 U.S.C. §§ 1154(a), 1155, 5107 (2012); 38 C.F.R. § 4.124a, Diagnostic Code 8100 (2017). 8. The criteria for an effective date earlier than August 30, 2014, for the award of service connection for PTSD have not been met. 38 U.S.C. §§ 5107, 5110 (2012); 38 C.F.R. § 3.400 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Duty to Notify and Assist Neither the Veteran nor her representative has raised any issues with the duty to notify or duty to assist. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015) (holding that "the Board's obligation to read filings in a liberal manner does not require the Board . . . to search the record and address procedural arguments when the veteran fails to raise them before the Board."); Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016) (applying Scott to a duty to assist argument). II. Withdrawals The Board may dismiss any appeal which fails to allege specific error of fact or law in the determination being appealed. 38 U.S.C. § 7105. An appeal may be withdrawn as to any or all issues involved in the appeal at any time before the Board promulgates a decision, and may be done in writing by the Veteran or his authorized representative, or on the record at hearing. 38 C.F.R. § 20.204. The Veteran stated on the record at the July 2017 hearing that she wished to withdraw her appeals for service connection for shingles, urinary tract infections, and kidney stones. The Veteran has withdrawn these appeals and, hence, there remain no allegations of errors of fact or law for appellate consideration in connection therewith. Accordingly, the Board does not have jurisdiction to review the appeals and they are dismissed. III. Service Connection Service connection is warranted where the evidence of record establishes that a particular injury or disease resulting in disability was incurred in the line of duty in active military service or, if pre-existing such service, was aggravated thereby. 38 U.S.C. § 1131; 38 C.F.R. § 3.303(a). Moreover, every veteran shall be taken to have been in sound condition when examined, accepted, and enrolled for service, except as to defects, infirmities, or disorders noted at the time of the examination, acceptance, and enrollment, or where clear and unmistakable evidence demonstrates that the injury or disease existed before acceptance and enrollment and was not aggravated by such service. 38 U.S.C. § 1111 (2012). Establishing service connection generally requires (1) medical evidence of a current disability; (2) medical or, in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and (3) medical evidence of a nexus between the claimed in-service disease or injury and the present disability. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004); see Caluza v. Brown, 7 Vet. App. 498, 506 (1995), aff'd per curiam, 78 F.3d 604 (Fed.Cir.1996) (table); Hickson v. West, 12 Vet. App. 247, 253 (1999); 38 C.F.R. § 3.303. Service connection also may be established on a secondary basis for: (1) a disability that is proximately due to or the result of a service-connected disease or injury; or, (2) any increase in the severity of a nonservice-connected disease or injury that is proximately due to or the result of a service-connected disease or injury, and not due to the natural progress of the nonservice-connected disease or injury. 38 C.F.R. §§ 3.310(a)-(b); see Allen v. Brown, 7 Vet. App. 439, 448 (1995). VA will not concede aggravation unless the baseline level of the non-service connected disability is established by medical evidence created before the onset of aggravation or by the earliest evidence created at any time between the onset of aggravation and the receipt of medical evidence establishing the current level of non-service connected disease or disability. 38 C.F.R. § 3.310(b). In determining whether service connection is warranted for a disability, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the veteran prevailing in either event, or whether a preponderance of the evidence is against the claim, in which case the claim is denied. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). A. Left Shoulder Strain The Veteran has asserted that she carried heavy objects during her time in service and that caused damage to her shoulder. She reported experiencing a should strain that never resolved during service. STRs document a visit in August 1998, when she complained of left shoulder pain. She was found to have a left shoulder rotator cuff injury. Her discharge examination was negative for any findings of a shoulder related condition. The Veteran underwent a VA examination in December 2013. She was diagnosed with a shoulder strain. The claims file was reviewed and indicated that in 1998 the Veteran was diagnosed with a left rotator cuff injury. Her discharge examination was normal. There was objective evidence of painful motion, and less movement than normal. The examiner concluded, that it was less likely than not that her shoulder condition was incurred in or caused by an in-service injury, event or illness. Rationale provided was there was one left shoulder condition documented during service, which was acute and self-resolved. Upon separation from service, she had a normal examination with no shoulder complaints. To conclude, the reported injury in service would not cause a chronic shoulder condition. At the Board hearing, the Veteran reported that her headaches affect her left side. She also furthered the argument that she believed her left shoulder condition is related to paralysis with migraines. Although this statement is acknowledged, the issue before the Board is a shoulder strain, and the Veteran has been granted service connection for hemiplegic migraine with left upper extremity peripheral neuropathy. Having considered all of the evidence of record, the Board finds that the preponderance of the evidence is against the claim. The Veteran filed for service connection in September 2013, reporting that her disability began during service. The Veteran was discharged from service in October 1998. In the appropriate circumstance, VA may consider the absence of any indication of a relevant medical complaint until so relatively long after service as one factor, just not the only or sole factor, in determining whether a disease or an injury in service resulted in chronic or persistent residual disability. Here, the gap of many years between service and the submission of a claim for VA benefits weighs against a nexus between service and current disability. The shoulder is a complex structure with any number of sources within it for complaints. Thus, a medical opinion on the question of a nexus with service was sought, of which it was unfavorable to the Veteran's claim. The Board also notes, that although VAMC treatment records contain reports of shoulder pain, there is no indication in these records that the Veteran's shoulder strain is in any way related to her time in service. These records contain no indication the Veteran was diagnosed with or found to have degenerative arthritis of the shoulder. The December 2013 VA examiner concluded it was less likely than not that a shoulder strain was incurred in or caused by an in-service event. The examiner explained that there was one left shoulder condition documented during service, which resolved. Upon separation from service, she had a normal examination with no shoulder complaints. The opinion is shown to have been based on a review of the Veteran's records and is accompanied by a sufficient explanation. The Veteran's lay statements were considered but ultimately the examiner concluded that there was no etiological relationship between the Veteran's current shoulder strain and service. For these reasons, the Board finds that the VA examiner's opinion is dispositive of the service connection nexus question presented in this case. In so finding, the Board notes that the Veteran has also expressed her own view that her shoulder strain is related to his service. Although lay persons are competent to provide opinions on some medical issues, such as feeling back pain, see Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011), as to the specific issue in this case, i.e., whether the disability affecting the Veteran's shoulder is etiologically related to service, such question falls outside the realm of common knowledge of a lay person as it involves a medical subject concerning an internal physical process extending beyond an immediately observable cause-and-effect relationship. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007) (providing that lay persons not competent to diagnose cancer); see also Woehlaert v. Nicholson, 21 Vet. App. 456 (2007) (providing that although the claimant is competent in certain situations to provide a diagnosis of a simple condition such as a broken leg or varicose veins, the claimant is not competent to provide evidence as to more complex medical questions). As such, the Board assigns little probative value to the Veteran's assertions that her shoulder strain is in any way related to her military service. In sum, the most probative evidence of record is the 2013 VA examiner opinion finding no link between the Veteran's in-service shoulder-related complaints, and the currently diagnosed left shoulder strain. The Board notes that under the provisions of 38 U.S.C. § 5107(b), the benefit of the doubt is to be resolved in the claimant's favor in cases where there is an approximate balance of positive and negative evidence in regard to a material issue. The preponderance of the evidence, however, is against the Veteran's claim, and thus that doctrine is not applicable. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). The claim of entitlement to service connection for a left shoulder strain is denied. B. Low Back Disability The Veteran has asserted that she injured her back during service while stationed in Diego Garcia. She reported being medevac'd to the Philippines for treatment. She stated since that since time she has had a low back disability. She also has asserted that during service she did heavy lifting that led to her shoulder and back problems. STR's document a complaint of low back pain in May 1989, following which she was admitted to Ward Diego Garcia, with a diagnosis of low back pain. A June 1989 note indicates she was returning from Medevac for low back pain, and instructed to exercise, with a note that her low back pain had resolved. STRs document an emergency room visit in February 1990, for back pain, at which time she was pregnant. At a March 1990 follow up visit, she had muscle spasms of the low back. In January 1992, she complained of low back pain, and was diagnosed with pyelonephritis. In a statement in support received February 2014, the Veteran explained that though she had back pain in February 1990, when she was pregnant, she was only 8 weeks pregnant, and had already been treated for low back pain prior to this incident. The Veteran underwent a VA examination in October 2013, and was diagnosed with a low back sprain. Service treatment records were reviewed, with the evidence cited as: a June 1989 report of low back pain from which she recovered; a February 1990 emergency room visit, when she diagnosed with low back pain and pregnancy; and a March 1990 complaint of muscle spasms, following a fall in formation. She was diagnosed with acute muscle spasms with sciatica nerve symptoms. In January 1992, she was seen for complaints of low back pain, and diagnosed with pyelonephritis. The Veteran complained of low back pain on a daily basis. On examination she had pain on movement, and bilateral lumbar paraspinal muscle area tenderness. No image studies of the spine had been performed. The examiner opined that it was less likely than not that her back condition was incurred in or caused by an in-service injury, event, or illness. The rationale was that her episodes of low back pain while in service were associated with pyelonephritis, pregnancy, or were acute and self-resolved muscle strains. The examiner opined that the Veteran's back pain in service would not cause a chronic back condition. Having considered all of the evidence of record, the Board finds that the preponderance of the evidence is against the claim. The Veteran filed for service connection in September 2013, reporting that her disability began during service. The Veteran was discharged from service in October 1998. In the appropriate circumstance, VA may consider the absence of any indication of a relevant medical complaint until so relatively long after service as one factor, just not the only or sole factor, in determining whether a disease or an injury in service resulted in chronic or persistent residual disability. Here, the gap of many years between service and the submission of a claim for VA benefits weighs against a nexus between service and current disability. The low back is a complex structure with any number of sources within it for back complaints. Thus, a medical opinion on the question of a nexus with service was sought, of which it was unfavorable to the Veteran's claim. The Board also notes that although VAMC treatment records contain reports of low back pain, there is no indication in these records the Veteran's back pain is in any way related to her time in service. These records contain no indication the Veteran was diagnosed with or found to have degenerative arthritis of the spine. The October 2013 VA examiner concluded it was less likely than not that a back disability was incurred in or caused by an in-service event. The examiner explained and pointed out that the episodes of low back pain in service were either associated with pregnancy, pyelonephritis, or were self-resolved muscle strains. The opinion is shown to have been based on a review of the Veteran's records and is accompanied by a sufficient explanation. The Veteran's lay statements were considered, but ultimately the examiner concluded that there was no etiological relationship between the Veteran's current back disability and service. For these reasons, the Board finds that the VA examiner's opinion is dispositive of the service connection nexus question presented in this case. In so finding, the Board notes that the Veteran has also expressed her own view that her back disability is related to her service. Although lay persons are competent to provide opinions on some medical issues, such as feeling back pain, see Kahana, supra, as to the specific issue in this case, i.e., whether the disability affecting the Veteran's back is etiologically related to service, such question falls outside the realm of common knowledge of a lay person as it involves a medical subject concerning an internal physical process extending beyond an immediately observable cause-and-effect relationship. See Jandreau and Woehlaert, supra. In other words, the Veteran is not competent to attribute her current back complaints to her in-service back complaints. As such, the Board assigns little probative value to her assertions that her low back sprain is in any way related to her military service. In sum, the most probative evidence of record is the 2013 VA examiner opinion finding no link between the Veteran's in-service back related complaints, and the currently diagnosed low back sprain. The Board notes that under the provisions of 38 U.S.C. § 5107(b), the benefit of the doubt is to be resolved in the claimant's favor in cases where there is an approximate balance of positive and negative evidence in regard to a material issue. The preponderance of the evidence, however, is against the Veteran's claim, and thus that doctrine is not applicable. See Gilbert, supra. The claim of entitlement to service connection for a back disability is denied. IV. Increased Ratings Disability evaluations are determined by the application of VA's Schedule for Rating Disabilities (Rating Schedule), 38 C.F.R. Part 4. The percentage ratings contained in the Rating Schedule represent, as far as can be practicably determined, the average impairment in earning capacity resulting from diseases and injuries incurred or aggravated during military service and the residual conditions in civil occupations. 38 U.S.C. § 1155; 38 C.F.R. §§ 3.321(a), 4.1 (2017). The basis of disability evaluations is the ability of the body as a whole to function under the ordinary conditions of daily life, including employment. 38 C.F.R. § 4.10. Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. In Fenderson v. West, 12 Vet. App. 119 (1999), the Court held that in the case of an initial rating the Board must consider whether staged ratings were warranted during any period since service connection in order to compensate for changes in the disability over that period. Id. at 126-127. In its evaluation, the Board considers all information and lay and medical evidence of record. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Board gives the benefit of the doubt to the claimant. 38 U.S.C. § 5107(a). A. Bulimia The Veteran is in receipt of a non-compensable evaluation for bulimia, and for the reasons discussed below, the Board finds that a 10 percent rating, but no higher, is warranted. The noncompensable rating was assigned under the provisions of 38 C.F.R. § 4.130, Diagnostic Code 9521. Under diagnostic Code 9521, the rating criteria for bulimia nervosa is as follows: Self-induced weight loss to less than 80 percent of expected minimum weight, with incapacitating episodes of at least six weeks total duration per year, and requiring hospitalization more than twice a year for parenteral nutrition or tube feeding, a 100 percent rating. Self-induced weight loss to less than 85 percent of expected minimum weight with incapacitating episodes of six or more weeks total duration per year, a 60 percent rating. Self-induced weight loss to less than 85 percent of expected minimum weight with incapacitating episodes of more than two but less than six weeks total duration per year, a 30 percent rating. Binge eating followed by self-induced vomiting or other measures to prevent weight gain, or resistance to weight gain even when below expected minimum weight, with diagnosis of an eating disorder and incapacitating episodes of up to two weeks total duration per year, a 10 percent rating. Binge eating followed by self-induced vomiting or other measures to prevent weight gain, or resistance to weight gain even when below expected minimum weight with diagnosis of an eating disorder, but without incapacitating episodes, a 0 percent rating. The note to Diagnostic Code 9521 explains that "an incapacitating episode is a period during which bed rest and treatment by a physician are required." 38 C.F.R. § 4.130, Diagnostic Code 9521 (2017). In September 2015, the Veteran underwent a VA examination. The findings were binge eating following by measures to prevent weight gain, binge eating followed by self-induced vomiting, without incapacitating episodes. She had recurrent episodes of binge eating characterized by eating more food in a discrete period of time than a normal person would and a sense of loss of control over the eating. She also had compensatory behavior such as vomiting or taking laxatives, and fasting or exercising excessively. The binge eating occurred once per week, and had been going on for at least 3 months. She did not require bedrest and treatment by a physician, but she was referred to a residential treatment facility. She reported resisting this suggestion out of fear that she would be sexually victimized at the facility. There is an impact on her ability to work, in that she leaves her work station, and has used sick leave to cover for her issue, and had taken a week off of work due to her bulimia. In an October 2015 statement in support, she reported being recommended to enter a program in a mental facility to get her bulimia and PTSD under control, however, she is afraid to be a facility where she will be powerless and unable to protect herself, and does not want to take time off from work. She reported taking off 16 days from work due to being too weak from throwing up and or taking laxatives. A VAMC treatment record from May 2016, notes Topamax had been prescribed in an effort to curb binge eating. The Veteran was afforded a VA examination in February 2017. She was diagnosed with bulimia, resulting in alternating symptoms of constipation and diarrhea. She has been taking laxatives on a daily basis for the prior 2 years, and has had diarrhea for about one year. She has more or less constant abdominal distress. Her baseline weight is 190, and she weighed 171 at that time. She works at home, and the bulimia impacts her work on a daily basis. At the Board hearing she reported continuing issues with bulimia. Though the record does not indicate the Veteran has been prescribed bedrest by a physician, but she engages in binge eating and purging behavior, and has been referred to a treatment facility for a two week stay. Additionally she has reported missing over two weeks from work due to her bulimia. Consequently, the Board affords the Veteran the benefits of the doubt, and finds there is competent and credible evidence to warrant a 10 percent rating, but no higher, for bulimia. B. Migraine Headaches The Veteran is in receipt of a 30 percent evaluation prior to August 28, 2015, and 50 percent thereafter. Under Diagnostic Code 8100, a rating of 30 percent is warranted for characteristic prostrating attacks occurring on an average once a month over last several months. A 50 percent rating, the maximum scheduler rating available, is warranted for very frequent completely prostrating and prolonged attacks productive of severe economic inadaptability. See 38 C.F.R. § 4.124a, Diagnostic Code 8100 (2017). The rating criteria do not define "prostrating," nor is there a definition provided by the U.S. Court of Appeals for Veterans Claims. Fenderson v. West, 12 Vet. App. 119 (1999) (in which the Court quotes Diagnostic Code 8100 verbatim but does not specifically address the matter of what is a prostrating attack.). According to DORLAND'S ILLUSTRATED MEDICAL DICTIONARY 1554 (31st ed. 2007), "prostration" is defined as "extreme exhaustion or powerlessness." The Veteran asserts that her headaches are more severe than currently rated and that a higher rating is warranted for the periods on appeal. At the Board hearing she stated that she experiences headaches on a daily basis. She reported taking breaks at work due to severity of headaches, and that she does not drive much due to the effects of the medication. She stated her ability to work is also impacted by the headaches, and she has to lie down. Several buddy statements were received in September 2013, outlining the severity of the Veteran's headaches. A September 2013 statement in support from her daughter, explains that the Veteran has headaches on a daily basis. And that she had been seen in bed for up to 3 days because of the severity of the headaches. A September 2013 statement from a colleague outlines that the Veteran would call in to work complaining of headaches, or leave work early on occasion due to her headaches. In the Veteran's September 2013 statement, she stated that she suffers from migraines 3 to 5 times per week, and cannot sleep or rest. In her notice of disagreement, received February 2014, she stated that she experiences debilitating migraines 3 to 5 times per week. She stated she was unable to sleep or rest. A January 2016 treatment note indicates the Veteran experienced migraines on a daily basis that affected her sleep, would cause elevated blood pressure, and hyperglycemia. A November 2015 note, indicates the headaches led to left side of face numbness, twitching and spasms, and elevated blood pressure. At a February 2016 peripheral nerve exam, the examiner commented on her migraines, noting she now had daily migraines headaches, and elevated blood sugar following a migraine episode. The Veteran underwent a VA examination in October 2013. She complained of daily migraine headaches. She was taking over the counter Excedrin and prescription medication, Immitrex. She reported difficulty sleeping at night due to headache symptoms. She denied limitations with activities of daily living. She reported pulsating and throbbing head pain. Symptoms associated with the headaches were nausea, vomiting, intermittent dizziness, and sensory changes, such as feeling of pins and needles in extremities. The duration of typical head pain was less than one day, and typically on the left side of the head. She had characteristic prostrating attacks of migraine headaches pain, more frequently than once per month. She did not have frequent prostrating or prolonged attacks of migraine headache pain. A MRI of the brain from 1997 was referenced, and the findings were normal. Her headache condition was deemed to have no impact on her ability to work. In August 2015, the Veteran was afforded a VA examination. The Veteran headaches occur on a daily basis, and interfere with sleep. Associated symptoms were nausea, vomiting, sensitivity to light, and left side of face with numbness and tingling. She had constant head pain, pulsating or throbbing head pain, localized to one side of the head, and the pain worsened with physical activity. She had characteristic prostrating attacks occurring once per month that have been productive of severe economic inadaptability. The effect on her work has been that because of her limited ability to sleep, she misses work, and has difficulty with concentration and attention. In May 2017, a VA opinion was rendered. The examiner stated she had hemiplegic migraine that is defined as the complaint of weakness during a migraine. She has intermittent hemiparesis and hemisensory symptoms on the left side during a migraine. For the period on appeal prior to August 28, 2015, the above findings do not support a rating in excess of 30 percent. In reaching this conclusion, the Board considered the Veteran's lay statements describing her migraine symptoms and medical evidence of record, but finds that the most probative evidence of record does not show that the Veteran experienced severe economic inadaptability to warrant a 50 percent rating prior to August 28, 2015. For the period from August 28, 2015, a rating higher than 50 percent for migraine headaches is not available under the rating schedule. The Board finds that a higher rating is not warranted under any other rating criteria, as the Veteran's symptoms, mainly frequent prostrating headaches, with nausea, light sensitivity and visual changes, have been accounted for by the criteria listed in Diagnostic Code 8100. Accordingly, an increased rating for migraine headaches is not warranted. Further, the Board has considered the lay evidence offered by the Veteran, in addition to the medical evidence cited above. Her factual recitation as to symptomatology associated with the headache condition is accepted as true. However, as a layperson, lacking in medical training and expertise, the Veteran cannot provide a competent opinion on a matter as complex as the present severity of her headache disability, and her assertions are far outweighed by the detailed opinions provided by the medical professionals who examined the Veteran's headache condition and discussed all relevant details for purposes of rating her disability. For these reasons, the Board finds that at no time during the periods in question has the disability warranted more than a 30 percent evaluation prior to August 28, 2015, or more than a 50 percent evaluation since. See Hart v. Mansfield, 21 Vet. App. 505 (2007). Because the preponderance of the evidence is against the claim, the benefit of the doubt provisions are inapplicable. 38 U.S.C. § 5107; 38 C.F.R. § 4.3. Accordingly, the Veteran's request for an increased rating is denied. V. Earlier Effective Date for grant of service connection for PTSD Unless specifically provided, the effective date of an award based on an original claim, a claim reopened after final adjudication, or a claim for increase, of compensation, dependency and indemnity compensation, or pension, shall be fixed in accordance with the facts found, but shall not be earlier than the date of receipt of application therefor. 38 U.S.C. § 5110(a) (2012). The Veteran contests the effective date of August 30, 2014, for the award of service connection for PTSD. Under the applicable criteria, the effective date of an award of disability compensation based on an initial claim shall be fixed in accordance with the facts found, but shall not be earlier than the date of receipt of application therefor. 38 U.S.C. § 5110(a) (2012). The implementing regulation provides that the effective date of an award of disability compensation is the day following separation from active service, if the claim is received within one year after separation from service; otherwise, the effective date is the later of the date of receipt of claim or the date that entitlement to service connection arose. 38 C.F.R. § 3.400(b)(2) (2017). A specific claim in the form prescribed by the Secretary of VA must be filed in order for benefits to be paid or furnished to any individual under the laws administered by VA. 38 U.S.C. § 5101(a)(1); 38 C.F.R. § 3.151(a). For claims received on or after March 24, 2015, VA amended its regulations governing how to file a claim. The effect of the amendment was to standardize the process of filing claims, as well as the forms accepted, in order to increase the efficiency, accuracy, and timeliness of claims processing, and to eliminate the concept of informal claims. See 38 C.F.R. § 3.155 ; 79 Fed. Reg. 57660-01. However, prior to the effective date of the amendment, an informal claim was any communication or action, indicating an intent to apply for one or more benefits under the laws administered by VA. Such informal claim must identify the benefit sought. 38 C.F.R. § 3.155(a) (2017). The evidence of record shows that the Veteran filed an informal claim in August 2014. Therefore, VA laws and regulations in effect prior to March 24, 2015, govern her claim for an earlier effective date. A "claim" is defined in the VA regulations as "a formal or informal communication in writing requesting a determination of entitlement, or evidencing a belief in entitlement, to a benefit." 38 C.F.R. § 3.1(p). An informal claim is "[a]ny communication or action indicating an intent to apply for one or more benefits." It must "identify the benefit sought." 38 C.F.R. § 3.155(a). The date of receipt of the claim, or "date of the claim," means the date of the application based upon which benefits are awarded, not the original claim for service connection. See Sears v. Principi, 16 Vet. App. 244, 246-47 (2002), aff'd, 349 F.3d 1326 (Fed. Cir. 2003). VA must look to all communications from a claimant that may be interpreted as applications or claims, formal and informal, for benefits and is required to identify and act on informal claims for benefits. Servello v. Derwinski, 3 Vet. App. 196, 198 (1992). If VA fails to forward an application form to the claimant after receipt of an informal claim, then the date of the informal claim must be accepted as the date of claim for purposes of determining an effective date. Id. at 200. The Veteran is seeking an effective date earlier than August 30, 2014, for the grant of service connection for PTSD. The Veteran filed an original claim for service connection for a mental health condition, to include PTSD, anxiety, depression, and sleep disturbances on November 18, 2014. She initiated her online application on August 30, 2014, which is considered the informal date of claim. The Veteran contends that her lay statements from September 2013, November 2013, and January 2014, which reported symptoms of sleepiness, numbness, stress, irritability, flight and anxiety should be considered informal claims for service connection for a mental health condition. The September 2013 statement was sent in support of a claim for increased rating for her migraine headaches, with the assertion that migraines caused her stress and irritability. The November 2013 statement, was in support of a claim for a higher evaluation for migraine headaches. The January 2014 statement was a statement in support of a claim for service connection for hypertension, in which she asserts that as her migraines have worsened as she suffers from sleep deprivation and anxiety, which contribute to high blood pressure. These statements, were cited in support of the Veteran's claim for an increased evaluation for her migraine headaches, and service connection for hypertension. There is no showing of intent to submit a claim for service connection for a mental health condition. The Veteran has also asserted in support of an earlier effective date, the fact that she was prescribed Lorazepam in July 2004 for anxiety and stress, and Citalopram Hydrobromide in March 2014. The date a prescription was ordered is not considered an informal claim for service connection. In MacPhee v. Nicholson, the United Stated Court of Appeals for the Federal Circuit (Federal Circuit) found that the mere mention of a condition in a medical record alone cannot be construed as a claim for service connection. 459 F.3d 1323, 1327 (Fed. Cir. 2006); see also 38 C.F.R. § 3.157 (prior to March 24, 2015). Rather, the Federal Circuit found that "a medical examination report will only be considered an informal claim for an increase in disability benefits if service connection has already been established for the disability." Id., (emphasis added). Prior to August 30, 2014, the Veteran was not service connected for an acquired psychiatric disorder. As such, the earliest effective date available for the grant of service connection for PTSD is August 30, 2014. As the preponderance of the evidence is against an effective date earlier than August 30, 2014, for the grant of service connection for PTSD, the claim must be denied. 38 U.S.C. § 5107(b) (2012); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). ORDER The appeal for service connection of shingles is dismissed. The appeal for service connection of urinary tract infections is dismissed. The appeal for service connection of kidney stones as secondary to urinary tract infections is dismissed. Entitlement to service connection for a left shoulder strain is denied. Entitlement to service connection for a low back disability is denied. Entitlement to a rating in excess of 30 percent for a headache condition, prior to August 28, 2015, is denied. Entitlement to a disability rating in excess of 50 percent for a headache condition, from August 28, 2015, is denied. Entitlement to an effective date prior to August 30, 2014, for the grant of service connection for PTSD is denied. REMAND Diabetes The Veteran has claimed service connection for diabetes, as secondary to migraines, PTSD, or bulimia. At the Board hearing she reported that PTSD triggers bulimia that then affects her blood sugar. She stated that because of pain she believes her blood sugar is affected and becomes difficult to manage. A VA examiner reviewed the file and rendered an opinion in March 2015. The examiner noted the Veteran has type 2 diabetes mellitus, and stated there is no objective evidence that diabetes is caused or aggravated by PTSD, or migraine headaches. A VAMC treatment note from November 2016, indicates the Veteran was seen for migraines, and it was noted that when her severe disabling headaches occur, she may have elevated blood pressure, and hyperglycemia. As no opinion has been rendered as to whether the Veteran's diabetes was caused or aggravated by her service-connected bulimia, and in an effort to clarify the treatment note from November 2016, an opinion must be rendered. Hypertension The Veteran has claimed service connection for hypertension, as secondary to migraines and/or to PTSD. At the Board hearing she stated that because she is in pain and constant stress, she has hypertension. She was afforded a VA examination in December 2013, and was found to suffer from hypertension. The examiner stated that the medical literature does not support migraine headaches causing hypertension. An addendum opinion was rendered in August 2015, at which time the examiner stated that hypertension is less likely than not caused by or aggravated beyond natural progression as a result of her migraine headaches. A November 2016 treatment note from the VAMC indicates the Veteran was seen for migraines, and it was noted that when her severely disabling headaches occur, she may have elevated blood pressure, and hyperglycemia. In January 2014, she stated her migraines contribute to high levels of stress, and have led to hypertension. As no opinion has been rendered as to whether the Veteran's hypertension was caused or aggravated by her service-connected PTSD, an opinion must be rendered. Face Numbness The Veteran has claimed service connection for facial numbness, to include as secondary to migraine-headaches. At the Board hearing she stated that her migraines cause face spasms and twitching. There are numerous reports of face numbness and tingling in the VAMC treatment records. In February 2015, the Veteran underwent a VA examination. The Veteran reported that during migraines she will have several hours of left upper facial numbness, which resolves after several hours. The cranial nerve affected was noted as being Cranial nerve V (trigeminal). She had moderate numbness. The examiner stated facial numbness is a symptom of migraine headaches, and is proximately due to or the result of migraines. The rationale was the Veteran reported numbness (not paralysis) during migraine headaches, which is a symptom of migraine headaches. The Veteran submitted a statement in support of her claim in October 2015, noting that the VA examiner made a finding of Cranial Nerve V being effected, and found to have moderate numbness. The Board notes the February 2015 examiner identified Cranial Nerve V as being affected, and the Veteran had moderate numbness. The examiner also stated the Veteran's facial numbness is a symptom of her headaches, and is proximately due to the migraines. These findings are inconsistent in nature, as it is not entirely clear as to whether the Cranial Nerve V is indeed separately affected and warrants a separate diagnosis, or is simply a symptom attached to the migraine headaches. As such, the Board finds that a VA examination and opinion addressing this issue would be helpful. Accordingly, the case is REMANDED for the following action: 1. Obtain copies of all of the Veteran's outstanding VA medical records. 2. Forward the Veteran's claims file to appropriate examiners for supplemental opinions regarding her claimed hypertension, diabetes, and face numbness (Cranial Nerve V). The claims folder (including a copy of this remand) must be provided to and reviewed by the examiner(s) as part of the examination. It is left to the examiner's discretion whether to reexamine the Veteran. (A) The diabetes examiner should opine whether it is at least as likely as not, i.e. 50 percent probability or greater, that the Veteran's diabetes was caused or aggravated by her service-connected migraines or bulimia, or is otherwise etiologically related to her active service. The examiner is asked to discuss the clinical significance of the November 2016 VAMC treatment note wherein the clinical noted that when the Veteran's severely disabling headaches occur, she may have elevated blood pressure, and hyperglycemia. (B) The hypertension examiner should opine as to whether it is at least as likely as not i.e. 50 percent probability or greater, that that the Veteran's hypertension was caused or aggravated by her service-connected PTSD, or is otherwise etiologically related to her active service. (C) The cranial nerve examiner should identify any facial nerve disabilities, and specifically discuss Cranial Nerve V. The examiner should opine as to whether it is at least as likely as not i.e. 50 percent probability or greater, that that any identified disability was caused or aggravated by her service-connected migraines, or is otherwise etiologically related to her active service. If possible, the examiner is asked to determine whether the Veteran has a separate disability of the Cranial Nerve V that was caused or aggravated by her service-connected migraines-or is her claimed facial numbness a manifestation of her migraine headaches. A complete rationale should be provided for all opinions. 3. Then, readjudicate the appeal. If the benefits sought on appeal are not granted, issue the Veteran and his representative a Supplemental Statement of the Case and provide the Veteran an opportunity to respond. The Veteran has the right to submit additional evidence and argument on the matter or matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C. §§ 5109B, 7112 (2012). ______________________________________________ H.M. WALKER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs