Citation Nr: 21061277 Decision Date: 10/01/21 Archive Date: 10/01/21 DOCKET NO. 14-29 310 DATE: October 1, 2021 ORDER Entitlement to service connection for osteoarthritis, also claimed as rheumatoid arthritis, is denied. Entitlement to service connection for hysterectomy is denied. REMANDED Entitlement to a total disability rating based on individual unemployability (TDIU) prior to October 21, 2008, is remanded. FINDINGS OF FACT 1. The Veteran's currently diagnosed arthritis was not manifest during service or for many years thereafter, and the competent and credible evidence fails to establish etiological relationship between this disability and her service. 2. The Veteran's currently diagnosed hysterectomy was not manifest during service or for many years thereafter, and the competent and credible evidence fails to establish etiological relationship between this disability and her service. CONCLUSIONS OF LAW 1. Arthritis was not incurred in or aggravated by service and may not be presumed related to service. 38 U.S.C. §§ 1110, 1111, 1131, 1132, 5103(a), 5103A; 38 C.F.R. §§ 3.159, 3.303, 3.307, 3.309. 2. A hysterectomy was not incurred in or aggravated by service. 38 U.S.C. §§ 1110, 1111, 1131, 1132, 5103(a), 5103A; 38 C.F.R. §§ 3.159, 3.303. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the United States Army from February 1974 to February 1978. These matters are on appeal from an October 2010 rating decision. A hearing was held before the Board in March 2018. A transcript of the hearing is associated with the claims file. In a July 2021 letter, the Veteran was advised that the Veterans Law Judge (VLJ) who conducted the March 2018 hearing was no longer employed by the Board and he had the right to an additional hearing before a different VLJ. 38 U.S.C. § 7107(c), 38 C.F.R. § 20.707. The letter instructed if the Veteran did not respond within 30 days, the Board would assume the Veteran does not want another hearing and proceed with a decision on the appellate record. As no response was received, the Board will proceed with adjudication. In August 2018 and December 2020, these matters and a claim of entitlement to service connection for bronchitis were remanded by the Board for further development. The claims of entitlement to service connection for osteoarthritis and hysterectomy are ready for adjudication. The claim for service connection for bronchitis was granted in a May 2021 Decision Review Officer (DRO) decision. The Veteran did not disagree with the disability evaluation or the effective date assigned. Therefore, this matter is no longer considered to be in appellate status. Service Connection Claims Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303 (a). Service connection requires competent evidence showing: (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); see also Caluza v. Brown, 7 Vet. App. 498 (1995). In addition, certain diseases, such as arthritis, are presumed to have been incurred in service if manifested to a compensable degree within one year after service. The presumption is rebuttable by probative evidence to the contrary. 38 U.S.C. §§ 1101, 1112, 1113; 38 C.F.R. §§ 3.307, 3.309(a). When chronicity in service is not adequately supported, then a showing of continuity after discharge is required to support a claim for such diseases. 38 C.F.R. § 3.303 (b); see Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Pertinent to a claim for service connection, such a determination requires a finding of current disability that is related to an injury or disease in service. See Brammer v. Derwinski, 3 Vet. App. 223 (1992). The requirement of a current disability is satisfied when the Veteran has a disability at the time he files his service connection claim or during the pendency of that claim, even if the disability resolves prior to the adjudication of the claim. McClain v. Nicholson, 21 Vet. App. 319, 321 (2007). However, when the record contains a recent diagnosis of disability prior to the Veteran's filing of a claim for benefits based on that disability, the report of the diagnosis is relevant evidence that the Board must address in determining whether a current disability existed at the time of the claim was filed or during its pendency. Romanowsky v. Shinseki, 26 Vet. App. 289 (2013). Under applicable regulation, the term "disability" means impairment in earning capacity resulting from diseases and injuries and their residual conditions. 38 C.F.R. § 4.1; see also Hunt v. Derwinski, 1 Vet. App. 49 (1990); Saunders v. Wilkie, 886 F.3d 1356, 1364-65 (Fed. Cir. 2018); Wait v. Wilkie, 33 Vet. App. 8, 17 (2020). 1. Arthritis The Veteran contends that she has arthritis that is related to her service. Specifically, she has consistently reported in written statements and in her hearing testimony that she had arthritis throughout her body when she went to the emergency room while pregnant during service. Her former spouse, who was also a fellow service-member and X-ray technician at that time, accompanied her to the emergency room. The service treatment records (STRs) show that the Veteran complained of spinal pain and was noted to have vertebral tenderness during service in April 1977. An August 1977 clinical note indicates a chief complaint of muscle cramps. However, an October 1977 separation examination indicates a normal clinical evaluation. Post-service, private treatment records include a January 1987 X-ray of the cervical and dorsal spine which indicates an impression of degenerative joint disease. A November 1996 report indicates a past medical history significant for degenerative joint disease (DJD). A July 1997 MRI of the cervical spine showed significant spondylosis at the C5-6 level with encroachment on the foramina and canal at this level by osteophytes. A June 1999 report indicates a diagnosis of DJD. A June 1999 X-ray examination of the lumbar spine indicates a diagnosis of very minimal lumbar degenerative hypertrophic changes. An August 2000 report indicates a diagnosis of DJD. In a May 2003 statement, the Veteran explained that she had problems with arthritis since 1975 during pregnancy with her first child. She described chest and back pains like a heart attack. Her husband was an X-ray technician and rushed her to the hospital for emergency treatment. After numerous X-rays she was informed that she had arthritis in her back, chest, hands, and knees. She had been taken medications for years since that time. Private treatment records include a March 2006 Report of Impairment Rating Evaluation which indicates that in November 2004 the Veteran was reportedly involved in a work-related accident. The Veteran explained that she was pushing a cart loaded with boxes when one of the boxes fell off of the cart and hit her. She then experienced pain in the back of her head and neck. Regarding her past medical history, the Veteran denied any prior cervical or head injuries. A January 2009 report indicates a sudden onset of chest heaviness and pain. The assessment was sudden onset of chest pain consistent with unstable angina and a very strongly positive cardiac risk factor. Records from the Social Security Administration (SSA) include a May 2009 Disability Determination which indicates a primary diagnosis of disorders of the back (discogenic and degenerative) and a secondary diagnosis of ischemic heart disease. A May 2009 Functional Capacity Assessment states that the Veteran alleged carpal tunnel syndrome, migraine headaches, diabetes, a neck injury, and heart stents with "AOD of October 2007" when she could no longer work due to neck pain and quit her job. In an October 2008 statement, the Veteran stated that she was diagnosed with rheumatoid arthritis during service. In a June 2009 statement the Veteran's friend "L.O." stated that the Veteran had pain in her legs and arms and knots in her legs and hands. In a June 2009 statement the Veteran's friend "W.D." indicated that when she resided in his home he noticed swelling in her hands and knuckles. Swollen feet caused difficulty walking. In statements dated in June 2009 and July 2009, the Veteran's former spouse, "R.E.W.," stated that she had back and chest pain during her first pregnancy. He was an X-ray technician at that time and stated that they were told that the Veteran was suffering from arthritis in her back and chest which would spread throughout her body. In July 2009 statement the Veteran's son stated that his mother told him that she had arthritis in her chest and back during service. In a July 2009 the Veteran's friend "S.F." stated that the Veteran experienced dramatic swelling in her hands, feet, and other parts of her body. She also appeared to be in tremendous pain and her body appeared to lock up while moving. In a February 2011 statement, the Veteran explained that symptoms of rheumatoid arthritis began during the second trimester of her first pregnancy. She stated that she awoke from a deep sleep with sharp shooting pains in her back which she thought was a sign of a heart attack. She was rushed to an Army hospital emergency room and was told that she had osteoarthritis which would spread throughout her body. She had no prior history of arthritis at that time. In March 2018, the Veteran testified that in early 1975 she had a spell of arthritis that she initially thought was a heart attack. She stated that she was informed that she had rheumatoid arthritis throughout her body which would continue to worsen. VA treatment records include a March 2018 addendum which shows that the physician found no evidence of inflammatory arthritis like rheumatoid arthritis. In March 2018 the Veteran testified that she had rheumatoid arthritis throughout service which she sought private treatment for after service. However, those private treatment records were no longer available. In August 2018, the Board remanded the claim to determine if the Veteran's spinal pain and vertebral tenderness in service, as well as muscle cramps, were possibly undiagnosed arthritis. In an October 2018 statement, P.L. and R.L. stated that they had known the Veteran for 30 years during which time she was diagnosed with rheumatoid arthritis. In a January 2019 statement the Veteran's former spouse stated that in October or November 1974 the Veteran woke up one night complaining of chest and neck pains. The emergency room doctor ordered X-rays to assist in determining the cause of her pain and after examining the X-rays stated that the Veteran was suffering from bronchitis. In August 2018, the Board remanded the claim for an etiological opinion. Pursuant to the Board's remand, on June 2019 VA non-degenerative arthritis and dysbaric osteonecrosis Disability Benefits Questionnaire (DBQ) examination the Veteran stated that her arthritis began with sudden back pain during pregnancy in 1975. She stated that rheumatoid arthritis was diagnosed as rheumatoid arthritis. However, the examiner stated that the Veteran did not have any current diagnosis associated with arthritis. O June 2019 VA back conditions DBQ examination the Veteran stated that arthritis began with sudden back pain during pregnancy in 1975 diagnosed as rheumatoid arthritis. After a thorough examination of the Veteran and review of the claims file, the examiner diagnosed lumbosacral strain and degenerative arthritis of the spine. In a July 2019 opinion, the examiner stated that "[a]fter reviewing service treatment records, there is no evidence in medical records that substantiate diagnosis of arthritis in 1975 as claimed by veteran. Service record is silent on arthritis. There is no sufficient evidence the vertebral tenderness which occurred in service in April 1977 was diagnosed as cramps and not related to arthritis. A nexus not established." However, in an August 2020 remand the Board found that an addendum opinion was necessary. The Board noted that the June 2019 VA examiner failed to address statements from the Veteran and her former spouse that she was diagnosed with arthritis during her first pregnancy. Additionally, the examiner's statement was unclear regarding her vertebral tenderness. The Board stated that an examiner should determine if the Veteran's vertebral tenderness could have been a manifestation of arthritis. The Board also noted that the record demonstrates that in 1987 the Veteran was diagnosed with degenerative joint disease, less than 10 years after service. Accordingly, pursuant to the Board's remand, on March 2021 VA cervical spine DBQ examination the Veteran presented with a history of being seen for neck pain in July 2005. She had neck pain related to a work-related incident, but a CT scan of the head in December 2004 was normal. A December 2004 CT scan of the cervical spine revealed partially calcified central and slightly left-sided C4-C5 disc protrusion impinging on the spinal canal. Spondylosis at C5-C6 with left foraminal stenosis was also noted. A December 2005 MRI of the cervical spine showed left C5 paramedian disc protrusion with spinal cord impingement with spondylosis at C5-C6 and left foraminal stenosis. After a thorough examination of the Veteran and a review of the claims file, the examiner diagnosed degenerative arthritis and degenerative disc disease other than IVDS (intervertebral disc syndrome) since August 1997 and spinal fusion in November 2005 and July 2009. In a March 2021 VA medical opinion the examiner opined that the claimed arthritis, including of the neck and middle back, was less likely than not incurred in or caused by the claimed in-service vertebral tenderness and muscle cramp. The rationale was that the claims file does not show that the Veteran was diagnosed with arthritis and there are no radiographic findings during her service years. Regarding whether the Veteran's complaints of vertebral tenderness were due to in-service (undiagnosed) arthritis, the examiner opined that she did not have a diagnosis of rheumatoid arthritis. The rationale was that even though there are lay statements regarding her vertebral pain in service this is not noted in the claims file. Regarding the lay statements that reference a trip to the emergency room while the Veteran was pregnant around 1974 at which time she was told that she had arthritis that would spread throughout her body, the examiner opined that there are no records to show this nor radiographic evidence during those years to confirm the diagnosis. The rationale was that rheumatoid arthritis is not diagnosed via X-rays. The examiner explained that if by chance the Veteran had advanced rheumatoid arthritis to be confirmed on X-rays, one would assume her X-ray findings in the 2000s would reflect this. However, this is not the case. Regarding the significance, if any, of the January 1987 X-ray report showing DJD of the cervical and dorsal spines, the examiner stated that treatment reports dated in January 1987 showed degenerative changes of the joint at C6-C7. However, this was 9 years after service and she reported a work-related neck injury in 2004. Furthermore, her muscle cramps in August 1977 were located in her calf and not hands. There was no evidence of any slight restriction of motion in extension and degenerative changes of the joint at C6-C7 until January 1987. However, this was 9 years after she left service. In addition, the claims file reported that she had a work-related injury in 2004 which resulted in a head and neck injury and eventually cervical fusion. The Board finds that the claim must be denied. Regarding rheumatoid arthritis, the competent medical evidence does not show diagnosis of, or disability related to rheumatoid arthritis. See Brammer, supra; see also McClain, supra; Romanowsky, supra; Saunders, supra. The Board finds there is no indication that any subjective complaints related to rheumatoid arthritis result in functional impairment of earning capacity. See Hunt, supra; Saunders, supra; Wait, supra. Consequently, the Board finds that, at no time during the pendency of the claim does the Veteran have a current diagnosis of any disability manifested by rheumatoid arthritis and the record does not contain a recent diagnosis of disability prior to the Veteran's filing of a claim. Therefore, service connection for rheumatoid arthritis is not warranted. Although the Veteran's spouse was a trained X-ray technician during service, nothing in the record demonstrates that he received any special training or acquired any medical expertise in diagnosing and evaluating rheumatoid arthritis. King v. Shinseki, 700 F.3d 1339, 1345 (Fed. Cir. 2012). Moreover, the March 2021 VA examiner explained that rheumatoid arthritis is not diagnosed via x-rays. The examiner stated that if by chance the Veteran had advanced rheumatoid arthritis to be confirmed on X-rays, one would assume her X-ray findings in the 2000s would reflect this. However, this is not the case. Regarding arthritis, including degenerative arthritis, there is no competent medical evidence to show that the Veteran has had arthritis that is related to her service. Moreover, post-service, the record does not reflect or reference any history of arthritis until over 8 years after discharge from active service. The mere absence of medical records does not contradict a Veteran's statements about her symptom history. See Buchanan v. Nicholson, 451 F.3d 1331, 1336 (Fed. Cir. 2006). However, if it is determined based upon reliable evidence that there was an extended period of time after service without any manifestations of the claimed condition, then that tends to weigh against a finding of a connection between the disability and service. See Maxson v. West, 12 Vet. App. 453 (1999), aff'd, 230 F.3d 1330 (Fed. Cir. 2000), aff'd sub nom. Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000); see also Horn v. Shinseki, 25 Vet. App. 231, 240 n.7 (2012). The Board finds in this case that the lack of evidence of any type of arthritis during service coupled with the fact that a diagnosis of arthritis was not made until over 8 years post-service, is sufficient to rebut a finding of service incurrence. In this case, the earliest post-service medical evidence of the Veteran's arthritis was in January 1987, which is over 8 years after service. This long period without problems weighs against the claim. In addition, continuity of symptomatology has also not been established, either through the competent evidence of record or through the Veteran's statements. Moreover, the Board finds that statements and testimony from the Veteran and her former spouse relating her claimed arthritis to her service are not credible and are afforded no probative value. Although the Veteran's former spouse was an X-ray technician who says she was diagnosed with arthritis during service around 1974 or 1975, this is uncorroborated by the STRs which are void of any X-ray evidence of arthritis or diagnosis of the same. Their contentions conflict with the absence of treatment evidence for over 8 years after service. In addition, in a January 2019 statement, the Veteran stated that X-rays performed in October or November 1974 in response to the Veteran's complaints of chest and neck pain were reviewed by an emergency room physician who diagnosed bronchitis which contradicts his other statements that arthritis was diagnosed. Finally, the March 2021 VA examiner stated that there are no radiographic findings during the Veteran's service years showing arthritis. 2. Hysterectomy The Veteran contends that her in-service pregnancy complications and sterilization is related to her post-service hysterectomy. The STRs include a July 1975 report shows that she pregnancy delivered with a pelvic laceration and umbilical cord rupture. A November 1976 post-partum check shows that in October 1976 she had a spontaneous delivery with a mid-line episiotomy in an uncomplicated pregnancy. A December 1976 consultation sheet shows that the Veteran requested evaluation for sterilization which she underwent in April 1977. Post-service, private treatment records include a May 1993 report which indicates an impression of menorrhagia ad dysmenorrhea relieved with medical treatment. In March 1993, she was seen for menorrhagia and dysmenorrhea. In May 1993, she underwent an endometrial ablation. VA treatment records include a July 2002 report which indicates that the Veteran attended a walk-in clinic with abnormal bleeding. She had a history of tubal ligation in 1977 and endometrial ablation in 1990 due to endometriosis. She experienced insidious onset of vaginal blood. The assessment was abnormal uterine bleeding, history of endometriosis, suspect herbal estrogenic effect. An October 2002 operative report indicates a preoperative diagnosis of postmenopausal vaginal bleeding, thickened endometrial stripe, and previous endometrial ablation with obliteration of endometrial cavity. An operative note indicates that the Veteran had a history of post-menopausal bleeding previous endometrial stripe which was thickened on ultrasound. An October 2002 history and physical indicates that the Veteran reported she did not have vaginal bleeding until July 2002 and was scheduled for a hysterectomy. VA treatment records include a January 2003 report which indicates a history of post-menopausal vaginal bleeding beginning in October 2002. The discharge summary indicates that the Veteran underwent a total abdominal hysterectomy with bilateral salpingo-oophorectomy. In a May 2003 statement, the Veteran indicated that she underwent sterilization in 1977 and had complications and blood loss in 1990. She had two children in 1975 and 1976. She states that she was informed that 90% of all sterilization surgery would lead to complete hysterectomies. She was sterilized in 1977. Around 1990 she underwent ablation surgery. She was becoming [anemic] due to blood loss and underwent another surgery around October 2002. The Veteran then underwent a complete hysterectomy. In an April 2010 statement the Veteran stated that the only way she could remain in service was to be sterilized. The doctor that sterilized her told her she would eventually have to have a hysterectomy. She included a statement from her former spouse who stated that they began dating in January 2001 and married in February 2002 shortly after which she began having gynecological problems. In March 2018 the Veteran testified that sterilization during service led to her post-service hysterectomy. In an August 2018 remand, the Board stated that the RO noted that the Veteran did not have her hysterectomy until 2002, approximately 24 years after separation from service. While the Board acknowledged that the Veteran's hysterectomy was not until 2002, there was some evidence of a pregnancy complication in service. In July 1975 the Veteran delivered her baby, but there was evidence of a pelvic floor laceration and umbilical cord rupture. Moreover, the Veteran underwent a sterilization procedure in April 1977 and she then required endometrial ablation in 1992 and eventually her hysterectomy in 2002. The sequence of these events suggests ongoing gynecological problems that originated in service, although at this time there is insufficient evidence to establish a nexus. Accordingly, the Board remanded the case for a VA examination and etiological opinion. Specifically, the Board previously requested that an examiner consider the Veteran's in-service pregnancy complications and sterilization, as well as post-service endometrial ablation, and address whether her eventual hysterectomy was related to service. In an October 2018 statement, P.L. and R.L. stated that they had known the Veteran for 30 years and agreed with the Veteran that sterilization during service led to a hysterectomy. Pursuant to the Board's remand, on June 2019 VA gynecological conditions DBQ examination the Veteran presented with a history of a gynecological disability with bleeding and spotting and treated with catherization of the uterus. She underwent a tubal ablation in 1990, a tubal ligation in 1996, and hysterectomy in 2002. After a thorough examination of the Veteran and a review of the claims file, the examiner diagnosed total hysterectomy since June 2019. In July 2019 examiner stated that there was insufficient evidence that the sterilization caused the hysterectomy in 2002 and there was no civilian medical report which stated the hysterectomy was a result of the sterilization. In a December 2020 remand, the Board found the July 2019 VA medical opinion to be conclusory is it did not provide adequate rationale for the conclusion that the hysterectomy is unrelated to service. Accordingly, the Board remanded the claim for an opinion as to whether the Veteran's hysterectomy resulted because of an in-service injury, event, or disease, to include her in-service pregnancy complications including pelvic floor laceration and umbilical cord rupture and sterilization. On March 2021 VA gynecological conditions DBQ examination the Veteran presented with a history of a third degree tear during her vaginal delivery in 1975. In 1976 after she had her second child her commanding officer told her to get sterilized to extend her year. In her forties she noticed a lot of menstrual bleeding and was seen by her OB-GYN. She was recommended for uterine ablation. In 2001 she noticed bleeding after she got married. She went to the hospital and a sonogram showing adhesion to uterus and she had a hysterectomy at the Dallas VA. After a thorough examination and review of the claims file, the examiner diagnosed hysterectomy with bilateral salpingectomy and oophorectomy. In a March 2021 VA medical opinion the examiner opined that the claimed condition was less likely than not incurred in or caused by the claimed in-service hysterectomy. The rationale was that according to the claims file the Veteran's hysterectomy occurred in October 2002 which is 24 years later. Therefore, it is reasonable to state that the Veteran's hysterectomy did not occur in service. The examiner further opined that the claimed hysterectomy was less likely than not incurred in service, to include pelvic floor laceration and umbilical cord rupture and sterilization. The rationale was that according to the claims file the cause of her hysterectomy was post-menopausal vaginal bleeding. Therefore, it is reasonable to state the Veteran's hysterectomy is not secondary to pelvic floor laceration and umbilical cord rupture and sterilization. The Board finds that the claim must be denied. In this case, there is no competent medical evidence that supports the conclusion that the Veteran's hysterectomy was incurred in or aggravated by her service or is otherwise related to her service. In this case, the earliest post-service medical evidence of the Veteran's hysterectomy was in October 2002 which is over 24 years after service. This long period weighs against the claim. See Buchanan supra; see also, Maxson, supra; see also Horn, supra. Moreover, to the extent that the Veteran believes that her hysterectomy is related to gynecological problems during service, the Board finds that her statements are credible. However, this contention is afforded little probative value in light of the March 2021 VA medical opinion which related the Veteran's post-service hysterectomy to post-menopausal vaginal bleeding. Finally, there is no competent medical evidence that the Veteran had a hysterectomy related to her service. Additional considerations The Board has taken the contention that the Veteran's arthritis and hysterectomy are related to her service, seriously (this was the basis of the Board's remands in order to address these medical questions). Although the Veteran, her family, and her friends might believe that she has arthritis and had a hysterectomy that are etiologically related to her service, the Board has closely reviewed the medical and lay evidence in the Veteran's claims file and finds no evidence that may serve as a medical nexus between the Veteran's service and her arthritis and hysterectomy. Although lay persons are competent to provide opinions on some medical issues, see Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011), the specific issue in this case, the etiology of the Veteran's currently diagnosed arthritis and post-service hysterectomy, falls outside the realm of common knowledge of a lay person. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007) (lay persons not competent to diagnose cancer). Regarding the Veteran's arthritis, as previously addressed, although the Veteran's former spouse was a trained X-ray technician during service, at which time they both say she was diagnosed with arthritis, the absence of any X-ray evidence of arthritis or diagnosis of the same during service lessens the probative value of any opinion that the Veteran's currently diagnosed arthritis is related to her service. In light of the above, the Board finds that the weight of the probative evidence is against a finding that the Veteran has arthritis or had a hysterectomy that is related to her service. (Continued on the next page) REASONS FOR REMAND TDIU The Veteran contends that she has been unable to work since October 2007 due to her headaches/migraines, breathing problems, and gynecological problems. See March 2010 VA Form 21-8940. Initially, the Board observes that a May 2021 DRO decision denied entitlement to a TDIU and granted service connection for bronchitis rated as 100 percent disabling, effective October 21, 2008. On this basis, a May 2021 Supplemental Statement of the Case deemed the TDIU claim as moot. As such, the issue of entitlement to a TDIU is moot for the period of appeal from October 21, 2008, as the maximum benefits available have been granted. See Buie v. Shinseki, 24 Vet. App. 242, 250 (2011). However, prior to October 21, 2008, the Veteran is service-connected for headaches, rated 30% disabling. Accordingly, her total combined rating is 30% and the Veteran does not meet the minimum schedular requirements for TDIU prior to October 21, 2008. See 38 C.F.R. § 4.16 (a). Therefore, the only basis for the assignment of a TDIU is on an extraschedular basis. See 38 C.F.R. § 4.16 (b). On November 2015 VA headaches DBQ examination the Veteran presented with a history of migraine headaches rated 6 to 7 out of 10 on the pain scale as frequent as 5 per week. The examiner opined that the headaches impacted her ability to work. Based on the Veteran's complaints of being unable to secure and follow substantially gainful occupation due to her service-connected headaches, remand for referral of the claim for TDIU prior to October 21, 2008, is required. In so remanding, the Board also notes that its referral of this claim for extraschedular consideration under § 4.16 (b) is simply a factual finding that does not bind the Board or require the Board to award an extraschedular rating should the claim be returned to the Board. See Ray v. Wilkie, 31 Vet. App. 58, 73 (2019). The matter is REMANDED for the following action: Refer this case to the Director, Compensation and Pension Service (C&P) for consideration of an extra-schedular TDIU award (38 C.F.R. § 4.16 (b)) prior to October 21, 2008. This referral should include a full statement of the Veteran's service-connected disabilities, as well as her employment, educational, and medical histories. KELLI A. KORDICH Veterans Law Judge Board of Veterans' Appeals Attorney for the Board T. Adams, Counsel The Board's decision in this case is binding only with respect to the instant matter decided. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.