ANKYLOSIS OF THE DIGITS

Summary

The veteran, who served from July 1998 to October 2005, appeals the denial of entitlement to a compensable initial rating for residuals of her left middle finger fracture, migraine headaches, and depression. Service connection for these conditions was previously granted with noncompensable initial ratings, and the appeal concerns the period from October 16, 2005, forward, as well as increased ratings prior to December 16, 2005. The Board reviewed the criteria for rating these conditions under the VA Schedule for Rating Disabilities, referencing Diagnostic Codes 5226 and 5229 for the finger fracture, Diagnostic Code 8100 for migraines, and Diagnostic Code 9434 for depression. The veteran's statements regarding the frequency and severity of her migraine headaches were found to be competent and credible, but did not meet the criteria for a rating higher than 10 percent, lacking evidence of prostrating attacks or severe economic inadaptability. Similarly, the evidence for depression did not meet the criteria for a rating higher than 10 percent, showing only mild or transient symptoms. The primary issue became the veteran's failure to report for multiple scheduled VA examinations between November 2012 and July 2017, despite repeated notifications and attempts to obtain her current address. The Board found that the veteran failed to report for these examinations without good cause. As current evaluations of these conditions cannot be established without these examinations, the claims for compensable ratings are denied. The Board noted that the veteran's left middle finger disability did not meet the criteria for ankylosis or significant limitation of motion, and her depression symptoms, while present, did not cause the level of occupational and social impairment required for higher ratings.

Rationale

No ankylosis of the left middle finger.; No gap between fingertip and proximal transverse crease on maximal flexion.; Extension not limited by more than 30 degrees.

Full Decision Text

Citation Nr: 18114556
Decision Date: 06/27/18	Archive Date: 06/27/18

DOCKET NO. 08-38 385
DATE:	June 27, 2018
ORDER
Entitlement to a compensable initial rating for residuals of left middle finger fracture is denied.
Entitlement to an increased initial rating for migraine headaches, currently evaluated as 10 percent disabling prior to December 16, 2005 and as noncompensable from December 16, 2005, is denied.
Entitlement to an increased initial rating for depression, currently evaluated as 10 percent disabling prior to December 16, 2005 and as noncompensable from December 16, 2005, is denied.
FINDINGS OF FACT
1. The evidence prior to December 16, 2005 does not show that the Veteran’s residuals of left middle finger fracture were manifested by limitation in full flexion to a gap of one inch between the fingertip and the proximal transverse crease of the palm, extension is not limited by more than 30 degrees, and does not result in a finger that is ankylosed.
2. The evidence prior to December 16, 2005 does not show that the Veteran’s migraine headaches were manifested by characteristic prostrating attacks averaging one in two months over the last several months, or prostrating attacks accompanied by scotoma, photophobia, phonophobia, nausea and occasional vomiting and occurring at least once per month.  Severe economic inadaptability was not shown.
3. The evidence prior to December 16, 2005 shows that the Veteran’s depression was manifested by symptoms productive of functional impairment comparable to occupational and social impairment due to mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress, or symptoms controlled by continuous medication.
4. The Veteran failed to report without good cause for the VA medical examinations in November 2012, October 2015, January 2016, and July 2017, to determine the current level of severity of her service-connected residuals of left middle finger fracture, migraine headaches, and depression.
CONCLUSIONS OF LAW
1. The criteria for a compensable initial rating for residuals of left middle finger fracture have not been met at any time during the period covered by this appeal.  38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. § 3.655, 4.71a, Diagnostic Code 5226 (2017).
2. The criteria for an initial rating in excess of 10 percent for migraine headaches, prior to December 16, 2005, have not been met.  38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. § 4.124a, Diagnostic Code 8100 (2017).
3. The criteria for a compensable rating for migraine headaches, from December 16, 2005, have not been met.  38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. § 3.655, 4.124a, Diagnostic Code 8100 (2017).
4. The criteria for an initial rating in excess of 10 percent for depression, prior to December 16, 2005, have not been met.  38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. § 4.130, Diagnostic Code 9434 (2017).
5. The criteria for a compensable rating for depression, from December 16, 2005, have not been met.  38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. § 3.655, 4.130, Diagnostic Code 9434 (2017).
REASONS AND BASES FOR FINDINGS AND CONCLUSIONS
The Veteran served on active duty from July 1998 to October 2005.
Increased Rating
Disability ratings are determined by the application of the VA’s Schedule for Rating Disabilities (Rating Schedule), which is based on the average impairment of earning capacity.  Separate diagnostic codes identify the various disabilities.  38 U.S.C. § 1155; 38 C.F.R. Part 4 (2017).  Pertinent regulations do not require that all cases show all findings specified by the Rating 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 (2017).
Evaluation of a service-connected disability requires a review of
 to October 2005.
Increased Rating
Disability ratings are determined by the application of the VA’s Schedule for Rating Disabilities (Rating Schedule), which is based on the average impairment of earning capacity.  Separate diagnostic codes identify the various disabilities.  38 U.S.C. § 1155; 38 C.F.R. Part 4 (2017).  Pertinent regulations do not require that all cases show all findings specified by the Rating 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 (2017).
Evaluation of a service-connected disability requires a review of a veteran’s medical history with regard to that disorder.  However, the primary concern in a claim for an increased evaluation for service-connected disability is the present level of disability.  While the entire recorded history of a disability is important for more accurate evaluations, the regulations do not give past medical reports precedence over current findings.  Francisco v. Brown, 7 Vet. App. 55, 58 (1994).
Where a veteran appeals the initial rating assigned for a disability, evidence contemporaneous with the claim and the initial rating decision granting service connection would be most probative of the degree of disability existing at the time that the initial rating was assigned and should be the evidence “used to decide whether an original rating on appeal was erroneous.”  See Fenderson v. West, 12 Vet. App. 119, 126 (1999).  If later evidence indicates that the degree of disability increased or decreased following the assignment of the initial rating, “staged” ratings may be assigned for separate periods of time.  Id.
Service connection for residuals of left middle finger fracture, migraine headaches, and depression was granted in a June 2006 rating decision effective from October 16, 2005, with noncompensable initial ratings.  As such, the rating period on appeal for the initial ratings for these disabilities is from October 16, 2005.  38 C.F.R. § 3.400(o)(2) (2017).  In a February 2012 rating decision, the RO implemented a February 2012 Board decision that granted increased 10 percent initial ratings for migraine headaches and depression for the period prior to December 16, 2005; noncompensable ratings are assigned from December 16, 2005.  See AB v. Brown, 6 Vet. App. 35, 38 (1993) (where a claimant has filed a notice of disagreement as to an RO decision assigning a particular rating, a subsequent RO decision assigning a higher rating, but less than the maximum available benefit, does not abrogate the pending appeal).
1. Entitlement to a compensable initial rating for residuals of left middle finger fracture.
The Veteran’s residuals of left middle finger have been evaluated by analogy under 38 C.F.R. § 4.71a, Diagnostic Code 5226, which pertains to ankylosis of this digit.  Under Diagnostic Code 5226, a maximum 10 percent disability rating is warranted where there is favorable or unfavorable ankylosis.
The Board has also considered Diagnostic Code 5229.  Diagnostic Code 5229 contemplates limitation of motion of the middle finger.  It provides a noncompensable rating for a gap of less than one inch (2.5 centimeters) between the fingertip and the proximal transverse crease of the palm, with the finger flexed to the extent possible, and; extension is limited by no more than 30 degrees.  A 10 percent rating is afforded for a gap of one inch (2.5 centimeters) or more between the fingertip and the proximal transverse crease of the palm, with the finger flexed to the extent possible, or; with extension limited by more than 30 degrees.  38 C.F.R. § 4.71a, Diagnostic Code 5229.  See Johnson v. Brown, 7 Vet. App. 95 (1994) (only one disjunctive “or” requirement must be met in order for an increased rating to be assigned).
The December 15, 2005 VA examination report reveals that the Veteran’s left middle finger was injured while playing football in 1999.  The Veteran reported it was splinted and it did not heal then and it has slight flexion deformity, with limited range of motion on flexion.  There was no ankylosis of any digits.  There was no gap between the finger and proximal transverse crease of the hand on maximal flexion of the finger.  The hand strength and dexterity was normal.  There was painful motion
7 Vet. App. 95 (1994) (only one disjunctive “or” requirement must be met in order for an increased rating to be assigned).
The December 15, 2005 VA examination report reveals that the Veteran’s left middle finger was injured while playing football in 1999.  The Veteran reported it was splinted and it did not heal then and it has slight flexion deformity, with limited range of motion on flexion.  There was no ankylosis of any digits.  There was no gap between the finger and proximal transverse crease of the hand on maximal flexion of the finger.  The hand strength and dexterity was normal.  There was painful motion against resistance at 20 degrees of distal interphalangeal joint.  The Veteran stated her grip was not that good anymore and she could not hold certain objects.  In her January 2007 notice of disagreement, the Veteran described that her left middle finger is slightly bent with a lump on top of it, with a noticeable scar.
After reviewing the claims file, the Board finds that the Veteran is not entitled to a compensable rating for her residuals of left middle finger fracture because at no time during the claim period has the Veteran demonstrated ankylosis of the left middle finger.  The objective medical evidence and the Veteran’s statements regarding her symptomatology show disability that more nearly approximates that which warrants the assignment of a noncompensable rating under Diagnostic Code 5226.  See 38 C.F.R. § 4.71a.  As the evidence also reflects that the Veteran’s left middle finger disability is not manifested by limitation of motion of the third digit with a gap of one inch between the fingertip and the proximal transverse crease of the palm (with the finger flexed) or with extension limited by more than 30 degrees, a compensable rating is also not warranted under Diagnostic Code 5229.  Id. 
A Note to Diagnostic Code 5226 states that with ankylosis, the rater should also consider whether an additional rating is warranted for resulting limitation of motion of other digits or interference with overall function of the hand.  38 C.F.R. § 4.71a.  However, there is no evidence of limitation of motion of other digits or interference with overall function of the left hand.  Specifically, the December 2006 VA examiner found that there was no ankylosis resulting in limitation of motion of other digits and the hand strength and dexterity was normal.
A Note to Diagnostic Code 5227 also states that consideration should be given as to whether evaluation as amputation is warranted.  In reviewing the record, the Veteran’s left middle finger disability cannot be considered equivalent to amputation, as she still has her left middle finger and function in all parts of the finger, even if she does report pain, limited motion, and weakened grip strength.  
2. Entitlement to an initial rating in excess of 10 percent for migraine headaches, prior to December 16, 2005.
Under Diagnostic Code 8100, the maximum 50 percent rating is warranted for migraines with very frequent completely prostrating and prolonged attacks, productive of severe economic inadaptability.  A 30 percent rating is warranted for migraines with characteristic prostrating attacks occurring on an average once a month over the last several months.  A 10 percent rating is warranted for migraines with characteristic prostrating attacks occurring on an average once a month over the last several months.  A noncompensable rating is assigned with less frequent attacks. Id.  The rating criteria do not define “prostrating” nor has the Court of Appeals for Veterans Claims.  Cf. Fenderson, 12 Vet. App. at 126-127 (quoting Diagnostic Code 8100 verbatim but not specifically addressing the definition of a prostrating attack).  By way of reference, in DORLAND’S ILLUSTRATED MEDICAL DICTIONARY 1554 (31st Ed. 2007), “prostration” is defined as “extreme exhaustion or powerlessness.”
The Veteran underwent a VA general medical examination in December 2005.  The examiner noted that the Veteran started having headaches since 2000 but was told she had migraine headaches since 2003 for which he was given medications.  Currently, she was pregnant and she was unable to take Fiorcet but she was taking Tylenol.  In her January 2007 notice of disagreement, the Veteran indicated that she experienced migraine headaches about two to three times a week.  In a May 2008 written statement, the Veteran reported she has had migraines more frequently in the last three years.  She had to increase the amount of migraine medicine and switched to a stronger medicine.  Migr
 “extreme exhaustion or powerlessness.”
The Veteran underwent a VA general medical examination in December 2005.  The examiner noted that the Veteran started having headaches since 2000 but was told she had migraine headaches since 2003 for which he was given medications.  Currently, she was pregnant and she was unable to take Fiorcet but she was taking Tylenol.  In her January 2007 notice of disagreement, the Veteran indicated that she experienced migraine headaches about two to three times a week.  In a May 2008 written statement, the Veteran reported she has had migraines more frequently in the last three years.  She had to increase the amount of migraine medicine and switched to a stronger medicine.  Migraine come an average of three to four times a week.  
After reviewing the evidence, the Board finds that an initial rating in excess of 10 percent is not warranted for the Veteran’s service connected migraine headaches prior to December 16, 2005.  
In making this determination, the Board finds that the Veteran’s statements are competent evidence regarding the frequency and severity of her current headache symptoms.  See Barr v. Nicholson, 21 Vet. App. 303, 307 (2007) (holding that lay testimony is competent to establish the presence of observable symptomatology); Layno v. Brown, 6 Vet. App. 465, 469 (1994).  Furthermore, the Board has no reason to doubt the credibility of the Veteran’s statements in this case.  The Veteran has reported symptoms, which included migraine headaches occurring approximately two to four times a week.  
However, based on her reports, the nature of the headaches is not clear.  While the evidence of record shows that the Veteran’s migraine headaches occur at least once a week, there was no evidence of characteristic prostrating attacks occurring on an average once a month over the last several months.  Nor was there evidence of severe economic inadaptability due to migraine headaches.  Therefore, these symptoms do not meet the criteria required for a rating in excess of 10 percent under Diagnostic Code 8100.
3. Entitlement to an initial rating in excess of 10 percent for depression, prior to December 16, 2005.
The Veteran’s depression is evaluated under the General Rating Formula for Mental Disorders, 38 C.F.R. § 4.130, Diagnostic Codes 9434.  
Under the General Rating Formula for Mental Disorders, 38 C.F.R. § 4.130, Diagnostic Code 9411.  Ratings are assigned according to the degree of occupational and social impairment resulting from manifestations of the disability at issue.  However, the use of the term “such as” in 38 C.F.R. § 4.130 demonstrates that the symptoms after that phrase are not intended to constitute an exhaustive list, but rather are to serve as examples of the type and degree of the symptoms, or their effects, that would justify a particular rating.  Mauerhan v. Principi, 16 Vet. App. 436 (2002).
Under the provisions for rating psychiatric disorders, a noncompensable rating is assigned when a mental condition has been formally diagnosed, but symptoms are not severe enough either to interfere with occupational and social functioning or to require continuous medication.  38 C.F.R. § 4.130, General Rating Formula for Mental Disorders.
A 10 percent disability rating is assigned when there is occupational and social impairment due to mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress, or symptoms controlled by continuous medication.  Id.
A 30 percent disability rating is assigned when there is evidence of occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, mild memory loss (such as forgetting names, directions, recent events).  Id.
A 50 percent rating requires evidence of occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships.  Id.
A 70 percent rating is warranted when there is occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermitt
 with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships.  Id.
A 70 percent rating is warranted when there is occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work like setting; inability to establish and maintain effective relationships.).  Id.
A 100 percent rating is warranted when there is total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name.  Id.
When evaluating a mental disorder, the rating agency shall consider the frequency, severity, and duration of psychiatric symptoms, the length of remissions, and the Veteran’s capacity for adjustment during periods of remission.  The rating agency shall assign a rating based on all the evidence of record that bears on occupational and social impairment, rather than solely on the examiner’s assessment of the level of disability at the moment of the examination.  When evaluating the level of disability from a mental disorder, the rating agency will consider the extent of social impairment, but shall not assign a rating solely on the basis of social impairment.  38 C.F.R. § 4.126.
The evidence considered in determining the level of impairment under 38 C.F.R. § 4.130 is not restricted to the symptoms provided in the diagnostic code.  Instead, the VA must consider all symptoms of a claimant’s condition that affect the level of occupational and social impairment, including (if applicable) those identified in the DSM-IV (Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders (4th ed. 1994)).  See Mauerhan, 16 Vet. App. 436.
Within the DSM-IV, Global Assessment Functioning (GAF) scores are a scale reflecting the “psychological, social, and occupational functioning on a hypothetical continuum of mental health-illness.”  See Carpenter v. Brown, 8 Vet. App. 240, 242 (1995); see also Richard v. Brown, 9 Vet. App. 266, 267 (1996).  While not determinative, a GAF score is highly probative as it relates directly to the veteran’s level of impairment of social and industrial adaptability, as contemplated by the rating criteria for mental disorders.  See Massey v. Brown, 7 Vet. App. 204, 207 (1994).
Effective August 4, 2014, VA amended the portion of the Schedule for Rating Disabilities dealing with mental disorders to remove outdated references to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV), and replaced them with references to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-V).  See 79 Fed. Reg. 149, 45094 (August 4, 2014).  The provisions of the interim final rule apply to all applications for benefits that are received by VA or that were pending before the Agency of Original Jurisdiction (AOJ) on or after August 4, 2014.  The provisions of this interim final rule apply to claims that had been certified for appeal to the Board prior to August 4, 2014.  VA adopted as final, without change, the interim final rule, effective March 19, 2015.  80 Fed. Reg. 53, 14308 (March 19, 2015).  This appeal was certified to the Board in June 2009.  As such, the provisions of DSM-V are not for application.
According to DSM-IV, a GAF score ranging from 31-40 reflects some impairment in reality testing or communication (e.g., speech is at times illogical, obscure or irrelevant) or major impairment in several areas, such as work or school, family
 final rule apply to claims that had been certified for appeal to the Board prior to August 4, 2014.  VA adopted as final, without change, the interim final rule, effective March 19, 2015.  80 Fed. Reg. 53, 14308 (March 19, 2015).  This appeal was certified to the Board in June 2009.  As such, the provisions of DSM-V are not for application.
According to DSM-IV, a GAF score ranging from 31-40 reflects some impairment in reality testing or communication (e.g., speech is at times illogical, obscure or irrelevant) or major impairment in several areas, such as work or school, family relations, judgment, thinking, or mood (e.g., depressed man avoids friends, neglects family, and is unable to work; child frequently beats up other children, is defiant at home, and is failing at school).  A GAF score of 41-50 reflects serious symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent shoplifting) or any serious impairment in social, occupational or school functioning (e.g. no friends, unable to keep a job).  GAF score of 51-60 represents moderate symptoms (e.g., flat affect and circumstantial speech, occasional panic attacks) or moderate difficulty in social, occupational, or school functioning, (e.g., few friends, conflicts with peers or co-workers).  A GAF score of 61-70 denotes some mild symptoms (e.g., depressed mood and mild insomnia) or some difficulty in social, occupational, or school functioning (e.g., occasional truancy, or theft within the household), but generally functioning pretty well, has some meaningful interpersonal relationships.  A GAF score of 71-80 indicates that, if symptoms are present, they are transient and expectable reactions to psychosocial stressors (e.g., difficulty concentrating after family argument); no more than slight impairment in social, occupational, or school functioning (e.g., temporarily falling behind in schoolwork).
The Veteran was provided a VA mental disorders examination in December 2005.  She complained of mild depression.  She was depressed at the beginning but with treatment she improved and was currently off psychotropics.  She was dealing better and feeling better without any medication.  On mental status examination, the Veteran appeared clean and appropriately dressed.  Her psychomotor activity was unremarkable, and her speech was clear and coherent.  She was cooperative, friendly, and attentive.  Her affect was appropriate and her mood was dysphoric.  Her attention was intact.  The Veteran was fully oriented.  Her thought process was goal-directed, relevant, and coherent; and her thought content was unremarkable.  There were no delusions.  She understood the outcome of her behavior and that she had a problem.  She had mild sleep impairment, which did not interfere with daily activity.  No hallucinations, inappropriate behavior, obsessive/ritualistic behavior, panic attacks, or suicidal or homicidal thoughts were shown.  The Veteran had good impulse control with no episodes of violence.  The Veteran was able to maintain minimum personal hygiene and had no problem with activities of daily living.  Her memory was normal.  She was capable of managing her financial affairs.  The examiner noted a diagnosis of depression not otherwise specified, in remission on Axis I and assigned a GAF score of 70.  The examiner reported that the Veteran had no impairments in functional status but found that the Veteran had mild or transient decreased efficiency, productivity, and reliability occasionally; and mild or transient inability to perform work tasks and impaired work, family, and other relationships only during periods of stress.  
Regarding social and family relationships, the Veteran was married for three years and was in a good relationship.  She had a child and was six months pregnant.  She also reported positive relationships with her father and sister.  Regarding occupational history, the Veteran was currently not working.  She was a housewife and took care of her child.  She stated unemployment was not due ot the mental disorder’s effects.
The psychiatric findings on VA examination in December 2005 show that the Veteran was fully oriented; her affect was appropriate; and her attention, insight and judgment were intact.  Her memory was also normal.  Her GAF score was 70, which is indicative of mild symptoms, such as depressed mood and mild insomnia, or some difficulty in social or occupational functioning.  The Veteran was unemployed but she reported her unemployment was not due to her mental disorder.  Moreover, the examiner commented that the Veteran’s mental symptoms resulted in only mild or transient symptoms that decrease work efficiency or inability to perform occupational tasks occasionally or only during periods of significant stress. 
Indeed, no significant mental symptoms were reported other than mild depression and mild
 mental disorder’s effects.
The psychiatric findings on VA examination in December 2005 show that the Veteran was fully oriented; her affect was appropriate; and her attention, insight and judgment were intact.  Her memory was also normal.  Her GAF score was 70, which is indicative of mild symptoms, such as depressed mood and mild insomnia, or some difficulty in social or occupational functioning.  The Veteran was unemployed but she reported her unemployment was not due to her mental disorder.  Moreover, the examiner commented that the Veteran’s mental symptoms resulted in only mild or transient symptoms that decrease work efficiency or inability to perform occupational tasks occasionally or only during periods of significant stress. 
Indeed, no significant mental symptoms were reported other than mild depression and mild sleep impairment.  Consequently, the evidence prior to December 16, 2005 shows that the Veteran’s disability warrants a 10 percent rating, but it does not show depression resulted in symptomatology similar in frequency, severity, or duration to those symptoms listed for occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as depressed mood, anxiety, suspiciousness, panic attacks weekly or less often, chronic sleep impairment, or mild memory loss.
If an exceptional case arises where a rating based on the disability rating schedule is found to be inadequate, consideration of an extraschedular rating commensurate with the average earning capacity impairment due exclusively to the service-connected disability or disabilities will be made.  38 C.F.R. § 3.321(b)(1).  However, an extraschedular analysis is not required in every case.  When extraschedular consideration is not “specifically sought by the claimant nor reasonably raised by the facts found by the Board, the Board is not required to discuss whether referral is warranted.”  Yancy v. McDonald, 27 Vet. App. 484, 494 (2016); see also Doucette v. Shulkin, 28 Vet. App. 366, 369-370 (2017) (holding that either the veteran must assert that a schedular rating is inadequate or the evidence must present exceptional or unusual circumstances to raise the extraschedular issue).  Here, neither the Veteran nor his representative has raised any other issues, nor have any other issues been reasonably raised by the record.
4. Entitlement to compensable rating for residuals of left middle finger fracture from December 16, 2005.
5. Entitlement to a compensable rating for migraine headaches from December 16, 2005.
6. Entitlement to a compensable rating for depression from December 16, 2005.
In February 2012 and July 2015, the Board directed the RO to take steps to verify the Veteran’s current address and schedule the Veteran for VA examinations to determine the current severity of her service-connected disabilities.  
The Veteran was scheduled for VA examinations for the disabilities at issues in November 2012; however, the record reflects that she failed to report for the hand, finger and scar examination and refused a mental disorder evaluation at the scheduled location.  The examinations were therefore cancelled on November 29, 2012.  Subsequently, the RO contacted the Veteran’s representative in order to determine her current address, and received correspondence dated in September 2015 with the Veteran’s stated address according to her representative.  The RO then requested in September 2015 authorization from the Veteran to obtain additional identified records from any medical service providers that treated her for the service-connected disabilities on appeal.  In addition, the Veteran was notified of a scheduled examination in October 2015 via phone and through a letter mailed to her address; however, as she did not answer the phone call and did not respond to the letter within 10 days.  Subsequently, the examination was cancelled.  She was later rescheduled for examinations to evaluate all three disabilities on appeal, with each of the examinations to occur on January 9, 2016.  She did not appear for these scheduled examinations.  As the claims file contained only one notification to the Veteran of these scheduled examinations, which was dated February 11, 2016, the Board remanded the matter to the RO in January 2017 to afford one more opportunity for the Veteran to appear for VA examinations.
Pursuant to the Board’s January 2017 remand, the RO once again requested the nearest VA Medical Center in June 2017, to schedule the Veteran for VA examinations; however, the Veteran failed to report to the examinations.  
A June 2017 letter from the RO specifically notified the Veteran that it is her responsibility to report for any scheduled examinations and to cooperate in the development of the claims.  It was noted that the consequences for failure to report for a VA examination
 contained only one notification to the Veteran of these scheduled examinations, which was dated February 11, 2016, the Board remanded the matter to the RO in January 2017 to afford one more opportunity for the Veteran to appear for VA examinations.
Pursuant to the Board’s January 2017 remand, the RO once again requested the nearest VA Medical Center in June 2017, to schedule the Veteran for VA examinations; however, the Veteran failed to report to the examinations.  
A June 2017 letter from the RO specifically notified the Veteran that it is her responsibility to report for any scheduled examinations and to cooperate in the development of the claims.  It was noted that the consequences for failure to report for a VA examination without good cause may include denial of the claims.  38 C.F.R. §§ 3.158, 3.655 (2012).  
Although it appears that the Veteran’s address has since changed and she now resides overseas, she was notified by a letter dated in June 2017 to her new overseas address of the scheduling of VA examinations on July 20, 2017.  This letter was not returned as undeliverable.  The Veteran has not requested that the VA examinations be rescheduled, nor has she provided good cause for failing to report for the scheduled examinations.  The supplemental statement of the case in October 2017 notified the Veteran that further consideration of her claims was based, in part, on her failure to report for the VA examinations.  Claimants bear the burden of keeping VA apprised of their whereabouts, and VA does not have a burden to turn up heaven and earth to locate them if they fail to do so.  Hyson v. Brown, 5 Vet. App. 262, 265 (1993); see also Ashley v. Derwinski, 2 Vet. App. 307 (1992) (addressing the presumption of regularity). 
VA’s regulations provide that, when entitlement or continued entitlement to a benefit cannot be established or confirmed without a current VA examination or reexamination and a claimant, without good cause, fails to report for such examination, or reexamination, action shall be taken in accordance with paragraph (b) or (c) of this section as appropriate.  38 C.F.R. § 3.655(a).  When the examination was scheduled in conjunction with any other original claim, a reopened claim for a benefit which was previously disallowed, or a claim for increase, the claim shall be denied.  38 C.F.R. § 3.655(b).
As the Veteran, without good cause, failed to report for her scheduled VA examinations, and as entitlement to a compensable initial rating for residuals of left middle finger fracture from December 16, 2005, entitlement to a compensable rating for migraine headaches from December 16, 2005, and entitlement to a compensable rating for depression from December 16, 2005 cannot be established without a current VA examination, the claims are denied.  38 C.F.R. § 3.655.
 
LANA K. JENG
Veterans Law Judge
Board of Veterans’ Appeals
ATTORNEY FOR THE BOARD	M. J. In, Counsel