Citation Nr: 0610464 Decision Date: 04/11/06 Archive Date: 04/26/06 DOCKET NO. 95-08 465 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Hartford, Connecticut THE ISSUES 1. Entitlement to a higher initial evaluation than 60 percent (as a staged rating) for Hodgkin's disease for the period from November 1, 1986 through October 22, 1995. 2. Whether a single rating of 60 percent or higher under the prior rating criteria for Hodgkin's disease is warranted for the period beginning October 23, 1995. 3. Entitlement to an increased evaluation for peripheral neuropathy of the right upper extremity, rated 20 percent disabling from October 23, 1995. 4. Entitlement to an increased evaluation for peripheral neuropathy of the left upper extremity, rated 20 percent disabling from October 23, 1995. 5. Entitlement to an increased evaluation for peripheral neuropathy of the right lower extremity, rated 10 percent disabling from October 23, 1995. 6. Entitlement to an increased evaluation for peripheral neuropathy of the left lower extremity, rated 10 percent disabling from October 23, 1995. 7. Entitlement to an increased evaluation for hypothyroidism, rated 10 percent disabling from October 23, 1995. 8. Entitlement to an increased evaluation for depression, rated 50 percent disabling. 9. Entitlement to an earlier effect date than May 15, 2000, for the grant of an increased evaluation to 50 percent disabling for depression. 10. Entitlement to an increased evaluation for gastroesophageal reflux disease (GERD), rated 10 percent disabling for the period from October 23, 1995 through September 30, 2003. 11. Entitlement to a higher initial evaluation than 30 percent for irritable bowel syndrome (IBS). 12. Entitlement to an earlier effective date than October 1, 2003, for the grant of service connection for IBS. 13. Entitlement to service connection for a headache disorder as secondary to service-connected Hodgkin's disease. 14. Whether new and material evidence has been received to reopen a claim of entitlement to service connection for heart disease as secondary to service-connected Hodgkin's disease. REPRESENTATION Appellant represented by: Robert V. Chisholm, Attorney WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD D. Schechter, Counsel INTRODUCTION The veteran had active service from September 1966 to May 1969. This appeal originally arose from a May 1994 rating action which granted service connection for Hodgkin's disease as a residual of exposure to Agent Orange, and assigned a 100% rating from September 1985 through October 1986, and a noncompensable rating from November 1986. The veteran appealed both the effective date of the termination of the 100% rating, and the noncompensable rating as inadequate. By hearing officer's decision of April 1995, the RO granted a 30% rating for Hodgkin's disease from November 1986. By decision of February 1997, the Board of Veterans Appeals (Board) denied a rating in excess of 30% for Hodgkin's disease. The veteran's representative in June 1997 requested reconsideration of that decision, but by letter of July 1997, the Motion for Reconsideration was denied by the Senior Deputy Vice Chairman of the Board, by direction of the Chairman. By an October 1998 Order, the U.S. Court of Veterans Appeals (Court) vacated the February 1997 Board decision and remanded the case to the Board for development and readjudication including consistent with a September 1998 Joint Motion for Remand by the appellant and the VA General Counsel (Joint Motion). Accordingly, the Board in February 1999 remanded the case for additional development consonant with Court remand instructions. The RO by a March 2003 rating action granted a 60 percent evaluation for inactive Hodgkin's disease for the period from November 1, 1986 through October 22, 1995, and granted separate ratings for individual residuals of Hodgkin's disease based on changed rating criteria for Hodgkin's disease beginning October 23, 1995. The issues now before the Board, besides the initial ratings for Hodgkin's disease assigned under the old rating criteria for Hodgkin's disease, include effective dates and ratings for disorders service connected as residuals of Hodgkin's disease or as secondary to Hodgkin's disease, and claims for service connection or to reopen a claim service connection for disorders as secondary to Hodgkin's disease, as listed in the Issues list of this decision, above. While one issue addressed by the RO in the course of appeal was propriety of application of 38 C.F.R. § 3.105(e) to a compensation reduction, as related to the assignment of a rating for Hodgkin's disease other than 100 percent beginning November 1, 1986, that issue is not reflected in the Issues list for this decision because it is encompassed within the analysis, in the Reasons and Bases portion of this decision, addressing the first listed issue, of entitlement to a higher initial evaluation than 60 percent (as a staged rating) for Hodgkin's disease for the period from November 1, 1986 through October 22, 1995. As noted in greater detail below, the criteria for rating Hodgkin's disease changed effective October 23, 1995. Prior to that date, single ratings were based on residuals. On and after that date, individual ratings were assigned for multiple disabilities, rated separately. In this case, as of October 23, 1995, the combined rating was raised from a single 60 percent to a combined 70 percent rating. As such, the new criteria were deemed more favorable to the appellant. FINDINGS OF FACT 1. Active Hodgkin's disease and treatment for active Hodgkin's disease were not present beyond October 24, 1985. 2. For the period beginning November 1, 1986, Hodgkin's disease was not manifested by frequent episodes of high and progressive fever or febrile episodes with only short remission, generalized edema, ascites, pleural effusion, or severe anemia with marked general weakness. 3. For the period from November 1, 1986 through October 22, 1995, the veteran did not have compensable levels of peripheral neuropathies of the upper and lower extremities. Pathology present was rated as part of the 60 percent rating assigned. 4. For the period from November 1, 1986 through October 22, 1995, symptoms of hypothyroidism inclusive of sluggish mentality and other indications of myxedema, with decreased levels of circulating thyroid hormones, as were required signs and symptoms of moderately severe hypothyroidism were not shown. Pathology present was rated as part of the 60 percent rating assigned. 5. For the period from November 1, 1986 through October 22, 1995, symptoms of GERD inclusive of persistently recurrent epigastric distress with dysphagia, pyrosis, and regurgitation, accompanied by substernal or arm or shoulder pain, productive of considerable impairment of health, were not shown. Pathology present was rated as part of the 60 percent rating assigned. 6. For the period from November 1, 1986 through October 22, 1995, residuals of Hodgkin's disease, rated separately, inclusive of right upper extremity peripheral neuropathy, left upper extremity peripheral neuropathy, right lower extremity peripheral neuropathy, left lower extremity peripheral neuropathy, hypothyroidism, and GERD, did not result in combined disability in excess of 60 percent. 7. For the period beginning October 23, 1995, the veteran has been assigned separate evaluations for residuals of Hodgkin's disease - inclusive of right upper extremity peripheral neuropathy, left upper extremity peripheral neuropathy, right lower extremity peripheral neuropathy, left lower extremity peripheral neuropathy, hypothyroidism, and GERD - which result in a combined service-connected rating for these residuals in excess of 60 percent beginning October 23, 1995. 8. For the rating period beginning October 23, 1995, right upper extremity peripheral neuropathy associated with Hodgkin's disease was manifested by mild loss of functional use of the hand; moderate loss of use of the right hand was not shown. 9. For the rating period beginning October 23, 1995, left upper extremity peripheral neuropathy associated with Hodgkin's disease was manifested by mild loss of functional use of the hand; moderate loss of use of the left hand was not shown. 10. For the rating period beginning October 23, 1995, right lower extremity peripheral neuropathy associated with Hodgkin's disease was manifested by symptoms equated with mild incomplete paralysis of the sciatic nerve; symptoms equated with moderate incomplete paralysis of the sciatic nerve were not shown. 11. For the rating period beginning October 23, 1995, left lower extremity peripheral neuropathy associated with Hodgkin's disease was manifested by symptoms equated with mild incomplete paralysis of the sciatic nerve; symptoms equated with moderate incomplete paralysis of the sciatic nerve were not shown. 12. For the rating period beginning October 23, 1995, symptoms of hypothyroidism inclusive of sluggish mentality and other indications of myxedema, with decreased levels of circulating thyroid hormones, as were required signs and symptoms of moderately severe hypothyroidism were not shown. Also for that period, fatigability, constipation, and mental sluggishness were not all present. 13. For the rating period at issue, the veteran's depression is not manifested by occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood. Manifestations of depression that might result in that level of impairment, which are not present or are not present to such a degree as to cause that level of impairment, include the following: 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 worklike setting); inability to establish and maintain effective relationships. 14. There was no pending claim for an increased evaluation for depression at the time of receipt of that claim for an increased evaluation for depression on October 15, 2000. 15. VA or private medical evidence does not show disability of depression, for the year prior to the May 15, 2000 date of receipt of an increased rating claim for depression, manifested by 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. Rather, during that year, as shown primarily by subsequent evidence, the veteran's depression would be more closely approximated as a disorder causing 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 primarily to symptoms of depressed mood and chronic sleep impairment. 16. For the rating period from October 23, 1995 through September 30, 2003, the veteran's gastroesophageal reflux disease (GERD) was manifested by some dysphagia or pyrosis, but was not manifested by regurgitation, was not accompanied by substernal or arm or shoulder pain, and was not productive of considerable impairment of health. 17. For the rating period beginning October 1, 2003, the veteran's IBS with gastroesophageal reflux disease (GERD) is not manifested by malnutrition or only fair health during periods of remission. 18. For the rating period beginning October 1, 2003, the veteran's IBS with GERD is not manifested by frequent hospitalization or a marked interference with employment. 19. The veteran on October 1, 2003 submitted a claim of entitlement to service connection for IBS as secondary to service-connected Hodgkin's disease. 20. The October 1, 2003 claim for service connection for IBS was an initial claim; there was no pending, unaddressed claim for service connection for that disorder at the time of receipt of that claim. 21. The veteran does not have a current headache disorder. 22. The RO declined to reopen a claim for coronary artery disease as secondary to service-connected Hodgkin's disease by an April 2000 rating decision; that determination was not timely appealed and is final. The appellant was provided notice of all that action, and that decision is the last final denial of this claim on any basis. 23. Evidence received since the April 2000 denial of entitlement to service connection for coronary artery disease as secondary to service-connected Hodgkin's disease is cumulative, does not bear directly and substantially upon the specific matter under consideration, or is not so significant that it must be considered together with all the evidence of record to fairly decide the merits of the veteran's claim of service connection for paranoid schizophrenia. CONCLUSIONS OF LAW 1. The assignment of a 60 percent disability rating for Hodgkin's disease for the period from November 1, 1986 through October 22, 1995 was proper as a staged initial rating with the grant of service connection; rating Hodgkin's disease based on combined ratings of separately rated residuals was not warranted for this period. 38 U.S.C.A. §§ 1155, 5102, 5103, 5103A, 5107 (West 2002 & Supp. 2005); 38 C.F.R. § 4.117, 4.119, 4.124a, Diagnostic Codes 7709, 7903 (1995); 38 C.F.R. §§ 3.102, 3.159, 3.321, 3.326, 4.1, 4.3, 4.7, 4.114, 4.119, Diagnostic Codes 7346, 7903, 8512, 8520 (2005); Fenderson v. West, 12 Vet. App Vet. App. 119 (1999). 2. Rating of the veteran's inactive Hodgkin's disease based on residuals with combined ratings in excess of 60 percent disabling was appropriate for the period beginning October 23, 1995. 38 C.F.R. § 4.117, Diagnostic Code 7709 (2005). 3. For the rating period beginning October 23, 1995, the criteria for a rating in excess of 20 percent for right upper extremity peripheral neuropathy have not been met. 38 U.S.C.A. §§ 1155, 5103A, 5107 (West 2002 & Supp. 2005); 38 C.F.R. §§ 3.102, 3.159, 3.326, 4.1, 4.2, 4.7, 4.10, 4.126, Diagnostic Code 8512 (2005). 4. For the rating period beginning October 23, 1995, the criteria for a rating in excess of 20 percent for left upper extremity peripheral neuropathy have not been met. 38 U.S.C.A. §§ 1155, 5103A, 5107 (West 2002 & Supp. 2005); 38 C.F.R. §§ 3.102, 3.159, 3.326, 4.1, 4.2, 4.7, 4.10, 4.124a, Diagnostic Code 8512 (2005). 5. For the rating period beginning October 23, 1995, the criteria for a rating in excess of 10 percent for right lower extremity peripheral neuropathy have not been met. 38 U.S.C.A. §§ 1155, 5103A, 5107 (West 2002 & Supp. 2005); 38 C.F.R. §§ 3.102, 3.159, 3.326, 4.1, 4.2, 4.7, 4.10, 4.124a, Diagnostic Code 8520 (2005). 6. For the rating period beginning October 23, 1995, the criteria for a rating in excess of 10 percent for left lower extremity peripheral neuropathy have not been met. 38 U.S.C.A. §§ 1155, 5103A, 5107 (West 2002 & Supp. 2005); 38 C.F.R. §§ 3.102, 3.159, 3.326, 4.1, 4.2, 4.7, 4.10, 4.124a, Diagnostic Code 8520 (2005). 7. For the rating period beginning October 23, 1995, the criteria for a rating in excess of 10 percent for hypothyroidism have not been met. 38 U.S.C.A. §§ 1155, 5103A, 5107 (West 2002 & Supp. 2005); 38 C.F.R. § 4.119, Diagnostic Code 7903 (1995); 38 C.F.R. §§ 3.102, 3.159, 3.326, 4.1, 4.2, 4.7, 4.10, 4.119, Diagnostic Code 7903 (2005). 8. For the rating period at issue, the criteria for a rating in excess if 50 percent for depression are not met. 38 U.S.C.A. §§ 1155, 5103A, 5107 (West 2002 & Supp. 2005); 38 C.F.R. §§ 3.102, 3.159, 3.326, 4.1, 4.2, 4.7, 4.10, 4.126, 4.130, Diagnostic Code 9434 (2005). 9. An effective date prior to May 15, 2000 for a 50 percent disability rating for depression is not warranted. 38 U.S.C.A. §§ 5110 (a), (b)(2), 5103A, 5107 (West 2002 & Supp. 2005); 38 C.F.R. §§ 3.102, 3.159, 3.326 3.400 (o)(2) (2005). 10. For the rating period from September 25, 1995 through September 30, 2003, the criteria for a rating in excess of 10 percent for GERD are not met. 38 U.S.C.A. §§ 1155, 5103A, 5107 (West 2002 & Supp. 2005); 38 C.F.R. §§ 3.102, 3.159, 3.326, 4.1, 4.2, 4.7, 4.20, 4.114, Diagnostic Code 7346 (2005). 11. For the rating period beginning October 1, 2003, the criteria for an initial rating in excess of 30 percent for IBS with GERD have not been met. 38 U.S.C.A. §§ 1155, 5102, 5103, 5103A, 5107 (West 2002 & Supp. 2005); 38 C.F.R. §§ 3.102, 3.159, 3.321, 3.326, 4.1, 4.3, 4.7, 4.114, Diagnostic Codes 7319, 7323, 7345 (2005). 12. The criteria for an effective date prior to October 1, 2003, for the grant of service connection for IBS are not met. 38 U.S.C.A. §§ 5103, 5110, 5111 (West 2002 & Supp. 2005); 38 C.F.R. §§ 3.102, 3.159, 3.326, 3.400 (2005). 13. A headache disorder was not incurred or aggravated secondary to service-connected Hodgkin's disease. 38 U.S.C.A. §§ 1110, 1131, 5103A, 5107 (West 2002 & Supp. 2005); 38 C.F.R. §§ 3.102, 3.159, 3.310, 3.326 (2005). 14. The October 1996 decision that denied service connection for coronary artery disease as secondary to service-connected Hodgkin's disease is final. 38 U.S.C.A. § 7105 (West 2002); 38 C.F.R. §§ 20.302, 20.1103 (2005). 15. New and material evidence sufficient to reopen the previously denied claim of service connection for coronary artery disease as secondary to service-connected Hodgkin's disease has not been submitted. 38 U.S.C.A. § 5108 (West 2002); 38 C.F.R. § 3.156 (2001). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Veterans Claims Assistance Act of 2000, Pub. L. No. 106-475, 114 Stat. 2096 (2000) (VCAA) Under 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126 (West 2002), VA has an enhanced duty to notify a claimant as to the information and evidence necessary to substantiate claims for VA benefits. See also, 38 C.F.R. §§ 3.102, 3.159, 3.326(a) (2005). The law requires VA to inform veterans of the evidence needed to substantiate their claims, what specific evidence they are responsible for obtaining, and what specific evidence VA will undertake to obtain. 38 U.S.C.A. § 5103(a). VA regulations also specify that VA will notify veterans to submit relevant evidence in their possession. 38 C.F.R. § 3.159(b). VA has fulfilled these requirements in this case. The veteran has been informed of the information and evidence necessary to substantiate his claim through an October 2002 VCAA letter addressing the veteran's claims of entitlement to higher evaluations for service-connected Hodgkin's disease and depression; through a February 2004 VCAA letter addressing the claim of entitlement to an earlier effective date for a grant of an increased evaluation for depression, and addressing the claim for an increased evaluation for depression; through a March 2004 VCAA letter addressing the request to reopen a claim for service connection for heart disease as secondary to service-connected Hodgkin's disease, and addressing the claims of entitlement to service connection for headaches and irritable bowel syndrome (IBS), both claimed as secondary to service-connected Hodgkin's disease. By these letters, the veteran was informed of evidence required to support these claims for benefits, and was informed of information and evidence that he should submit in furtherance of the claims. He was also by these letters informed of the assistance VA would provide in obtaining that evidence. He was requested to submit any pertinent evidence in his possession, and was asked to provide information about all pertinent medical evidence including corresponding contact information. He was informed that VA would then assist him by requesting relevant evidence. He was also told that it was ultimately his responsibility to see that pertinent evidence is obtained. By the appealed rating decisions and statements of the case and supplemental statements of the case, the veteran was informed of development already undertaken, as well as evidence of record pertinent to his claims. These decisions, statements of the case, and supplemental statement of the case also addressed claims on appeal which were downstream of claims resolved by the RO granting benefits, or downstream of the other claims on appeal for which a VCAA letter was provided. These downstream issues include ratings for disabilities as residuals of Hodgkin's disease, which are assigned separate ratings in lieu of a single rating for Hodgkin's disease under 38 C.F.R. § 4.117, Diagnostic Code 7709 (2005); a claim for a higher initial evaluation for IBS; and a claim of entitlement to an earlier effective date for the grant of service-connected for IBS. For these downstream issues, the rating decisions, statements of the case and supplemental statements of the case properly informed the veteran of evidence required to support these claims for benefits, what information and evidence that he should submit in furtherance of the claims, and what assistance VA would provide in obtaining that evidence. By these issued documents as well as by the above noted VCAA letters, the veteran was amply informed that it was ultimately his responsibility to see that pertinent evidence was obtained in furtherance of his claims. With regard to the downstream issues, VA's General Counsel has held that a VCAA notice is not required for such downstream issues, in cases where notice was afforded for the originating issue of service connection, and that a United States Court of Appeals for Veterans Claims (Court) decision suggesting otherwise was not binding precedent. VAOPGCPREC 8- 2003, 69 Fed.Reg. 25180 (2004); see Grantham v. Brown, 114 F.3d 1156 (1997). The Board is bound by this General Counsel opinion. 38 U.S.C.A. § 7104 (West 2002). The RO requested that the veteran inform of private medical sources of evidence pertinent to his claims; VA requested records from all these indicated sources, and all records obtained were associated with the claims folders. As noted above, the veteran was informed of all evidence obtained, and that it was ultimately his responsibility to see that evidence is obtained to support his claims. All indicated VA records from sources where the veteran received treatment or evaluation, have been obtained and associated with the claims folders. The veteran was also afforded numerous VA examinations to address the veteran's claimed disorders and the medical questions implicated by these claims. These treatment records and VA examinations are discussed in the body of this decision, below. The Board notes that while some VA treatment records were added to the claims folder subsequent to the most recent supplemental statement of the case in March 2003 addressing the issue of an increased evaluation for service-connected Hodgkin's disease, as associated with a March 2003 RO rating action assigning separate ratings for neuropathy affecting each of the upper and lower extremities, those treatment records did not address current residuals of Hodgkin's disease, and particularly did not address peripheral neuropathies. Additionally, the veteran in a March 2006 submitted statement informed that his symptoms of Hodgkin's disease and associated neuropathies of the extremities remained unchanged since onset of his Hodgkin's disease. Hence, there is no reasonable possibility that failure of the RO to review these additional VA records prejudiced the RO's review of the veteran's claim for increased evaluation for peripheral neuropathy residuals of Hodgkin's disease, or otherwise prejudiced those rating issues. Hence, there is no necessity, either to afforded the veteran due process or to fulfill the duty to assist pursuant to the VCAA, for remand of those increased rating issues. As noted in the Introduction, above, the Court by an October 1998 Order approved a September 1998 Joint Motion for Remand which required that the Board remand the case for certain development, and that the Board address certain issues in its decision. The Board's address of issues as directed by that Joint Motion are discussed in detail below. The Board's February 1999 Remand required that indicated VA and private records be sought, and that VA examinations to address the veteran's Hodgkin's disease and his residuals and secondary disorders, be obtained. As noted above, VA records were obtained and associated with the claims folder, and private records were properly requested and records obtained were associated with the claims folder. The veteran was afforded VA examinations to address his Hodgkin's disease and its residuals and secondary disabilities, as discussed in detail below, and these examinations satisfactorily addressed the medical issues implicated in the claims on appeal. The Board is also satisfied that development requested in the February 1999 remand has been satisfactorily completed. See Stegall v. West, 11 Vet. App. 268 (1998). The veteran addressed his claims by numerous submitted statements and by testimony at an RO hearing conducted in April 1995. The veteran did not request the opportunity of a Board hearing in the course of his appeals. The Board is satisfied that the veteran was afforded opportunity to address his claims on appeal. In view of the foregoing, the action taken by the RO complies with all of the requirements of law, thereby allowing the Board to consider the issue of entitlement to a higher initial evaluation for bilateral hearing loss. Quartuccio v. Principi, 16 Vet. App. 183 (2002). The Court has recently held that the notice requirements in 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b)(1) must be provided to a claimant prior to initial RO adjudication of the claim. Pelegrini v. Principi, 18 Vet. App. 112 (2004). Here initial VCAA notice was provided prior to initial adjudication of those claims submitted after promulgation of the VCAA; Pelegrini is inapplicable to those claims adjudicated prior to promulgation of the VCAA. Id. Nonetheless, 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b)(1) remain applicable, including provisions pertaining to when notice is issued. In this instance, however, the Board finds that the veteran was provided the necessary notice and assistance required, as discussed above, since he was given ample notice and opportunity to remedy deficiencies in his claims. The Court has recently held, in that regard, that an error is not prejudicial when the error did not affect "the essential fairness of the [adjudication]." Mayfield v. Nicholson, 19 Vet. App. 103 (2005), reversed on other grounds, No. 05-7157, (Fed. Cir. April 5, 2006). During the pendency of this appeal, on March 3, 2006, the Court issued a decision in the consolidated appeal of Dingess/Hartman v. Nicholson, Nos. 01-1917 and 02-1506, which held that the VCAA notice requirements of 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) apply to all five elements of a service connection claim. Those five elements include: 1) veteran status; 2) existence of a disability; 3) a connection between the 38 U.S.C.A. § 1151 care or treatment which is the basis of claim and the disability; 4) degree of disability; and 5) effective date of the disability. The Court held that upon receipt of an application for a claim for benefits, 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) require VA to review the information and the evidence presented with the claim and to provide the claimant with notice of what information and evidence not previously provided, if any, will assist in substantiating or is necessary to substantiate the elements of the claim as reasonably contemplated by the application. Dingess/Hartman v. Nicholson, Nos. 01-1917 & 02-1506 (U.S. Vet. App. March 3, 2006). Additionally, this notice must include notice that a disability rating and an effective date for the award of benefits will be assigned if entitlement to benefits is awarded. Id. Here, the Board has considered application of Dingess/Hartman, but finds no prejudice to the veteran resulting from any failure to inform of the above-noted five crucial elements of disability claims. The veteran's status as a veteran was established and there was no denial of claims on that basis. The existence of disability and a connection between the service-connected disorder, Hodgkin's disease, and the claimed secondary disabilities, would only potentially impact the secondary service-connected claims for a headache disorder and heart disease, and the claim for an earlier effective date for the grant of service connection for IBS. However, those issues of existence of disability and connection to a service-connected disorder were addressed by the RO as relevant elements of the claims in the course of development of the veteran's claims, including as discussed above, and the veteran was afforded ample opportunity to remedy deficiencies in his claim related to these elements; hence no prejudice ensued from any such potential failure to so inform. Any failure to notify the veteran of the elements of severity of disability and effective date do not prejudice the veteran in the claims here adjudicated, since these issues were also addressed by the RO in the course of development of the claims for earlier effective date for disability ratings, and for higher or increased disability ratings which would be potentially impacted by these claim elements, so that the veteran was given ample opportunity to remedy any deficiencies in his claims as to these elements as well. As the notice that a disability rating and effective date would be assigned if an appeal is granted, the veteran was advised of such elements by the RO in the course of claims development for those claims involving grants of service connection which are potentially impacted by these elements. The veteran was provided this notice in particular by the rating actions granting service connection and the accompanying decision notification letters. The veteran also had de facto notice of these last two elements, since he appealed both the effective date and the initial rating assigned for each appealed decision granting service connection. Assuming arguendo that VA did fail to fulfill any duty to notify and assist the claimant, the Board finds any such error to be harmless. Of course, an error is not harmless when it "reasonably affect(s) the outcome of the case." ATD Corp. v. Lydall, Inc., 159 F.3d 534, 549 (Fed. Cir. 1998). In this case, however, because there is not a scintilla of evidence that any failure on the part of VA to further comply with the VCAA reasonably affects the outcome of this case, the Board finds that any such failure is harmless. While perfection is an aspiration, the failure to achieve it in the administrative process, as elsewhere in life, does not, absent injury, require a repeat performance. Miles v. Mississippi Queen, 753 F.2d 1349, 1352 (5th Cir. 1985). Laws Concerning Evidentiary Review Lay persons are not competent to offer medical opinions; where the determinative issue involves a medical diagnosis, competent medical evidence is required. Espiritu v. Derwinski, 2 Vet. App. 492, 494-95 (1992). Laws Concerning Service Connection Claims To establish service connection for a claimed disability, the facts must demonstrate that a disease or injury resulting in current disability was incurred in the active military service or, if pre-existing active service, was aggravated therein. 38 U.S.C.A. § 1110 (West 2002); 38 C.F.R. § 3.303 (2005). Secondary service connection may be granted where the evidence shows that a chronic disability has been caused or aggravated by a service-connected disability. 38 C.F.R. § 3.310; Allen v. Brown, 7 Vet. App. 439 (1995). The Board notes that claims for service connection here addressed are for service connection as secondary to service- connected Hodgkin's disease. The veteran does not claim, and the record does not otherwise raise the issues, of any entitlement to service connection on a direct basis or on any first-year-post-service presumptive basis, and hence those bases of service connection are not here considered. See 38 C.F.R. §§ 3.303, 3.307, 3.309 (2005). Laws Concerning Rating Claims Disability evaluations are assigned to reflect levels of current disability. The appropriate rating is determined by the application of a schedule of ratings which is based on average impairment of earning capacity. Separate diagnostic codes identify the various disabilities. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4. When 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. Where entitlement to compensation has already been established and an increase in the disability rating is at issue, the present level of disability is of primary concern. Although a rating specialist is directed to review the recorded history of a disability in order to make a more accurate evaluation, see 38 C.F.R. § 4.2 (2005), the regulations do not give past medical reports precedence over current findings. Francisco v. Brown, 7 Vet. App. 55 (1994). The evaluation of the same disability or the same manifestation under different diagnoses is to be avoided. 38 C.F.R. § 4.14 (2005). The VA General Counsel has held that where a law or regulation changes during the pendency of a claim for increased rating, the Board should first determine whether application of the revised version would produce retroactive results. In particular, a new rule may not extinguish any rights or benefits the claimant had prior to enactment of the new rule. VAOPGCPREC 7-2003 (Nov. 19, 2003). However, if the revised version of the regulation is more favorable, the implementation of that regulation under 38 U.S.C.A. § 5110(g), can be no earlier than the effective date of that change. The VA can apply only the earlier version of the regulation for the period prior to the effective date of the change. Claims Addressing Hodgkin's Disease Ratings: for an Increased Evaluation from the 60 Percent Evaluation Assigned from November 1, 1986 through October 22, 1995, and from the Combined Rating Based on Separate Ratings for the Various Residuals of Inactive Hodgkin's Disease for the Period Beginning October 23, 1995 The rating schedule for evaluating Hodgkin's disease changed during the pendency of this appeal. Under the applicable rating criteria in effect prior to October 23, 1995, a 100 percent rating is assigned for acute (malignant) or chronic types of Hodgkin's disease with frequent episodes of high and progressive fever or febrile episodes with only short remissions, generalized edema, ascites, pleural effusion, or severe anemia with marked general weakness. A 60 percent rating is warranted if there is evidence of general muscular weakness with loss of weight and chronic anemia, or secondary pressure symptoms such as marked dyspnea, edema with pains and weakness of extremity, or other evidence of severe impairment of general health. A minimum 30 percent evaluation is assigned where there is evidence of occasional low-grade fever, mild anemia, fatigability or pruritus. A note to Diagnostic Code 7709 provides that a 100 percent rating will be continued for one year following cessation of surgical, x- ray, antineoplastic, chemotherapy, or other therapeutic procedure. If there has been no local recurrence or invasion of other organs, the disease is to be rated based on residuals. 38 C.F.R. § 4.117, Diagnostic Code 7709 (1995). Effective on and after October 23, 1995, a 100 percent rating evaluation is assigned with active disease or during a treatment phase. A 100 percent rating shall continue beyond the cessation of any surgical, radiation, antineoplastic chemotherapy or other therapeutic procedures for at least six months. Thereafter, if there has been no local recurrence or metastasis, rating is based on residuals. 38 C.F.R. § 4.117, Diagnostic Code 7709 (2005). The veteran contends, in effect, that he currently suffers from residuals of Hodgkin's disease that warrant a 100% disability rating beyond October 31, 1986, and otherwise warrant a higher evaluation than the 60 percent assigned from November 1, 1986 through October 22, 1995, and more than the combined evaluation assigned for residuals of Hodgkin's disease assigned beginning October 23, 1995. A review of the record discloses that the veteran was hospitalized at the Meriden-Wallingford Hospital in October 1984 for a left scalene node biopsy. Clinical stage II-B nodular sclerosing Hodgkin's disease was diagnosed. A computerized tomography (CT) scan of the chest showed a large, lobulated anterior mediastinal mass with mediastinal adenopathy and left pleural effusion. A CT scan of the abdomen showed only left pleural effusion, and a CT scan of the pelvis was negative. Radiation therapy notes of A. Silberstein, M.D., dated in April, May, July, and November 1985 trace the veteran's receipt of chemotherapy and radiation therapy; in November 1985, the doctor stated that the veteran completed his chemotherapy on October 22, 1985, was doing well, and appeared to be in remission. In a statement of December1985, M. Baxter, M.D., stated that the veteran completed a total of 6 cycles of MOPP chemotherapy according to the Yale Protocol on October 24, 1985. The chemotherapy originally started in November 1984 and continued for 3 cycles until April 1985. The veteran then underwent radiation therapy and received a total of 3060 R over a 23-day period, first to the entire mediastinum and the cervical and supraclavicular areas, and then the remainder delivered to the superior mediastinum, left hilum, and left supraclavicular areas. In June 1985, the veteran restarted MOPP chemotherapy, and the final dose was delivered on October 24, 1985. After chemotherapy, he developed marrow toxicity with rather severe thrombocytopenia and leukopenia on 2 occasions. In a June 1986 radiation therapy note, Dr. Silberstein stated that the veteran had had the last dose of chemotherapy on October 24, 1985, and that clinically he remained in remission. After physical examination in July 1986, Dr. Baxter concluded that the veteran continued to remain in remission. On physical examination of November 1986, J. Godsall, M.D., noted that the veteran went into remission and did very well following treatment with radiation and MOPP therapy, that he had had no chemotherapy or Prednisone for a year, that he currently took no medications, that there was little evidence clinically of recurrence of Hodgkin's disease, and that there was no indication for a further work- up. In a statement of December 1986, Dr. Baxter stated that there was no evidence of any possible recurrence of Hodgkin's disease. In a July 1987 radiation therapy note, Dr. Silberstein stated that the veteran had received the last dose of chemotherapy in October 1985. The veteran's current complaints included low-grade headaches, frequent fatigue, and a particular sensitivity to cold in the left hand. After examination, the doctor stated that there was no obvious evidence of recurrent Hodgkin's disease. On outpatient examination by Dr. Godsall in July 1987, the veteran complained of periods of diarrhea and constipation and occasional cramping abdominal pain, and multiple muscular pains. On physical examination by R. Allen, M.D., in May 1988, the veteran's Hodgkin's disease was noted to be in remission, and he was noted to be doing well. On outpatient examination by Dr. Godsall in July 1988, the veteran complained of fatigue, myalgias, and pruritic skin lesions. In a July 1988 radiation therapy note, Dr. Silberstein stated that the veteran completed treatment for Stage II-B Hodgkin's disease with a large mediastinal mass in "November 1987" [which date the Board finds most likely represents a typographical error, when viewed in the context of other objective evidence of record, including previous and subsequent reports from Dr. Silberstein himself, which clearly indicates that the veteran received his last dose of chemotherapy in October 1985], which treatment consisted of 3 cycles of MOPP followed by low-dose radiation, followed by 3 more cycles of MOPP. The veteran's numerous continuing complaints included extreme sensitivity of the hands to cold, muscle aches, intermittent constipation, and occasional diarrhea. After examination, the doctor opined that the veteran remained clinically in remission. On outpatient examination by Dr. Godsall in early September 1988, the veteran complained of generalized fatigue, and slight lower quadrant abdominal pain with constipation and a burning feeling in the stomach and esophagus. The assessment was question of a spastic colon. On outpatient examination in mid-September 1988 by D. Sack, M.D., the veteran complained of left lower quadrant discomfort. Current examination of the abdomen showed a palpably-tender sigmoid. It was felt that the veteran had a spastic colon. After outpatient examination by Dr. Godsall in January 1989, the assessment was abdominal pain, felt to be due to an irritable bowel. In a radiation therapy note dated in October "1978" [which date the Board finds most likely represents a typographical error, and should more properly be dated "1989" when viewed in the context of other objective evidence of record], Dr. Silberstein commented that there had not been any evidence of recurrent Hodgkin's disease. The veteran's numerous complaints included extreme sensitivity to cold, muscle aches in the joints and extremities, cyclic fatigue, and constipation occasionally broken by diarrhea which had been attributed to an irritable bowel. On physical examination subsequently in October 1989 by S. Bobrow, M.D., an oncologist, for evaluation of the veteran's multiple symptoms and follow-up for Hodgkin's disease, the doctor stated that he reviewed the veteran's medical history, noting that treatment with combined modality therapy including the Yale- MOPP regimen as well as low-dose radiation therapy had been completed in "1984." The doctor felt that the veteran had done well over the past 5 years, noting however multiple symptoms including intermittent fatigue, abdominal pain, arthralgias, and myalgias which had been unexplained over the past several years. He further noted that the veteran had not had any constitutional symptoms to suggest a recurrence of Hodgkin's disease. After examination, the doctor was unable to explain the veteran's multiple non-specific complaints. On outpatient examination in January 1990 by J. Fuller, M.D., the veteran was noted to be apparently in remission from Hodgkin's disease following chemotherapy and radiation therapy in 1984/85. He currently complained of left-sided abdominal pain and general fatigue and malaise, and the assessments included Hodgkin's disease and irritable bowel syndrome. After outpatient examination in August 1990 by Dr. Thomas, the assessment was irritable bowel, status post numerous investigations to prove otherwise. In September 1990, Dr. Fuller commented that most of the veteran's complaints were quite odd. In an October 1990 radiation therapy note, Dr. Silberstein stated that the veteran had received chemotherapy and radiation therapy for Hodgkin's disease in 1985, and had been in complete remission since that time. The veteran was noted to have had assorted complaints including muscle aches, discomfort in bones, occasional nausea, and some shortness of breath on exertion. On outpatient examination in December 1990 by Dr. Fuller, the veteran gave a several-day history of chest tightness and a cough productive of sputum, sinus pressure, head congestion, decreased appetite, and severe fatigue. The examiner noted that the veteran's lymphoma was in remission and that he had persistent severe fatigue symptoms. The assessment was chronic bronchitis, question of chronic asthma. In June 1991, P. Burch, M.D., diagnosed probable migraine. On outpatient examination in July 1991, J. Goodman, M.D., noted that the veteran had done quite well postoperatively with his Hodgkin's lymphoma, except for some element of chronic fatigue syndrome since then, and continued periodic complaints of abdominal distress and bloating. In a June 1992 radiation therapy note, Dr. Silberstein noted that the veteran had been treated for Hodgkin's disease with chemotherapy and radiation therapy in 1985, and was currently being seen for a 7-year follow-up evaluation. The veteran's current complaints included difficulty swallowing associated with significant heartburn, a feeling of bloating in the stomach, episodes of diarrhea, and a several-year history of intermittent migraine symptoms. After examination, the doctor stated that there was no evidence to suggest that the veteran had recurrent Hodgkin's disease, and that he did not understand the etiology of the veteran's symptomatology, which seemed to be namely gastrointestinal in nature. On outpatient examination in July 1992, Dr. Goodman felt that the veteran had chronic fatigue syndrome, and noted complaints of periodic abdominal bloating with epigastric discomfort. In a November 1993 radiation therapy note, Dr. Silberstein stated that the veteran had been treated for Hodgkin's disease with chemotherapy and radiation therapy in 1985, and was currently being seen for a follow-up evaluation. The veteran reiterated his years-long gastrointestinal complaints. On VA examination of May 1994, the veteran was noted to be receiving follow-up evaluations for Hodgkin's disease with Dr. Silberstein, a radiation therapy physician. His current complaints included chronic fatigue, neck pain, and headaches, and intermittent constipation. After examination, the doctor opined that the veteran's Hodgkin's disease was in remission, that there had been no acute attacks, and that he had last received chemotherapy and radiation therapy in "December 1985" [which date the Board finds most likely represents a typographical error, when viewed in the context of other objective evidence of record which clearly establishes that the veteran received his last dose of chemotherapy in October 1985]. On VA psychiatric examination of July 1994, the examiner noted that the veteran had received chemotherapy, MOPP, and radiation therapy, finished his treatment of Hodgkin's disease in 1985, and was currently in remission. His current complaints included symptoms of weakness, anhedonia, and decreased energy levels. At the April 1995 RO hearing on appeal, the veteran testified that he had stomach and breathing problems, problems with stamina, chronic fatigue, and headaches. On VA examination of July 1995, the veteran's complaints included chronic lethargy and occasional night sweats. After examination, the examiner stated that the veteran's Hodgkin's disease had been in remission since 1985, that there had been no acute attacks, and that he had last received chemotherapy, X-ray, or surgical treatment for Hodgkin's disease in 1985. On VA psychiatric examination of September 1995, the veteran's complaints included periodic aches and pains in the stomach, back, legs, and bones. After examination, the examiner noted that the major ruminations that the veteran suffered from were related to the aches and pains he felt were associated with Hodgkin's disease. In November 1993 the veteran sought treatment for a suspicious lump under his arm of several days duration. However, a furuncle was assessed and no evidence of recurrence of Hodgkin's disease was found. In February 1998 the veteran was treated for large follicular papules of the legs and buttocks. Folliculitis was assessed. April 1998 CT examinations of the abdomen and pelvis were negative for lymphadenopathy. In a July 1998 record, Samuel N. Bobrow, a private physician working in the field of oncology and hematology, specifically addressed the veteran's history of past Hodgkin's disease and various symptomatic complaints in the years following 1985 treatment for Hodgkin's disease. The physician noted that while the veteran had multiple non-specific symptoms, he did not believe these reflected recurrence of Hodgkin's disease, particularly since recent CT scans of the abdomen and pelvis and x-rays of the chest were negative for recurrent lymphadenopathy. An August 1998 chest scans noted marked reduction in anterior mediastinal lymphadenopathy as compared to prior CT scans in July 1985. In October 1998 the veteran was seen for follow up for various conditions including his history of Hodgkin's disease. That examiner noted that an old lymph node in the chest was shown by August 1998 chest CT to have markedly improved. An April 1998 abdominal CT taken earlier was also noted to have been unremarkable. The veteran underwent colonoscopy with treatment for diverticulosis and hemorrhoids in September 1999. He was also treated for ongoing gastroesophageal reflux at that time. The veteran was afforded a VA examination in November 2002 specifically to address the extent of any ongoing Hodgkin's disease residuals. The veteran continued to assert various symptoms which he attributed to the disorder, including chronic fatigue, aches and pains all over his body, paresthesias, "lumps and boils", being prone to infection, bleeding easily, difficulty raising his arms and legs due to pain, intermittent tingling of some parts, night sweats, difficulty sleeping. The examiner assessed that there was no recurrence of Hodgkin's disease since 1985. However, he did assess that the veteran's GERD did not present symptom until the veteran was treated for Hodgkin's disease. He also assessed that the veteran's hypothyroidism was the result of radiation treatment to the neck for Hodgkin's disease. He also attributed the veteran's mild peripheral neuropathy of the extremities to chemotherapy for Hodgkin's disease. In the September 1998 Joint Motion incorporated into the October 1998 Court Order, the Board was instructed to determine the exact date when the veteran's treatment for Hodgkin's disease terminated. It was noted that a July 1988 radiation therapy note had indicated that his treatment did not conclude until November 1987, and that other evidence had indicated that he was still treated for Hodgkin's disease after November 1987 with visits to an oncologist. The Board was further instructed to define the term "treatment phase" used in assigning a 100% rating for Hodgkin's disease under Diagnostic Code 7709 (38 C.F.R. § 4.117, as in effect on and after October 23, 1995). In seeking a definition for the term "treatment phase" contained in Diagnostic Code 7709 (as in effect on and after October 23, 1995), the Board looks to the term in the context of the provisions of the entire Diagnostic Code, which reads substantially as follows: "7709 Hodgkin's disease: With active disease or during a treatment phase, 100%. NOTE: The 100% rating shall continue beyond the cessation of any surgical, radiation, antineoplastic chemotherapy or other therapeutic procedures. 6 months after discontinuance of such treatment, the appropriate disability rating shall be determined by mandatory VA examination. Any change in evaluation based upon that or any subsequent examination shall be subject to the provisions of 38 C.F.R. § 3.105(e). If there has been no local recurrence or metastasis, rate on residuals." After reviewing the term "treatment phase" in Diagnostic Code 7709 in the context wherein that term follows a reference to "active disease" and precedes a Note referring to "the cessation of any surgical, radiation, antineoplastic chemotherapy and other therapeutic procedures," the Board, after consultation of Dorland's Illustrated Medical Dictionary (26th edition 1981), defines the term "treatment phase" in that Diagnostic Code as "the varying aspects or stages of the management and care of a patient for the purpose of combating Hodgkin's disease, directed immediately to the cure of the disease and designed to produce full remission of the disease. "Medical management and care of patients contemplated in the immediate direction to the cure of, and the design to produce full remission of, the disease, i.e.: any surgical, radiation, antineoplastic chemotherapy or other therapeutic procedures ("therapeutic procedures" being further defined as "a series of steps by which the desired healing or curative result is accomplished," or more specifically, "a series of steps by which the desired result, healing or tending to overcome Hodgkin's disease and promote recovery, is accomplished"). Furthermore, the word "during" placed prior to the term "treatment phase" in Diagnostic Code 7709 indicates "throughout the duration of," i.e., "prior to the cessation of," the administration of any surgical, radiation, antineoplastic chemotherapy or other therapeutic procedures. Having thus defined the term "treatment phase" above as essentially an active, aggressive period of combative medical management and care designed to fully arrest, if not cure, the underlying malignant disease process, the Board, after a review of the voluminous evidence of record, finds that the veteran's treatment for Hodgkin's disease terminated in late October 1985, when the entirety of the evidence, detailed above, reliably establishes that he received his last dose of chemotherapy. In reaching this determination of the date of termination of treatment for Hodgkin's disease, the Board has considered Dr. Silberstein's July 1988 radiation therapy note wherein it was indicated that the veteran completed treatment for Hodgkin's disease in "November 1987." The Board finds that this single notation in the voluminous record of "November 1987" as the date the veteran reportedly completed treatment for Hodgkin's disease most likely represents a typographical error, when viewed in the context of all the other voluminous objective evidence of record, from several VA and private medical sources including Dr. Silberstein himself, which consistently and more reliably specifies the date of termination of the veteran's treatment for Hodgkin's disease with chemotherapy and radiation therapy as late October 1985. Moreover, the Board finds that the veteran's post-October 1985 office visits to oncologists and physicians who previously treated him with chemotherapy and radiation therapy, for follow-up examinations and evaluations for the purpose of monitoring the evolving status of his Hodgkin's disease, may not properly be construed as a continuation of his "treatment phase" for Hodgkin's disease as defined by the Board, above, to be contemplated by Diagnostic Code 7709, inasmuch as all private and VA medical evidence of record subsequent to October 1985 consistently shows that the Hodgkin's disease was in full remission, without local recurrence or metastasis, and that the veteran underwent no further active, aggressive medical treatment such as surgical, radiation, antineoplastic chemotherapy, or other such combative therapeutic procedures. In this regard, the Board notes that the headings on most of Dr. Silberstein's medical reports contained in the record from 1985 to 1993 are entitled "Radiation Therapy Note." The Board finds that this mere heading is misleading, to the extent it would lead one to believe that radiation therapy continued to be administered to the veteran beyond October 1985. A review of the content of each of the medical reports of Dr. Silberstein contained in the record subsequent to October 1985 and entitled "Radiation Therapy Note" discloses that they are medical report forms on which the doctor recorded the veteran's past medical history pertaining to treatment and evaluation of Hodgkin's disease, and noted current clinical findings and assessments regarding the status of the disease - all of which consistently reflected that the disease remained in full remission and was without local recurrence or metastasis, and that no additional surgical, radiation, antineoplastic chemotherapy, or other such therapeutic procedures were performed or administered. The Board notes that the September 1998 Joint Motion incorporated into the October 1998 Court Order directed the Board to address the issue of whether the veteran's depression and chronic fatigue syndrome were "evidence of severe impairment of general health," and thus were factors which should have been considered in determining whether the veteran was entitled to a rating in excess of 30% for Hodgkin's disease under the provisions of Diagnostic Code 7709 (38 C.F.R. § 4.117, as in effect prior to October 23, 1995). With regard to the matter of depression, the Board first notes that no psychiatric manifestations are listed as residuals of lymphogranulomatosis (Hodgkin's disease) to be considered in arriving at any percentage disability rating under Diagnostic Code 7709 (38 C.F.R. § 4.117, as in effect prior to October 23, 1995). Second, the criteria for a 60% rating specify "secondary pressure symptoms, such as marked dyspnea, edema with pains and weakness of extremity, or other evidence of severe impairment of general health." Noting the organic, rather than functional, nature of the secondary pressure symptoms specified in the rating criteria, the Board finds that adding a functional component such as symptoms of depression to the list of secondary pressure symptoms restricted to the organic would constitute an inappropriate and unauthorized expansion of the rating criteria contemplated by the stated provisions of Diagnostic Code 7709 (38 C.F.R. § 4.117, as in effect prior to October 23, 1995). The Board finds no basis to consider symptoms of depression as a component of the term "evidence of severe impairment of general health" in determining the veteran's entitlement to a rating in excess of 60% under Diagnostic Code 7709 (38 C.F.R. § 4.117, as in effect prior to October 23, 1995), and that the RO properly considered the veteran's contentions regarding an etiological relationship between his depression and his service-connected Hodgkin's disease as a separate and distinct claim for service connection for depression under the provisions of 38 C.F.R. § 3.310(a), unrelated to his claim for an increased rating for Hodgkin's disease. In this regard, the Board further notes the provisions of 38 U.S.C.A. § 1155 (West 1991) and 38 C.F.R. § 4.25(b) (1998), to the effect that, except as otherwise provided in the VA Schedule for Rating Disabilities (Rating Schedule) (38 C.F.R. Part 4), disabilities arising from a single disease entity are to be rated separately as are all other disabling conditions, if any. As noted above, Diagnostic Code 7709 (38 C.F.R. § 4.117, as in effect prior to October 23, 1995) makes no provision for consideration of psychiatric symptoms as a basis for entitlement to any percentage disability rating under that Diagnostic Code, and the Rating Schedule does provide for separate disability ratings for mental disorders. Moreover, the Board notes that service connection for depression was granted by rating action of November 1995, and the veteran has been in receipt of a separate 10% disability rating for that disorder under Diagnostic Code 9405 since July 1995. The veteran's separately rated depression as secondary to service-connected Hodgkin's disease, is the subject of a separate increased evaluation claim, separately addressed by this decision. The Board also notes the provisions of 38 C.F.R. § 4.14 (1998) regarding the avoidance of pyramiding, to the effect that the evaluation of the same disability under various diagnoses is to be avoided. Dyspnea, tachycardia, nervousness, fatigability, etc., may result from many causes; some may be service-connected, others, not. Both the use of manifestations not resulting from service-connected disease in establishing the service- connected evaluation and the evaluation of the same manifestation under different diagnoses are to be avoided. The RO has assigned a 60 percent evaluation for the veteran's Hodgkin's disease for the period from November 1, 1986 through October 22, 1995. As addressed above, the disease was inactive and not under current treatment therapy during this period and is properly rated as inactive. Accordingly, the preponderance of the evidence is against assignment of a rating above the 60 percent assigned for Hodgkin's disease for the period from November 1, 1986 through October 22, 1995. As noted, a 60 percent evaluation under the prior criteria contemplated evidence of general muscular weakness with loss of weight and chronic anemia, or secondary pressure symptom such as marked dyspnea, edema with pains and weakness of extremities, or other evidence of severe impairment of general health. 38 C.F.R. § 4.118, Diagnostic Code 7709 (1995). Despite the veteran's numerous complaints over the interval from November 1, 1986 through October 22, 1995, objective findings of any of these criteria were not present, except perhaps some dyspnea as subsequently documented. Severe impairment of general health was not found. Nonetheless, the RO assigned the 60 percent evaluation for Hodgkin's disease over that period, and the veteran appealed, requiring review of possibilities for a still higher evaluation. None of the criteria for a 100 percent evaluation under the old code are met, inclusive of frequent episodes of high and progressive fever or febrile episodes with only short remissions, generalized edema, ascites, pleural effusion, or severe anemia with marked general weakness. Diagnostic Code 7709 (1995). Quite simply, none of these disabling symptoms of Hodgkin's disease are shown during the interval from November 1, 1986 through October 22, 1995, which, as noted, was over a year post treatment therapy and with no evidence of active recurrence of the disease. Also under the prior rating criteria, the Board may consider a rating higher than the 60 percent assigned for the period from November 1, 1986 through October 22, 1995, based on a combined evaluation of separately rated residual disabilities. Diagnostic Code 7709 (1995). Peripheral neuropathies of the upper and lower extremities were not medically found and attributable to the veteran's Hodgkin's disease until January 2000 and November 2002 VA neurological examination, and the Board finds no cognizable, medical evidence of these neuropathies present to a compensable degree during the period from November 1, 1986 through October 22, 1995, so as to warrant a rating under applicable rating codes. Hence, the preponderance of the evidence is against these peripheral neuropathies, separately rated, contributing to a combined rating of separately rated residuals of Hodgkin's disease in excess of the 60 percent already assigned for the rating period from November 1, 1986 through October 22, 1995. 38 C.F.R. § 4.118, Diagnostic Code 7709 (1995); 38 C.F.R. § 4.124a, Diagnostic Codes 7709, 8512, 8520 (2005). Pathology present should have been rated as part of the 60 percent rating assigned. While hypothyroidism was diagnosed during the November 1, 1986 to October 22, 1995 interval and treated with Synthroid, and was subsequently attributed to treatment for Hodgkin's disease (as discussed below), more than a 10 percent evaluation was not warranted for that disorder as a separately rated residual of Hodgkin's disease over the November 1, 1986 to October 22, 1995 interval. Under 38 C.F.R. § 4.119, Code 7903 for hypothyroidism, as in effect before June 6, 1996, a 30 percent rating was warranted for moderately severe hypothyroidism with sluggish mentality and other indications of myxedema, with decreased levels of circulating thyroid hormones (T4 and/or T3 by specific assays). A 10 percent rating was warranted for moderate hypothyroidism with fatigability. A notation following the "old" Code 7903 provided that a minimum rating of 10 percent was assigned when continuous medication is required for control of hypothyroidism. Diagnostic Code 7903 (1995). Because sluggish mentality and other indications of myxedema, with decreased levels of circulating thyroid hormones, as were required signs and symptoms of moderately severe hypothyroidism to support a 30 percent evaluation under Diagnostic Code 7903 as then applicable, were not shown, the preponderance of the evidence was against a more than 10 percent evaluation being warranted as a separate rating for hypothyroidism residuals of Hodgkin's disease. Pathology present would have been rated as part of the 60 percent rating assigned. While GERD may also be rated separately as a residual of Hodgkin's disease, GERD was also not found to be significantly disabling over the November 1, 1986 through October 22, 1995 interval. As discussed below, GERD is rated by analogy to sliding hiatal hernia under Diagnostic Code 7346. Under that code, a 60 percent evaluation is assigned when there are symptoms of pain, vomiting, material weight loss and hematemesis or melena with moderate anemia; or other symptom combinations productive of severe impairment of health. A 30 percent rating is assigned when there is persistently recurrent epigastric distress with dysphagia, pyrosis, and regurgitation, accompanied by substernal or arm or shoulder pain, productive of considerable impairment of health. A 10 percent rating is assigned when there are two or more of the symptoms for the 30 percent evaluation with less severity. 38 C.F.R. § 4.114, Diagnostic Code 7346. During the November 1, 1986 through October 22, 1995 interval, as shown by the records discussed above, the veteran has complained of some epigastric distress and pyrosis, but generally not the other symptoms of GERD. Hence, the preponderance of the evidence is against assignment of more than a 10 percent evaluation for GERD as a residual of Hodgkin's disease over the November 1, 1986 through October 22, 1995 interval. Absent ratings for separate disabilities as residuals of Hodgkin's disease which would together combine to more than the 60 percent evaluation assigned for Hodgkin's disease for the November 1, 1986 through October 22, 1995 interval, rating Hodgkin's disease over that interval, under the old rating criteria for Hodgkin's disease, based on separate residuals rather than the 60 percent assigned for Hodgkin's disease over that interval, is not warranted. 38 C.F.R. §§ 4.25, 4.118, Diagnostic Code 7709 (2005). The preponderance of the evidence is thus against the claim for a still higher evaluation than the 60 percent assigned for Hodgkin's disease for this period from November 1, 1986 through October 22, 1995, and, therefore, the benefit of the doubt doctrine does not apply. 38 U.S.C.A. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). The veteran has raised an argument of applicability of 38 U.S.C.A. § 5112 and 38 C.F.R. § 3.105(e) to VA's change of the rating for Hodgkin's disease from 100 percent to 60 percent effective November 1, 1986. The veteran contends that this constituted a reduction and hence appropriate notice procedures should have been followed prior to such a reduction. However, the Board notes that by a May 1994 rating action the RO granted a the 100 percent evaluation for Hodgkin's disease from September 6, 1985 through October 31, 1986, simultaneously with a grant of a zero percent evaluation for that disease in inactive remission following treatment. Because both ratings were assigned simultaneously, this was not a reduction following a running award, but rather an assignment of staged ratings. See Fenderson v. West, 12 Vet. App Vet. App. 119 (1999) (staged ratings to be assigned upon an initial rating where supported by the evidentiary record). Hence, laws governing ratings reductions, inclusive of 38 C.F.R. § 3.105(e), are here inapplicable. Similarly, the subsequent RO increases in the rating assigned effective from November 1, 1986, to the currently assigned 60 percent evaluation effective from November 1, 1986, are made in the course of appellate review of this initial rating, and hence are initial ratings and constitute no reduction following a running award. The prior rating criteria for Hodgkin's disease informs as follows: The 100 percent rating will be continued for 1 year following the cessation of surgical, X-ray, antineoplastic chemotherapy or other therapeutic procedure. At this point, if there has been no local recurrence or invasion of other organs, the rating will be made on residuals. Note following 38 C.F.R. § 4.117, Diagnostic Code 7709 (1995). As discussed, the 60 percent evaluation assigned effective from November 1, 1986, assigned a rating for inactive Hodgkin's disease one year following cessation of active treatment. The Board notes that the veteran was assigned separate ratings for different disabilities with nonspecific diagnoses which the RO attributed to Hodgkin's disease, effective from October 23, 1995, and that those separate ratings were noted to combine to a rating in excess of the 60 percent previously assigned. For the period from October 23, 1995, one question at issue is whether a single rating for residuals of Hodgkin's disease, of itself and based on the prior rating criteria, may be assigned in excess of the combined ratings for all the distinct conditions found to be associated with Hodgkin's disease and service-connected on that basis. These conditions include were all service connection effective October 23, 1995, and rated as follows: mild peripheral neuropathy of the right and left upper extremities, each rated 20 percent disabling; mild peripheral neuropathy of each of the lower extremities, each rated 10 percent disabling; hypothyroidism associated with Hodgkin's disease, rated 10 percent disabling; and GERD associated with Hodgkin's disease, rated 10 percent disabling. The combined rating of all these disorders associated with Hodgkin's disease, when considering bilateral factors for the two upper extremities and the two lower extremities, was 70 percent from October 23, 1995, and hence in excess of the 60 percent previously assigned for Hodgkin's disease residuals as a single entity. Hence, for the period from October 23, 1995, one question is whether a single rating for Hodgkin's disease residuals under the old rating criteria is assignable which is in excess of 70 percent. As already determined, above, the veteran's Hodgkin's disease was appropriately reduced from a 100 percent disability rating effective October 31, 1986, based on the disease no longer being active. Hence, the highest possible rating for Hodgkin's disease under the old Diagnostic Code 7709 criteria, for the period beginning October 31, 1986, was a 60 percent evaluation based on inactive disease with significant residual symptoms. 38 C.F.R. § 4.117, Diagnostic Code 7709. Because this rating is lower than the combined 70 percent evaluation assigned effective from October 23, 1995, under the new rating criteria, the new and not the old rating criteria is applicable because that is the higher evaluation. VAOPGCPREC 7-2003; 38 U.S.C.A. § 5110(g). As addressed in part above, the RO by a March 2003 rating action, based on residuals of Hodgkin's disease and effective from the October 23, 1995 effective date for the change in rating criteria, assigned a 10 percent evaluation for hypothyroidism under Diagnostic Code 7903; assigned a 10 percent evaluation for GERD; assigned a 20 percent evaluation for peripheral neuropathy of the right upper extremity based on mild peripheral neuropathy under Diagnostic Code 8512; assigned a 20 percent evaluation for peripheral neuropathy of the left upper extremity based on mild peripheral neuropathy also under Diagnostic Code 8512; assigned a 10 percent evaluation for peripheral neuropathy of the left lower extremity based on mild peripheral neuropathy also under Diagnostic Code 8520; and assigned a 10 percent evaluation for peripheral neuropathy of the right lower extremity based on mild peripheral neuropathy also under Diagnostic Code 8520. The ratings for hypothyroidism is addressed separately below. The rating for GERD is addressed together with adjudication of the initial rating for IBS, also separately below. Under the codes for neuropathy of the extremities, a higher disability rating is assignable if there is moderate peripheral neuropathy. 38 C.F.R. § 4.124a, Diagnostic Codes 8512, 8520 (2005). Under Diagnostic Code 8512, the rating is based on intrinsic muscles of the hand, affecting some or all of the flexors of the wrist and fingers. The rating is based on loss of functional use of the hand. As noted, if there is mild loss of use a 20 percent evaluation is assigned; this is applicable whether it is the major or minor hand. If there is moderate loss of use, for the major hand a 40 percent evaluation is assigned, and for the minor hand a 30 percent evaluation is assigned. 38 C.F.R. § 4.124a, Diagnostic Code 8512. Under Diagnostic Code 8520, the rating is based on sciatic nerve paralysis, where complete paralysis would be evidence by the foot dangling and dropping, no active movement of muscles below the knee, and flexion of the knee weekend, or, rarely, lost. Where the paralysis is incomplete, if mild a 10 percent evaluation is assigned, and if moderate a 20 percent evaluation is assigned. 38 C.F.R. § 4.124a, Diagnostic Code 8520. Two recent VA neurological examinations were conducted in January 2000 and November 2002. There are no subsequent or prior evaluations significantly addressing the level of peripheral neuropathic impairment associated with the veteran's Hodgkin's disease, and hence the Board must rely substantially on the findings from these examinations. Helpfully, the veteran informed in a March 2006 submission that his symptoms of Hodgkin's disease, including those associated with alleged lack of feeling, tingling, and weakness in extremities, have been consistent since onset of the disease. Hence, the veteran has not alleged increased severity since the most recent neurological evaluation in November 2002, and the Board deems these most recent evaluations in January 2000 and November 2002 to suffice for evaluating the nature and extent of the veteran's peripheral neuropathies associated with his Hodgkin's disease for rating purposes. At the January 2000 VA examination the veteran complained of tingling in his arms and fingers and pain that prevented him from holding up his arms. He also complained that his legs would fall asleep very easily if he lies still. The veteran reported being limited in his activities, in that he could not perform such chores as cleaning the gutters or working under the car. He reported that regarding athletic activities he could still bat right-handed, but not left- handed, adding that he used to be able bat left handed as well even though his right hand was his major hand. The examiner noted that tests were done including visual, auditory, and somatosensory evoked potentials - to address some complained-of neurological problems such as dizziness and loss of balance and numbness or difficulty moving limbs - but these tests were all negative for pathology. An MRI could not be performed reportedly due to the veteran's claustrophobia. The veteran also presented other complaints, including muscle weakness and cramps, pain in the muscles and joints, and swelling of the hands and feet. The January 2000 VA examiner reviewed the veteran's records including his history of Hodgkin's disease without evidence of recurrence. Upon the examination, the examiner noted that veteran was a heavy and muscular male, cranial nerves II through XII were unremarkable, and motor examination showed normal power and bulk throughout. There was no pronator drift, but there was slight weakness of the interossei of the fingers. While some weakness of the abductor pollicis brevis was first indicated bilaterally, this was shown not to be the case with some encouragement, with normal muscle strength demonstrated. Deep tendon reflexes were 1+ and symmetric at relevant upper extremity points bilaterally, and 2+ and symmetric at relevant lower extremity points bilaterally. Plantar responses were downgoing, and light touch was normal in the hands and feet, though pinprick was diminished in the fingers and feet, and felt sharply on the forearms, right distal leg, and above the knee on the left. Vibration sense was mildly decreased in the toes but position sense was intact in the toes. Thigh and elbow motor flexion demonstrated more difficulty on the left, though good strength was demonstrated. Tandem and heel walking also showed some difficulties. The examiner assessed that some peripheral neuropathic residuals of the chemotherapy treatment for Hodgkin's disease were possible, and some demonstrated difficulties with balance were conceivable also associated with his peripheral neuropathy. Upon a November 2002 VA examination (already noted above as to some details regarding Hodgkin's disease), the veteran complained of aches and pains all over his body and paresthesias. He also complained that he constantly scratched his legs and arms. He reported that he had difficulty raising his arms due to pain, and that he had intermittent tingling in the feet and hand, as well as between his shoulders and spine. (Other, unrelated complaints including those psychiatric in nature, are not here addressed for the veteran's neurological residuals; the veteran's appealed rating for depression is addressed separately, below.) The November 2002 VA examiner observed that the veteran was alert and oriented times three, with cranial nerves two through twelve intact. Pinprick sensation was diminished in both feet and both toes, above the medial aspect of both legs, and diffusely above both knees. There was decreased vibratory sensation in the toes bilaterally. Gait was wide- based, and there was a loss of balance with tandem gait. Deep tendon reflexes were 2+ bilaterally in the upper extremities, and 1+ bilaterally in the lower. The examiner assessed mild peripheral neuropathy likely the result of the veteran's chemotherapy for Hodgkin's disease. The Board thus concludes, as supported by these January 2000 and November 2002 VA examiner's findings essentially of mild neuropathy affecting each of the extremities, that the preponderance of the evidence is against assignment of a higher disability rating based on moderate neurological impairment for either the right or left upper extremity under Diagnostic Code 8512, and is against assignment of a higher disability rating based on moderate neurological impairment for either the right or left lower extremity under Diagnostic Code 8520. Hence, the preponderance of the evidence is against a higher disability ratings for his peripheral neuropathy residuals of Hodgkin's disease than the 20 percent assigned for each of the upper extremities under Diagnostic Code 8512, and is against a higher disability rating than the 10 percent assigned for peripheral neuropathy of each of the lower extremities, for the rating period beginning October 23, 1995. The veteran complained at the January 2000 VA examination of certain unusual pain sensations of the spine associated with spontaneous, intermittent development and resolution of what he described as boils under the skin, and he made similar complaints at the November 2002 VA examination. However, the January 2000 VA neurological examiner noted the absence of supportive neurological findings, and concluded that the described symptoms could not be associated as residuals of the veteran's Hodgkin's disease. The November 2002 VA examiner did not comment on these complaints. There are not other examination or treatment records in the claims folder with a careful medical assessment of this reported condition and where a positive association is drawn to the veteran's Hodgkin's disease. Accordingly, the Board concludes that the preponderance of the evidence is against assignment of additional distinct rating(s) based on these reported back symptoms as part of his Hodgkin's disease residuals. The benefit of doubt regarding this issue accordingly does not apply. 38 U.S.C.A. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Claim for a rating greater than 10 percent for hypothyroidism for the period beginning October 23, 1995 The veteran contends that his hypothyroidism associated with Hodgkin's disease is more disabling than is reflected in the 10 percent evaluation assigned beginning October 23, 1995. VA's Schedule for Rating Disabilities has been revised with respect to the regulations pertaining to evaluations of disorders of the endocrine system. 38 C.F.R. § 4.119 was amended, effective June 6, 1996, and now includes new rating criteria for hypothyroidism. As noted, since this appeal was pending at the time the applicable regulation was amended, the veteran is entitled to consideration of the old criteria based on a rating assigned from the period before June 6, 1996 forward, or under the new criteria from their effective date. VAOPGCPREC 7-2003. Under 38 C.F.R. § 4.119, Code 7903 as in effect before June 6, 1996, a 30 percent rating was warranted for moderately severe hypothyroidism with sluggish mentality and other indications of myxedema, with decreased levels of circulating thyroid hormones (T4 and/or T3 by specific assays). A 10 percent rating was warranted for moderate hypothyroidism with fatigability. A notation following the "old" Code 7903 provided that a minimum rating of 10 percent was assigned when continuous medication is required for control of hypothyroidism. Diagnostic Code 7903 (1995). Over the rating period at issue, the veteran has had intermittent constipation or diarrhea, which has been associated with irritable bowel syndrome (IBS) and not generally with hypothyroidism. The veteran has been treated with Synthroid for hypothyroidism on an ongoing basis. The veteran has not been found to have significant fatigability despite medication, and has not been found to have mental sluggishness. At a December 1999 VA examination to assess any conditions associated with Hodgkin's disease, the examiner noted that the veteran appeared to be in good overall health though he was grossly overweight. Blood tests were normal and thyroid size was normal. The veteran reported multiple symptoms including severe fatigue, body pruritis, shaking spells, migraine headaches, and gastrointestinal problems, but no conditions were identified upon examination. Cardiac evaluation showed a normal sinus rhythm. At a January 2000 VA respiratory examination the veteran reported having significant dyspnea on exertion, and chronic fatigue syndrome. He reported playing golf regularly, but not walking as fast as his golf partners, and becoming out of breath whenever exerting himself. Pulmonary function tests did not show a source of his dyspnea. At a January 2000 VA treatment evaluation, the veteran's diagnosed hypothyroidism was noted, but the veteran was unsure of his Synthroid use, and hence it is unclear that the veteran was taking Synthroid as prescribed. At a November 2002 VA examination for lymphatic disorders, the veteran's hypothyroidism was noted to be treated with Synthroid and stable. Reviewing the record as a whole, the preponderance of the medical evidence is to the effect that the veteran's hypothyroidism has been effectively treated with Synthroid, and the veteran's reports of chronic fatigue do not support more than a moderate level of disability. Severe fatigue is not in evidence. The veteran has reported working with sustained full-time employment and engaging in leisure sports including golf and (implicitly, as noted above) baseball. He has not been observed upon his many examination and treatments of records to be notably fatigued. Additionally, all three symptoms are required for a 30-percent evaluation under the new criteria: fatigability, constipation, and mental sluggishness. Diagnostic Code 7903 (2005). While some records note complaints of fatigue, and there are recurrent complaints of constipation alternating with diarrhea, mental sluggishness has not been one of the veteran's complaints, and no examiner of record assessed mental sluggishness. Accordingly, because the veteran has been treated with Synthroid on an ongoing basis for his hypothyroidism, and has not been medically found to have all the symptoms required for a 30 percent evaluation under the new code, the preponderance of the evidence is against assignment of a higher, 30 percent evaluation for hypothyroidism under the new code. Severe hypothyroidism with sluggish mentality and other indications of myxedema, with decreased levels of circulating thyroid hormones are not shown to warrant a 30 percent evaluation under the old code. Diagnostic Code 7903 (1995). The evidence more nearly approximates the criteria for a 10 percent evaluation, based on hypothyroidism controlled by medication. 38 C.F.R. § 4.7. The preponderance of the evidence is thus against the claim for a higher evaluation for hypothyroidism than the 10 percent assigned, and, therefore, the benefit of the doubt doctrine does not apply. 38 U.S.C.A. § 5107(b); Gilbert v. Derwinski. Claim for an Earlier Effective Date than May 15, 2000 for a Grant of an Increased Evaluation for Depression to 50 Percent Disabling, and Claim for an Increased Rating for Depression Under the General Rating Formula for Mental Disorders, which is applicable for rating depression, a 30 percent rating is assigned where there is 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). A 50 percent evaluation is assigned where there is 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. A 70 percent rating is assigned where 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 worklike setting); inability to establish and maintain effective relationships. A 100 percent rating is assigned in cases of 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. 38 C.F.R. 4.130, Diagnostic Code 9434 (2005). A Global Assessment of Functioning (GAF) Scale, and a score assigned thereon, reflects the "psychological, social, and occupational functioning on a hypothetical continuum of mental health-illness." Richard v. Brown, 9 Vet. App. 266, 267, quoting the American Psychiatric Association's DIAGNOSTIC AND STATISTICAL MANUAL OF MENTAL DISORDERS (4th ed.) (DSM-IV) p. 32. GAF scores ranging between 61 to 70 reflect 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, and has some meaningful interpersonal relationships. Scores ranging from 51 to 60 reflect 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). See Carpenter v. Brown, 8 Vet. App. 240, 242 (1995). A claim for an increased evaluation for an already service- connected disorder will be granted, if and to the extent entitlement is warranted, effective upon the date of receipt of the claim or date entitlement arose, whichever is later. 38 C.F.R. § 3.400(o)(1). However, as an exception to that general rule, if the claim is filed within one year of the date that the evidence shows that an increase in disability has occurred, an increased rating shall be granted effective from the earliest date within that prior year that an increase is factually ascertainable (not necessarily the date of receipt of the evidence). 38 C.F.R. § 3.400(o)(2). Here, on May 15, 2000, the veteran submitted a claim for an increased rating for depression. There is no evidence of record factually (by medical evidence) supporting a finding of depression warranting a higher disability rating than the 30 percent previously assigned for the entire year period prior to that May 15, 2000 date of receipt claim for increased rating. There is also no indication of a prior, unaddressed claim for an increased rating for depression. The primary documents addressing the veteran's level of psychiatric impairment proximate in time to May 15, 2000, are August 2000 and October 2002 VA psychiatric examinations. As discussed below, the Board finds that these examinations show a level of disability really more closely approximating that warranting a 30 percent evaluation and not the 50 percent evaluation assigned. The Board does not find medical or mental health treatment or evaluation records addressing the year interval prior to May 15, 2000 and indicating that a 50 percent evaluation is warranted for that year period. The Board accordingly must conclude that the preponderance of the evidence is against entitlement to an effective date earlier than May 15, 2000, for an increased evaluation to 50 percent disabling for depression, since the preponderance of the cognizable (medical) evidence is against the presence of that greater level of disability within the year prior to May 15, 2000. 38 C.F.R. § 3.400(o)(1), (2). The preponderance of the evidence is against the earlier effective date claim, and, therefore, the benefit of the doubt doctrine does not apply. 38 U.S.C.A. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). At an August 2000 VA psychiatric examination, the veteran reported a history of alcohol abuse of 15-years duration until 1986, but he reported not abusing alcohol since then, not abusing substances now, and not feeling the need to do so. The veteran complained of a depressed mood for some amount of time each day. The veteran reported a loss of interest in outside activities, so that whereas he used to golf and fish, he now has to force himself to do these things. However, he also admitted to going to some sporting events with his children. Complained of erratic weight gain and loss. As the Board has already addressed in the discussion within this decision of the veteran's IBS claim, the veteran's recent weight loss was not was not shown by the evidence to be characterized by the erratic swings he alleged. The veteran also voiced a similarly improbable complaint regarding sleep patterns, alleging that he would sleep for two to three days at a time, and then might only sleep one night in an entire week. The veteran admitted, however, to not having missed significant time from work, which would seem an impossible outcome when sleeping two to three days at a time. He also complained of some irritability and aggravation daily, difficulty with concentration and decisiveness, and not feeling as productive as others at work. He reported having some suicidal ideation and an occasional plan. However, as assessed by the October 2002 VA examiner, as discussed below, this so-called suicidal ideation is actually more reflective of the veteran's lack of faith in others, including his family, whom he considers do not sufficiently value his existence. Thus, while the veteran presents the thoughts as suicidal ideation, they are actually mechanism the veteran uses to blame others through his belief that they are not ascribing to him the work to which he believes himself entitled. (See the Board's discussion of the October 2002 VA examination, below). The August 2000 VA examiner noted that the veteran had not been evaluated by VA for his depression since 1995, and that the depression had not interfered with his full-time work or some of his social functioning. The examiner did not that the veteran's reported sleep impairment with associated propensity for irritability and aggravation, would impair his functioning to some degree. The veteran reported having received Prozac to treat his depression, but averred that the medication had become ineffective over time, and he reported no current medication for depression. Upon examination, the examiner found the veteran's anhedonia and anxiety to be moderate, with full range of affect demonstrated. However, anger was moderate to severe, and the examiner assessed moderate to severe loneliness. Nonetheless, cognitive functioning - including attention, concentration, memory functioning, and judgement in work, family, and social settings - was not significant impaired, though the veteran demonstrated some difficulty with abstraction, tending to think concretely. The veteran did express beliefs of entitlement, and suspicions that VA was consciously not giving him what he was due. The examiner found little likelihood that the veteran would act out or carry out any suicidal act. Overall, the examiner characterized the veteran's condition as a dysthymic disorder associated with his Hodgkin's disease, and emphasized that it was not significant impairing of the veteran's functioning. The August 2000 examiner assigned a GAF of 60 presently and in the past year. At an October 2002 VA psychiatric examination, the examiner noted that the veteran suffered most prominently from irritability, with anger and bitterness toward the government, blaming the government for his Hodgkin's disease, and blaming physicians for perceived poor medical care. The examiner noted that the veteran also had marked anhedonia, with moderately severe mood disturbance. The examiner noted that the veteran's reported suicidal ideation was tied up in the veteran's cynical view that others, including his family, believed they would be better off without him. The examiner concluded that the veteran's tendencies to blame others and to harbor a sense of entitlement contributed to his mood disorder. The examiner concluded that while the veteran had a major depressive disorder, diagnosed as such, there was no indication that the condition significantly impaired his work functioning, but rather primarily affected his level of enjoyment. The examiner noted that the veteran had a basically positive relationship with his grown children, and while he characterized his relationship with his wife as having minimal contact and generally sleeping in separate rooms, no significant social dysfunction was identified. The examiner also found no significant behavioral or impulse impairment or cognitive impairments. The examiner assigned a GAF of 55. Upon review of the claims folder as a whole, including psychiatric and non-psychiatric examinations in recent years and VA and private treatment records contained within the claims folder, the Board finds the two recent VA psychiatric examinations to be reasonably consistent and representative of the level of psychiatric impairment otherwise shown by the record as a whole. Based on the findings of the VA examiners in August 2000 and October 2002, the Board notes that the veteran's depression is not manifested by those characteristics which are generally associated with a 50 percent disability rating - flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks; difficulties in comprehension; significantly impaired memory or judgment; or impaired abstract thinking. While the veteran does have a mood impairment, this is not shown to significantly impair obtaining or maintaining work or social relationships, or to result in significantly reduced reliability and productivity in social and occupational settings. Rather, mental health examiners' findings suggest that the veteran's mood disorders (associated with his general pattern of blaming others and sense of entitlement) would be more properly characterized as producing occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks. Hence, the Board finds that the veteran's depression signs and symptoms more closely approximate the rating criteria for a 30 percent rating than a 50 percent rating. The Board finds that an even higher, 70 percent evaluation, representing deficiencies in most areas such as work, school, family relations, judgment, thinking, or mood, are certainly not shown. These conclusions are consistent with the GAF scores assigned by the VA examiners, in the 55 to 60 range, reflecting moderate symptoms, such as moderate difficulty in social or occupational functioning. DSM-IV. The preponderance of the evidence is thus against the claim of entitlement to an increased rating above the 50 percent assigned for depression, and, therefore, the benefit of the doubt doctrine does not apply. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 4.130, Diagnostic Code 9434; Gilbert v. Derwinski, 1 VET. APP. 49 (1990). Claim for Increased Evaluation for GERD for the period from October 23, 1995 through September 30, 2003 As discussed above, the veteran was assigned a 10 percent evaluation for GERD as a residual of Hodgkin's disease for the period beginning October 23, 1995, the effective date for the change in rating criteria for Hodgkin's disease which dictated rating residuals of inactive Hodgkin's disease separately. 38 C.F.R. § 4.117, Diagnostic Code 7709. Hence, the Board must consider the appropriate rating for GERD for the period from October 23, 1995 to September 30, 2003. As discussed below, pursuant to applicable regulation, from November 1, 2003 the veteran was assigned a single rating for IBS and GERD. See 38 C.F.R. § 4.113 (2005) (restriction as explicated below). There is no Diagnostic Code specific to GERD. See 38 C.F.R. Part 4 (2005), generally. The Board has reviewed the question of GERD as presented in this case, and finds that 38 C.F.R. § 4.114, Diagnostic Code 7346, is the appropriate analogous rating code in this case, as was also determined by the RO. The Board bases this analogous rating on applicable law governing analogous ratings which provides that when an unlisted condition is encountered, it will be permissible to rate under a closely related disease or injury in which not only the functions affected, but also the anatomical localization and symptomatology are closely analogous. 38 C.F.R. § 4.20 (2005). Diagnostic Code 7346 addresses ratings for hiatal hernia, a condition of the muscle surrounding the opening between the esophagus and the stomach, which, when chronically relaxed in the case of a hiatal hernia, allows the stomach to enter the space normally occupied by the esophagus, and allows stomach contents, inclusive of stomach acids, to enter the esophagus. The symptoms and functions affected by hiatal hernia are also those affected by GERD, since gastroesophageal reflux is by definition a condition which occurs when stomach contents, inclusive of stomach acids, re-enter the esophagus (i.e., reflux) through the gastroesophageal juncture. Hence, the Board here appropriately rates GERD by analogy to hiatal hernia because this is a closely related disease or injury in which not only the functions affected, but also the anatomical localization and symptomatology are closely analogous. 38 C.F.R. § 4.20. Other disorders of the alimentary system also present symptom sets which overlap those for GERD. See variously 38 C.F.R. § 4.114, Diagnostic Codes 7203-7354 (2003). Of these, duodenal ulcer, rated under Diagnostic Code 7305, also addresses a close anatomical locality, as proximate to the stomach. 38 C.F.R. § 4.114, Diagnostic Code 7305. However, hiatal hernia most closely approximates the symptom set and anatomical location of GERD, and hence is most appropriate for rating GERD. Under Diagnostic Code 7346, a 60 percent evaluation is assigned when there are symptoms of pain, vomiting, material weight loss and hematemesis or melena with moderate anemia; or other symptom combinations productive of severe impairment of health. A 30 percent rating is assigned when there is persistently recurrent epigastric distress with dysphagia, pyrosis, and regurgitation, accompanied by substernal or arm or shoulder pain, productive of considerable impairment of health. A 10 percent rating is assigned when there are two or more of the symptoms for the 30 percent evaluation with less severity. 38 C.F.R. § 4.114, Diagnostic Code 7346. The evidentiary record reflects that for the period in question, from October 23, 1995 through September 30, 2003, the primary identified symptom of the veteran's GERD was epigastric pain or distress, and these symptoms have been adequately controlled with medication over the rating period. As a December 1999 VA examiner noted, the veteran reported a history of GERD symptoms inclusive of heart burn at the end of meals, worsened by certain foods, which symptoms became severe despite antacids. However, he reported that in the mid-1990's he began treatment with proton inhibitor medication, which produced good relief of symptoms. He reported remaining on this medication, as it was necessary to maintain symptom relief. The veteran also reported having some ongoing solid and liquid food dysphagia, particularly with cold liquids, with associated retrosternal chest pain and pressure. He reported also some occasional nausea relieved by eating. He denied vomiting and reported excellent appetite. The December 1999 VA examiner note that September 1999 endoscopic examination showed no pathologic findings, whereas a colonoscopy showed left-sided diverticulosis and hemorrhoids, with the terminal ilium normal and only diminutive, non-pathogenic polyps found. The examiner diagnosed history of moderated GERD with daily medication. Other complained-of symptoms of gas or bloating or constipation or diarrhea, as noted in treatment records during the period and at the December 1999 VA examination , have not been associated with the veteran's GERD, and are not included among rating criteria provided in Diagnostic Code 7346. For the period from October 23, 1995 through September 30, 2003, the veteran's GERD has thus been controlled by proton pump inhibitor medication, with good control of symptoms. Symptoms which would warrant a 30 percent evaluation, including persistently recurrent epigastric distress with dysphagia, pyrosis, and regurgitation, accompanied by substernal or arm or shoulder pain, productive of considerable impairment of health, have not been present. The condition's symptoms have over the period consisted of some dysphagia or pyrosis, as noted, without more, and hence a 30 percent evaluation is more appropriate, as the disability picture more nearly approximates the criteria required for that rating. 38 C.F.R. §§ 4.7, 4.114, Diagnostic Code 7346. The preponderance of the evidence is against the claim for a higher evaluation than the 10 percent assigned for GERD for the period from October 23, 1995 through September 30, 2003, and, therefore, the benefit of the doubt doctrine does not apply. 38 U.S.C.A. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Claim for a Higher Initial Evaluation for IBS The veteran also contends that he should be granted a higher initial rating for his irritable bowel syndrome (IBS) than the 30 percent assigned. At the time of an initial rating, separate ratings can be assigned for separate periods of time based on the facts found - a practice known as "staged" ratings. Fenderson v. West, 12 Vet. App 119 (1999). As the RO appropriately noted, the veteran was already service connected for GERD effective from October 23, 1995, with a 10 percent evaluation assigned from that date, and GERD and IBS must be rated as a single condition. Regulations prohibit rating GERD separate from IBS. According to 38 C.F.R. § 4.114, ratings under Diagnostic Codes 7301 to 7329 inclusive, 7331, 7342, and 7345 to 7348 inclusive will not be combined with each other. A single evaluation will be assigned under the diagnostic code which reflects the predominant disability picture, with elevation to the next higher evaluation where the severity of the overall disability warrants such elevation. 38 C.F.R. § 4.113 (2005). IBS is rated under Diagnostic Code 7319. Under that code, where there is severe disability, with diarrhea, or alternating diarrhea and constipation, with more or less constant abdominal distress, a 30 percent evaluation is assigned. That is the highest schedular rating that may be assigned for IBS. 38 C.F.R. § 4.114, Diagnostic Code 7319 (2005). Since the disability is already rated at the maximum with the 30 percent rating assigned, a higher rating can only be achieved if the veteran's disability meets the criteria for another diagnostic code for a similar disorder. The veteran's GERD is shown by recent VA treatment records to be treated with Prilosec. Recent treatment records also show some gastrointestinal upset complaints associated with his taking Zocor for hyperlipidemia, with the veteran switching to an alternative medication. As reflected in a November 2002 VA lymphatic system examination report, the veteran is obese and not noted to be suffering from nutritional deficiencies. A VA gastrointestinal examination in July 2005 noted the veteran's complaints of chronic symptoms including intermittent fatigue, unexplained arthralgias and myalgias, and abdominal pain consisting of a daily burning discomfort when ingesting solids and liquids. He also complained of alternating constipation and loose stools. He further alleged daily nausea and occasional vomiting, though he denied melena. He reported having difficulty sleeping at night and awaking feeling bloated. He also reported difficulty with bowel movements, with diarrhea two to three times on some days and constipation other days. However, the examiner noted that the veteran did not have constitutional symptoms such as would suggest systemic complications rather than alimentary symptoms. The July 2005 examiner noted that a 2001 upper endoscopy confirmed the presence of a hiatal hernia and the absence of esophagitis. A 2000 colonoscopy revealed only two small polyps that were removed. On examination, the abdomen was obese, with no masses and only mild subjective soreness in the lower left quadrant to deep palpation, without rebound. Feces were heme negative, and there was no edema in the extremities. The examiner assessed mild to moderate functional impairment due to chronic daily IBS. The examiner noted that the veteran's symptom complex of chronic abdominal pain and altered bowel habits were a nonspecific but primary characteristic of IBS. At an August 2000 VA psychiatric evaluation the veteran did reported erratic weight fluctuations, with reduction in weight between December 1999 and August 2000 from 259 to 229. However, the Board notes that upon VA examination for Hodgkin's disease and nutritional disorders in December 1999 the veteran's weight was 246 pounds, not 259. While the veteran's weight was not recorded on the August 2000 VA psychiatric examination report, at a VA lymphatic systems examination in January 2000 his weight was 143 pounds, and at a VA cardiovascular examination in February 2000 weight was 240 pounds. These figures suggest a gradual weight reduction of 17 pounds between December 1999 and August 2000 (assuming an accurate self-report of current weight then of 229 pounds), and not an erratic swings of weight during that interval. The Board further notes there is no indication of anorexia or nutritional deficiency generally, but rather a diagnosis of obesity. A higher rating of 40 percent under Diagnostic Code 7323, ulcerative colitis, would be warranted where there is daily fatigue, malaise, and anorexia with minor weight loss and hepatomegaly; or incapacitating episodes (with symptoms such as fatigue, malaise, nausea, vomiting, anorexia, arthralgia, and right upper quadrant pain) having a total duration of at least four weeks, but less than six weeks, during the past 12-month period. 38 C.F.R. § 4.114, Diagnostic Code 7345 (2005). A higher rating is not warranted under this code since ulcerative colitis was not shown upon 2000 colonoscopy and has not been diagnosed, symptoms of anorexia and hepatomegaly have not been found upon examinations, and incapacitating episodes have also not been shown. There are no findings of right upper quadrant pain or incapacitating episodes lasting four to six weeks. Likewise, a higher rating of 60 percent is not warranted under 38 C.F.R. § 4.114, Diagnostic Code 7323 (2005), which requires severe ulcerative colitis with numerous attacks yearly and malnutrition with fair health during remissions. At no time during the appeal period, beginning October 1, 2003, was there evidence of malnutrition or only fair health during remissions. Accordingly, the preponderance of the evidence is against the claim of entitlement to a higher initial evaluation for IBS, and, therefore, the benefit of the doubt doctrine does not apply. 38 U.S.C.A. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). The findings and assessments made at the July 2005 VA gastrointestinal examination are sufficiently consistent with those reflected in prior examination and treatment records, including as noted above, to serve as a basis of adjudicating the appealed claim addressing the nature and severity of the veteran's IBS and GERD for the period beginning October 1, 2003. The Board has reviewed the entire record and finds that the 30 percent rating confirmed by virtue of this decision for IBS reflects the most disabling this disorder has been since the October 1, 2003 effective date of service connection, which is the beginning of the appeal period. Thus, the Board concludes that staged ratings for this disorder are not warranted. Fenderson. Claim for an Earlier Effective Date for the Grant of Service Connection for IBS than November 1, 2003 The veteran contends that he should be granted an effective date earlier than November 1, 2003, for service connection for IBS. The effective date for a grant of a claim for service connection shall be the day after separation from service or date entitlement arose, if the claim is received within one year of separation from service, otherwise it shall be the date of receipt of claim. 38 U.S.C.A. § 5110(b)(1) (West 2002); 38 C.F.R. § 3.400(b)(2)(i) (2005). Here, no claim for service connection for IBS was received within a year of the veteran's separation from service in May 1969. In a letter received by VA on October 1, 2003, the veteran contended that he had digestive disorder conditions characterized as irritable bowel syndrome (IBS) and manifested by indigestion, cramps, loose bowels, gas, and constipation, as due to his service-connected Hodgkins disease or treatment for that disease. He also then noted persistence of his GERD. The RO accepted this letter as a claim for service connection for IBS as secondary to service- connected Hodgkin's disease. By a June 2004 rating action the RO granted service connection for IBS, assigning an effective date of October 1, 2003, based on the date of receipt of claim. The Board finds no prior submission by the veteran that might be construed as a formal or informal claim for service connection, despite the veteran's contentions in the letter received on October 1, 2003, that he had IBS symptoms since his Hodgkins Disease ended in November 1985. A claim must be filed in a form designated by the Secretary, and while an informal claim may potentially initiate a claim for benefits, it must specify the benefit sought. 38 U.S.C.A. § 5101(a) (West 2002); 38 C.F.R. §§ 3.151(a), 38 C.F.R. § 3.155(a) (2005). No such prior formal or informal claim is shown in the record. Neither the veteran nor his representative has articulated a basis by which an effective date earlier than October 1, 2003 may be assigned, and neither has indicated a prior submission that might conceivably be construed as an earlier formal or informal claim for service connection for IBS as secondary to Hodgkin's disease. Accordingly, absent an alternative basis for assignment of an earlier effective date for the grant of service connection, the appropriate date is the date of receipt of claim. 38 U.S.C.A. § 5001(a) (West 2002); 38 C.F.R. § 3.151(a) (2005). Accordingly, the preponderance of the evidence is against assignment of an early effective date for service connection for IBS than October 1, 2003. The preponderance of the evidence is against the claim for an earlier effective date for service-connected for IBS, and, therefore, the benefit of the doubt doctrine does not apply. 38 U.S.C.A. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Claim for service connection for headaches as secondary to service-connected Hodgkin's disease At a December 1999 VA examination to assess any conditions associated with Hodgkin's disease, the veteran reported multiple symptoms including severe fatigue, body pruritis, shaking spells, migraine headaches, and gastrointestinal problems. However, the examiner made no findings of a headache condition, and did not diagnose a headache condition, due to Hodgkin's disease or otherwise. At an August 2000 VA psychiatric examination the veteran presented with numerous complaints of ongoing difficulties including depression, insomnia and hypersomnia, irritability, aggravation, psychomotor agitation, fatigue or loss of energy, feelings of worthlessness, difficulty concentrating and being decisive, recurrent thoughts of death and suicidal ideation, and excessive worry. At an October 2002 VA psychiatric examination the veteran's dysthymia or depression was addressed. Current symptoms were noted, including most prominently mood disturbance with moderate irritability. The veteran then addressed what he considered to be multiple serious illnesses from which he suffered. However, he did not mention headaches. The veteran exhibited marked anhedonia and considerable blame of others for present difficulties associated with an underlying sense of entitlement. The veteran's Hodgkin's disease, reported heart attack, and IBS were noted. The examiner provided a thorough summary of the veteran's current and past concerns including as related to physical and mental difficulties, but made no notation of any reported headaches. The veteran was afforded a general VA examination in November 2002 addressing his body systems, inclusive of physical and psychological disorders, including present complaints and symptoms as related to his Hodgkin's disease. However, at that examination he did not report having any current or past headaches. The veteran has argued that he did not report headaches at past evaluations because, in effect, he did not wish to be perceived as a complainer and did not wish to excessively bother the physicians. The Board concludes that it is beyond credibility that the veteran would have had ongoing migraine headaches in recent years and not reported them than at any VA examination or any treatment, other than a single VA examination in December 1999, when he also reported multiple other disorders which were also medically unsubstantiated, such as body pruritis and shaking spells. Other systemic symptoms, such as sleep impairment, irritability, difficulty concentrating, loss of energy, and various pains and discomforts, were reported at recent examinations where chronic headaches were not. By a March 2004 development letter, the RO specifically asked the veteran to supply evidence, or inform of the existence of evidence, of current headaches and of a causal link between his service-connected Hodgkin's disease and current headaches. He did not respond to that request. While a veteran may bear witness to his own subjective occasional headaches, the existence of headaches as a disability is a medical question requiring a medical diagnosis to establish its existence. Espiritu. The veteran was advised of the need for such evidence by the March 2004 development letter. Absent evidence of current disability, the preponderance of the evidence is against the veteran's claim of entitlement to service connection for headaches as secondary to service- connected Hodgkin's disease. 38 U.S.C.A. § 5107; 38 C.F.R. § 3.310. The preponderance of the evidence is against the claim, and, therefore, the benefit of the doubt doctrine does not apply. 38 U.S.C.A. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Request to Reopen Claim for Service Connection for Heart Disease as Secondary to Service-Connected Hodgkin's Disease When a claim is disallowed by a final rating action or by an action of the Board of Veterans' Appeals, it may not thereafter be reopened and allowed, and no claim based upon the same factual basis shall be considered. 38 U.S.C.A. §§ 7104(b), 7105 (West 2002). However, when a claimant requests that a claim be reopened after a final decision and submits evidence in support thereof, a determination as to whether such evidence is new and material must be made. 38 U.S.C.A. § 7105 (West 2002); 38 C.F.R. § 20.1105 (2005). Section 5108 of Title 38 of the United States Code provides that, "[i]f new and material evidence is presented or secured with respect to a claim which has been disallowed, the Secretary shall reopen the claim and review the former disposition of the claim." The regulations provide that new and material evidence means evidence not previously submitted to agency decision makers which bears directly and substantially upon the specific matter under consideration, which is neither cumulative nor redundant, and which by itself or in connection with evidence previously assembled is so significant that it must be considered in order to fairly decide the merits of the claim. 38 C.F.R. § 3.156(a) (2005). Current case law provides for the following analysis when a claimant seeks to reopen a final decision based on new and material evidence. First, it must be determined whether new and material evidence has been presented under 38 C.F.R. § 3.156(a). Second, if new and material evidence has been presented, the merits of the claim must be evaluated after ensuring the duty to assist has been fulfilled. See Hodge v. West, 155 F.3d 1356 (Fed. Cir. 1998). By an April 2000 rating action the RO denied entitlement to service connection for coronary artery disease as secondary to service-connected Hodgkin's disease. The veteran did not appeal that decision, and it became final. See 38 U.S.C.A. § 7105 (West 2002); 38 C.F.R. §§ 20.302, 20.1103 (2005). Evidence of record at the time of that decision included service medical records and post-service VA examination and treatment records, as well as private treatment records. The RO based that decision on all the evidence of record, inclusive of these myriad pieces of medical evidence then of record, none of which contained a medical opinion causally associating the veteran's Hodgkin's disease and his claimed coronary artery disease. The RO based that decision primarily on a February 2000 VA examination which specifically addressed this issue of secondary service connection for coronary artery disease. That examiner noted that the veteran had never had a syncopal episode, and had no history of rheumatic heart disease or heart failure. A positive history of hyperlipidemia and hypothyroidism was noted, as was proven coronary artery disease status post angioplasty with stenting. The examiner opined that the veteran's cardiac condition was not related to his Hodgkin's disease. Evidence received since that last prior final denial in April 2000, has consisted of unrelated VA examination records, VA treatment records including for ongoing coronary artery disease, and various submitted statements by the veteran. However, none of the newly received medical records addressed whether the veteran's coronary artery disease was caused or aggravated by his Hodgkin's disease or treatment for Hodgkin's disease. Hence, the evidence added to the claims folder since the April 2000 RO decision, while showing current coronary artery disease, does not lend any additional support for the claim for service connection for coronary artery disease as secondary to service-connected Hodgkin's disease, since current, chronic coronary artery disease had already been established. The veteran's statements and contentions directed at this issue are essentially duplicative of his prior statements and contentions, to the effect that his Hodgkin's disease and treatment for that disease affected his multiple body systems, including his cardiovascular system. Then, as now, those lay statements were not cognizable to support a causal link between Hodgkin's disease and coronary artery disease; medical evidence is required to address questions requiring medical expertise. Espiritu. Because the new evidence is thus essentially cumulative of prior evidence of record for purposes of supporting the claim, it is not new to that extent, and since it does not further the claim or indicate the presence of evidence which might further the claim, it is not so significant that it must be considered together with all the evidence of record to fairly decide the merits of the veteran's claim of entitlement to service connection for coronary artery disease as secondary to service-connected Hodgkin's disease. 38 C.F.R. § 3.156. Accordingly, reopening of the claim is not warranted. (CONTINUED ON NEXT PAGE) ORDER A higher initial evaluation than 60 percent for Hodgkin's disease for the period from November 1, 1986 through October 22, 1995 is denied. A singular rating (as opposed to combined ratings for residuals) for Hodgkin's disease of greater than 60 percent for the period beginning October 23, 1995 is denied. A higher evaluation than 20 percent for the period beginning October 23, 1995 for peripheral neuropathy of the right upper extremity is denied. A higher evaluation than 20 percent for the period beginning October 23, 1995 for peripheral neuropathy of the left upper extremity is denied. A higher evaluation than 10 percent for the period beginning October 23, 1995 for peripheral neuropathy of the right lower extremity is denied. A higher evaluation than 10 percent for the period beginning October 23, 1995 for peripheral neuropathy of the left lower extremity is denied. A higher evaluation than 10 percent for hypothyroidism for the period beginning October 23, 1995 is denied. An increased evaluation for depression, rated 50 percent disabling, is denied. An earlier effective date than May 15, 2000 for the grant of a 50 percent evaluation for depression is denied. A higher evaluation than 10 percent for GERD for the period from October 23, 1995 through September 30, 2003 is denied. A higher initial evaluation for IBS than the 30 percent assigned is denied. An earlier effective date than October 1, 2003 for the grant of service connection for IBS is denied. Secondary service connection to headaches is denied. New and material evidence has not been received to reopen a claim of secondary service connection for heart disease is denied. ____________________________________________ MICHAEL D. LYON Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs