Citation Nr: 0814517 Decision Date: 05/02/08 Archive Date: 05/12/08 DOCKET NO. 05-33 984 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Cheyenne, Wyoming THE ISSUES 1. Entitlement to an increased evaluation in excess of 30 percent for gastroesphogeal reflux disease with sliding hiatal hernia associated with duodenal ulcer by history, esophageal diverticulum, Barrett's esophagitis, diverticulosis coli and hyperplastic colonic polyps. 2. Entitlement to separate compensable evaluations of 20 percent for service-connected duodenal ulcer, 30 percent for gastroesophageal reflux disease, and 30 percent for sliding hiatal hernia. REPRESENTATION Appellant represented by: Veterans of Foreign Wars of the United States ATTORNEY FOR THE BOARD Kristi L. Gunn, Associate Counsel INTRODUCTION The veteran served on active duty from April 1970 to July 1973. This case comes before the Board of Veterans' Appeals (Board) on appeal from an April 2004 rating decision of the Cheyenne, Wyoming, Department of Veterans Affairs (VA) Regional Office (RO), which continued the noncompensable evaluation for duodenal ulcer by history and denied service connection for diverticulitis. In the April 2004 rating decision, the RO also granted service connection and assigned the following disability evaluations: sliding hiatal hernia, 10 percent disabling; gastroesophageal reflux disease (GERD), 10 percent disabling; and hemorrhoids, 0 percent disabling. The veteran contests the evaluations assigned for GERD, sliding hiatal hernia, and duodenal ulcer. Subsequently thereafter, in a July 2004 rating decision, the RO granted a combined evaluation of 30 percent disabling for the veteran's GERD with sliding hiatal hernia associated with duodenal ulcer by history, effective November 2003. The veteran was advised of the above grant of an increased rating by the July 2004 rating decision. However, she did not withdraw her appeal. Thus, this appeal continues. See AB v. Brown, 6 Vet. App. 35 (1993). It is also noted that based on a May 2006 addendum, the RO in June 2006, recharacterized the veteran's service-connected disability as gastroesophageal reflux disease with sliding hiatal hernia associated with duodenal ulcer by history, esophageal diverticulum, Barrett's esophagitis, diverticulosis coli and hyperplastic colonic polyps. The issue is stated on the title page. However, the matter of entitlement to a separate compensable rating for esophageal diverticulum and Barrett's esophagitis is addressed further in the remand portion of the decision below and is REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. FINDINGS OF FACT 1. All relevant evidence necessary for an equitable disposition of the veteran's appeal has been obtained. 2. The veteran's service-connected GERD with sliding hiatal hernia associated with duodenal ulcer by history is currently manifested by complaints of abdominal pain, heartburn, and vomiting without objective findings of recurrent hematemesis or melena, anemia, weight loss, or any other symptom combinations productive of severe impairment of health. 3. The veteran's GERD, sliding hiatal hernia, and duodenal ulcer may not be separately evaluated. CONCLUSIONS OF LAW 1. The criteria for entitlement to a disability evaluation in excess of 30 percent for GERD with sliding hiatal hernia associated with duodenal ulcer by history, diverticulosis coli and hyperplastic colonic polyps have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.159, 4.7, 4.10, 4.20, 4.114, Diagnostic Code 7346 (2007). 2. The criteria for entitlement to separate compensable evaluations of 20 percent for service-connected duodenal ulcer, 30 percent for GERD, and 30 percent for sliding hiatal hernia have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.159, 4.114 (2007). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Decision The veteran seeks a higher evaluation for her service- connected GERD with sliding hiatal hernia associated with duodenal ulcer by history. Under the applicable criteria, disability evaluations are determined by the application of a schedule of ratings which is based on average impairment of earning capacity. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4. Separate diagnostic codes identify the various disabilities. VA has a duty to acknowledge and consider all regulations which are potentially applicable through the assertions and issues raised in the record, and to explain the reasons and bases for its conclusion. Schafrath v. Derwinski, 1 Vet. App. 589 (1991). In this case, service connection for duodenal ulcer, by history, was granted by means of a November 1983 rating decision and assigned a noncompensable evaluation under Diagnostic Code 7305, effective August 1983. By correspondence received in February 2004, the veteran filed informal claims seeking an increased rating for her service- connected duodenal ulcer, as well as service connection for sliding hiatal hernia, GERD, and hemorrhoids. In the April 2004 rating decision, the RO continued the noncompensable evaluation for the veteran's service-connected duodenal ulcer, but also granted service connection for sliding hiatal hernia (10 percent disabling), GERD (10 percent disabling), and hemorrhoids (0 percent disabling), effective November 2003. The veteran appealed therefrom. In the July 2004 rating decision, the RO determined that a 30 percent combined evaluation, effective November 2003, was warranted for the veteran's overall disability, encompassing GERD with sliding hiatal hernia associated with duodenal ulcer by history. In 2006, the disability was recharacterized to include esophageal diverticulum, Barrett's esophagitis, diverticulosis coli and hyperplastic colonic polyps. The 30 percent evaluation was continued under Diagnostic Codes 7399-7346. The veteran contends that a higher evaluation in excess of 30 percent is warranted for her disabilities, and asserts that separate evaluations should be assigned for each disability. In general, when an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). However, when the current appeal arose from the initially assigned rating, consideration must be given as to whether staged ratings should be assigned to reflect entitlement to a higher rating at any point during the pendency of the claim. Fenderson v. West, 12 Vet. App. 119 (1999). The 30 percent currently assigned for symptoms related to GERD with sliding hiatal hernia associated with duodenal ulcer by history, diverticulosis coli and hyperplastic colonic polyps, is contemplated by analogy to Diagnostic Codes 7399-7346. The use of Diagnostic Code 7399 represents an unlisted disability that required rating by analogy to one of the disorders rated under 38 C.F.R. § 4.114. See 38 C.F.R. § 4.27 (2007) (hyphenated diagnostic codes are used when a rating under one diagnostic code requires use of an additional diagnostic code to identify the basis for the evaluation assigned; the additional code is shown after the hyphen). A 30 percent evaluation under Diagnostic Code 7346 is warranted for a hiatal hernia with persistently recurrent epigastric distress with dysphagia, pyrosis, and regurgitation, accompanied by substernal or arm or shoulder pain, productive of considerable impairment of health. A 60 percent evaluation is in order for symptoms of pain, vomiting, material weight loss and hematemesis or melena with moderate anemia; or other symptom combinations productive of severe impairment of health. Weight loss is a criterion for a disability rating higher than currently assigned for the veteran's gastrointestinal disorder under Diagnostic Code 7346. For purposes of evaluating conditions in Section 4.114, the term "substantial weight loss" means a loss of greater than 20 percent of the individual's baseline weight, sustained over three months or longer; and the term "minor weight loss" means a weight loss of 10 to 20 percent of the individual's baseline weight, sustained for three months or longer. The term "inability to gain weight" means that there has been substantial weight loss with inability to regain it despite appropriate therapy. "Baseline weight" means the average weight for the two-year-period preceding onset of the disease. See 38 C.F.R. § 4.112. In March 2004, the veteran was afforded a VA examination for her service-connected gastrointestinal disabilities. The veteran reported that she was diagnosed with hiatal hernia in February 2000 and GERD approximately ten years ago. She experiences bad heartburn, vomiting, and food sticking to her esophagus approximately one to two times a month. The veteran informed the examiner that she takes prescribed medication twice daily and avoids spicy foods. She admitted that there were no limitations secondary to her service- connected duodenal ulcer or that she experienced problems working due to her gastrointestinal complaints. Physical examination of the veteran revealed a well-developed and well-nourished female. The veteran's weight was 200 pounds, and her heart demonstrated regular rate and rhythm with no murmurs, rubs, or gallops. The lungs were clear to auscultation bilaterally, and the abdomen produced normal bowel sounds. There were no hepatosplenomegaly or masses, but mild tenderness in the right upper quadrant area was noted. The examiner diagnosed the veteran with duodenal ulcer, hemorrhoids, sliding hiatal hernia, GERD, and diverticulitis. In October 2004, the veteran was hospitalized for rectal bleeding. The October 2004 VA outpatient treatment record noted that the veteran had severe cramping and bleeding, but denied fever, chills, dysuria, and lightheadedness. The treatment record reported the veteran's history of duodenal ulcer and GERD with no major changes in her weight, chest pain, abdominal pain, diarrhea, or skin problems. The veteran weighed 197 pounds, and the abdomen was soft with tenderness along the descending colon area. There were no hemorrhoids present and no blood present at the anal opening. The veteran was admitted to the hospital and diagnosed with several gastrointestinal disabilities, including lower gastrointestinal bleed probably from diverticulosis, diverticulosis of the descending colon and the sigmoid, duodenal ulcer disease, and GERD. The veteran was afforded a second VA examination for her service-connected gastrointestinal disabilities in March 2005. She informed the examiner that she has daily dyspepsia and regurgitation after every meal. She stated that her symptoms are alleviated with brown sugar or peanut butter, pancakes, fruits, and apples. The veteran reported that she has "breakthrough" heartburn approximately one day per week and excessive belching approximately three days a week. Ingesting Tums or drinking milk improves her breakthrough symptoms, and she denied having had an upper endoscopy. Upon physical examination, the examiner observed that the veteran was mildly obese with pain being a two out of ten, in terms of intensity. Bowel sounds were active, and the abdomen was soft and mildly tender in the right lower quadrant. Rectal examination revealed some external hemorrhoids. The examiner diagnosed the veteran with duodenal ulcer, GERD, sliding hiatal hernia, multiple colonic polyps, diverticulosis, and hemorrhoids. In March 2006, the veteran returned to her local VA outpatient facility with complaints of heartburn. She indicated that due to her heartburn and peptic ulcers, she was placed on a low fiber diet, which she has maintained for years. The veteran reported taking the prescribed medication, Ranitidine, regularly, and denied having nausea, vomiting, or abdominal pain. An esophagogastroduodenoscopy was performed, which revealed irregular gastroesophageal (GE) junction, small distal esophageal diverticulum, and small to moderate hiatal hernia. The veteran was assessed with irregular GE junction, rule out Barrett's esophagitis, hiatal hernia, and esophageal diverticulum. Based upon the current medical evidence, the Board finds that the veteran's symptoms more closely approximate the criteria for a 30 percent rating under Diagnostic Code 7346. There is no evidence that the veteran experiences material weight loss, hematemesis, melena, or anemia, all of which are criteria set forth for a 60 percent rating, as described above. While the veteran experiences epigastric pain and vomiting, those symptoms are contemplated by the 30 percent currently assigned. Additionally, the medical evidence of record does not show the veteran has had material weight loss associated with her service-connected gastrointestinal disabilities. As stated previously, the October 2004 VA outpatient treatment record stated that the veteran had no major changes with her weight. In fact, the veteran has actually gained weight since her initial gastrointestinal disability was originally service-connected. As the records show, the veteran weighed 147 pounds upon entry into service and 160 pounds upon separation in June 1973. After service, the veteran's weight has fluctuated from 212 pounds to 193 pounds over the course of the appeal. Thus, the veteran has not exhibited any material weight loss, and a higher rating under Diagnostic Code 7346 is not warranted. The Board has also considered whether the veteran's service- connected gastrointestinal disabilities may be rated under any other diagnostic codes to warrant a higher rating. See Schafrath v. Derwinski, 1 Vet. App. 589 (1991). The veteran's service-connected stomach disability is not manifested by the moderately severe symptoms that are commensurate with an increased rating of 40 percent under Diagnostic Code 7305. The rating criteria for evaluating duodenal ulcer is listed under Diagnostic Code 7305. A 30 percent evaluation is not afforded under Diagnostic Code 7305. Rather a 40 percent evaluation rating is warranted for moderately severe symptoms, with less than severe symptoms but with impairment of health manifested by anemia and weight loss or recurrent incapacitating episodes averaging 10 days or more in duration at least four or more times a year. A 60 percent rating is warranted for severe symptoms with pain only partially relieved by standard ulcer therapy, periodic vomiting, recurrent hematemesis or melena, with manifestations of anemia and weight loss productive of definite impairment of health. 38 C.F.R. § 4.114, Diagnostic Codes 7304, 7305 (2007). Overall, the medical evidence does not show that the veteran has anemia associated with her gastrointestinal disabilities. No VA examiner has reported a history or evidence of anemia. Furthermore, as previously stated, the medical evidence also fails to show that the veteran has had weight loss to such a degree that there is an impairment of health. Moreover, the record reflects that the veteran has not had any incapacitating episodes due to her service-connected disabilities. Although the veteran does report epigastric pain, nausea, and vomiting associated with her gastrointestinal disabilities, the veteran does not contend and the medical evidence does not show that any physician has prescribed bedrest to treat her symptoms. Based on the foregoing, the Board finds that an increased rating for GERD with sliding hiatal hernia associated with duodenal ulcer by history under Diagnostic Code 7305 is not warranted. Additionally, a higher rating is not warranted under DCs 7319 (Irritable colon syndrome), 7323 (Ulcerative colitis), or 7323 Diverticulitis). The veteran is already rated at 30 percent, the maximum rating allowable under 7319 and there is no evidence of severe ulcerative colitis with numerous attacks a year and malnutrition and the health only fair during remissions. Finally, the Board notes that the veteran contends that her service-connected disabilities warrant separate evaluations. Specifically, in an October 2005 personal statement, the veteran requests 20 percent for duodenal ulcer under Diagnostic Code 7305, 30 percent for GERD under Diagnostic Code 7203, and 30 percent for sliding hiatal hernia under Diagnostic Code 7346. However, VA regulations provide that 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. See 38 C.F.R. § 4.114. In this case, the veteran's duodenal ulcer and sliding hiatal hernia fall within the category of assigning a single evaluation due to their respective diagnostic codes, which was done by the RO as reflected in the July 2004 rating decision. It is also noted that GERD is not ratable under 7203. In view of the Court's holding in Fenderson, supra, the Board has considered whether the veteran was entitled to staged ratings for her service-connected GERD, with sliding hiatal hernia associated with duodenal ulcer by history as the Court indicated can be done in this type of case. However, upon reviewing the longitudinal record in this case, we find that, at no time during the pendency of this appeal for an increased rating has her disability been more or less disabling than as currently rated under the present decision. The veteran is competent to report her symptoms, and the Board does not doubt the sincerity of the veteran's belief that her service-connected gastrointestinal disabilities have worsened. The Board also acknowledges the veteran's mother and friend statements regarding the veteran's symptoms; however, the objective clinical findings do not support their assertions for the reasons stated above. As the preponderance of the evidence is against the veteran's claim for an increased rating for GERD with sliding hiatal hernia associated with duodenal ulcer by history, the benefit-of- the-doubt doctrine is not for application, and an increased rating must be denied. See 38 U.S.C.A. § 5107(b); Gilbert, 1 Vet. App. at 55. II. Duty to Notify & Assist The Veterans Claims Assistance Act of 2000 (VCAA) imposes obligations on VA in terms of its duty to notify and assist claimants. When VA receives a complete or substantially complete application for benefits, it is required to notify the claimant and the representative, if any, of any information and medical or lay evidence that is necessary to substantiate the claim. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b) (2007); Quartuccio v. Principi, 16 Vet. App. 183 (2002). In Pelegrini v. Principi, 18 Vet. App. 112, 120-21 (2004), the Court held that VA must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide; and that (4) VA will request that the claimant provide any evidence in his possession that pertains to the claim. For an increased-compensation claim, section § 5103(a) requires, at a minimum, that the Secretary notify the claimant that, to substantiate a claim, the claimant must provide, or ask the Secretary to obtain, medical or lay evidence demonstrating a worsening or increase in severity of the disability and the effect that worsening has on the claimant's employment and daily life. Vazquez-Flores v. Peake, 22 Vet. App. 37 (2008). Further, if the Diagnostic Code under which the claimant is rated contains criteria necessary for entitlement to a higher disability rating that would not be satisfied by the claimant demonstrating a noticeable worsening or increase in severity of the disability and the effect that worsening has on the claimant's employment and daily life (such as a specific measurement or test result), the Secretary must provide at least general notice of that requirement to the claimant. Additionally, the claimant must be notified that, should an increase in disability be found, a disability rating will be determined by applying relevant Diagnostic Codes, which typically provide for a range in severity of a particular disability from noncompensable to as much as 100 percent (depending on the disability involved), based on the nature of the symptoms of the condition for which disability compensation is being sought, their severity and duration, and their impact upon employment and daily life. As with proper notice for an initial disability rating and consistent with the statutory and regulatory history, the notice must also provide examples of the types of medical and lay evidence that the claimant may submit (or ask the Secretary to obtain) that are relevant to establishing entitlement to increased compensation-e.g., competent lay statements describing symptoms, medical and hospitalization records, medical statements, employer statements, job application rejections, and any other evidence showing an increase in the disability or exceptional circumstances relating to the disability. Vazquez-Flores, 22 Vet. App. 37 (2008). In regards to the claim for an increased rating, the RO sent a letter to the veteran in March 2004 regarding the VCAA notice requirements for increased rating claims. In the letter, the veteran was informed that the evidence necessary to substantiate the claim for an increased evaluation would be evidence showing that her disability is worse than the current evaluation contemplates. It also informed her that on her behalf, VA would make reasonable efforts to obtain records that were not held by a federal agency, such as records from private doctors and hospitals. The letter stated that she would need to give VA enough information about the records so that it could obtain them for her. Finally, she was told to submit any evidence in her possession that pertained to the claim. While the Board acknowledges the March 2004 letter, the VCAA duty to notify has not been satisfied because the letter did not specifically advise the veteran that he could provide medical or lay evidence demonstrating a worsening or increase in severity of her disability and the effect that worsening has on her employment and daily life. The letter also failed to notify the veteran that she may submit evidence such as lay statements, medical statements, employer statements, job application rejections, and any other evidence indicative of an increase in his disabilities or exceptional circumstances relating to the disabilities. In Sanders v. Nicholson, 487 F.3d 881 (Fed. Cir. 2007), the United States Court of Appeals for the Federal Circuit held that any error by VA in providing the notice required by 38 U.S.C. § 5103(a) and 38 C.F.R. § 3.159(b)(1) is presumed prejudicial, and that once an error is identified as to any of the four notice elements the burden shifts to VA to demonstrate that the error was not prejudicial to the appellant. The Federal Circuit stated that requiring an appellant to demonstrate prejudice as a result of any notice error is inconsistent with the purposes of both the VCAA and VA's uniquely pro-claimant benefits system. Instead, the Federal Circuit held in Sanders that all VCAA notice errors are presumed prejudicial and require reversal unless VA can show that the error did not affect the essential fairness of the adjudication. To do this, VA must show that the purpose of the notice was not frustrated, such as by demonstrating: (1) that any defect was cured by actual knowledge on the part of the claimant, see Vazquez-Flores v. Peake, 22 Vet. App. 37 (2008) ("Actual knowledge is established by statements or actions by the claimant or the claimant's representative that demonstrate an awareness of what was necessary to substantiate his or her claim.") (citing Dalton v. Nicholson, 21 Vet. App. 23, 30-31 (2007)); (2) that a reasonable person could be expected to understand from the notice what was needed; or (3) that a benefit could not have been awarded as a matter of law. Sanders, 487 F.3d at 889. Additionally, consideration also should be given to "whether the post-adjudicatory notice and opportunity to develop the case that is provided during the extensive administrative appellate proceedings leading to the final Board decision and final Agency adjudication of the claim ... served to render any pre-adjudicatory section 5103(a) notice error non-prejudicial." Vazquez-Flores v. Peake, 22 Vet. App. 37 (2008). In this case, the Board finds that the notice errors did not affect the essential fairness of the adjudication because the veteran had actual knowledge of what was necessary to substantiate her claim for an increased rating, which is shown by her statements contending that her disabilities have worsened in severity and affect her overall daily functioning. The Board finds that by way of the veteran's actual knowledge and the overall development of her claim throughout the pendency of this appeal, the errors of notice are non-prejudicial to the veteran. In addition to the foregoing analysis, to whatever extent the recent decision of the Court in Dingess v. Nicholson, 19 Vet. App. 473 (2006), requires more extensive notice in claims for compensation, e.g., as to potential downstream issues such as disability rating and effective date, the Board finds no prejudice to the veteran in proceeding with the present decision. Since the claims are being denied, any such effective date questions are moot. The veteran has had ample opportunities to meaningfully participate in the adjudicative claims process. Any error or deficiency in this regard is harmless, and not prejudicial. VA must also make reasonable efforts to assist the claimant in obtaining evidence necessary to substantiate the claim for the benefit sought, unless no reasonable possibility exists that such assistance would aid in substantiating the claims. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159 (2007). In connection with the current appeal, VA obtained the veteran's service medical records and VA outpatient treatment records dated August 1983 to March 2006. The veteran was also provided a VA examination in connection with her claim for an increased rating. For the foregoing reasons, the Board concludes that all reasonable efforts were made by VA to obtain evidence necessary to substantiate the claims. The evidence of record provides sufficient information to adequately evaluate the claims. Therefore, no further assistance to the veteran with the development of evidence is required, nor is there notice delay or deficiency resulting in any prejudice to the veteran. 38 U.S.C.A. § 5103A(a)(2); 38 C.F.R. § 3.159(d); see Mayfield v. Nicholson, 19 Vet. App. 103 (2005), rev'd on other grounds, 444 F.3d 1328 (Fed. Cir. 2006). ORDER Entitlement to an increased evaluation in excess of 30 percent for GERD, with sliding hiatal hernia, associated with duodenal ulcer, by history is denied. Entitlement to separate compensable evaluations of 20 percent for service-connected duodenal ulcer, 30 percent for GERD, and 30 percent for sliding hiatal hernia is denied. REMAND As noted in the Introduction section of this decision, in June 2006, the RO recharacterized the veteran's service- connected disability as gastroesophageal reflux disease with sliding hiatal hernia associated with duodenal ulcer by history, esophageal diverticulum, Barrett's esophagitis, diverticulosis coli and hyperplastic colonic polyps. As noted above, VA regulations provide that there are diseases of the digestive system, particularly within the abdomen, which, while differing in the site of pathology, produce a common disability picture characterized in the main by varying degrees of abdominal distress or pain, anemia and disturbances in nutrition. Consequently, certain coexisting diseases in this area, as indicated in the instruction under the title "Diseases of the Digestive System," do not lend themselves to distinct and separate disability evaluations without violating the fundamental principle relating to pyramiding as outlined in 38 C.F.R. § 4.14. 38 C.F.R. § 4.113. Thereafter, applicable regulations provide that 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. § 4.114. However, in this case, the veteran has at times, complained of pain when eating and having food stuck in her esophagus, and diagnoses of Barrett's esophagitis and esophageal diverticulum have been made. See June 2006 rating determination and SSOC. If objectively confirmed, the discomfort and preventive measures associated with difficulty swallowing and avoidance of food due to obstruction could be separately compensated under 38 C.F.R. § 4.114, Diagnostic Codes 7203, 7204, or 7205 (2007). Because the rating schedule does not prohibit the assignment of a separate rating in this regard, and the clinical evidence of record is insufficient to render an equitable determination, additional action is warranted. Accordingly, the case is REMANDED for the following action: 1. Schedule the veteran for the appropriate VA examination to determine the current level of impairment due solely to Barrett's esophagitis and esophageal diverticulum. The claims folder should be made available to the examiner for review. The examiner is asked to comment on whether dysphagia is the result of the Barrett's esophagus and esophageal diverticulum, and whether the veteran can swallow food or only liquid. The examiner is also asked to describe whether the veteran's symptoms are moderate or severe, or productive of any impairment of health. If no impairment is present the examiner should state so. 2. After the above development is completed, adjudicate the claim of whether a compensable rating is warranted for Barrett's esophagus and esophageal diverticulum. If any benefit sought on appeal remains denied, furnish the veteran a supplemental statement of the case and return the case to the Board. The veteran has the right to submit additional evidence and argument on the matter the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2007). ____________________________________________ C. CRAWFORD Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs