Citation Nr: 1523286 Decision Date: 06/02/15 Archive Date: 06/16/15 DOCKET NO. 09-30 819 ) DATE ) ) ) On appeal from the Department of Veterans Affairs Regional Office in Roanoke, Virginia THE ISSUES 1. Entitlement to a rating in excess of 10 percent for gastroenteritis/gastritis. 2. Whether new and material evidence has been submitted to reopen the claim of entitlement to service connection for diabetes mellitus, type II. REPRESENTATION Veteran is represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD C. Banister, Associate Counsel INTRODUCTION The Veteran served on active duty from June 1966 to March 1970. These matters come before the Board of Veterans' Appeals (Board) on appeals from a December 2008 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in San Diego, California, and an April 2009 rating decision by the RO in Roanoke, Virginia. The issue of whether new and material evidence has been submitted to reopen the claim of entitlement to service connection for diabetes mellitus, type II, is addressed in the remand portion of the decision below. FINDING OF FACT Manifestations of the Veteran's service-connected gastroenteritis/gastritis include mild to moderate reflux; intolerance to certain foods; intermittent diarrhea and constipation; frequent abdominal pain, bloating, and discomfort, worsening after meals; and excessive belching and flatulence. CONCLUSION OF LAW The criteria for a rating in excess of 10 percent for gastroenteritis/gastritis have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2014); 38 C.F.R. § 4.114, Diagnostic Code 7307. REASONS AND BASES FOR FINDING AND CONCLUSION VA has a duty to notify and assist veterans in substantiating claims for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2014); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.3216(a) (2014). Proper notice from VA must inform the veteran of any information and medical or lay evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the veteran is expected to provide. Quartuccio v. Principi, 16 Vet. App. 183 (2002). This notice must be provided prior to an initial unfavorable decision on a claim by the RO. Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004). The notice requirements apply to all five elements of a service connection claim, including: (1) veteran status; (2) existence of a disability; (3) a connection between the appellant's service and the disability; (4) degree of disability; and (5) effective date of the disability. 38 U.S.C.A. § 5103(a); 38 C.F.R. 3.159(b); see also Dingess/Hartman v. Nicholson, 19 Vet. App. 473, 488 (2006). Further, this notice must include information that a disability rating and an effective date for the award of benefits will be assigned if service connection is awarded. Id. at 486. As will be discussed herein, the Veteran's claims file has been reconstructed and therefore, does not contain the initial letter to the Veteran with the requisite notice requirements. However, an April 2011 statement of the case indicates that in January 2009, the RO sent the Veteran a letter describing the evidence needed to substantiate his increased rating claim and offering assistance in obtaining evidence to support that claim. See Quartuccio, 16 Vet. App. at 187-88. Furthermore, the statement of the case included the relevant laws and regulations regarding VA's duty to assist and the rating criteria for gastroenteritis. Moreover, "[t]here is a presumption of regularity that attaches to actions of public officials." Woods v. Gober, 14 Vet. App. 214, 220 (2000) (citing INS v. Miranda, 459 U.S. 14, 18 (1982)); United States v. Chemical Foundation, 272 U.S. 1, 14-15 (1926); see also Woods, 14 Vet. App. at 220; see Schoolman v. West, 12 Vet. App. 307, 310 (1999) (applying the presumption as to whether the RO sent the claimant the application form for dependency and indemnity compensation benefits, and noting that the presumption of regularity in the administrative process may be rebutted by "clear evidence to the contrary"). As there is no indication from the record that the RO did not send the above-referenced letter, the Board finds that the RO satisfied the notice requirements with respect to the Veteran's increased rating claim. The duty to assist the Veteran has been satisfied. The RO obtained the Veteran's identified VA and private treatment records. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. There is no indication in the record that additional evidence relevant to the Veteran's claim is available and not part of the record. See Pelegrini v. Principi, 18 Vet. App. 112, 116 (2004). The Veteran was provided VA examinations in February 2009, August 2011, and January 2013 to assess the severity of his service-connected gastroenteritis/gastritis. The examiners reviewed the Veteran's claims file and administered thorough clinical evaluations which provided findings pertinent to the rating criteria, and all of which allowed for fully informed evaluations of the disability at issue. See Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). As there is no indication that any failure on the part of VA to provide additional notice or assistance reasonably affects the outcome of the Veteran's increased rating claim, the Board finds that any such failure is harmless. See Mayfield v. Nicholson, 20 Vet. App. 537, 542-43 (2006); see also Dingess/Hartman, 19 Vet. App. at 486; Shinseki v. Sanders, 129 S. Ct. 1696 (2009) (reversing prior case law imposing a presumption of prejudice on any notice deficiency and clarifying that the burden of showing that an error is harmful or prejudicial normally falls upon the party attacking the agency's determination); Fenstermacher v. Phila. Nat'l Bank, 493 F.2d 333, 337 (3d Cir. 1974)( "[N]o error can be predicated on insufficiency of notice since its purpose had been served."). According to a May 2010 correspondence, the Veteran's claims file was not of record at the RO in Roanoke, Virginia, and had to be rebuilt. In November 2012, the Board found that the RO did not properly document the steps taken to secure the Veteran's claims file and remanded the above-captioned claims in order to document such attempts or rebuild the claims file in accordance with the procedures set forth in M21-1MR, Part III, subpart ii, Chapter 4, Section D. Pursuant to M21-1MR, Part III, subpart ii, Chapter 4, Section D, if a claims folder is missing, the RO must request the Records Management Center conduct a missing folder search and request a physical check for the folder in the file bank by sending an email to the Veterans Service Center Manager of any RO where there is reason to believe the folder may be located. If negative replies are received from both locations, the RO must rebuild the claims folder to include: (1) preparation of a rebuilt folder; (2) development for any evidence or documents required for reconstruction; and (3) an update of the Beneficiary Identification and Records Locator System "LOC" screen to show that the folder at the RO is a rebuilt folder. Thereafter, the RO must prominently mark the cover of the rebuilt folder with the words "Rebuilt Folder." The evidence of record shows that the RO requested that the Records Management Center conduct a missing folder search in November 2012. In December 2012, the Records Management Center indicated that the claims folder could not be located. In January 2013, the RO requested a physical search for the file at any RO where there was reason to believe the file may be located. A June 2013 correspondence from the RO in Roanoke, Virginia, indicates that the RO was unable to locate the Veteran's claims file after a thorough search of the file bank. Accordingly, the RO rebuilt the Veteran's claims file and marked the cover with the words "Rebuilt Folder." The rebuilt claims file appears to contain all available service treatment records and personnel records, VA treatment records, private treatment records, and written statements from the Veteran and his representative. The evidence of record also contains documentation of the steps taken within VA to obtain all missing correspondences, rating decisions, notices of disagreement, substantive appeals, statements of the case, and supplemental statements of the case. In December 2012, the RO sent the Veteran a letter informing him that his claims file was being rebuilt and requested that he submit any copies of relevant documents he had, including VA correspondences, medical records, personnel records, and any other pertinent evidence. Subsequently, the Veteran submitted an envelope of documents in his possession relating to his claims. Upon review of the record, it appears that all relevant documents pertaining to the above-captioned claims have been obtained, with the exception of some correspondences VA sent to the Veteran. Accordingly, the Board finds that the RO complied with the procedural requirements set forth in M21-1MR, Part III, subpart ii, Chapter 4, Section D. In the November 2012 remand, the Board also ordered additional development. With respect to the Veteran's increased rating claim, the Board directed the RO to provide the Veteran with another VA examination to assess the current severity of his service-connected gastroenteritis/gastritis and attempt to obtain records from the Social Security Administration (SSA). While in remand status, the Veteran was provided a VA examination in January 2013. Additionally, the RO requested the Veteran's records from SSA, and received a response in December 2012 indicating that SSA had no records for the Veteran. In a June 2013 supplemental statement of the case, the RO confirmed and continued the already assigned 10 percent disability rating, and the claim was remitted to the Board for further appellate review. Based on the foregoing, the Board finds that the RO substantially complied with the November 2012 remand directives with respect to the Veteran's increased rating claim. See Stegall v. West, 11 Vet. App. 268, 271 (1998). Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (Rating Schedule). 38 C.F.R. Part 4 (2014). The Rating Schedule is primarily a guide in the evaluation of disability resulting from all types of diseases and injuries encountered as a result of or incident to military service. The ratings are intended to compensate, as far as can practicably be determined, the average impairment of earning capacity resulting from such diseases and injuries and their residual conditions in civilian occupations. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1 (2014). In an October 1970 rating decision, service connection was granted for gastroenteritis, to which a noncompensable rating was assigned, effective March 19, 1970. See 38 C.F.R. § 4.114, Diagnostic Code 7399-7307. Subsequently, the RO increased the Veteran's disability rating to 10 percent, effective July 8, 2002. In January 2009, the Veteran submitted a claim of entitlement to a rating in excess of 10 percent for his service-connected gastroenteritis. In a May 2009 rating decision, the RO continued the 10 percent disability rating pursuant to the criteria set forth in 38 C.F.R. § 4.114, Diagnostic Code 7399-7307. During an August 2012 hearing before the Board, the Veteran testified that he experienced symptoms of gas pain and discomfort, abdominal cramps, and belching. The Veteran reported having diagnoses of gastroenteritis, gastroesophageal reflux disease (GERD), and a hiatal hernia. He also stated that he was told by a doctor that he had an ulcer, but it was never written down. When asked whether he thought these diagnoses were all related, the Veteran indicated that he believed the different diagnoses affected one another because of his diabetes. The Veteran testified that his gastrointestinal (GI) issues prevented him from eating certain foods, such as milk and fried or spicy foods. In February 2009, the Veteran underwent a VA examination, during which he reported symptoms of almost daily bloating and frequent flatulence. The bloating sensation was occasionally associated with mild, crampy abdominal pain. The Veteran reported being treated for a stomach ulcer; however, he could not recall when. The examiner noted that the Veteran had a questionable history of GERD, for which he took Protonix. The Veteran denied having a history of ulcerative colitis, Crohn's disease, or irritable bowel syndrome. He also denied weight changes, hematemesis, melanotic stools, anemia, surgery, hospitalization, and functional impairment. His medications included Dicyclomine and Simethicone, which somewhat alleviated his symptoms. A physical examination of the abdomen was normal without evidence of organomegaly, tenderness, masses, ascites, distention, or aortic aneurism. There was no ventral, femoral, or inguinal hernia. The examiner noted that the Veteran's symptoms only minimally affected his ability to perform usual occupational and daily living activities and found no evidence of active gastroenteritis at the time of the examination. A May 2008 VA treatment record indicates that the Veteran complained of gas, including flatulence and belching. The diagnosis was flatulence and GERD. The plan was to order Simethicone for relief, continue Protonix, follow GERD precautions, continue the recommended diet, and exercise. A September 2009 VA treatment record indicates that one of the Veteran's chief complaints was gastritis. The Veteran indicated that he went to the emergency room the day before and waited a few hours, but was not seen by an emergency room physician. The Veteran reported a history of GERD and hiatal hernia. His symptoms included an increase in abdominal gas and pain, despite taking his medications. The Veteran denied symptoms of nausea, vomiting, or diarrhea. The record indicates that the Veteran also reported bilateral side pain, and a urinalysis from the previous day was positive for hematuria. The treatment provider noted that the Veteran had a history of renal stones. A physical examination of the abdomen was soft, nontender to palpation, and no abnormal mass or hepatosplenomegaly. The diagnoses included "pain, due to [chronic lower back pain], vs. renal stones, vs. GERD vs. diabetic gastroparesis." The physician ordered an ultrasound of the kidneys and referred him to GI service for GERD symptoms. Another September 2009 VA treatment record indicates that the Veteran reported abdominal pain. He stated that he did not eat any new foods, and the pain came on suddenly. He stated that he produced a lot of gas and frequently belched. The record indicates that the Veteran reported being told that he had a hiatal hernia several years ago and "has been dealing with this off and on." The diagnoses were gastritis and GERD. An October 2009 VA outpatient surgery consultation note indicates that the Veteran's chief complaint was GERD. The Veteran had no dysphagia or other GI symptoms. The diagnosis was gastritis. In November 2009, the Veteran underwent an esophagogastroduodenoscopy (EGD). The results of the upper GI endoscopy revealed mild prominence of the cricopharyngeus and a possible small Zenker's diverticulum. The swallowing mechanism was normal, and no aspiration occurred. There was no evidence of a hiatal hernia. Reflux could not be demonstrated, and gastric emptying occurred without delay. The stomach retained some fluid, but the stomach and esophagus were otherwise unremarkable. There was no definite abnormality seen in the duodenal sweep and visualized proximal small bowel. A gastric biopsy revealed moderate chronic gastritis with focal mild activity and focal changes suggestive of erosion; no evidence of intestinal metaplasia; and scant H. pylori bacteria. A gastroesophageal junction biopsy revealed benign squamous-gastric type mucosa with chronic and acute inflammation and squamous reactive changes suggestive of gastroesophageal reflux, and no evidence of intestinal metaplasia or dysplasia. In January 2010, the Veteran reported problems with his stomach. He stated that his medications have not helped much. The diagnoses were abdominal pain and gastritis. In February 2010, the Veteran reported chronic abdominal pain, bloating, and discomfort, which was worse after meals. He also reported constant belching and excessive flatulence. He indicated that he tried several medications with minimal results. The Veteran denied early satiety, nausea, vomiting, mucousy stools, hematochezia, melena, anorexia, weight loss, fever, cough, hoarseness, chest pain, or shortness of breath. Upon physical examination, the abdomen that was soft, nontender to palpation, and without evidence of hepatosplenomegaly or abnormal masses. The treatment provider opined that it was more than likely that the Veteran had GERD, which was complicated by diabetic gastroparesis. The treatment provider also noted that the Veteran's chronic elevations in blood urea nitrogen, creatinine, and amylase levels indicated that the Veteran may have chronic renal disease, which could also account for his persistent GI symptoms. A May 2010 VA pathology report revealed the presence of H. pylori bacteria, no evidence of intestinal metaplasia, and no evidence of intestinal metaplasia. The diagnosis was moderate chronic active gastritis. A May 2010 VA treatment record shows that an EGD/colonoscopy revealed a bacterial infection in the Veteran's stomach, which causes 90 percent of most ulcers. The treatment provider prescribed two different antibiotics. The Veteran was instructed to follow up after completing the medication. A July 2010 VA treatment record shows that the Veteran complained of bloating and cramping. An upper GI series showed no ulcers or tumors. The treatment provider indicated that the Veteran may have gastroparesis. The plan was to avoid acidic foods and drinks, eat a more bland diet, and continue Pantoprazole. In September 2010, the Veteran reported chronic abdominal pain, bloating, and discomfort, which worsened after meals, associated with constant eructation and excessive flatulence. The treatment provider opined that the Veteran had GERD complicated by diabetic gastroparesis. A July 2011 VA emergency care note indicates that the Veteran reported to the emergency room with symptoms of diarrhea five times a day and nausea, but no vomiting. The Veteran also reported tactile fever and chills two days earlier. The impression was probable viral gastroenteritis. The diagnosis on discharge was abdominal pain and diarrhea. The following day, the Veteran returned to the emergency department with complaints of fleeting chest pains. He stated that his stomach issues had improved. During an August 2011 VA examination, the Veteran reported feeling sick, sluggish, and weak, with difficulty breathing and loss of appetite. The Veteran reported symptoms of gas, belching, difficulty breathing, abdominal distention, diarrhea, constipation, and constant, localized abdominal pain. The Veteran stated that his symptoms occurred daily and began immediately after eating. He also indicated that movement precipitated the pain, but lying down or resting alleviated it. He denied symptoms of nausea, vomiting, fainting, and black tarry stools. The condition did not affect the Veteran's body weight or cause incapacitation. In terms of functional impairment, the Veteran stated that he could not function normally because movement caused increased gas, weakness, shortness of breath, and feeling sick, sluggish, and off balance. A physical examination of the Veteran's abdomen revealed abdominal tenderness to palpation. There was no evidence of anemia, malnutrition, hepatomegaly, distension of the superficial veins, striae on the abdominal wall, flank tenderness to palpation, an ostomy, ventral hernia, ascites, splenomegaly, and aortic aneurysm. The examiner indicated that the Veteran's gastroenteritis was active. A July 2012 VA pharmacy clinic record indicates that the Veteran reported being told in the military that he had peptic ulcer disease. A March 2012 VA primary care note indicates that the Veteran reported no shortness of breath or abdominal pain. There was no change in bowl or bladder symptoms. The diagnoses included GERD and gastroparesis. A July 2012 VA nutrition outpatient note indicates that the Veteran reported recent episodes of nausea and diarrhea, alternating with constipation. He denied vomiting. An August 2012 VA primary care telephone encounter note indicates that the Veteran reported that his GI symptoms had improved in the past couple weeks. In September 2012, the Veteran reported chronic stomach bloating. He denied experiencing nausea or vomiting. The assessment was gastroparesis. The treatment provider gave the Veteran instructions on changing his diet in order to alleviate his symptoms. In January 2013, the Veteran underwent another VA examination, during which he reported symptoms of frequent abdominal gas, bloating, intermittent diarrhea at least twice a week, with intervening normal formed bowl movements, and occasional regurgitation of stomach contents. He also reported food intolerances, including dairy products. He stated that he had to eat a bland diet and was able to identify certain foods over time that triggered his symptoms. He stated that in 1970, he was told that he had presumed peptic ulcer disease. A physical examination revealed an abdomen that was soft, nontender, and nondistended, without any masses or organomegaly. The examiner indicated that the Veteran had recurring episodes of symptoms that were not severe, approximately four or more times per year, lasting approximately one to nine days in duration, and recurring episodes of severe symptoms that occurred four or more times per year, lasting less than one day. The examiner also indicated that the Veteran had periodic, pronounced abdominal pain that occurred at least monthly and only partially relieved by standard ulcer therapy. There was no evidence of anemia, weight loss, nausea, vomiting, hematemesis, or melena, and the Veteran did not experience incapacitating episodes. There was no evidence of nodular lesions, ulcers, hemorrhages, hypertrophic gastritis, postgastrectomy syndrome, vagotomy with pyloroplasty or gastroenterostomy, or peritoneal adhesions following an injury or surgical procedure of the stomach or duodenum. The examiner reviewed the findings of the November 2009 endoscopy and noted reflux, but otherwise there were no significant changes. The examiner opined that all of the symptoms reported by the Veteran appeared to be due to GERD and presumed irritable bowel syndrome, to include abdominal gas, bloating, and diarrhea. The examiner indicated that the two conditions were not part and parcel of the Veteran's service-connected gastritis/gastroenteritis because gastritis is a clinically separate and distinct diagnosis. The examiner opined that neither the Veteran's GERD nor presumed irritable bowel syndrome were causally related to his service-connected gastritis/gastroenteritis and cited medical literature to support the opinion. In April 2013, the Veteran reported symptoms of bloating and intermittent constipation. The assessment was generalized GI tract dysmotility, to include GERD, complicated by peptic ulcer disease, diabetic gastroparesis, and constipation. The plan was to proceed with a course of Prostigmin and continue standard anti-reflux measures and a maximum dose of Protonix daily. In December 2014, the Veteran submitted a written statement and additional VA treatment records, along with a waiver of RO jurisdiction. The Veteran stated that he experienced symptoms of severe gas, cramps, and diarrhea. A December 2014 VA emergency care note indicates that the Veteran was discharged with a diagnosis of enteritis. The treatment provider recommended taking Imodium AD and avoiding food for 24 hours. Pursuant to Diagnostic Code 7307, a 10 percent disability rating is warranted for chronic gastritis with small nodular lesions and symptoms; a 30 percent disability rating is warranted for chronic gastritis with multiple small eroded or ulcerated areas and symptoms; and a maximum 60 percent disability rating is warranted for chronic gastritis with severe hemorrhages or large ulcerated or eroded areas. 38 C.F.R. § 4.114, Diagnostic Code 7307. The Veteran's treatment records show symptoms of mild to moderate reflux; intolerance to certain foods; intermittent diarrhea and constipation; frequent abdominal pain, bloating, and discomfort, worsening after meals; and excessive belching and flatulence. As a result, the Veteran had to take medication daily and alter his diet. Treatment records contain diagnoses of viral gastroenteritis, H. pylori bacterial infection, chronic gastritis, GERD, generalized GI tract dysmotility, and diabetic gastroparesis. Although the Veteran asserts that he has a hiatal hernia, ulcers, and received a diagnosis of peptic ulcer disease, there is no evidence in the Veteran's medical records to support this. The Veteran is competent to report matters about which he has first-hand knowledge. See Layno v. Brown, 6 Vet. App. 465, 469-70 (1994). However, hiatal hernias and stomach ulcers are not the types of conditions that the Veteran is able to identify. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (2007). Additionally, the evidence of record does not show that the Veteran has specialized education or training sufficient to diagnose gastrointestinal disorders. Thus, the Veteran's testimony is not competent evidence of the presence of a hiatal hernia, ulcers, or a diagnosis of peptic ulcer disease. The Veteran's treatment records include peptic ulcer disease under the Veteran's "problem list;" however, the records indicate that this diagnosis was provided as part of the Veteran's "personal history." See LaShore v. Brown, 8 Vet App 406 (1995) (holding that a lay history is not transformed into competent evidence merely because it was transcribed by a medical professional). Additionally, an April 2013 VA treatment record indicates that the Veteran's generalized GI tract dysmotility was "complicated by peptic ulcer disease." However, the record also indicates that Veteran's chief complaint was "generalized GI tract dysmotility to include GERD complicated by [peptic ulcer disease]." As no diagnostic testing was performed during that visit, the diagnosis of peptic ulcer disease was reported by the Veteran. This is consistent with numerous other VA treatment records indicating that the Veteran reported being told he had peptic ulcer disease during or shortly after service. As none of the diagnostic tests in the Veteran's treatment records revealed the presence of ulcers or other gastric lesions, the probative evidence of record does not support a finding that the Veteran has ulcers or a current diagnosis of peptic ulcer disease. Based on the foregoing, the Board finds that the Veteran's service-connected gastroenteritis/gastritis is not manifested by multiple small eroded or ulcerated areas and symptoms. Thus, a disability rating of 30 percent is not warranted. See 38 C.F.R. § 4.114, Diagnostic Code 7307. Additionally, the evidence of record does not show that the Veteran's service-connected gastroenteritis/gastritis is manifested by severe hemorrhages or large ulcerated or eroded areas. Thus, a maximum disability rating of 60 percent is not warranted. See 38 C.F.R. § 4.114, Diagnostic Code 7307. The Board has also considered whether the Veteran's service-connected gastroenteritis/gastritis warrants a higher disability rating under an alternative diagnostic code. However, the medical evidence of record does not contain diagnoses or symptoms contemplated by the rating criteria set forth in any of the other diagnostic codes pertaining to digestive disorders. See 38 C.F.R. § 4.114, Diagnostic Codes 7200 - 7354 (2014). As such, a higher disability rating is not warranted under an alternative diagnostic code. Generally, evaluating a disability using the corresponding or analogous diagnostic codes contained in the Rating Schedule is sufficient. See 38 C.F.R. §§ 4.20, 4.27 (2014). Because the ratings are averages, an assigned rating may not completely account for each individual veteran's circumstance, but nevertheless would still be adequate to address the average impairment in earning capacity caused by disability. In exceptional cases where the rating is inadequate, it may be appropriate to assign an extraschedular rating. 38 C.F.R. § 3.321(b) (2014). The threshold factor for extraschedular consideration is a finding that the evidence before VA presents such an exceptional disability picture that the available schedular evaluation for that service-connected disability is inadequate, a task performed either by the RO or the Board. Id.; see Thun v. Peake, 22 Vet. App. 111, 115 (2008), aff'd, 572 F.3d 1366 (2009); see also Fisher v. Principi, 4 Vet. App. 57, 60 (1993) ("[R]ating [S]chedule will apply unless there are 'exceptional or unusual' factors which render application of the schedule impractical"). Therefore, initially, there must be a comparison between the level of severity and symptomatology of a veteran's service-connected disability with the established criteria found in the Rating Schedule for that disability. Thun, 22 Vet. App. at 115. If the criteria reasonably describe the veteran's disability level and symptomatology, then the disability picture is contemplated by the Rating Schedule, the assigned schedular evaluation is, therefore, adequate, and no referral is required. The Board finds the Veteran's disability picture is not so unusual or exceptional in nature as to render the already assigned schedular rating inadequate. The Veteran's service connected gastroenteritis/gastritis is evaluated as a digestive disorder, the criteria of which is found by the Board to specifically contemplate the level of occupational and social impairment caused by his gastroenteritis/gastritis. 38 C.F.R. § 4.71a, Diagnostic Code 5271. Throughout the pendency of this appeal, the Veteran's service-connected gastroenteritis/gastritis was manifested by mild to moderate reflux; intolerance to certain foods; intermittent diarrhea and constipation; frequent abdominal pain, bloating, and discomfort, worsening after meals; and excessive belching and flatulence. As a result, the Veteran had to take daily medication and avoid certain foods. Despite having an intolerance to specific foods, there was no evidence of anorexia, anemia, malnutrition, or weight changes. Furthermore, throughout the pendency of this appeal, the Veteran had no ulcers, hiatal hernia, esophageal stricture, hematemesis, melanic stools, or early satiety, and he did not experience incapacitating episodes. The Rating Schedule provides for ratings in excess of 10 percent for certain manifestations of digestive disorders, but the Board finds that the evidence of record does not demonstrate that sufficient symptoms were present for any distinct period throughout the appeal period. See Hart, 21 Vet. App. at 509-10. Additionally, the Veteran may be awarded an extraschedular rating based on the combined effect of multiple conditions in an exceptional circumstance where the evaluation of the individual conditions fails to capture all the service-connected disabilities experienced. Johnson v. McDonald, 2013-7104, 2014 WL 3562218 (Fed. Cir. Aug. 6, 2014). However, in this case, there are no additional symptoms that have not been attributed to a specific service-connected disability. See Mittleider v. West, 11 Vet. App. 181 (1998). Accordingly, this is not an exceptional circumstance in which extraschedular consideration may be required to compensate the Veteran for a disability that can be attributed only to the combined effect of multiple conditions. While there may have been day-to-day fluctuations in the manifestations of the Veteran's service-connected gastroenteritis/gastritis, the evidence shows no distinct periods of time during the appeal period, when the Veteran's service-connected gastroenteritis/gastritis varied to such an extent that a rating greater or less than 10 percent would be warranted. See Hart, 21 Vet. App. at 507. In reaching this decision, the Board considered the doctrine of reasonable doubt; however, as the preponderance of the evidence is against assigning the Veteran's service-connected gastroenteritis/gastritis a rating in excess of 10 percent, the doctrine is not for application. Gilbert v. Derwinski, 1 Vet. App. 49, 56 (1990). ORDER A rating in excess of 10 percent for gastroenteritis/gastritis is denied. REMAND In October 2008, the Veteran submitted a claim to reopen the issue of entitlement to service connection for diabetes mellitus, type II. During a November 2012 hearing before the Board, the Veteran testified that he received a diabetes screening while he was stationed at Hanscom Air Force Base in Bedford, Massachusetts. He stated that his blood sugar was tested, and it was high. He further testified that he was sent to the Navy Hospital in Chelsea, Massachusetts, for further testing, but the results were negative for diabetes. In the November 2012 remand, the Board directed the RO to attempt to obtain the Veteran's 1968 service treatment records from the Bedford Naval Hospital. As the Veteran's service treatment records contained records after March 1968, the RO requested records from Bedford Naval Hospital dated January 1968 through March 1968. In February 2013, the National Personnel Records Center indicated that there was no listing for any such entity. In June 2013, the RO informed the Veteran that it was unable to obtain service treatment records from the Bedford Naval Hospital and requested that the Veteran provide the records if they were in his possession. In a July 2013 written statement, the Veteran indicated that the RO erred in requesting records from the Bedford Naval Hospital and should have requested records from the Chelsea Naval Hospital. Although the Veteran testified that the blood test performed at Chelsea Naval Hospital was negative for diabetes, the Veteran appears to assert that VA should have obtained these records pursuant to his service connection claim. Thus, VA's duty to assist requires that that VA attempt to obtain the Veteran's service treatment records from the Chelsea Naval Hospital from January 1968 through March 1968. See 38 C.F.R. 3.159(c)(1) (2014). Accordingly, the case is remanded for the following action: 1. The RO must attempt to obtain the Veteran's service treatment records from the Chelsea Naval Hospital in Chelsea, Massachusetts, dated January 1968 through March 1968, as per the Veteran's July 2013 written statement. All attempts to secure this evidence must be documented in the claims file by the RO. If, after making reasonable efforts to obtain the named records, the RO is unable to secure the same, the RO must notify the Veteran and (a) identify the specific records the RO is unable to obtain; (b) briefly explain the efforts that the RO made to obtain those records; (c) describe any further action to be taken by the RO with respect to the claim; and (d) that he is ultimately responsible for providing the evidence. The Veteran and his representative must then be given an opportunity to respond. 2. After completing the above action, and any other development as may be indicated by any response received as a consequence of the action taken in the paragraph above, the claim to reopen the issue of entitlement to service connection for diabetes mellitus, type II, must be re-adjudicated. If the benefit sought on appeal remains denied, a supplemental statement of the case must be provided to the Veteran and his representative. After the Veteran has had an adequate opportunity to respond, the appeal must be returned to the Board for further appellate review. No action is required by the Veteran until he receives further notice; however, he may present additional evidence or argument while the case is in remand status at the RO. Kutscherousky v. West, 12 Vet. App. 369 (1999). ______________________________________________ JOY A. MCDONALD Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs