Citation Nr: 1131160 Decision Date: 08/24/11 Archive Date: 09/07/11 DOCKET NO. 08-01 123 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Oakland, California THE ISSUE Entitlement to an increased rating for gastroesophageal reflux disease (GERD), currently evaluated as 30 percent disabling. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD E. D. Anderson, Associate Counsel INTRODUCTION The Veteran served on active duty from April 1942 to March 1946. This case comes before the Board of Veterans' Appeals (Board) on appeal from a July 2007 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Oakland, California. In December 2009, the Veteran testified before the undersigned at a video-conference hearing. The hearing transcript is associated with the claims folder. This matter has been remanded to the Board by a February 2011 Order of the United States Court of Appeals for Veterans' Claims (Court). Please note this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2010). 38 U.S.C.A. § 7107(a)(2) (West 2002). FINDING OF FACT The Veteran's GERD results in recurrent epigastric distress with dysphagia, pyrosis, regurgitation and emesis which contributes to anemia, but does not result in material weight loss, hematemesis, melena or other symptom combinations productive of severe impairment of health. CONCLUSION OF LAW The criteria for a rating greater than 30 percent for GERD have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 4.1-4.7, 4.20, 4.27, 4.112, 4.114, Diagnostic Codes (DC) 7304-7307, 7346 (2010). REASONS AND BASES FOR FINDING AND CONCLUSION Disability evaluations are determined by the application of the facts presented to VA's Schedule for Rating Disabilities (Rating Schedule) at 38 C.F.R. Part 4. The percentage ratings contained in the Rating Schedule represent, as far as can be practicably determined, the average impairment in earning capacity resulting from diseases and injuries incurred or aggravated during military service and the residual conditions in civilian occupations. 38 U.S.C.A. § 1155; 38 C.F.R. §§ 3.321(a), 4.1. In evaluating the severity of a particular disability, it is essential to consider its history. 38 C.F.R. § 4.1; Peyton v. Derwinski, 1 Vet. App. 282 (1991). Where there is a question as to which of two evaluations shall be applied, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that evaluation. 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 importance. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). However, separate ratings may also be assigned for separate periods of time based on the facts found. Hart v. Mansfield, 21 Vet. App. 505 (2007). The relevant temporal focus for adjudicating an increased rating claim is on the evidence concerning the state of the disability from the time period one year before the claim was filed until VA makes a final decision on the claim. Id. See generally 38 U.S.C.A. § 5110(b)(2). Pertinent regulations do not require that all cases show all findings specified by the Rating Schedule, but that findings sufficiently characteristic to identify the disease and the resulting disability and above all, coordination of rating with impairment of function will be expected in all cases. 38 C.F.R. § 4.21. Therefore, the Board has considered the potential application of various other provisions of the regulations governing VA benefits, whether or not they were raised by the Veteran, as well as the entire history of the Veteran's disability in reaching its decision. Schafrath v. Derwinski, 1 Vet. App. 589 (1991). GERD is not among the listed conditions in VA's Schedule for Rating Disabilities. 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 the anatomical localization and symptomatology are closely analogous. 38 C.F.R. § 4.20. According to the policy in the schedule, when a disability is not specifically listed, the DC will be "built up," meaning that the first 2 digits will be selected from that part of the schedule most closely identifying the part of the body involved, and the last 2 digits will be "99." 38 C.F.R. § 4.27. The RO has rated the Veteran's GERD under DC 7399-7346, as analogous to hiatal hernia. As the Board will discuss in greater detail below, the Board can find no other more appropriate code to use in rating this disability. Under DC 7346, the currently assigned 30 percent rating contemplates persistently recurrent epigastric distress with dysphagia, pyrosis and regurgitation accompanied by substernal or arm or shoulder pain, productive of considerable impairment of health. 38 C.F.R. § 4.114, DC 7346. A 60 percent disability rating is warranted 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. Id. Weight loss is a consideration in evaluating digestive system disorders. VA regulations provide that, for purposes of evaluating conditions in 38 C.F.R. § 4.114, the term "substantial weight loss" means a loss of greater than 20 percent of the individual's baseline weight, sustained for 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. 38 C.F.R. § 4.112. Ratings under Diagnostic Codes 7301 to 7329, inclusive, 7331, 7342, and 7345 to 7348, inclusive, will not be combined with each other. A single disability rating will be assigned under the diagnostic code which reflects the predominant disability picture, with rating to the next higher evaluation where the severity of the overall disability warrants such rating. See 38 C.F.R. § 4.114. Applying the criteria to the facts of this case, the Board finds that the criteria for a rating greater than 30 percent for GERD have not been met for any time during the appeal period. The Board notes that the Veteran's GERD results in recurrent epigastric distress with dysphagia, pyrosis, regurgitation and emesis which contributes to anemia, but does not result in material weight loss, hematemesis, melena or other symptom combinations productive of severe impairment of health. Historically, the Veteran filed a claim of service connection for GERD in January 2003. Private clinical records reflected treatment for GERD with Prilosec. The Veteran's weight ranged from 143 to 147 pounds. On VA Compensation and Pension (C&P) examination in March 2004, the Veteran reported GERD symptoms of epigastric pain and burning after eating a meal with regurgitation. He further described an inability to sleep flat on his back or sides at night. The examiner noted that the Veteran was taking Protonix with good mild to moderate control, providing evidence against this claim as it clearly indicates "good mild to moderate control" of the disability at issue. An April 2004 RO rating decision granted service connection for GERD and assigned an initial 10 percent disability rating under DC 7399-7346. Thereafter, the Veteran's VA clinical records reflect his report of daily symptoms of epigastric burning lasting 30 minutes to a couple of hours as well as throat symptoms intermittently during the day. He further described intermittent solid and liquid dysphagia. An endoscopy in May 2005 demonstrated moderate-sized sliding hiatus hernia and possible short segment Barrett's esophagus. Biopsy diagnosis was significant for cardiac type gastric mucosa with mild chronic inflammation and no intestinal metaplasia (Barrett's esophagus). The Veteran's weight ranged from 136 to 142 pounds. VA C&P examination in December 2005 included the Veteran's additional complaint of daily dysphagia for solid foods, daily pyrosis with acid reflux, burning sensation to a moderate degree in the mouth and throat especially with burping, moderate epigastric discomfort, and daily acid reflux. The examiner diagnosed sliding hiatal hernia, GERD with mild chronic inflammation and no evidence of Barrett's esophagus. The examiner noted that the Veteran was symptomatic daily but was able to maintain his state of nutrition and health, providing more evidence against this claim. An RO rating decision dated January 2006 increased the evaluation for GERD to 30 percent disabling. The Veteran filed his claim for an increased rating in February 2007. VA clinical records from February 2006 to April 2007 reflect the Veteran's continued complaint of GERD symptoms. His weight ranged from 140 to 145 pounds. On VA C&P examination in April 2007, the Veteran described his general state of health as poor. He continued to have daily reflux of acid in his throat which previously had mostly occurred when lying down at night. Now, these symptoms even occurred while sitting several times a day. The Veteran had mild discomfort with swallowing solid food. He rinsed his mouth and took an antacid at least twice daily. The Veteran slept at a 30 degree incline with an extra pillow. He tended to get left upper quadrant sharp discomfort but denied substernal or true epigastric discomfort. There was no history of hematemesis or melena. The Veteran occasionally regurgitated partially digested food and had nausea, but he denied vomiting. He ate small meals more frequently with in-between snacks. The Veteran had never required a blood transfusion or iron due to anemia. His weight remained stable at 140 pounds. Importantly, the Veteran described his GERD symptoms as a nuisance to his activities of daily living, requiring him to alter his diet and eating habits (the Board finds that the fact that the Veteran would indicate the problem was a nuisance only provides factual evidence against his own claim, indicating to the Board, at best, the moderate nature of the problem). The examiner diagnosed moderate-sized hiatal hernia with GERD and biopsy evidence of mild chronic inflammation. Thereafter, a VA endocrinology consultation in June 2007 noted that the Veteran had osteoporosis with risk factors which included low body weight. He was prescribed Fosamax. In September 2007, the Veteran was referred for a gastroenterology consultation due to report of a worsening of GERD symptoms. He described some intermittent symptoms of fatigue. He weighed 142 pounds. During an October 2007 gastroenterology consultation, the Veteran described decreased control of his GERD symptoms with proton pump inhibitor therapy. He generally described GERD symptoms of some regurgitation when lying down with episodes of epigastric discomfort and burning. The examiner indicated that the Veteran's treatment for osteoporosis with Alendronate (Fosamax) may be contributing to his GERD symptoms. The Veteran weighed 140 pounds. Thereafter, an April 2008 VA clinical record noted that the Veteran was stable and appeared healthy, providing more evidence against this claim. His GERD symptoms were reported as stable in September 2008. The Veteran's weight ranged from 139 to 145 pounds. At his hearing in December 2009, the Veteran described GERD symptoms of recurrent acid reflux, daily vomiting of bile material, sleep difficulty due to acid reflux, and a 9-pound weight loss since 2007. He currently weighed 131 pounds. He further indicated that acid regurgitation had led to a dental disorder which required treatment. Thereafter, VA clinical records reflect that the Veteran weighed 143.9 pounds in January 2010. Laboratory testing in February 2010 revealed anemia. A March 2010 gastroenterology consultation reflected a history of the Veteran having a progressive worsening of anemia over the last three years from prior normal baseline values. He had a documented iron deficiency with 2 out of 3 positive fecal occult blood tests. He had severe GERD with significant pyrosis at nighttime. Aside from this, the Veteran did not have gastrointestinal symptoms of dysphagia, abdominal pain, unexplained weight loss, change in bowel habits or gastrointestinal bleeding. At that time, the Veteran weighed 138 pounds. He was given an impression of anemia of unknown etiology with one potential cause being poor iron absorption from high dose proton pump inhibitor therapy. Colonoscopy and esophagogastroduodenoscopy were ordered. An April 2010 colonoscopy resulted in impressions of positive fecal occult blood test results likely due to large sigmoid colon polyp, and iron deficiency anemia "most likely due to a combination of occult blood loss from large colon polyp, as well as patient's gastritis." Biopsy diagnoses reflected assessments of chronic gastritis of the stomach, oxyntic mucosa with chronic gastritis at the gastroesophageal junction, and reflex esophagitis with cardiac-type metaplasia. In a letter dated April 29, 2010, the Veteran was advised of the results of the examination of his esophagus, stomach, and duodenum. He was informed that his "largest polyp was oozing blood, and this is the most likely reason for your anemia." Such a medical finding provides evidence against this claim as it indicates a nonservice connected problem has caused the anemia. On VA C&P examination in April 2010, the Veteran reported repeated heartburn with regurgitation of bitter gastric secretions into his mouth. He had emesis regularly, but denied hematemesis or melena. He reported occasional dysphagia. His GERD symptoms occurred at all times of the day, and were not merely postprandial. The Veteran reported a 6-pound weight loss in the last month. Due to reflux symptoms, the Veteran was unable to sleep lying down. In addition to rabeprazole, he used TUMS and baking soda as needed for relief but did not obtain much benefit. The examiner noted that, in February 2010, the Veteran was found to have severe iron deficiency anemia with two out of three stool samples positive for occult blood. Esophagogastroduodenoscopy and colonoscopy demonstrated hiatal hernia, non-erosive antral gastritis and duodenitis, diverticulosis coli, and colon polyps. On examination, the Veteran presented as a well-developed, thin elderly male. He appeared slightly pale. He weighed 136 pounds. The abdomen was soft with mild deep direct mid-epigastric tenderness. The examiner diagnosed severe GERD, hiatal hernia, iron deficiency anemia secondary to gastrointestinal bleeding, antral gastritis and duodenitis, diverticulisis coli, and colon polyps. As reflected above, the Veteran's GERD has been manifested by symptoms of recurrent epigastric distress with dysphagia, pyrosis and regurgitation. These symptoms support the currently assigned 30 percent rating under DC 7346. The Veteran has been diagnosed with iron deficiency anemia. A VA gastroenterologist in February 2010 indicated that the Veteran's anemia could be potentially due to poor iron absorption from high dose proton pump inhibitor therapy. A subsequent colonoscopy resulted in an impression of iron deficiency anemia "most likely due to a combination of occult blood loss from large colon polyp, as well as patient's gastritis," although the Veteran was later informed that his large colon polyp was "the most likely reason" for his anemia. The April 2010 VA examiner indicated that the Veteran's anemia was due to "gastrointestinal bleeding." On this record, the Board finds that the medical opinions are somewhat ambiguous regarding the extent, if any, that the Veteran's GERD contributes to his anemia. Where it is not possible to distinguish the effects of a nonservice-connected condition from those of a service-connected condition, the reasonable doubt doctrine dictates that all symptoms be attributed to the Veteran's service-connected disability. See Mittleider v. West, 11 Vet. App. 181 (1998). For purposes of this decision, the Board will assume that the Veteran's GERD contributes to his anemia. The April 2010 VA examiner indicated that the Veteran was also describing emesis, or vomiting. Thus, the Veteran demonstrates pain, vomiting and anemia due to GERD which are factors for consideration in a 60 percent schedular rating under DC 7346. However, the Veteran has repeatedly denied experiencing symptoms of hematemesis or melena. The medical records document that the Veteran's weight has ranged between 136 to 145 pounds. The Veteran described weighing 131 during his Board hearing in December 2009, but was shown to weigh almost 144 pounds one month later, providing highly probative evidence against a claim that this condition cause material weight loss. While the Veteran has had periods of weight loss, he has later regained weight, and the record does not reflect consistent weight loss. Overall, the Veteran has not experienced "material weight loss" during the appeal period as defined by 38 C.F.R. § 4.112. A review of the Veteran's weight (as cited above) clearly indicates to the Board that the Veteran's weight has remained relatively stable, undermining the Veteran's contention regarding weight issues associated with the service connected disability greatly. Furthermore, the Veteran is not shown to result in a combination of symptoms productive of severe impairment of health. While the Veteran is described as being thin with a low body weight, the Veteran has also been described as in good health and well-developed during the appeal period. There is no medical opinion of severe impairment of health due to GERD and significant evidence (as cited above) that indicates the minimal to moderate nature of the problem. A detailed review of the post-service treatment records provides the Board with significant medical evidence against this claim, undermining the Veteran's contentions regarding the nature and extent of this disability. The treatment records are found to simply not support the Veteran's claim, and are found instead to provide highly probative evidence against the claim, indicating a minimal to moderate (at best) problem associated with the service connected disability. The Veteran's contentions regarding poor health associated with this disability is simply not seen in objective testing and the examinations cited above. While the Veteran clearly has some problems associated with this disability, if he did not there would be no basis to grant the Veteran a 30 percent evaluation. Overall, the Board finds that the Veteran's GERD symptomatology does not meet or more nearly approximate the criteria for a 60 percent rating under DC 7346. In so deciding, the Board has accepted the Veteran's report of GERD symptoms such as recurrent epigastric distress with dysphagia, pyrosis, regurgitation and emesis as credible evidence supporting the claim. However, with respect to findings such as material weight loss and symptom combination productive of severe impairment of health, the Board places greater probative value on the clinical findings of record which are recorded by physicians having greater expertise and training than the Veteran in evaluating his GERD disability. Objective testing and treatment records affirmatively provide evidence against this claim. The Veteran has suggested that he would be more appropriately rated under another diagnostic code, such as Diagnostic Code 7305 or 7306. Under Diagnostic Codes 7304 and 7305, which rate gastric and duodenal ulcers, a 60% rating is assigned when severe; 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. A 40% rating is assigned when moderately severe; less than above 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 20% rating is assigned when moderate; recurring episodes of severe symptoms two or three times a year averaging 10 days in duration; or with continuous moderate manifestations. A 10% rating is assigned when mild; with recurring symptoms once or twice yearly. 38 C.F.R. § 4.114, Diagnostic Code 7304-7305. Under Diagnostic Code 7306, 10 percent evaluation is warranted for a mild marginal (gastrojejunal) ulcer with brief episodes of recurring symptoms once or twice yearly. A 20 percent evaluation would require demonstrated evidence of a moderate marginal ulcer with episodes of recurring symptoms several times a year. These symptoms include vomiting, recurring melena or hematemesis, and weight loss. A 40 percent rating is for assignment when the ulcer is moderately severe, with intercurrent episodes of abdominal pain at least once a month partially or completely relieved by ulcer therapy, and with mild and transient episodes of vomiting or melena. The next higher rating of 60 percent is assigned when the ulcer is severe, and the same as pronounced with less pronounced and less continuous symptoms with definite impairment of health. A 100 percent schedular rating is assigned for ulcer disease which is pronounced, with periodic or continuous pain unrelieved by standard ulcer therapy with periodic vomiting, recurring melena or a hematemesis, and weight loss, so as to render the individual totally incapacitated. 38 C.F.R. § 4.114, Diagnostic Code 7306. Under Diagnostic Code 7307 chronic hypertrophic gastritis, with small nodular lesions, and symptoms is rated 10 percent disabling. Chronic hypertrophic gastritis, with multiple small eroded or ulcerated areas, and symptoms, is rated 30 percent disabling. Chronic hypertrophic gastritis, with severe hemorrhages, or large ulcerated or eroded areas, is rated 60 percent disabling. Atrophic gastritis, which is a complication of a number of diseases, including pernicious anemia, is to be rated on the underlying condition. 38 C.F.R. § 4.114, Diagnostic Code 7307. While the Board has considered the Veteran's argument, it finds that the Veteran is more appropriately rated under Diagnostic Code 7346. Diagnostic Codes 7304-7307 focus on symptoms such as hematemesis, melena, weight loss, and hemorrhaging, which the Veteran does not have. The Veteran does suffer from anemia, vomiting, and pain, which the above codes rate; however, vomiting, pain, and impairment of health are also considered under Diagnostic Code 7346. In addition, Diagnostic Code 7346 rates symptoms such as pyrosis, dysphagia, and regurgitation, which none of the other diagnostic codes contemplate. A review of the Veteran's complaints shows that he appears to complain more of heartburn, dysphagia, and regurgitation than any other GERD symptoms. These symptoms also appear to be some of the most frequently experienced and longest standing. As such, the Board finds that Diagnostic Code 7346 is most analogous not only to the functions affected by the Veteran's disability, but also the anatomical localization and symptomatology, and most closely reflects the predominant disability picture. Accordingly, the Board finds that a rating under another diagnostic code is not appropriate at this time. The evaluation of this problem is complex, for reasons the Board has attempted to cite above. Clearly, in such complex cases, the Veteran must be given every benefit of the doubt. However, it is important for the Veteran to understand that this benefit of the doubt was given when he was awarded the 30 percent evaluation. Even if the Board were to evaluate the Veteran service connected disability under any other diagnostic code, the Board finds it would not provide a basis to grant this claim. Objective testing, and in some cases the Veteran's own statements, simply provide highly probative evidence against a finding that the Veteran has the type of problems associated with a higher evaluation under the codes cited above. For example, the post-service medical record, overall, is found by the Board to provide evidence against a finding that the Veteran has intercurrent episodes of abdominal pain at least once a month partially or completely relieved by ulcer therapy and with mild and transient episodes of vomiting or melena or any other problem that would provide a basis to grant an increased evaluation. The service connected disability simply does not cause such a problem, notwithstanding the Veteran's statements or other pieces of evidence within the claims file that would, arguably, support this claim, in light of medical records/examinations which the Board finds clearly provides evidence against this claim. The overall evidence that the Board has given great probative weight provides not only evidence that does not support this claim, but evidence against this claim. Some of the Veteran's own statements to health care providers (not the Board) do not clearly support the current evaluation, let alone a higher evaluation. As the preponderance of the evidence is against the claim, the benefit of the doubt doctrine does not apply. See 38 U.S.C.A. § 5107(b); Ortiz v. Principi, 274 F.3d 1361, 1364, 1365 (Fed. Cir. 2001). Finally, the Board is aware of the Veteran's complaints as to the effects of his service-connected GERD has had on his activities of work and daily living. The Veteran describes the need to change his diet and eating habits. He has been retired for many years. However, in the Board's opinion, all aspects of the Veteran's GERD impairment are more than adequately encompassed in the assigned 30 percent schedular rating. Notably, the criteria of DC 7346 adequately address all of the symptomatology reported by the Veteran. As the assigned schedular evaluation is adequate, there is no basis for extraschedular referral in this case. 38 C.F.R. § 3.321(b). See Thun v. Peake, 22 Vet. App. 111, 114-15 (2008). The Board further observes that there is no evidence of any unusual or exceptional circumstances, such as marked interference with employment or frequent periods of hospitalization related to the service-connected GERD disability at issue, that would take the Veteran's case outside the norm so as to warrant an extraschedular rating. Therefore, referral by the RO to the Chief Benefits Director of VA's Compensation and Pension Service, under 38 C.F.R. § 3.321, is not warranted. See Bagwell v. Brown, 9 Vet. App. 337 (1996). As provided for by the Veterans Claims Assistance Act of 2000 (VCAA), VA has a duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2010); 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a) (2010). The Veteran filed a claim for an increased rating in February 2007. A pre-adjudicatory RO letter dated March 2007 advised the Veteran of the types of evidence and/or information deemed necessary to substantiate the claim as well as the relative duties upon himself and VA in developing the claim. The Veteran was further advised as to how VA determines a disability rating and an effective date of award. This letter substantially complied with the generic type of notice pertinent to the increased rating claim at issue. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b); Quartuccio v. Principi, 16 Vet. App. 183 (2002); Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004); Vazquez- Flores v. Shinseki, 580 F. 3d 1270 (Fed. Cir. 2009). VA has a duty to assist the Veteran in the development of the claim. This duty includes assisting the Veteran in the procurement of STRs and pertinent treatment records and providing an examination when necessary. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. The Board finds that all necessary development has been accomplished, and therefore appellate review may proceed without prejudice to the Veteran. See Bernard v. Brown, 4 Vet. App. 384 (1993). The RO has obtained the Veteran's STRs and VA clinical records. The Veteran has not reported obtaining Social Security Administration disability benefits. The Board remanded this claim in January 2010, in part, to assist the Veteran in associating with the claims folder records from his dentist Dr. J. In February 2010, the RO sent the Veteran a letter advising him to submit these records directly or, alternatively, to return a provided VA Form 21-4142 authorizing VA to obtain those records on his behalf. The Veteran did not respond. Thus, the Board has no further duty to obtain those records. See Wood v. Derwinski, 1 Vet. App. 190, 193 (1991) (holding that the duty to assist is not a "one-way street" with a claimant having an obligation to provide information essential in obtaining evidence for the claim). Otherwise, the Veteran has not reported any additional records relevant to the claim on appeal. The Board also remanded this case in January 2010 to investigate the Veteran's report of increased severity of GERD symptoms since his prior VA examination in April 2007. The VA examination report obtained, dated April 2010, fully addresses the clinical findings necessary to decide the claim as well as the Board's remand directives. Since that last VA examination, the lay or medical evidence does not suggest an increased severity of symptoms to the extent that a higher schedular rating for GERD may still be possible. Thus, there is no duty to provide further medical examination on this claim. See VAOPGCPREC 11-95 (Apr. 7, 1995). For the reasons expressed above, the Board finds that no further notice or assistance to the Veteran is required to fulfill VA's duty to assist him in the development of his claim. Smith v. Gober, 14 Vet. App. 227 (2000), aff'd 281 F.3d 1384 (Fed. Cir. 2002); Dela Cruz v. Principi, 15 Vet. App. 143 (2001); see also Quartuccio, 16 Vet. App. 183 (2002). ORDER A rating greater than 30 percent for GERD is denied. ____________________________________________ JOHN J. CROWLEY Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs